Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia.

Objectives: This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka). Design: A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data. Findings: There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries. Recommended actions include: (1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks.

Routine clinical chemistry and haematological test reference intervals for healthy adults in the Bhutanese population.

Laboratory medicine plays a critical role in the modern healthcare system, and it is reported to influence 60-70% of clinical decision makings. The quantitative laboratory test results are interpreted by comparing to the Reference Intervals (RIs) and therefore the use of appropriate RIs is critical. Clinical laboratories in Bhutan have been randomly using RIs from textbooks and manufacturer's package inserts without even verifying their applicability and therefore lessening their contribution to clinical decision makings. To improve the healthcare service delivery in Bhutan, this study aims to establish routine clinical chemistry and haematological test RIs for healthy adults in the Bhutanese population. Out of 1150 (male, n = 570; female, n = 580) healthy Bhutanese adults listed for the study through a simple random sampling technique, 1002 (male, n = 405; female, n = 597) individuals were assessed and 815 (male, n = 372; female, n = 443) individuals were enrolled in the study. An adequate volume of venous blood was drawn from these participants with the use of standard phlebotomy technique for clinical chemistry and haematological analysis. The laboratory data were analysed with the use of statistical methods recommended by the International Federation of Clinical Chemistry and Laboratory Medicine and Clinical and Laboratory Standards Institute. After excluding the test results indicating underlying pathology and statistically detected outliers, a maximum of 775 (male, n = 346; female, n = 429) and 784 (male, n = 351; female, n = 433) individuals test values were eligible for clinical chemistry and haematology RIs establishment respectively. Statistically, there were no significant differences between age groups of same-sex for both test categories; however, significant differences between sex were observed for various test parameters in both test categories. Our RIs are generally comparable to other published literature. The established RIs are applicable to all the adult Bhutanese population; however, clinical laboratories should validate the transference of these RIs before using them for clinical purposes.

The effect of ultrasound or phonophoresis as an adjuvant treatment for non-specific neck pain: systematic review of randomised controlled trials.

OBJECTIVE: To determine the effectiveness of ultrasound/phonophoresis as an adjuvant to exercise or manual therapy for the improvement of patient-centred outcomes in adults with non-specific neck pain (NSNP). METHODS: Seven electronic databases were systematically searched up to September 2020. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to judge the Quality of Evidence (QoE). RESULTS: Six studies involving 249 participants were included. The QoE was very low GRADE. Phonophoresis with capsaicin plus exercise improved pain at immediate post-treatment (MD: -3.30 [-4.05, -2.55]) but not with diclofenac sodium plus exercise as compared to exercise. Continuous ultrasound (CUS) plus exercise improved pain and pressure pain threshold (PPT) at immediate post-treatment (pain: MD: -3.42 [-4.08, -2.7]); (PPT: MD: 0.91 [0.68, 1.14]) and at intermediate-term as compared to exercise. CUS or high power pain threshold (HPPT) ultrasound plus manual therapy and exercise showed no benefit for pain reduction (MD: -0.75 [-2.08, 0.58]) did not improve function/disability (MD: -1.05 [-4.27, 2.17]) at immediate or short-term as compared to manual therapy and exercise. CONCLUSIONS: Due to high risk of bias, inconsistency, and indirectness the QoE is very low in support of benefit of ultrasound/phonophoresis as an adjuvant treatment for NSNP.Implication for rehabilitationDue to high risk of bias, inconsistency, and indirectness the quality of evidence (QoE) is very low in support of benefit of adding ultrasound or phonophoresis to exercise or manual therapy for pain reduction or improvement in function/disability for those with sub-acute and chronic myofascial associated neck pain. However, our confidence in the findings is very low and conclusions are likely to change as more evidences emerges.Clinicians using ultrasound therapy as an adjuvant intervention for management of chronic myofascial associated neck pain should carefully consider the available evidence on ultrasound, including the benefits and costs involved.

Alcohol policy compliance among retailers in Bhutan: a multisite community intervention study.

BACKGROUND: Alcohol use is a major public health problem in Bhutan. Compliance with regulations at the point of sale is an important strategy in alcohol control. Retail outlets were briefed on sale regulations and provided notification of rules, which they were directed to display on the premises. The extent to which licensed alcohol outlets responded to possible alcohol purchases was assessed through the use of young proxy-purchasers, adults feigning alcohol intoxication and sober adults. A total of 854 visits (pre versus post visits) were made across four district towns. Two towns (Damphu town in Tsirang district and Pema Gatshel town in Pema Gatshel district) received pre- and post-intervention purchase surveys, while the other two neighbouring towns (Khuruthang town in Punakha and Bajo town in Wangdue) were administered only baseline surveys. METHOD: We used a pre- and post-test community intervention design covering all alcohol retailers both on premise (bar, hotel, restaurant, karaoke bars) and off premise (grocery shops). Compliance with alcohol regulations at the point of sale was assessed through the use of young proxy-purchasers, adults feigning alcohol intoxication and sober adults. RESULTS: Retailers rarely checked the age and/or identification (ID) of the proxy-purchasers before the intervention. There was a 22.7% (8.6, 37) percent increase in compliance with laws after the intervention. While some strategies are suggested, the strongest and most effective measure to prevent under-age drinking and service to intoxicated individuals is more rigorous enforcement of existing liquor laws. CONCLUSION: Alcohol control requires ongoing government enforcements, supplemented by public awareness and knowledge.

Bronchial Artery Embolization in Life-Threatening Hemoptysis: Outcome and Predictive Factors.

PURPOSE: To determine the outcome and predictive factors of clinical success of bronchial artery embolization in life-threatening hemoptysis. MATERIAL AND METHODS: We reviewed all bronchial artery embolization procedures performed for life-threatening hemoptysis between January 2008 and December 2018. The outcomes and predictive factors of clinical success following embolization were evaluated. RESULTS: One hundred and eighty-four bronchial artery embolization procedures performed in 145 patients were eligible for the study. The technical and clinical success rates of the procedures were 170/184 (92.4%) and 129/184 (70.1%), respectively. The unstable hemodynamics and prothrombin time/international normalized ratio >1.5 was associated with lower clinical success rate, while embolization of more than one vessel was associated with higher clinical success rate. CONCLUSION: Bronchial artery embolization is a safe and effective procedure for controlling bleeding in life-threatening hemoptysis. However, low clinical success rate was noted in patients with unstable hemodynamics and coagulopathy, while multiple vessel embolization was associated with higher clinical success.

Leadership and management competencies required for Bhutanese primary health care managers in reforming the district health system.

OBJECTIVE: This study aims to identify the required management competencies, current competency levels, and strategies for improving the management competencies of Bhutanese primary health care (PHC) managers. METHODS: A quantitative method with a cross-sectional survey using self-administered questionnaires. This study recruited 339 PHC managers across Bhutan. The data were analyzed using statistical software. RESULTS: This study identified three competency domains and seven key sub-domain competencies. People domain was perceived to be the highest required competency with a mean score of 4.2376, followed by execution (4.1851), and the transformation (4.0501) domains. For the seven key sub-domains, the communication sub-domain (4.3220) was perceived as the highest required competency, followed by professionalism (4.2967), managing change (4.1776), relationship building (4.1686), analytical thinking (4.1091), leadership (4.0980), and innovative thinking (3.9794). The current competency levels of PHC managers in domains and sub-domain competencies were the people domain (3.7322), execution (3.6471), and the transformation (3.5554). For the sub-domains, communication (3.8092), professionalism (3.7939), relationship building (3.6603), analytical thinking (3.6396), leadership (3.5805), managing change (3.5723), and innovative thinking (3.4543). CONCLUSION: Findings of Bhutan health managers' competencies are consistent with the findings of other international contexts. This study suggests that agencies responsible for health system need to focus more on the competencies defined by the study to positively influence health leadership and management development interventions.

Towards the introduction of pneumococcal conjugate vaccines in Bhutan: A cost-utility analysis to determine the optimal policy option.

BACKGROUND: Due to competing health priorities and limited resources, many low-income countries, even those with a high disease burden, are not able to introduce pneumococcal conjugate vaccines. OBJECTIVE: To determine the cost-utility of 10- and 13-valent pneumococcal conjugate vaccines (PCV10 and PCV13) compared to no vaccination in Bhutan. METHODS: A model-based cost-utility analysis was performed in the Bhutanese context using a government perspective. A Markov simulation model with one-year cycle length was used to estimate the costs and outcomes of three options: PCV10, PCV13 and no PCV programmes for a lifetime horizon. A discount rate of 3% per annum was applied. Results are presented using an incremental cost-effectiveness ratio (ICER) in United State Dollar per quality-adjusted life year (QALY) gained (USD 1 = Ngultrum 65). A one-way sensitivity analysis and a probabilistic sensitivity analysis were conducted to assess uncertainty. RESULTS: Compared to no vaccination, PCV10 and PCV13 gained 0.0006 and 0.0007 QALYs with additional lifetime costs of USD 0.02 and USD 0.03 per person, respectively. PCV10 and PCV13 generated ICERs of USD 36 and USD 40 per QALY gained compared to no vaccination. In addition, PCV13 produced an ICER of USD 92 compared with PCV10. When including PCV into the Expanded Programme on Immunization, the total 5-year budgetary requirement is anticipated to increase to USD. 3.77 million for PCV10 and USD 3.75 million for PCV13. Moreover, the full-time equivalent (FTE) of one health assistant would increase by 2.0 per year while the FTE of other health workers can be reduced each year, particularly of specialist (0.6-1.1 FTE) and nurse (1-1.6 FTE). CONCLUSION: At the suggested threshold of 1xGDP per capita equivalent to USD 2708, both PCVs are cost-effective in Bhutan and we recommend that they be included in the routine immunization programme.

Ecological status of high altitude medicinal plants and their sustainability: Lingshi, Bhutan.

BACKGROUND: Human beings use plants for a multitude of purposes of which a prominent one across the globe is for their medicinal values. Medicinal plants serve as one of the major sources of income for high altitude inhabitants in the Himalaya, particularly in countries like Nepal, and Bhutan. People here harvest huge volumes of medicinal plants indiscriminately, risking their sustainability. This paper attempts to identify some of the priority medicinal plant species harvested in the wild and assess their ecological status for their judicious utilization, and to help provide policy guidance for possible domestication and support strategic conservation frameworks. RESULTS: Out of the 16 priority species identified by the expert group, collectors' perception on ecological status of the priority species differed from survey findings. Chrysosplenium nudicaule (clumps) ranked as most threatened species followed by Corydalis dubia, and Meconopsis simplicifolia. Onosma hookeri, Corydalis crispa and Delphinium glaciale were some of the species ranked as threatened species followed by Halenia elliptica (not in priority list). Percent relative abundance showed irregular pattern of species distribution. High species evenness was recorded among Nardostachys grandiflora, Chrysosplenium nudicaule, Saussurea gossypiphora and Aconitum orochryseum with average species density of 8 plant m-2. Rhodiola crenulata, and Dactylorhiza hatagirea followed by Meconopsis horridula and Meconopsis simplicifolia were ranked as most threatened species with average species density of 0.4, 0.4, 5.6 and 6.0 plant m-2, respectively. The most abundant (common) species was Onosma hookeri (plant m-2). Species composition and density also differed with vegetation, altitude, slope and its aspects. CONCLUSION: Priority species identified by expert group were found vulnerable and patchy in distribution. Survey results and collectors' perceptions tally to an extent. Some of the species (Dactylorhiza hatagirea, Rhodiola crenulata, Meconopsis simplicifolia and Meconopsis horridula) were critically low in plant density with less than a plant per m2 while Delphinium glaciale, Fritillaria delavayi and Aconitum orochryseum were confined to narrow altitude range. Collectors were aware that most species identified in priority list are threatened and existing harvesting plan are hardly implemented as it is not pragmatic. Moreover, major chunk of medicinal plants harvested remain unaccounted as illegal harvest and marketing seemed to occur across the borders. Policing and monitoring would continue to be a challenge given the rugged terrain and harsh climate. In-depth study and further monitoring of low density species is suggested to ensure its sustainability through long term strategy development.

Assessment of the genetic variability amongst mandarin (Citrus reticulata Blanco) accessions in Bhutan using AFLP markers.

BACKGROUND: Bhutan is a small Himalayan country lying within the region considered to be the origin of citrus. Diverse citrus wild types grow naturally in different climates, elevations and edaphic conditions, but only mandarin is cultivated commercially. The first report of Huanglongbing (also known as greening disease) in Bhutan in 2003, and the threat it posed to the country's citrus orchards prompted the collection of mandarin germplasm from across the country. This paper describes the genetic diversity of mandarin accessions in Bhutan using amplified fragment length polymorphic (AFLP) markers. RESULTS: Twenty three accessions of Bhutanese mandarin were analyzed using AFLP markers to assess the genetic variability that is believed to exist only in Bhutan and some parts of North East India and South China. Five primer pairs (E-ACA/M-CAG, E-ACG/M-CAT, E-ACC/M-CTT, E-AAG/M-CAA and E-ACA/M-CTC) were identified (based on the number and quality of polymorphic bands produced) and used for the analyses. A total of 244 bands were scored visually of which 126 (52%) were polymorphic with an average polymorphism information content of 0.95 per marker. A cluster dendrogram based on multiscale bootstrap sampling categorized twenty three accessions into two broad groups containing eight and 14 accessions, respectively. Group A consisted accessions (Tsirang1, Tsirang3, Sarpang1, Dagana4, Samtse4, Dagana1, and Trongsa2) from five districts (Tsirang, Sarpang, Samtse, Dagana and Trongsa) and their grouping was strongly supported by bootstrap analysis (B p-value = 96%, AU p-value = 86%). Cluster B consisted of 14 accessions divided into three sub-groups (1, 2 and 3). However, bootstrap value supported significantly for subgroup1 (containing accessions: Tsirang4, Sarpang5, and Tsirang2) and subgroup3 (with accessions - Zhemgang2, Zhemgang3 and Zhemgang4). CONCLUSION: This study indicates that Bhutanese mandarin germplasm collected from across the country are genetically diverse although the level of variability differed among the accessions assessed. The variation in genetic variability was observed irrespective of where the accessions were collected suggesting that phenotype and geographical location can serve a basis for future germplasm collection in Bhutan. Further, five primer pair combinations could separate 23 mandarins accessions considered in this study, suggesting that AFLP markers can be a useful tool for future identification.