Appendicular actinomycosis: The first reported case of an uncommon finding of a common ailment from Nepal.

Key Clinical Message: Actinomycosis is a rare cause of appendicitis with an incidence of 0.3-1 incident per year per 100,000 people. A significant preoperative diagnostic challenge exists and is usually diagnosed incidentally on histopathological examination. Abstract: Appendicular actinomycosis, a rare, chronic granulomatous infection caused by actinomyces species, holds a significant preoperative diagnostic summons and is often diagnosed serendipitously during the regular histopathological examination. Herein, we present a case of a 36-year-old female who presented with features suggestive of acute appendicitis, underwent laparoscopic appendicectomy, and was diagnosed with appendicular actinomycosis from the histopathological examination.

Defining Collective Priorities: Research and Learning Agendas for Family Planning Across 6 Countries.

Evidence should be the foundation for a well-designed family planning (FP) program, but existing evidence is rarely aligned with and/or synthesized to speak directly to FP programmatic needs. Based on our experience cocreating FP research and learning agendas (FP RLAs) in Côte d'Ivoire, Malawi, Mozambique, Nepal, Niger, and Uganda, we argue that FP RLAs can drive the production of coordinated research that aligns with national priorities.To cocreate FP RLAs, stakeholders across 6 countries conducted desk reviews of 349 documents and 106 key informant interviews, organized consultation meetings in each country to prioritize evidence gaps and generate research and learning questions, and, ultimately, formed 6 FP RLAs comprising 190 unique questions. We outline the process for consensus-driven development of FP RLAs and communicate the results of an analysis of the questions in each FP RLA across 4 technical areas: self-care, equity, high impact practices, and youth. Each question was categorized as a learning versus research question, the former indicating an opportunity to synthesize existing evidence and the latter to conduct new research to answer the question. Themes emerging from the data shed light on shared evidence gaps across the 6 countries. We argue that similarities and differences in the questions in each FP RLA reflect the unique implementation experience and context, as well as each country's placement on the FP S-curve. Early uses of the FP RLAs include informing the development of FP costed implementation plans and FP2030 commitments. FP RLAs have also been discussed in multiple thematic working groups. For FP stakeholders, these FP RLAs represent a consensus-based agenda that can guide the generation and synthesis of evidence to answer each country's most pressing questions, ultimately driving progress toward increasingly evidence-based programming and policy.

How Home Delivery of Antiretroviral Drugs Ensured Uninterrupted HIV Treatment During COVID-19: Experiences From Indonesia, Laos, Nepal, and Nigeria.

INTRODUCTION: Faced with the coronavirus disease (COVID-19) pandemic, governments worldwide instituted lockdowns to curtail virus spread. Health facility closures and travel restrictions disrupted access to antiretroviral (ARV) therapy for people living with HIV. This report describes how HIV programs in Indonesia, Laos, Nepal, and Nigeria supported treatment continuation by introducing home delivery of ARVs. METHODS: Staff supporting the programs provided accounts of when and how decisions were taken to support ARV home delivery. They captured programmatic information about home delivery implementation using an intervention documentation tool. The 4 country experiences revealed lessons learned about factors favoring successful expansion of ARV home delivery. RESULTS: Three of the countries relied on existing networks of community health workers for ARV delivery; the fourth country, Indonesia, relied on a private sector courier service. Across the 4 countries, between 19% and 51% of eligible clients were served by home delivery. The experiences showed that ARV home delivery is feasible and acceptable to health service providers, clients, and other stakeholders. Essential to success was rapid mobilization of stakeholders who led the design of the home delivery mechanisms and provided leadership support of the service innovations. Timely service adaptation was made possible by pre-existing differentiated models of care supportive of community-based ARV provision by outreach workers. Home delivery models prioritized protection of client confidentiality and prevention measures for COVID-19. Sustainability of the innovation depends on reinforcement of the commodity management infrastructure and investment in financing mechanisms. CONCLUSION: Home delivery of ARVs is a feasible client-centered approach to be included among the options for decentralized drug distribution. It serves as a measure for expanding access to care both when access to health services is disrupted and under routine circumstances.

Factors associated with HIV testing and counselling services among women and men in Nepal: a cross-sectional study using data from a nationally representative survey.

OBJECTIVES: This study is set up to explore the factors associated with Human Immunodeficiency Virus (HIV) testing among women and men in Nepal. STUDY DESIGN: Nepal Demographic and Health Survey, 2016 adopts a cross-sectional design. SETTING: Nepal. PARTICIPANTS: Women and men of age 15-49 years. PRIMARY OUTCOME MEASURES: Our primary outcome was ever tested for HIV. We used multivariable analysis at a 95% level of significance to measure the effect in outcome variables. RESULTS: About one in 10 women (10.8%) and one in five men (20.5%) ever tested for HIV. Women who had media exposure at least once a week ((adjusted odds ratio (aOR)=2.8; 95% CI: 1.4 to 5.3) were more likely to get tested for HIV compared with those who had no media exposure at all. Similarly, those who had their recent delivery in the health facility (aOR=3.9; 95% CI: 2.4 to 6.3) were more likely to get tests for HIV compared with those delivered elsewhere. Likewise, among men, compared with adolescents (15-19 years), those from older age groups were more likely to get tested for HIV. Compared with no education, secondary (aOR=2.3; 95% CI: 1.4 to 3.6) and higher education (aOR=1.7; 95% CI: 1.0 to 2.8) had higher odds of getting tested for HIV. Similarly, wealth quintiles in richer and richest groups were more likely to get tested for HIV compared with the poorest quintile. Other characteristics like media exposure, paid sex and 2+ sexual partners were positively associated with being tested for HIV. CONCLUSIONS: HIV testing is not widespread and more men than women are accessing HIV services. More than two-thirds of women who delivered at health facilities never tested for HIV. It is imperative to reach out to people engaging in risky sexual behaviour, people with lower educational attainment, and those in the lower wealth quintile for achieving 95-95-95 targets by 2030.

Availability and readiness to provide sexually transmitted infections and HIV testing and counselling services in Nepal: evidence from comprehensive health facility survey.

OBJECTIVE: We assessed the availability and readiness of health facilities to provide sexually transmitted infections (STI) and HIV testing and counselling (HTC) services in Nepal. DESIGN: This was a cross-sectional study. SETTING: We used data from the most recent nationally representative Nepal Health Facility Survey (NHFS) 2015. A total of 963 health facilities were surveyed with 97% response rate. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of this study was to assess the availability and readiness of health facilities to provide STI and HTC services using the WHO Service Availability and Readiness Assessment (SARA) manual. RESULTS: Nearly three-fourths (73.8%) and less than one-tenth (5.9%) of health facilities reported providing STI and HTC services, respectively. The mean readiness score of STI and HTC services was 26.2% and 68.9%, respectively. The readiness scores varied significantly according to the managing authority (private vs public) for both STI and HTC services. Interestingly, health facilities with external supervision had better service readiness scores for STI services that were almost four points higher than compared with those facilities with no external supervision. Regarding HTC services, service readiness was lower at private hospitals (32.9 points lower) compared to government hospitals. Unlike STI services, the readiness of facilities to provide HTC services was higher (4.8 point higher) at facilities which performed quality assurance. CONCLUSION: The facility readiness for HTC service is higher than that for STI services. There are persistent gaps in staff, guidelines and medicine and commodities across both services. Government of Nepal should focus on ensuring constant supervision and quality assurance, as these were among the determining factors for facility readiness.

Pandemic influenza preparedness (PIP) framework: Progress challenges in improving influenza preparedness response capacities in the Eastern Mediterranean Region, 2014-2017.

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014-2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons.

Epidemiology of severe cases of influenza and other acute respiratory infections in the Eastern Mediterranean Region, July 2016 to June 2018.

BACKGROUND: Influenza surveillance systems in the Eastern Mediterranean Region have been strengthened in the past few years and 16 of the 19 countries in the Region with functional influenza surveillance systems report their influenza data to the EMFLU Network. This study aimed to investigate the epidemiology of circulating influenza viruses, causing SARI, and reported to the EMFLU during July 2016 to June 2018. METHODS: Data included in this study were collected by 15 countries of the Region from 110 SARI sentinel surveillance sites over two influenza seasons. RESULTS: A total of 40,917 cases of SARI were included in the study. Most cases [20,551 (50.2%)] were less than 5years of age. Influenza virus was detected in 3995 patients, 2849 (11.8%) were influenza A and 1146 (4.8%) were influenza B. Influenza A(H1N1)pdm09 was the predominant circulating subtype with 1666 cases (58.5%). Other than influenza, respiratory syncytial virus was the most common respiratory infection circulating, with 277 cases (35.9%). CONCLUSION: Influenza viruses cause a high number of severe respiratory infections in EMR. It is crucial for the countries to continue improving their influenza surveillance capacity in order detect any unusual influenza activity or new strain that may cause a pandemic.

A review of family planning policies and services in WHO Eastern Mediterranean Region Member States.

BACKGROUND: Family planning (FP) is a cost-effective public health and development intervention. Eastern Mediterranean Region (EMR), has one of the lowest contraceptive prevalence rate (CPR) and high unmet need for family planning. AIMS: The aim of this review is to assist Member States in highlighting those areas that need strengthening to improve quality of FP services in information and commodity supplies. METHODS: A structured questionnaire focusing on FP services was sent to 22 Member States of the WHO Eastern Mediterranean Region between August and December, 2015. Sixteen (73%) countries responded. RESULTS: Family planning services are part of the basic health benefits package and are delivered at hospitals, primary healthcare centres and outreach clinics to all women regardless of their ability to pay in the majority of Member States. In 16 Member States the family planning/birth spacing (FP/BS) counselling and FP methods are provided by general practitioner/ family doctor, nurses and midwives. In many Member States the services are integrated with child health, STI and HIV services. In 16 Member States FP/BS is part of the pre- and in-service training programmes for all cadres of healthcare providers. FP/BS is actively promoted through effective social marketing of FP/BS methods in two thirds of Member States. CONCLUSIONS: The findings of the survey indicate that national policies and programmes endorse FP to achieve national targets. Despite progress in many areas in FP services, many countries still struggle with weak implementation of FP programmes. There are also policy gaps for key vulnerable groups including the poor, the disabled and adolescents. This review highlighted policy and programmatic gaps required to strengthen those FP services that can help improve maternal and infant health outcomes. Special programmes for adolescents, refugees and persons with disabilities need to be streamlined and strengthened.

Field test results of the motherhood method to measure maternal mortality.

BACKGROUND & OBJECTIVES: Measuring maternal mortality in developing countries poses a major challenge. In Nepal, vital registration is extremely deficient. Currently available methods to measure maternal mortality, such as the sisterhood method, pose problems with respect to validity, precision, cost and time. We conducted this field study to test a community-based method (the motherhood method), to measure maternal and child mortality in a developing country setting. METHODS: Motherhood method was field tested to derive measures of maternal and child mortality at the district and sub-regional levels in Bara district, Nepal. Information on birth, death, risk factors and health outcomes was collected within a geographic area as in an unbiased census, but without visiting every household. The sources of information were a vaccination registry, focus group discussions with local health workers, and most importantly, interview in group setting with women who share social bonds formed by motherhood and aided by their peer memory. Such groups included all women who have given birth, including those whose babies died during the measurement period. RESULTS: A total of 15,161 births were elicited in the study period of two years. In the same period 49 maternal deaths, 713 infant deaths, 493 neonatal deaths and 679 perinatal deaths were also recorded. The maternal mortality ratio was 329 (95%CI: 243-434)/100,000 live birth, infant mortality rate was 48 (44-51)/1000LB, neonatal mortality rate was 33 (30-36)/1000LB, and perinatal mortality rate was 45 (42-48)/1000 total birth. INTERPRETATION & CONCLUSIONS: The motherhood method estimated maternal, perinatal, neonatal and infant mortality rates and ratios. It has been field tested and validated against census data, and found to be efficient in terms of time and cost. Motherhood method can be applied in a time and cost-efficient manner to measure and monitor the progress in the reduction of maternal and child deaths. It can give current estimates of mortalities as well as averages over the past few years. It appears to be particularly well-suited to measuring and monitoring programmes in community and districts levels.