Evolution of Influenza A(H3N2) Viruses in Bhutan for Two Consecutive Years, 2022 and 2023.

BACKGROUND: Influenza A viruses pose a significant public health threat globally and are characterized by rapid evolution of the hemagglutinin (HA) gene causing seasonal epidemics. The aim of this study was to investigate the evolutionary dynamics of A(H3N2) circulating in Bhutan during 2022 and 2023. METHODS: We analysed 166 whole-genome sequences of influenza A(H3N2) from Bhutan, obtained from the GISAID database. We employed a Bayesian Markov Chain Monte Carlo (MCMC) framework, with a curated global dataset of HA sequences from regions with significant migration links to Bhutan. Phylogenetic, temporal, and phylogeographic analyses were conducted to elucidate the evolutionary dynamics and spatial dissemination of the viruses. RESULTS: Our phylogenetic analysis identified the circulation of influenza A(H3N2) Clade 3C.2a1b.2a.2 in Bhutan during 2022 and 2023, with viruses further classified into three subclades: 2a.3 (39/166), 2a.3a.1 (58/166) and 2a.3b (69/166). The TMRCA estimates suggest that these viral lineages originated approximately 1.93 years prior to their detection. Phylogeographic analysis indicates introductions from the United States in 2022 and Australia in 2023. The mean evolutionary rate across all gene segments was calculated to be 4.42 × 10-3 substitutions per site per year (95% HPD: 3.19 × 10-3 to 5.84 × 10-3), with evidence of purifying selection and limited genetic diversity. Furthermore, reassortment events were rare, with an estimated rate of 0.045 events per lineage per year. CONCLUSION: Our findings show that primary forces shaping the local evolution of the influenza A(H3N2) in Bhutan are largely stochastic, with only sporadic instances of adaptive change, and thus underscore the importance of continuous surveillance to mitigate the impact of evolving strains.

Does parent-child connectedness influence substance use among Bhutanese adolescents: evidence from a national survey?

BACKGROUND: Adolescent substance use is recognized as a global health crisis that threatens adolescents' physical and mental health worldwide. Alcohol is the most available one; WHO findings suggest that more than 155 million adolescents, representing over a quarter of the adolescent population aged between 11 and 15, use alcohol-based drinks worldwide. Since adolescents are the future of the world, protecting them from substance use is of paramount importance. OBJECTIVES: This study aimed to explore the prevalence of adolescent substance use (alcohol, marijuana, and tobacco) among Bhutanese adolescents and examine the association with parent-child connectedness as a protective factor while controlling sociodemographic, socio-emotional distress, and other contextual factors. METHODS: A total of 7576 school-going adolescents' data from the 2016 Global School-based Student Health Survey (GSHS) Bhutan dataset were used in this study. To analyze the relationship between predictor and outcome variables, both univariate and multivariate binary logistic regression models were constructed utilizing the "complex samples" tool of SPSS 25. A significance level of p ≤ 0.05 was used for the analyses. RESULTS: An estimated 30.7% of the Bhutanese school-going adolescents used tobacco, 25.8% consumed alcohol, and 12.7% used marijuana. Parent-child connectedness: (i) child's homework supervision and (ii) child's free time supervision by parents significantly lower the odds of using tobacco and alcohol consumption, while parents understanding child's problem showed no significant association with substance use among the respondents. However, no significant association was found between parent-child connectedness and marijuana use. Besides parental connectedness, anxiety, bullying, passive smoking, school truancy, being involved in fights, or being attacked were also significantly associated with adolescents' substance use. CONCLUSION: Parental connectedness has been found to be an important factor that can lead to a substantive reduction in substance use among the adolescents of Bhutan. However, the lesson is pertinent for any global initiatives aiming to prevent the harmful use of substances among global adolescents.

Pattern and Prevalence of Retinal Vein Occlusion in Bhutan: A 3-Year National Survey at Vitreoretinal Clinics.

Purpose: We conducted this study to determine the pattern and prevalence of retinal vein occlusion (RVO) in Bhutan to inform national health policy as no data has been compiled previously. Methods: A retrospective cross-sectional survey was conducted over 3 years, including all new RVO cases. For patients with bilateral RVO, one eye was chosen randomly. Demographic, clinical, and diagnostic details, including optical coherence tomography, fluorescein angiography, and fundus photography, were collected. Results: Of 141 RVO new patients included, aged 50.5 ± 20.2 years, there were more males (62.4%) than females (37.6%) significantly (p = 0.031), and 59.6% of total patients were from an urban setting. Farmers were the most affected group (44, 31.2%), followed by housewives (34, 24.1%), and the working group (33, 23.4%). Blurry vision (64, 45.5%), sudden loss of vision (17, 12.1%), including unsatisfactory cataract surgery (8, 5.7%) were common presenting complaints. Systemic hypertension (HT) (36, 25.5%), and diabetes mellitus (DM) (17, 12.1%), were associated systemic diseases. The prevalence of RVO was 4.8% (141/2913 all new retinal patients over the survey). Branch RVO (BRVO) was the most common type (77, 54.6%), followed by central RVO (CRVO) 56, (39.7%), and hemi-central RVO (HCRVO) (8, 5.7%). Superotemporal BRVO was the most common subtype (30, 39%) followed by inferotempoal (19, 24.7%). Best correct visual acuity (BCVA) was worse than 6/60 in 38 eyes (25.5%). BCVA was not significantly different between BRVO and CRVO eyes. Intraocular pressure was significantly lower in HCRVO eyes (p = 0.015) compared to BRVO and CRVO eyes. Conclusion: In Bhutan, 8.5% of RVO patients were bilateral. HT was associated significantly as a risk factor. Incidental findings of RVO during routine eye check-up and evaluating for unsatisfactory cataract surgery were common. Therefore, Bhutan needs to control noncommunicable diseases such as diabetes and HT to reduce RVO, and RVO-related blindness and complications.

Prevalence and factors associated with postpartum depression among Bhutanese mothers: a cross-sectional study.

PURPOSE: This study investigated the prevalence of postpartum depression (PPD) and explored associated factors among mothers attending postnatal care in Bhutan. METHODS: A cross-sectional study was conducted from August to November 2023 at a national referral hospital in Thimphu, the capital city of Bhutan. In total, 314 mothers were recruited. Sociodemographic, psychosocial, obstetric, and infant-related data were collected using questionnaires. The Edinburgh Postnatal Depression Scale, with a threshold of ≥11, was employed to screen for PPD, and logistic regression was used to test the potential factors. RESULTS: The prevalence of PPD was 14.97%. Mothers with a perceived change in body image (adjusted odds ratio [AOR], 4.40; 95% confidence interval [CI], 1.91-10.17; p=.001), perceived heightened stress after delivery (AOR, 3.74; 95% CI, 1.45-9.67; p=.006), poor relationship with inlaws (AOR, 2.57; 95% CI, 1.24-5.30; p=. 011), and negative birth experience (AOR, 2.42; 95% CI, 1.17-5.00; p=.016) demonstrated significantly higher odds of developing PPD. However, mothers with a higher monthly family income (Bhutanese ngultrum [Nu.] 20,000 to <50,000; AOR, 0.35; 95% CI, 0.13-0.92; p=.033), ≥Nu. 50,000 (AOR, 0.37; 95% CI, 0.13-1.07, p=.067) compared to

Phylogenetic exploration, codon usage bias, and genomic divergence in Hydrocotyle: a comparative plastome study across different geographical locations.

Hydrocotyle himalaica from Bhutan, a perennial herb that thrives from 1500 to 2600 m, possesses both ecological importance and medicinal properties. The plastome analysis revealed a length of 153,383 bp, showing variation from conspecific taxa in China. Its standard structure comprises two IR regions (18,336 bp IRa and 18,336 bp IRb), an LSC region of 97,944 bp, and an SSC region of 18,767 bp, with a GC content of 37.63%. Non-coding regions showed higher mutation susceptibility, with Pi values from 0.006 to 0.107. An AT-rich codon bias was consistent across all 18 Hydrocotyle species. Nucleotide composition and GC% in coding sequences differed among the species. The codon preference in Hydrocotyle is shaped by multiple factors, with natural selection being the primary influence, as indicated by the ENC-plot, PR2-plot, and Neutrality-plot. Codon usage patterns varied, with RSCU values from 0 to 2.23. Codons ending in A or U had RSCU > 1, while those ending in C or G had RSCU < 1. GC2 content surpassed GC3 and GC1 in most genes. The phylogenetic analysis placed H. himalaica, sourced from Kanglung, Bhutan, within the monophyly of the Hydrocotyloideae subfamily. However, the species showed weaker bootstrap support (BS < 50) with H. javanica and H. hookeri subsp., a deviation from a prior report on the same species from Jiangkou, Guizhou, China. This analysis highlighted the genomic characteristics and evolutionary relationships of H. himalaica from Bhutan, underscoring the need for a comprehensive phylogenetic, ecological, and botanical characterization to confirm intra-specific variation within Hydrocotyle species.

Sources and pathways of spring flow and climate change effects in the Dungju Ri & Yude Ri catchments, Bhutan Himalaya.

Springs and streams are vital water sources for supporting the livelihood of Himalayan residents. Escalating climate change, population growth, and economic development strain the region's freshwater resources. A national survey reveals declining spring and stream flows in Bhutan, necessitating an improved understanding of their generation. Monthly grab water samples were collected during April 2022-January 2023 from main streams, springs and other source waters at various elevations at Yude Ri and Dungju Ri catchments, Bhutan Himalayas. Samples were analyzed for pH, specific conductance, and major ions and end-member mixing analysis in combination with diagnostic tools of mixing models was used to determine sources, relative contributions, and recharge dynamics of spring flows. The results indicated that direct precipitation dominated spring flows (0.59 ± 0.21), followed by shallow groundwater (0.31 ± 0.18), and soil subsurface water (0.10 ± 0.15). The contributions of spring flow components followed an elevation gradient, with higher and lower fractions, respectively, of direct precipitation and shallow groundwater at higher elevations, e.g., 0.90 ± 0.1 to 0.13 ± 0.08 for direct precipitation and 0.03 ± 0.03 to 0.37 ± 0.19 for shallow groundwater from 3266 m to 1558 m. Spring flows primarily relied on precipitation (∼70 % from both direct precipitation and soil water), making them very sensitive to changes in precipitation. Significant contributions of shallow groundwater also indicated the vulnerability of spring flows to decreased snowfall relative to rainfall and the earlier onset of snowmelt, particularly for those located in the snow-rain transition zone (∼2500 m). Our results suggest high vulnerability of spring flows to the climate change in the Himalayas.

Case series: star anise toxicity presenting to the emergency department in Eastern Regional Referral Hospital in Bhutan.

BACKGROUND: Star anise fruit has been used in spice in Asian cuisine, ingredient for traditional medicines, component for antiviral drugs and as parts of tea and beverage across the globe. Toxicity from these plants has been reported due to adulteration with similar toxic species and from consumption with high toxic dose. Most physician and public are unaware of these adverse effects. CASES: We present two cases of star anise toxicity. Both of the patients presented with gastrointestinal and neurological symptoms after consumption of the said fruit. All of the labs and imaging test was negative for other causes and star anise toxicity diagnosis was made after detailed history, events and related symptoms. They were managed supportively and discharged after 24 h of observation. CONCLUSION: Emergency department doctors should be vigilant about possible star anise toxicity in patient presenting with suggestive symptoms, negative investigation for other possible cause and in area where these plant species is available. A detailed drug and ingestion history is essential.

Lessons Learned From Bhutan on extending Girls-Only HPV Vaccination Program to Boys: A Qualitative Study.

In 2020, Bhutan pioneered a school-based gender-neutral human papillomavirus (HPV) vaccination program, achieving an impressive 96% vaccination coverage rate by 2021. This study, conducted through 49 in-depth interviews with community leaders, policymakers, parents, teachers, and health workers, and 12 focus group discussions with boys who received HPV vaccination. We used conventional content analysis to analyze the data. Enablers of the extension of gender-neutral HPV vaccination included social mobilization and advocacy efforts, which encompassed community engagement and leadership and collaborations with schools. Equally crucial were proficient program management and the strategic use of digital interventions. Challenges included tracking and reaching eligible adolescents. Vaccinated boys perceived school-based vaccination to be a key enabler of vaccine update. The study concludes that extending a girls-only HPV vaccination program to gender-neutral is feasible and acceptable in Bhutan. Findings related to challenges and ways for overcoming them can support other countries interested in gender-neutral HPV vaccination program.

'There is no such word as palliative care for us at the moment': A mixed-method study exploring the perceptions of healthcare professionals on the need for palliative care in Bhutan.

Background: The need for palliative care is ever-increasing globally. However, it is least developed or not available in most low-and-middle-income-countries including Bhutan. Objective: This study was aimed at exploring the perspectives of Bhutanese healthcare professionals on the need for palliative care in the country. Design: This is a cross-sectional, mixed-method study. Setting/subjects: The study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews. Results: While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from 1 day to 6 weeks. Ninety-five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan. Conclusion: Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan.

'There is no such word as palliative care for us at the moment': A study exploring the perceptions of healthcare professionals on the need for palliative care in Bhutan Palliative care is least developed in most low-and-middle-income-countries. This study was aimed at exploring the perspectives of healthcare professionals on the need for palliative care in Bhutan. Utilising both quantitative and qualitative approaches, the study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews. While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from one day to six weeks. Ninety five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan. Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan.

Arrowhead chronicles: A case series on arrow injuries in the head and neck region of Bhutanese archers.

Arrow injuries in Bhutan present a unique public health challenge, reflecting the cultural significance of archery in this Himalayan kingdom. Despite being a traditional sport and an integral part of Bhutanese identity, the growing incidence of arrow-related injuries raises concerns about safety and highlights the need for targeted preventive measures. In this case series, we present six cases of arrow injuries in the head and neck region offering insights into our experiences and the challenges encountered in their management. Additionally, cultural and regulatory aspects influencing archery practices and safety protocols are considered. The findings underscore the importance of community education, enhanced safety measures, and regulatory interventions to reduce the prevalence of arrow injuries while preserving the cultural heritage of archery in Bhutan. Addressing this issue necessitates a multidisciplinary approach that combines public health initiatives, cultural sensitivity, and policy interventions.

Knowledge, attitude and practice of caries prevention in children among Bhutanese oral health professionals.

BACKGROUND: Dental caries remains prevalent among children in Bhutan, despite an increasing number of oral health professionals (OHPs). Insights into caries preventive practices among OHPs can identify areas for capacity building. AIM: This cross-sectional descriptive study assessed the knowledge, attitude and practice of caries prevention in children among OHPs in Bhutan. DESIGN: A self-administered online questionnaire was sent to all active registered OHPs. RESULTS: The respondents included 73 dentists and 61 dental hygienists (88% response rate) with a mean experience of 8.4 ± 7.1 years. Many practitioners rarely saw children; most of them, however, exhibited a positive attitude towards caries prevention in children, yet lacked knowledge and practice, especially in younger children. Caries risk factors were not all recognized, and assessment was not practised. Many forms of fluoride were available, but their efficacy was underestimated. Fluoridated toothpaste was underutilized in younger children. Preventive practice relied mainly on giving advice. The most common limitations on preventive practice were the unavailability of materials and treatment prioritized over prevention. CONCLUSION: Caries prevention in Bhutanese children requires a systematic approach in the oral healthcare system and further education of OHPs. Proactive strategies, time management and efficient distribution of preventive materials could promote better practice.

The occurrence and human health risk assessment of total and aflatoxin B1 in selected food commodities in Bhutan.

Aflatoxins are mycotoxins that contaminate staple foods globally and pose a significant health risk. To the best of our knowledge, information on the occurrence of aflatoxins in Bhutanese diets is scarce. This study aimed to estimate the aflatoxin levels in selected foodstuffs in Bhutan and determine the health risk associated with aflatoxin exposure. Ten different types of food commodities were randomly collected from farmers' markets, shelves of supermarkets, and wholesale and retail shops from 20 districts of the country. The samples were subjected to analysis by an enzyme-linked immunosorbent assay for both total aflatoxins (B1, B2, G1 and G2) and aflatoxin B1. Among the 315 samples included, 48.81% and 79.35% were positive for total aflatoxins and aflatoxin B1, respectively. The overall mean total aflatoxin concentration was 11.49 ± 12.83 µg/kg, and that for B1 was 17.62 ± 23.99 µg/kg. The most prevalent food commodity with the highest aflatoxin contamination was chili products. In addition, the estimated daily intake and margin of exposure to aflatoxin B1 via the consumption of chili products ranged from 0.98 to 5.34 ng kg-1 bw day-1 and from 74.90 to 408.10, indicating a risk for public health. The liver cancer risk was estimated to be 0.01 and 0.007 cancers per year per 100,000 population resulting from the consumption of chili products. The present findings revealed the presence of total aflatoxins and aflatoxin B1 in the selected samples. The margin of exposure values was exorbitant, demanding a stringent public health measure. Notably, these results suggest the need for routine monitoring of aflatoxin contamination in the region and stress rigorous safety management strategies to reduce exposure.

South Asia's COVID-19 History and Surveillance: Updated Epidemiological Assessment.

BACKGROUND: This study updates our findings from the COVID-19 pandemic surveillance we first conducted in South Asia in 2020 with 2 additional years of data for the region. We assess whether COVID-19 had transitioned from pandemic to endemic at the point the World Health Organization (WHO) ended the public health emergency status for COVID-19 on May 5, 2023. OBJECTIVE: First, we aim to measure whether there was an expansion or contraction in the pandemic in South Asia around the WHO declaration. Second, we use dynamic and genomic surveillance methods to describe the history of the pandemic in the region and situate the window of the WHO declaration within the broader history. Third, we aim to provide historical context for the course of the pandemic in South Asia. METHODS: In addition to updating the traditional surveillance data and dynamic panel estimates from our original study, this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID) to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a 1-sided t test to determine whether regional weekly speed or transmission rate per 100,000 population was greater than an outbreak threshold of 10. We ran the test iteratively with 6 months of data across the sample period. RESULTS: Speed for the region had remained below the outbreak threshold for over a year by the time of the WHO declaration. Acceleration and jerk were also low and stable. While the 1-day persistence coefficients remained statistically significant and positive (1.168), the 7-day persistence coefficient was negative (-0.185), suggesting limited cluster effects in which cases on a given day predict cases 7 days forward. Furthermore, the shift parameters for either of the 2 most recent weeks around May 5, 2023, did not indicate any overall change in the persistence measure around the time of the WHO declaration. From December of 2021 onward, Omicron was the predominant variant of concern in sequenced viral samples. The rolling t test of speed equal to 10 was statistically insignificant across the entire pandemic. CONCLUSIONS: While COVID-19 continued to circulate in South Asia, the rate of transmission had remained below the outbreak threshold for well over a year ahead of the WHO declaration. COVID-19 is endemic in the region and no longer reaches the threshold of the pandemic definition. Both standard and enhanced surveillance metrics confirm that the pandemic had ended by the time of the WHO declaration. Prevention policies should be a focus ahead of future pandemics. On that point, policy should emphasize an epidemiological task force with widespread testing and a contact-tracing system.

A quality of care assessment for women of childbearing potential with epilepsy in Bhutan: An observational study.

BACKGROUND & OBJECTIVE: In lower-middle income countries such as Bhutan, the treatment gap for epilepsy is over 50% as compared to a treatment gap of less than 10% in high-income countries. We aim to analyze the quality of epilepsy care for women of childbearing potential in Bhutan using the Quality Indicators in Epilepsy Treatment (QUIET) tool, and to assess the usefulness of the tool's section for women with active epilepsy (WWE) in the Bhutanese setting. METHODS: A prospective convenience cohort was enrolled in Thimphu, Paro, Punakha, and Wangdue, Kingdom of Bhutan, in 2022. Bhutanese women of childbearing potential at the time of enrollment (18-44 years old) were evaluated for the diagnosis of active epilepsy and underwent a structured survey-based interview with Bhutanese staff. Participants were surveyed on their epilepsy, pregnancy, and antiseizure medicine (ASM) histories. The clinical history and quality of epilepsy care of adult WWE were assessed using a section of the QUIET tool for women, an instrument originally developed by the U.S. Department of Veterans Affairs to analyze the quality of epilepsy care for American adults. RESULTS: There were 82 Bhutanese WWE of childbearing potential, with mean age of 30.6 years at enrollment (range 18-44, standard deviation (SD) 6.6) and mean age of 20.3 years at epilepsy diagnosis (range 3-40, SD 8.0)). 39 % (n = 32) had a high school or above level of education, and 42 % (n = 34) were employed. 35 % (n = 29) reported a seizure within the prior week, and 88 % (n = 72) reported a seizure within the prior year. 49 % (n = 40) of participants experienced > 100 lifetime seizures. All but one participant took antiseizure medications (ASMs). At enrollment, participants presently took no (n = 1), one (n = 3), two (n = 37), three (n = 25), four (n = 11), or over five (n = 5) ASMs. The most common ASMs taken were levetiracetam (n = 40), phenytoin (n = 27), carbamazepine (n = 23), phenobarbital (n = 22), and sodium valproate (n = 20). 61 % of all WWE took folic acid. Of the 40 previously pregnant WWE, eight (20 %) took folic acid during any time of their pregnancy. 35 % (n = 29) used betel nut (doma, quid) and 53 % (n = 21) of pregnant WWE used betel nut during pregnancy. CONCLUSIONS: Based on data about WWE participants' ASM, supplement, and substance use, our study identified the high use of first generation ASMs (including valproate), frequently in polytherapy, and betel nut use as treatment gaps in women of childbearing potential age with active epilepsy in Bhutan. To address these gaps for locations such as Bhutan, we propose modifications to the QUIET tool's "Chronic Epilepsy Care for Women" section.

Chewing Doma (Fermented Betel Nut): Culture versus Cancer?

Dr. Amol PatelAreca nut consumption is embedded in many cultures, including that of Bhutan, several parts of India, and other South Eastern countries. Traditional fermenting of areca nut results in the production of what is called doma in Bhutan. The process enhances its carcinogenic potential and is tightly linked to oral and upper gastrointestinal cancers. As many as 45% of Bhutanese people chew doma. It is the number one cause of cancers of the oral cavity, oropharynx, hypopharynx, and larynx. We propose the slogan "Don't chew your way to cancer, say no to doma" would help in reducing oral and esophageal cancers in Bhutan.

Rural-urban inequalities in health care utilization in Bhutan: a decomposition analysis.

BACKGROUND AND OBJECTIVE: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. METHODS: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca-Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. RESULTS: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural-urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. CONCLUSIONS: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Using Implementation Research to Inform Scaling of Parenting Programs: Independently Conducted Case Studies from Zambia and Bhutan.

Two case studies of parenting programs for parents of children 0 to 36 months of age, developed and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and UNICEF Zambia, were conducted by an independent research group. The focus was on how program delivery and scale-up were revised on the basis of feedback from implementation research. Feedback on workforce delivery quality was based on observations of deliveries using a monitoring form, as well as survey and interview data collected from the workforce. In-depth interviews with the resource team during the fourth year of implementation revealed how the feedback was used to address horizontal and vertical scaling. Delivery quality was improved in some cases by revising the delivery manual, offering refresher courses, and instituting regular monitoring. Scaling challenges in Zambia included slow progress with regard to reaching families in the two districts, which they addressed by trialing group sessions, and stemming workforce attrition. The challenges in Bhutan were low attendance and reducing the workload of providers. Vertical scaling challenges for both countries concerned maintaining demand through continuous advocacy at community and government levels to sustain financing and to show effectiveness in outcomes.

Demographic risk factors for extra-pulmonary tuberculosis: a rising public health threat in Bhutan.

BACKGROUND: Recently, extra-pulmonary tuberculosis (EPTB) has been increasingly reported in Bhutan, rising from 26% in 2001 to 39% in 2010. In 2016, almost half (49%) of all reported TB cases were classified as EPTB. Thus, this study was conducted to understand the epidemiology and identify risk factors contributing to increasing notification of EPTB in Bhutan. METHODS: A case-control study was conducted by recruiting all 110 cases of nationally notified EPTB (Extrapulmonary bacteriologically confirmed/EPBC) as cases and 235 Pulmonary TB (Pulmonary bacteriologically confirmed/PBC) as controls. Data were collected on socio-demography, clinical and diagnostic, behavioral and lifestyle and environmental exposures using a structured questionnaire between April and September, 2018. RESULTS: The median age of the cases was 25 years, ranged 9-79 years. Lymphatic TB was predominant (n = 78; 70.91%) followed by genitourinary TB (n = 4 (3.64%). The likelihood of EPTB decreased with increase in age (p = 0.023). The odds of EPTB in females was 1.65 times higher than the males (p = 0.038). Increase in Body Mass Index (adjusted odds ratio (AOR): 1.1; 95% confidence interval (CI): 1.052-1.200) and urban residency were (AOR 1.6; 95% CI 1.016-2.805) were found to have higher odds of developing EPTB. CONCLUSION: Females, urban residents, and those with higher BMI are at increased risk of developing EPTB. These at-risk groups can be used to target limited public health resources to control EPTB in Bhutan.

Outbreak of glossitis in a boarding school, diagnostic challenges and the outcome after treatment with Vitamin B Complex tablets: A retrospective descriptive study.

Objectives: The study aimed to understand the cause of glossitis that occurred among boarding students in a central school in Chhukha, Bhutan, and the outcome after 15 days of treatment with a vitamin B complex tablet. Methods: The researcher extracted data from the treatment records of patients treated for glossitis from 30 September 2020 to 30 October 2020 at the boarding school and conducted a retrospective descriptive study. A total of 97 records were used in the study: the age, gender,date of reporting to school, treatment, dietary preferences, and outcome of treatment. Results: In all, 63 (64.9%) patients were females. The students who were staying in the hostel for longer duration were more in proportion among the patients. About 80% of the patients had subjective improvement after treatment with two doses of one tablet of vitamin B complex tablet for 15 days. There were no deaths. Conclusion: The study could not ascertain the definite cause of glossitis among boarding students but 80 % of the patients showed subjective improvement after treatment with daily two doses of 32.5 mg of vitamin B complex tablet. The study recommends a prospective study to understand the cause of glossitis among boarding students to prevent similar future outbreaks.

Uncommon culprits: Foreign body grass fragments in buccal mucosa presenting as recurrent buccal abscess in a pediatric patient - a case report.

Foreign body ingestion is a common occurrence in the pediatric population, often involving the gastrointestinal tract. However, the presence of foreign bodies in the oral cavity, particularly within the buccal mucosa, is relatively rare. This case report describes an unusual presentation of a foreign body embedded in the buccal mucosa and discusses the diagnostic and management challenges associated with such cases. A 10-month-old female child with no significant previous medical history presented with recurrent buccal abscess. Following the removal of the foreign body (grass fragments), the child experienced a complete recovery.