A qualitative assessment of methadone maintenance therapy program in Nepal: evidence to scaling up at national level.

Methadone maintenance therapy is widely accepted form of substitution therapy in people with Opioid dependent client. It is a kind of harm reduction strategy which prevents the spread of HIV and hepatitis among injecting drug users. It also improves quality of life and help decrease crime and other social issues. The program has been in Nepal for few years. The clients are increasing more each day and the demand for the program is also increasing. There is an urgent need of scaling-up the program in Nepal to address the increasing number of clients and unreached clients. This is an attempt to assess qualitatively the methadone maintenance therapy program in Nepal to generate evidences as a support to existing programs and to scale up the program in unreached population. The qualitative study revealed that the clients had adequate knowledge on the program and the program is quite satisfactory. However, they have to wait for a long to get enrollment in the program, there is no counseling session and they were more concern about the quality of the drug. Despite many lacunae, the participants found the program very useful in terms of developing good relation with family members, decreasing the necessity of money, being able to attend social functions, health and economic benefits, time saving, easily getting job. On the other hand, they were experiencing adverse effect such as decreasing sexual performance, dental caries, nausea, social stigma due to misuse of the program by some clients which are not properly addressed by the program. The program can be improved by making it priority problem at national level by the government, improving it as one stop shopping such as providing counseling, medicine and skill development program at one place.

Cholera outbreak in far-western region of Nepal.

BACKGROUND: There was an outbreak of diarrheal diseases in districts of far-western region of Nepal in late-2009 followed by massive outbreak in Jajarkot district of mid-western region in early-2009. The objective of this study was to explore the causative organism and analyse the sensitivity pattern of the antibiotics in the local context to suggest the use of medicine in future diarrhea outbreak in Nepal. METHODS: A descriptive study was conducted from three districts of Far-western region (Achham, Baitadi and Doti) from middle of the April to September 2009 to observe the trend of morbidity.Similarly, 51 stool samples were taken from the patients for the laboratory analysis using Cary Blair Transport Media and carried out microbiological analysis. RESULTS: Out of the total 51 stool samples tested, 27 were diagnosed as Vibrio cholerae. All the isolates were sensitive to commonly used antibiotics except Nalidixic acid and Cotrimoxazole. The highest number of cases was seen in the month of July-August. CONCLUSIONS: Cholera was found to be the most important cause for the occurrence of outbreak in far-western region in 2009. The commonly used antibiotics can be prescribed along with the appropriate rehydration measures.

Climate change and occurrence of diarrheal diseases: evolving facts from Nepal.

BACKGROUND: Climate change is becoming huge threat to health especially for those from developing countries. Diarrhea as one of the major diseases linked with changing climate. This study has been carried out to assess the relationship between climatic variables, and malaria and to find out the range of non-climatic factors that can confound the relationship of climate change and human health. METHODS: It is a Retrospective study where data of past ten years relating to climate and disease (diarrhea) variable were analyzed. The study conducted trend analysis based on correlation. The climate related data were obtained from Department of Hydrology and Meteorology. Time Series analysis was also being conducted. RESULTS: The trend of number of yearly cases of diarrhea has been increasing from 1998 to 2001 after which the cases remain constant till 2006.The climate types in Jhapa vary from humid to per-humid based on the moisture index and Mega-thermal based on thermal efficiency. The mean annual temperature is increasing at an average of 0.04 °C/year with maximum temperature increasing faster than the minimum temperature. The annual total rainfall of Jhapa is decreasing at an average rate of -7.1 mm/year. Statistically significant correlation between diarrheal cases occurrence and temperature and rainfall has been observed. However, climate variables were not the significant predictors of diarrheal occurrence. CONCLUSIONS: The association among climate variables and diarrheal disease occurrence cannot be neglected which has been showed by this study. Further prospective longitudinal study adjusting influence of non-climatic factors is recommended.

Molecular screening of major bacterial enteropathogens in human stool samples from diarrhoeal outbreak sites.

BACKGROUND: V. cholera types have been implicated often in a number of occasions in diarrhoeal outbreaks in Nepal. The recent outbreak in Far Western Nepal, 2009, was also attributed primarily to V. cholera. Molecular tools were used for the first time on some of the samples from the outbreak to screen for major pathogens present in those samples. METHODS: A commercial multiplex PCR kit based bacterial enteropathogen screening assessment was carried out on 33 human stool samples from areas of a diarrhoeal outbreak in Nepal. A total of 10 pathogenic bacterial strains at the genus level were targeted using primers provided by the manufacturer. RESULTS: Bacterial pathogens were detected in 23 samples (69.7%). Vibrio species was detected at an overall frequency of 36.4% followed by Aeromonas spp (33.3%) and Shigella spp (15.2%) along with Verocytotoxin producing E. coli (VTEC) family (15.2%). The frequency of singly occurring pathogen in all samples was 18.2% with most of the bacterial pathogens detected in combination with other pathogens at a frequency of 60.6%. The study also shows that majority 73 (86%) of the research centers didn't start the research yet. CONCLUSIONS: This first ever molecular screening study shows that bacterial screening is indeed possible in diarrhoeal samples. The results obtained from this study will enable monitoring of future such outbreaks using similar techniques.

Will visceral leishmaniasis be eliminated from Nepal? A review of recent (1994-2006) control efforts.

The Visceral Leishmaniasis (VL) control program in Nepal launched in 1993 includes provision of free diagnostic test, treatment along with vector control by indoor residual spraying. However, even after 14 years the disease is far from being controlled. Elimination of VL by 2015 has recently been identified as a regional priority with high level of political commitment. We analyzed the VL control effort in Nepal over the period 1994-2006 and tried to formulate recommendations for the VL elimination initiative. To document performance of the VL control program in Nepal we used literature review and a case study. First, we reviewed articles on VL in Nepal published in medical journals through Pubmed, ISI Web of Science, Google scholar and by hand searching. Secondly, the grey literature, mainly the reports on VL drafted by the Ministry of Health was reviewed for the period 1994-2006. Thirdly, a case study is presented to analyze the performance of the VL elimination program in a "pilot district", where the program was launched in 2006. There are only few studies available on VL in Nepal discussing the epidemiology, diagnosis, treatment, vector bionomics, human behavior and prevention. The review of the grey literature from 1994-2006 revealed that the VL incidence rate remained almost constant since 1993 despite the control efforts. The case study showed that there is a lack of trained human resources, laboratory facilities and treatment guidelines which is hindering the decentralization of the VL elimination program.

Pandemic influenza A (H1N1) 2009 outbreak investigation in Nepal.

BACKGROUND: The World Health Organization, on 24 April 2009, announced a Public Health emergency of international concern caused by a new influenza virus Pandemic Influenza A 2009. The objective of this study was to analyze the basic epidemiology and distribution of Pandemic Influenza A 2009 in order to understand the course of Pandemic Influenza A 2009 in Nepal. METHODS: The analyses were based upon all confirmed and probable cases that consulted Avian Influenza Control Project and National Public Health Laboratory during 29 April 2009 to 21 September 2010. RESULTS: Out of total 739 suspected samples collected, Pandemic Influenza A 2009 was detected in 210 cases in different districts of Nepal. The majority of cases were from the urban settlement of Kathmandu valley, Chitwan and Kaski and among age group 11-30 years. The clinical attack rate for Influenza like illness (ILI) was 28.48%. There was no significant difference between the clinical presentation of ILI and confirmed cases of Pandemic Influenza A 2009. CONCLUSIONS: This study presented the investigation of outbreak that helped to inform the course of epidemic in affected population and therefore urge for public health interventions.

Incidence of congenital heart disease in tertiary care hospital.

AIMS AND OBJECTIVES: The present study was under taken to determine the spectrum, clinical profile and outcome of patients with congenital heart disease (CHD) admitted to a tertiary care hospital. MATERIALS AND METHODS: This is a retrospective, observational hospital based study conducted during January 2006 to December 2006. Out of 14461 admissions, 84 were cases of CHD. Only patients with echocardiographic proof of CHD were included in the study. Detailed clinical and laboratory findings and outcome of all cases were noted in pre-structured formats. Data were entered in MS-excel. Data was analyzed by software SPSS version 10. RESULTS: The incidence of CHD was 5.8 per 1000 hospitalized patients. Out of 84 CHD cases, 51 were males and 33 females; with a male to female ratio of 1.5:1. CHD presented more frequently during infancy (46 %). Acyanotic heart disease was detected in 58 (69 %) cases while cyanotic heart disease was detected in 26 (31%) cases. Among acyanotic heart disease, ventricular septal defect (VSD) was found in 49 (58.3%), atrial septal defect (ASD) in 4 patients (4.8%), endocardial cushion defect (ECD) in 2 patients (2.4%) and dextrocardia was found in 3 patients (3.6%). Among cyanotic heart disease, Tetralogy of Fallot (TOF) accounted for 13.1%, total anomalous pulmonary venous connection (TAPVC) 3.6%, transposition of great arteries (TGA) with VSD 1.2% and unspecified cases of heart disease was found in 13.1%. VSD and TOF were the most common lesions while other CHD like ASD, dextrocardia, TAPVC, ECD, TGA with VSD were encountered less frequently. The most common clinical presentations were failure to thrive (FTT) and developmental delay (86.9%), breathlessness (69%), lower respiratory tract infection (LRTI) (52%), congestive cardiac failure (CCF) (46%), cyanosis (20.2%), cyanotic spell (9.5%) and infective endocarditis (9.5%). The mortality rate was 20 %. CONCLUSION: The incidence of CHD was 5.8 per thousand hospitalized children. VSD, TOF were the most common congenital cardiac lesion. VSD was observed either isolated or associated with other lesions like TGA. The mortality rate was 20 %. The mortality usually occurred in those patients complicated with congestive cardiac failure, lower respiratory tract infection and infective endocarditis.

Acid base and electrolyte disturbance in diarrhoea.

OBJECTIVE: The present study was undertaken to study the frequency of electrolyte imbalance in children with diarrhoea and the relationship between electrolyte abnormalities and mortality. MATERIALS AND METHODS: This is a retrospective, observational hospital based study. Fifty seven children admitted to paediatric ward with diarrhoea and dehydration was evaluated for electrolyte and acid base status at presentation. The variables were analyzed using chi-square and student t- test. RESULTS: Majority (70%) of patients were below 2 years of age. There were 37 (65%) males and 20(35%) females. Electrolyte disturbance was observed in 46 (80%) patients while acid base disturbance was observed in all (100%) where the estimations were done. The major electrolyte disturbances noted were hyponatremia (56%), which was either isolated (26%) or associated with hypokalemia (26%). The second common abnormality was hypokalemia (46%) which was again either isolated (14%) or associated with hyponatremia (26%). About 10% patient had hypernatremia and about 3% had hyperkalemia. Twenty one (37 %) patients had mixed electrolyte imbalance. ABG analysis was performed only in 16 patients. Arterial blood gas analysis could be performed only in 16 patients. Metabolic acidosis was present in 15 (94%) while one (6%) had metabolic alkalosis. Out of 57, five patients (8.7%) expired. All of them had electrolyte abnormalities. Out of five patients who died one had isolated hyponatremia, 2 had hyponatremia + hypokalemia, while one each had hypernatremia + hypokalemia and hypernatremia+ hyperkalemia. Statistically significant mortality was observed in patients presenting with either hyponatremia or hypokalemia as compared to the group with normal electrolytes. CONCLUSION: Hyponatremia, hypokalemia and metabolic acidosis are common electrolyte and acid-base abnormalities in children with diarrhoea and dehydration and often responsible for mortality.

Prevalence and determinants of unmet need for family planning in a district of eastern region of Nepal.

OBJECTIVES: The unmet need for family planning is defined as the discrepancy between individual's contraceptive behaviors and their stated fertility preferences--The extent of which is very high in developing countries like Nepal. This study explores the unmet need and its determinants. METHODS: Among the teaching district of B.P. Koirala institute of Health Sciences, in the Eastern Region of Nepal, a district was selected randomly to conduct a cross-sectional study. A total of 1079 women were selected using systematic random sampling. We compared different demographic variables and sex-ration to unmet need by using means, percentage and applied chi-squared test where applicable. RESULT: The extent of unmet need is 25 percent with 9.5 percent for spacing and 15.5 percent for limiting. The mean age at marriage is 16(+/-3.2) years. A strong association of gender preferences towards male child and unmet need exist, which is highly significant. CONCLUSION: Unmet need is high despite extensive family planning program in Nepal. Mean age at marriage below legal age, low female education and gender discrimination are the factors responsible for unmet need.