Teaching District Concept of BP Koirala Institute of Health Sciences: An Inter-disciplinary Community Based Medical Education and Health Service Delivery Model in Rural Nepal.

Community based education trains health professional students to deal with the community health problems. The attitude and skills they gain as planners for health care provision are applicable in both hospital and community settings. BP Koirala Institute of Health Sciences has implemented a model of Community based education which encompasses the health institutions, organisations and the communities of the sixteen districts in eastern Nepal and refers to this concept as the 'Teaching District" concept of B P Koirala Institute of Health Sciences. This paper seeks to describe the concept and its implementation. Almost 20 years have passed since first initiated; and pending a comprehensive evaluation, this concept has gathered a great deal of experience to serve as a model for partnership between academic health sciences institutions with the district health system of Nepal.

Corneal ulceration in south-east Asia III: prevention of fungal keratitis at the village level in south India using topical antibiotics.

AIM: To determine whether topical antifungal prophylaxis distributed by paid village health workers (VHWs) in south India is necessary after corneal abrasion to prevent fungal keratitis in a population where half of the ulcers are fungal. METHODS: Two panchayaths (village administrative units in Madurai district with a combined population of 48 039 were followed prospectively for 18 months by 15 VHWs who were trained to identify post-traumatic corneal abrasions. Patients fulfilling the eligibility criteria were randomised into two groups and treated with either 1% chloramphenicol and 1% clotrimazole ointment or 1% chloramphenicol and a placebo ointment three times a day for 3 days. Patients, doctors and VHWs were blinded to treatment. RESULTS: During the 18-month period, 1365 people reported to VHWs with ocular injuries, of whom 374 with corneal abrasions were eligible for treatment. Of these, 368 (98.5%) abrasions healed without complications. Two patients had mild localised allergic reactions to the ointment, two dropped out and two patients in the placebo group developed microscopic culture-negative corneal stromal infiltrates that healed in 1 week with natamycin drops. CONCLUSIONS: Both fungal and bacterial ulcers that occur after traumatic corneal abrasions seem to be effectively prevented in a village setting using only antibiotic prophylaxis.

Corneal ulceration in South East Asia. I: a model for the prevention of bacterial ulcers at the village level in rural Bhutan.

AIM: To prove that antibiotic distribution by grassroots volunteer village health workers (VVHWs) in Bhutan is an effective and efficient public health intervention for the prevention of post-traumatic corneal ulceration. METHODS: 55 villages in two districts in Bhutan were selected for the study. A defined population of 10 139 individuals was followed prospectively for 18 months by 31 VVHWs who were trained to identify post-traumatic corneal abrasions with fluorescein dye and a blue torch and to administer 1% chloramphenicol ointment three times a day for 3 days to the eyes of individuals who fulfilled the eligibility criteria. RESULTS: During the 18 month period 135 individuals reported to VVHWs with an ocular injury and 115 were found to have a corneal abrasion. All 115 were treated with 1% chloramphenicol ointment three times a day for 3 days and all healed without sequelae CONCLUSIONS: Corneal ulcers that occur following traumatic corneal abrasions can be effectively prevented, even in the setting of isolated rural conditions such as those that exist in villages in Bhutan, by using relatively simple preventative measures that local VVHWs can easily be taught to employ.

Corneal ulceration in South East Asia. II: a strategy for the prevention of fungal keratitis at the village level in Burma.

AIM: To prove that topical antifungal and antibiotic prophylaxis distributed by grass roots village health workers (VHWs) in Burma is an effective public health intervention for the prevention of post-traumatic microbial keratitis in a population where the majority of ulcers are fungal. METHODS: Three villages in Bago District with a combined population of 16,987 were selected for the study. This defined population was followed prospectively for 12 months by 15 VHWs who were trained to identify post-traumatic corneal abrasions with fluorescein dye and a blue torch and to administer 1% chloramphenicol and 1% clotrimazole ointment three times a day for 3 days to the eyes of individuals who fulfilled the eligibility criteria. RESULTS: During the 12 month period 273 individuals reported to VHWs with an ocular injury and 126 were found to have a corneal abrasion. All 126 were treated with 1% chloramphenicol and 1% clotrimazole ointment three times a day for 3 days, and all healed without sequelae. CONCLUSIONS: Both fungal and bacterial ulcers that occur following traumatic corneal abrasions can be effectively prevented in a village setting by using relatively simple measures that local volunteer public health workers can easily be taught to employ.

Epidemiologic characteristics, predisposing factors, and etiologic diagnosis of corneal ulceration in Nepal.

Corneal ulceration is one of the most frequent causes of blindness in developing countries. Between September 1985 and August 1987, 405 patients with corneal ulceration were examined at Tribhuvan University Teaching Hospital in Kathmandu, Nepal. Males and females were equally affected. The most common predisposing cause of ulceration was corneal trauma, usually with organic agricultural materials. Microorganisms were grown from 324 (80%) of the ulcers. Pure bacterial cultures were obtained from 256 (63.2%) of the patients, whereas pure fungal cultures were obtained from 27 (6.7%) of the patients. In 41 patients (10.1%), corneal cultures yielded a mixed growth of bacteria and fungi. Of a total of 398 bacterial isolates, 124 (31.1%) were positive for Streptococcus pneumoniae, the most commonly isolated organism in the series. Other frequently isolated bacteria included Staphylococcus epidermidis, S. aureus, and Pseudomonas species. Of 68 positive fungal isolates obtained, 32 (47.0%) were identified as Aspergillus species. Candida species and Fusarium species were less commonly seen.

Keratitis due to Aspergillus flavus successfully treated with thiabendazole.

A case of Aspergillus flavus keratitis treated successfully with 4% suspension of thiabendazole is reported. This seems to be the first case of successful treatment of keratomycosis with thiabendazole. All other reported cases treated with this drug either had their eyes removed or did not retain any useful vision. Its ability to penetrate ocular tissues, ability to remain in concentrations higher than the minimal inhibitory concentration of many fungi, and broad spectrum of activity make it a worthwhile drug for further investigation in keratomycosis.

The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal.

AIMS: To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion. METHODS: A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days. RESULTS: Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18-24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24-48 hours subsequently developed corneal ulceration. CONCLUSIONS: Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury.

Socioeconomic barriers to cataract surgery in Nepal: the South Asian cataract management study.

BACKGROUND: Previous studies have shown that, despite an increasing availability of cataract surgery, important socioeconomic barriers exist in the acceptance of surgery in many rural areas of south Asia. Nepal has developed a comprehensive national network of eye hospitals but the surgical coverage for the treatment of cataract blind is still low. AIMS: To determine the utilisation of cataract surgery and the level of physical and psychosocial impairment and the socioeconomic barriers to surgery in a group of non-acceptors of surgery. METHODS: Of 319 cataract patients identified in a field screening 96 non-acceptors of surgery were interviewed 1 year after an offer to undergo surgery. The interview included questions on visual function, quality of life, and socioeconomic variables on acceptance of cataract surgery. The quality of life questionnaire was based on the field validated protocol addressing the impact of visual impairment on physical and psychosocial functions. The questionnaire was adapted to the local conditions after pretesting. Data were analysed by degree of visual impairment. RESULTS: Of 319 cataract patients identified only 45.5% accepted surgery, with men accepting surgery more readily than women (RR = 1.31; 95% CI = 1.04-1.67) because of a significantly greater acceptance of surgery in men in the non-blind group. The acceptance rate was significantly higher in the blind group (RR = 1.74; 95% CI = 1.36-2.22) compared with those patients having impairment of vision and severe loss of vision. Of 96 non-acceptors interviewed only a further 13% accepted surgery after a second counselling. The most frequent reasons given for not accepting surgery were economic (48%) and logistical (44.8%) constraints followed by fear of surgery (33.3%) and lack of time (18.8%). Half of the subjects complained of problems with self care but only 10% needed help for their most basic every day activities. 17.7% said they needed help to visit neighbours and 26% needed help to attend the field or market. CONCLUSIONS: It was found that in this population with a majority of patients with severe vision loss and blind, even when offered transport and free surgery the utilisation of cataract surgery is below 60%. Medicine tends to be prescriptive based on technological advances that it is able to offer. Medical practice needs to develop a more holistic understanding of the needs of the communities cultivating a greater capability to analyse the role of cultural, social, and economic factors when planning medical services for the population.

Effect of intestinal helminth infection on some nutritional parameters among rural villagers in Nepal.

We report the prevalence of intestinal helminthiasis and its impact on health of Nepalese in two different rural Village Development Committees (VDC) in Nepal. A total of 261 school children from Okharpauwa VDC in Nuwakot district (Central Region) and 242 inhabitants of Boya VDC in Bhojpur district (Eastern Region) in Nepal were included in this study. The overall prevalence in these two different districts were 57.5% and 55.4%, respectively. Altogether four types of helminths were detected. In both districts, Ascaris lumbricoides was the commonest helminth. Mixed helminth infection in both study areas accounted for less than 5.0%. All helminth infected subjects were treated with a single dose of albendazole. Heavy Trichuris trichiura infection needed a second dose. Blood hemoglobin and serum total protein level in school children in Okharpauwa VDC increased significantly after chemotherapy (P < 0.05). Eosinophil count (10.1%; SD 5.0325) returned to normal (4.8%; SD 4.6997). Helminth infection in Boya VDC was more common in children than in adults. Serum total protein, albumin, total cholesterol and triglycerides levels were not influenced by the presence or absence of helminths among the inhabitants of Boya VDC. In both districts, more than 80.0% of the household had no latrine. In Boya VDC, 94.0% of inhabitants interviewed were not aware of other intestinal parasite other than A. lumbricoides.

Seroepidemiological study of Toxoplasma infection in central and western regions in Nepal.

The present study was carried out to ascertain the seroprevalence rate in different geographical areas in Central and Western Regions in Nepal. A total of 1,237 serum samples collected from Nuwakot (217), Kathmandu valley (402) and Chitawan (159) districts in Central Region, and Mustang (143), Surkhet (64) and Banke (252) districts in Western Region in Nepal were included in this study. Toxoplasma antibodies were detected by micro-latex agglutination (MLA) and enzyme linked immunosorbent assay (IgM-ELISA) methods. The seropositive rate in Central and Western Regions were found to be 48% and 49%, respectively; with an overall positive rate of 48 percent. Districtwise, the seropositive rate in Nuwakot, Kathmandu valley, Chitawan, Mustang, Surkhet and Banke districts were 38, 46, 64, 51, 67 and 44%, respectively. Interestingly, the relatively newly inhabited Surkhet district in Western Region and Chitawan district in Central Region showed significantly higher seropositive rate compared with those of two other districts in the respective Regions (p < 0.05). Ethnically, Tibeto-Burmans showed higher seropositive rates in Central Region (p > 0.05). In contrast, Indo-Aryans showed higher seropositive rate in Western Region (p > 0.05). Age related increase in seropositivity was observed only in Central Region. One percent of Toxoplasma antibody positive samples also showed Toxoplasma IgM antibody positivity.

Measuring the burden of ocular morbidity.

This hospital-based study highlights the spectrum of eye ailments in 35,273 patients who attended the Department of Ophthalmology at the B P Koirala Institute of Health Sciences, Eastern Nepal, during a 5-year period with varied clinical diagnosis. The attendance each year showed a progressive increase with a male preponderance. More than 13% of the patients were children. Cataract was the most common problem for which patients needed ophthalmic advice; diabetic and hypertensive retinopathy were frequent occurrences and infection was a common problem. Over 21% of the eyes examined had a refractive error: as high as 2.54% were amyblyopic caused by non-correction of refractive errors. Allergic conjunctivitis was frequently encountered. As shown by the magnitude of the problem, the existing eye care facilities must be enhanced and new strategies developed.

Monitoring the durability of long-lasting insecticidal nets in field conditions in Nepal.

Understanding and improving the durability of long-lasting insecticidal nets (LLINs) in the field is critical for the success of malaria prevention using mosquito nets, as well as contributing to procurement decisions based on the number of years of protection, rather than the current practice of unit cost. Using the recently published guidelines from the World Health Organization (WHO) some progress has been made in the monitoring and assessment of performance of nets in the field. This paper describes the protocol of an ongoing retrospective study of the attrition rate, physical integrity and bioefficacy of three polyester LLIN products that were distributed during 2010 to 2013 in Nepal. It is hoped that robust and auditable data on net survival (physical integrity and bioefficacy) of these three brands in different environments will assist the Nepal National Malaria Control Programme in planning future LLIN-replacement strategies, including behaviour-change communication about LLIN care and maintenance. The advantages and disadvantages of prospective and retrospective cross-sectional approaches are discussed, including appropriate strategies to validate the timing for mass distribution of nets. Similar studies should be done in other countries to (i) track LLIN durability to support management of resupply, and (ii) inform procurement decisions at the global level. New, more predictive, textile laboratory testing is also urgently needed.

Utilization of primary eye health services by people from a rural community of Nepal.

INTRODUCTION: Preventable and treatable eye diseases are still major causes of blindness in rural communities. OBJECTIVE: To find the factors influencing utilization of primary eye health services among the people in a rural community of Nepal. MATERIALS AND METHODS: This was a population-based study with a cross-sectional and descriptive design. Lete Ilaka in Mustang District of Nepal was the study site. Data of knowledge on eye diseases, availability of services and utilization of available services were obtained from female care takers. Association among variables was observed by bivariate analysis. RESULTS: A total of 216 female care takers participated in the study. The median age of the respondents was 39 years. Almost 80 % of the respondents had agriculture as their major occupation and more than a quarter were from lower castes (dalit) community. Low level of educational attainment (OR = 3.1, 95 % CI = 1.6-6.1) and poverty (OR = 2.0, 95 % CI = 1.13-3.43) among respondents were found to be significantly associated with a low level of awareness on eye diseases. The risk of not knowing about eye diseases increased more than 3.5 times when people were illiterate. Locally available eye health services and skills amongst the health workers were found inadequate. CONCLUSION: Low level of education, poor knowledge of eye diseases and great distance from home to health facilities were found to be factors on the demand side while inadequacy of eye health services and perceived inadequate skills among health workers were identified as factors in the supply side affecting utilization of eye health services among people of Mustang District.

Corneal blindness: a global perspective.

Diseases affecting the cornea are a major cause of blindness worldwide, second only to cataract in overall importance. The epidemiology of corneal blindness is complicated and encompasses a wide variety of infectious and inflammatory eye diseses that cause corneal scarring, which ultimately leads to functional blindness. In addition, the prevalence of corneal disease varies from country to country and even from one population to another. While cataract is responsible for nearly 20 million of the 45 million blind people in the world, the next major cause is trachoma which blinds 4.9 million individuals, mainly as a result of corneal scarring and vascularization. Ocular trauma and corneal ulceration are significant causes of corneal blindness that are often underreported but may be responsible for 1.5-2.0 million new cases of monocular blindness every year. Causes of childhood blindness (about 1.5 million worldwide with 5 million visually disabled) include xerophthalmia (350,000 cases annually), ophthalmia neonatorum, and less frequently seen ocular diseases such as herpes simplex virus infections and vernal keratoconjunctivitis. Even though the control of onchocerciasis and leprosy are public health success stories, these diseases are still significant causes of blindness--affecting a quarter of a million individuals each. Traditional eye medicines have also been implicated as a major risk factor in the current epidemic of corneal ulceration in developing countries. Because of the difficulty of treating corneal blindness once it has occurred, public health prevention programmes are the most cost-effective means of decreasing the global burden of corneal blindness.

The glutaraldehyde test as a rapid screening method for pulmonary tuberculosis: a preliminary report.

When equal parts of EDTA-blood and 2.5% glutaraldehyde solution were mixed, a shorter gelification time was observed in blood from patients with pulmonary tuberculosis--diagnosed by clinical and X-ray examination--than in blood from patients with other respiratory diseases or with non-respiratory diseases, or from healthy volunteers. Of a total of 539 persons tested, 267 had pulmonary tuberculosis as judged by clinical and X-ray examination and 238 of these reacted positively to the glutaraldehyde test with a gelification time of less than 10 minutes. When clinical examination and X-ray evaluation are used as bases for the diagnosis of pulmonary tuberculosis, the glutaraldehyde test gives a sensitivity of 89% and a specificity of 95%. It is suggested that this simple and cheap method, together with clinical examination, might be a useful screening tool for identifying cases of pulmonary tuberculosis in peripheral health posts in developing countries where X-ray and other facilities are lacking.

Seasonal hyperacute panuveitis of unknown etiology.

A severe form of unilateral uveitis, which in most cases leads to blindness within hours of its onset, has been seen in Nepal since 1975. This disease appears with the onset of autumn in early September and lasts until the end of December in two-year cycles (1975, 1977, 1979). However, some cases occurred in 1980 as well. As expected there was an outbreak of this disease in 1981. Although early cases were seen in patients from Western Nepal, the disease has since been identified in patients from various parts of the country. In one of the outbreaks (1977) in western Nepal some patients or their parents gave a history of a white moth sitting on the child's face or arm prior to the onset of ocular symptoms. Some of these were claimed to be followed by blister formation at the point of contact. These moths were presumed to be responsible for producing this uveitis in those cases. The present report describes the clinical features of the cases seen from the time the disease was first recognized, case histories of four cases seen during the last outbreak, results of laboratory experiments using the aqueous humor of these patients, and the results of experiments using three different varieties of moths.

Xerophthalmia among Nepalese children.

A nationwide sample survey was conducted between July 1980 and June 1981 to determine the prevalence of xerophthalmia among Nepalese children. Population proportionate random samples were drawn from the 12 geopolitical subdivisions of the country by employing multistage sampling technique. The survey population was defined as the child population of rural Nepal between the ages of 0 and 14 years. The per cent prevalence of xerophthalmia in Nepal was 1.65 for Bitot's spots, 0.02 for corneal ulcer, and 0.03 for corneal scar. While cases of Bitot's spots were more prevalent in the plains of Nepal, followed by the mountains and the hills, the reverse was true for corneal lesions. Vitamin A deficiency was found to be responsible for one-third of acquired bilateral blindness in preschool children. All corneal cases in the study were accompanied by diarrhea and malnutrition, indicating xerophthalmia to be symptomatic of the whole spectrum of malnutrition.

Corneal ulcers in Nepal.

In Kathmandu, Nepal, 133 cases of corneal ulcers were examined and scraped by the investigators during 1981. Corneal ulcers were seen to be more common in females during the active years of life, occurring more frequently during monsoon and autumn seasons. Trauma by vegetative matter was the common antecedent. Organisms were grown in about 50.0% of the cases. Bacteria were seen to be responsible in about 75.0%, and fungi in about 25.0% of growth-positive cases. Sensitivity tests in vitro showed that carbenicillin, chloramphenicol, cephaloridine, methicillin, and lincomycin were most effective against bacteria and clotrimazole was most effective against fungi.

[Results of operative couching of the lens (a study from Nepal)]. / Ergebnisse der operativen Reklination der Linse (Eine Studie aus Nepal).

In Southern Nepal 100 eyes were examined on which a couching operation (reclination of the lens) had been performed by "quacks". The postoperative period extended from 1 month to more than 10 years. At the time of the examination 42 eyes were found to be blind; 26 of these were still blind immediately after the operation or went blind again during the following 6 months. In the eyes in which vision was preserved throughout the first postoperative year, subsequent loss of vision was less than 10% a year. These surgical results may not appear desirable but they are at least acceptable considering that the couching had been performed in regions of Nepal where modern ophthalmic care is not yet available.