Factors affecting antenatal screening for HIV in Nepal: results from Nepal Demographic and Health Surveys 2016 and 2022.

OBJECTIVES: Antenatal screening for HIV remains low in Nepal. Identifying factors associated with the uptake of antenatal screening is essential to increase uptake and prevent mother-to-child transmission (MTCT). This study investigated the effects of individual-level and district-level characteristics on the utilisation of antenatal screening for HIV in Nepal and how these effects changed between 2016 and 2022. DESIGN: We used publicly available cross-sectional data from 2016 to 2022 Nepal Demographic and Health Surveys. SETTING: Stratified, multistage, random sampling was used to collect nationally representative data. PARTICIPANTS: 1978 and 2007 women aged 15-49 years who gave birth in the 2 years preceding the surveys. PRIMARY AND SECONDARY OUTCOME MEASURES: We used multilevel models to estimate associations between antenatal screening and potential factors influencing it in 2016 and 2022. We used districts as a random effect and looked at the intraclass correlation coefficients to disentangle the geographical effects. To distinguish barriers to HIV screening from barriers to accessing antenatal care (ANC) services, we performed similar analyses with whether the woman attended at least one ANC visit as the dependent variable. RESULTS: Factors associated with antenatal screening have not changed significantly between 2016 and 2022. Higher uptake of HIV screening was found among women with higher education, the pregnancy being desired later and women who had four or more ANC visits. Being from a poorer family and having low knowledge of MTCT and the medicines to prevent transmission were associated with lower uptake. From the supply side, no factors had a significant effect on antenatal screening. Factors associated with antenatal screening and those associated with any ANC were different. Our results also showed a partial importance of geographical factors on screening uptake. CONCLUSIONS: Our results supported that antenatal screening could be improved by enhancing access to information and improving the availability of free screening.

Detection of blaNDM-1,mcr-1 and MexB in multidrug resistant Pseudomonas aeruginosa isolated from clinical specimens in a tertiary care hospital of Nepal.

INTRODUCTION: Pseudomonas aeruginosa is an opportunistic pathogen, which causes healthcare-associated infections in immunosuppressed patients. They exhibit resistance to multiple classes of antibiotics via various mechanisms such as the over-expression of efflux pumps, decreased production of the outer membrane protein (D2 porin), over-expression of the chromosomally encoded AmpC cephalosporinase, modification of drugs, and mutation(s) at the target site of the drug. The bacteria also develop antibiotic resistance through the acquisition of resistance genes carried on mobile genetic elements. Limited data on phenotypic as well as genotypic characterization of MDR P. aeruginosa in Nepal infers the needs for this study. This study was carried out to determine the prevalence rate of metallo-ß-lactamase (MBL-producer) as well as colistin resistant multidrug resistant (MDR) P. aeruginosa in Nepal and also to detect MBL, colistin resistance, and efflux pump encoding genes i.e. blaNDM-1, mcr-1 and MexB respectively in MDR P. aeruginosa isolated from clinical samples. METHODS/METHODOLOGY: A total of 36 clinical isolates of P. aeruginosa were collected. All bacterial isolates were phenotypically screened for antibiotic susceptibility using Kirby Bauer Disc Diffusion method. All the multidrug resistant P. aeruginosa were phenotypically screened for MBL producer by Imipenem-EDTA combined disc diffusion test (CDDT). Similarly, MIC value for colistin was also determined by broth microdilution method. Genes encoding carbapenemase (blaNDM-1), colistin resistant (mcr-1) and efflux pump activity (MexB) were assayed by PCR. RESULTS: Among 36 P. aeruginosa, 50% were found to be MDR among which 66.7% were found to be MBL producer and 11.2% were found to be colistin resistant. Among MDR P. aeruginosa, 16.7%, 11.2% and 94.4% were found to be harbouring blaNDM-1, mcr-1 and MexB genes respectively. CONCLUSION: In our study, carbapenemase production (encoded by blaNDM-1), colistin resistant enzyme production (encoded by mcr-1), and expression of efflux pump (encoded by MexB) are found to be one of the major causes of antibiotic resistance in P. aeruginosa. Therefore, periodic phenotypic as well as genotypic study in Nepal on P. aeruginosa would provide the scenario of resistance pattern or mechanisms in P. aeruginosa. Furthermore, new policies or rules can be implemented in order to control the P. aeruginosa infections.

Prevalence of Multidrug Resistant Pseudomonas aeruginosa Isolated from Clinical Specimens in Tertiary Care Hospital.

BACKGROUND: Pseudomonas aeruginosa is an opportunistic pathogen, which causes nosocomial infections in human. The rapid increase in drug resistance of this pathogen is a global concern. The aim of this study was to determine the clinical burden of P.aeruginosa, its antibiotic susceptibility pattern along with metallo-ß-lactamase (MBL) detection. METHODS: The descriptive cross-sectional study was conducted in Upendra Devkota Memorial National Institute of Neurological and Allied Sciences from January to August 2021. Isolation and identification of P. aeruginosa from clinical specimens was performed by using standard laboratory procedure. All bacterial isolates were phenotypically screened for multidrug resistance using Kirby Bauer disc diffusion method. All the multidrug resistant P.aeruginosa were phenotypically screened for MBL producer by Imipenem-EDTA combined disc diffusion test (CDDT). RESULTS: A total of 770 samples were processed of which 36 isolates of P. aeruginosa were obtained. P.aeruginosa was isolated mainly from tracheal aspirates, sputum, blood and urine. Among 36 isolates, 50% were found to be multidrug resistant (MDR). More percentage of P.aeruginosa isolates were found resistant to aztreonam, ofloxacin and levofloxacin (52.8%). Furthermore, this study reveals antibiotics like piperacillin/tazobactam and carbapenem were found to be good choice for the treatment of infection caused by this organism. Among MDR isolates 66.7% were found to be MBL producer. CONCLUSIONS: The data in this study highlights the prevalence of multidrug resistant, MBL producer, and colistin resistant P.aeruginosa in clinical specimens. In this study, carbapenems and piperacillin/tazobactam were found to be most effective antimicrobial drugs for empirical therapy in P.aeruginosa infections.

A review of the maternal iron and folic acid supplementation programme in Nepal: Achievements and challenges.

In the late 1990s, an estimated 75% of pregnant women in Nepal were anaemic. Although iron and folic acid (IFA) supplements were available free of charge, coverage among pregnant women was very low. In response, the Government of Nepal launched the Iron Intensification Programme (IIP) in 2003 to improve the coverage of IFA supplementation and anthelminthic treatment during pregnancy, as well as promote the utilization of antenatal care. This review examined how the IIP programme contributed to Nepal's success in increasing the consumption of IFA supplements during pregnancy. Nepal's cadre of Female Community Health Volunteers were engaged in the IIP to support the community-based distribution of IFA supplements to pregnant women and complement IFA distribution through health facilities and outreach services. As a result, the country achieved a fourfold increase in the proportion of women who took IFA supplements during pregnancy between 2001 and 2016 (from 23% to 91%) and a 12-fold increase in the proportion who took IFA supplements for at least 90 days during pregnancy (from 6% to 71%). The increase in coverage of IFA supplements accompanied an increase in the coverage of antenatal care during the same period. By 2016, the prevalence of anaemia in pregnant women decreased to 46%, highlighting the need to tackle other causes of anaemia and improve haemoglobin concentration before pregnancy, while maintaining the successful efforts to reach pregnant women with IFA supplements at the community level.

Dietary Risk Factors Associated with Development of Gastric Cancer in Nepal: A Hospital-Based Case-Control Study.

OBJECTIVES: Gastric cancer (GC) is one of the most prevalent neoplasms and a leading cause of mortality globally. To our knowledge, its relationship with dietary factors is not adequately studied and understood in the Nepalese context. This study is aimed at exploring the relationship between the possible dietary risk factors responsible for gastric cancer in Nepal. METHODS: A hospital-based matched case-control study was conducted in two specialized cancer hospitals in Nepal. A total of 237 participants (79 cases and 158 controls) were included in the study. Patients diagnosed within one year (incidence case) with histologically confirmed gastric cancer were taken as cases, and healthy visitors of gastric and nongastric cancer patients without past and present history or not a suspected information of gastric cancer were included as controls. A face-to-face interview was conducted using a semi-structured food frequency questionnaire. Backward stepwise conditional logistic regression was used to estimate the magnitude of the association between the independent variables and gastric cancer. Results were presented as the crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence intervals (CI). A P value < 0.05 was considered statistically significant. RESULTS: In the adjusted multivariable conditional logistic regression model, an increased risk of gastric cancer was more likely to have higher odds among those respondents who had a high consumption of processed meat (AOR = 3.99, 95% CI: 0.90-17.66), preferences of a high amount of fats/oil (AOR = 4.64, 95% CI: 1.56-13.72), and preferences of high amounts of salts (AOR = 4.18, 95% CI: 1.30-13.44). Conversely, those respondents who consumed higher amounts of fruits (AOR = 0.21, 95% CI: 0.07-0.65) were seen to have lower odds of gastric cancer. CONCLUSIONS: Our study found an increased risk of gastric cancer with frequent consumption of red meat, processed meat, high preferences of salt, fats/oil, and condiments. Regular consumption of fruits had a protective effect against gastric cancer. Providing nutrition education, public awareness, and lifestyle modification are primary steps to promote the avoidance of risk factors and change unhealthy dietary habits to prevent gastric cancer in Nepal.

Prevalence and Mother-to-newborn Transmission of Hepatitis B Virus in Tertiary Care Hospital in Nepal.

BACKGROUND: The prevalence of hepatitis B infection is heterogeneous and ubiquitous. This study aimed to identify the prevalence of the infection among the pregnant women who attended in a tertiary care hospital, transmission of the infection in their newborn and associated risk factors. METHODS: A one year prospective study was conducted. Mother's venous blood was collected for the hepatitis B serological test during the antenatal care or before delivery; the newborn's cord blood was also collected for the HBsAg. RESULTS: A total 16400 pregnant women were tested; of them 53 were HBsAg positive. The total prevalence of the infection was 0.32% among the pregnant: 0.5% among the indigenous and 0.2% in other than indigenous. The infection was significantly high in the indigenous group compare to other than indigenous [2.596 (1.475-4.569), p=.001]. Thirty-two out of 53 hepatitis B positive pregnant were delivered in the hospital, of them 75% (n=24) were indigenous and 25% (n=8) were other than indigenous. Eight out of 32 were highly infectious (HBeAg+), of them majority (75%) were indigenous ethnicities. Twenty-one out of 32 were anti-HBe reactive, among which majority were indigenous ethnicities (76.2%). Six out of eight babies, born with HBeAg reactive mothers, were infected (75%), of which majority were indigenous ethnicities (67%). In total, one-fifth of the newborn delivered were HBsAg positive (18.8%). CONCLUSIONS: The prevalence of hepatitis B infection among the total pregnant was low. The proportion of the infection in the indigenous ethnicity was significantly high compared to other ethnic group, which shows that the infection was clustered among the indigenous people.

Prevalence and risk factors of hepatitis B infection among mothers and children with hepatitis B infected mother in upper Dolpa, Nepal.

BACKGROUND: Hepatitis B Virus (HBV) infection is a worldwide public health problem. In Nepal, the prevalence of HBV is found to be low (0.9%), although high prevalence (≥8%) of HBV infection is depicted among subgroup/population in the mountain region by various studies. This study assessed the prevalence and the risk of HBV infection among mothers, as well as among the youngest child under 5 years old living with hepatitis B positive mothers in Dolpa, the most remote mountain district of Nepal. METHODS: The cross sectional study survey was conducted between June and July 2014. All mothers with their youngest child under 5 years old were invited to participate in the survey and tested for hepatitis B surface antigen (HBsAg). The HBsAg positive mothers were further tested by 5-panel HBV test card. Children living with HBsAg positive mothers were also tested for HBsAg. RESULTS: One hundred fifty-one mothers, comprising 37% of the total study population in the selected Village Development Committees (VDCs), were surveyed in the mobile health camps. The seroprevalence of HBsAg among mothers and their youngest child under 5 years old living with HBsAg positive mothers were 17% (95% CI, 11.01-22.99%) and 48% (95%CI, 28.42-67.58%) respectively. The majority of HBV infected mothers were indigenous (84%) followed by Dalit (4%) and other castes (12%). Among HBV infected mothers, 40% were hepatitis B envelope antigen (HBeAg) positive. The prevalence of HBsAg was higher among children living with HBeAg positive mothers as compared to HBeAg negative (60% vs 40%) and male children compared to female (60% vs 33%). Thirty-six percent of children were vaccinated with a full course of the hepatitis B vaccine. Of these vaccinated children, 56% were HBsAg sero-positive. CONCLUSIONS: The HBV infection rate is high among mothers and children living with HBsAg positive mothers in the indigenous population of the most remote mountain community of Nepal.

Policy content and stakeholder network analysis for infant and young child feeding in Nepal.

BACKGROUND: Despite concerted effort from government and partners, Nepal continues to have a high burden of under nutrition among children. Identifying opportunities to strengthen policy support for infant and young child feeding (IYCF) is a key component to improve child survival, growth and development. This study aims to explore policy support for IYCF and to identify the influential stakeholders for IYCF for effective future policy development and programmatic action. METHODS: Policies relevant to IYCF were identified through web searches and direct approaches to relevant government ministries. Policy content was analysed based on four key domains focussed on mothers, using a qualitative synthesis approach. Three group interviews were conducted using the participatory tool "Net-Map", to identify the influential stakeholders in IYCF policy and programming processes. RESULTS: Twenty-six relevant policy documents were analysed for content relating to IYCF. General support for IYCF was found in most of the development plans and high-level health sector policies. Most implementation level documents included support for provision of correct information to mothers. Capacity building of frontline workers for IYCN and system strengthening were well supported through sectoral plans and policies. However, gaps were identified regarding maternity protection, support for monitoring and evaluation, and translation of high-level policy directives into implementation level guidelines, resulting in a lack of clarity over roles and responsibilities. Both government and non-governmental stakeholders, particularly donors, emerged as influential drivers of IYCF policy decisions in Nepal, through technical assistance and funding. The Nutrition Technical Committee under the Ministry of Health, UNICEF, Suaahara, USAID and WHO were identified as key actors providing technical assistance. Key funding agencies were identified as UNICEF and USAID. CONCLUSIONS: This study reveals strong policy support for key dimensions of IYCF, supported by a highly networked stakeholder environment. Opportunities to further strengthen IYCF policy in Nepal include: further support for training of frontline workers and complementary feeding interventions; extending maternity leave provisions; and clarifying roles and responsibilities of actors, particularly non-governmental actors. Engaging technical and funding agencies and developing partnerships with other relevant actors will be crucial for ensuring effective policy translates into effective practice.

Opportunities for strengthening infant and young child feeding policies in South Asia: Insights from the SAIFRN policy analysis project.

BACKGROUND: South Asian countries experience some of the highest levels of child undernutrition in the world, strongly linked to poor infant and young child feeding (IYCF) practices. Strong and responsive policy support is essential for effective interventions to improve IYCF. This study aimed to identify opportunities for strengthening the policy environment in the region to better support appropriate infant and young child feeding. METHODS: We mapped policies relevant to infant and young child feeding in India, Pakistan, Bangladesh, Sri Lanka and Nepal, based on a common matrix. The matrix described potentially relevant policies ranging from high-level strategic policy documents to implementation-level guidelines. We analyzed the data based on themes focused on caregiver interactions with IYCF interventions: provision of correct information to mothers, training of frontline workers, enabling mothers to engage with service providers and strategic support for IYCF. RESULTS: Policy support for IYCF was present in relation to each of the themes assessed. In all countries, there was support for nutrition in National Development Plans, and all countries had some level of maternity protection and restrictions on marketing of breast milk substitutes. Sectoral and implementation-level policy documents contained provisions for system strengthening for IYCF and for training of frontline workers. CONCLUSIONS: The key opportunities for strengthening IYCF policy support were in relation to translating strategic directives into implementation level documents; improving multi-sectoral support and coordination; and increased clarity regarding roles and responsibilities of frontline workers interacting with mothers. These findings can support efforts to strengthen IYCF policy at the national and regional level.

Determinants of infant and young child feeding practices in Rupandehi, Nepal.

BACKGROUND: Undernutrition is a major problem in Nepal and meeting the minimum dietary standard is essential for growth and development of young children. Continuous monitoring of such practices is important to inform policy and program formulation. This study aimed to assess complementary feeding practices, and associated factors in Western Nepal. METHODS: This was a cross-sectional study conducted in Rupandehi district of Western Nepal. Face-to-face interviews were conducted among 178 mothers of young children aged 6-23 months using a structured questionnaire and data on complementary feeding practices. These practices were reported as frequency distribution and the factors associated were ascertained using multiple logistic regression. RESULTS: Only 57% of mothers initiated complementary feeding at the age of 6 months. While the proportion of young children receiving minimum meal frequency was reasonably high (84 %), meal diversity (35%) and minimum acceptable diet (33%) remained low. Maternal education and having had their children's growth monitored were independently associated with receiving minimum acceptable diet. CONCLUSION: Few infants and young children received the recommended infant and young children feeding practices. Implementing health promotion programs that educate and enhance the skills of mothers should be a priority for future nutrition interventions.

Antenatal Iron-Folic Acid Supplementation Reduces Neonatal and Under-5 Mortality in Nepal.

BACKGROUND: Antenatal iron-folic acid (IFA) supplementation improves maternal anemia and poor pregnancy outcomes. Antenatal use of IFA supplements also has an effect on child survival. OBJECTIVE: The current study investigated the effect of antenatal IFA supplements on the risk of childhood mortality in Nepal over a 15-y period from 1996 to 2011. METHODS: Survival information of 12,891 singleton most recent live-born infants from pooled 2001, 2006, and 2011 Nepal Demographic and Health Surveys was used. Primary outcomes were mortality indicators in children <5 y of age and the main exposure variable was use of IFA supplements. Data were analyzed by using STATA 13.1 (StataCorp) and were adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for potential confounders. RESULTS: Antenatal use of IFA supplements significantly reduced the risk of early neonatal deaths by 45% [adjusted HR (aHR): 0.55; 95% CI: 0.38, 0.79] and total neonatal deaths by 42% (aHR: 0.58; 95% CI: 0.39, 0.85). Similarly, the risk of infant and under-5 mortality was significantly reduced by 32% and 48%, respectively. For mothers who started IFA at 1-4 mo of pregnancy and used 150-240 supplements, neonatal and under-5 mortality were significantly reduced by 55% (aHR: 0.45; 95% CI: 0.24, 0.85) and 57% (aHR: 0.43; 95% CI: 0.23, 0.78), respectively. Population attributable risk estimates found 15% of under-5 deaths were attributed to nonuse of IFA, and 29,000 under-5 deaths could be prevented in the next 5 y with universal IFA coverage. CONCLUSIONS: Antenatal IFA supplementation significantly reduces the risk of neonatal and under-5 deaths in Nepal. The greatest effect on child survival was found in women who started IFA early in pregnancy and took 150-240 supplements. Universal IFA coverage could improve neonatal and child survival.