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.

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.

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.

Environmental, Occupational, and Demographic Risk Factors for Clinical Scrub Typhus, Bhutan.

Underdiagnosis and underreporting of scrub typhus has increasingly affected public health in Bhutan since its initial detection in 2008. Identifying scrub typhus risk factors would support early diagnosis and treatment for this nonspecific febrile disease, reducing the incidence of potentially fatal complications. We conducted a hospital-based, case‒control study during October‒December 2015 in 11 scrub typhus‒prone districts. We identified harvesting cardamom as the major risk factor (odds ratio 1,519; p<0.001); other factors were traditional housing, largely caused by an outside toilet location, as well as owning a goat and frequently sitting on grass. Harvesting vegetables, herding cattle in the forest, and female sex were protective. Age had a nonlinear effect; children and the elderly were more likely to seek treatment for clinical scrub typhus. This study has informed public health policies and awareness programs for healthcare workers through development of National Guidelines for Prevention, Treatment and Control of Scrub Typhus in Bhutan.

An exploratory study on the perceptions of rabies and ill-health causations and health seeking behaviours of school children and local communities in southern Bhutan.

BACKGROUND: The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan. METHODS: We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data. RESULTS: The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments. CONCLUSION: There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with "One Health" public health sectors.

Healthcare in the Himalayan Kingdom of Bhutan: Lessons for the United States and other western healthcare systems.

Bhutan has demonstrated a trajectory of advances in healthcare, while still remaining true to its culture and traditional forms of medicine. Most recently, Bhutan gained international attention when it implemented a strategic Covid-19 vaccination programme that protected a greater percentage of its population than observed in Western industrialised nations. This accomplishment supports the idea that there are lessons from Bhutan to be shared with the rest of the world. In this work, we delineate our observations of the Bhutanese healthcare system, based on field observations in several Bhutanese cities, and results from surveys of Bhutanese physicians. We identify a number of unique practices that influence patient compliance, health education, and access to care in the Bhutanese system, that may be of particular interest and applicability to other healthcare systems. These include housing multiple health services at one location, fully funded medical visits, using non-physician teachers for health education and use of Gross National Happiness (GNH) measures in care.

How has the COVID-19 pandemic response impacted small-scale fish farmers in Bhutan?

The COVID-19 pandemic and related policy responses have exacerbated global food and nutrition insecurity by disrupting supply chains and destroying livelihoods. Previous studies show that the impact has been particularly severe for poor populations with limited livelihood options, who already faced food insecurity before the pandemic struck. This paper describes how COVID-19-related policy responses have impacted low-income, subsistence-oriented fish farmers in Bhutan. Based on nationally representative data collected between November 2020 and January 2021, the paper documents the responses of 353 Bhutanese fish farmers to the altered operating conditions and market disruptions caused by COVID-19. Results indicate that these farmers' access to inputs such as fish seed have suffered substantial disruptions. However, on the output side of the supply chain, some farmers have made significant gains in terms of increased demand and higher fish prices in informal markets. Furthermore, the food security of most farmers has suffered minimal impact. Overall, Bhutanese fish farmers have proved to be robust to COVID-19-induced adverse outcomes relative to commercial aquaculture producers elsewhere. Small-scale, subsistence-oriented production of fish along with other crops has benefitted the Bhutanese fish farmers by shielding them from the negative economic outcomes associated with market shocks and by directly preserving their food security. Nevertheless, the fish farmers require critical support to access essential inputs and upscale or maintain production infrastructure, so that they can continue fish production during the COVID-19 pandemic and become more robust in the long run.

An unusual presentation of scrub typhus in a child: a case report.

BACKGROUND: Scrub Typhus (ST) is an acute, febrile zoonotic disease caused by the bacterium Orientia tsutsugamushi which is endemic to the Asia-Pacific region. Infected adults rarely present with sensorineural hearing loss and otalgia. Though few cases of pediatric cases are known to present with otalgia, no pediatric cases of sensorineural deafness complicating ST have been reported to date. CASE PRESENTATION: A 5-year-old, previously healthy girl presented with a one-week history of high-grade intermittent fever, Headache and right ear pain with a recent onset of reduced hearing. She had a fever up to 39 °C, cervical lymphadenopathy, bilateral pleural effusion with diffuse infiltrations, and mild hepatosplenomegaly with no evidence of rash. Her initial examination was normal except for mildly enlarged tonsils. Unilateral right ear hearing loss was noted using Weber's test. Evidence of progressive, mild anemia, and raised inflammatory markers was noted. Diagnosis of scrub typhus was confirmed by positive detection of Orentia tsutsugamushi IgM antibodies on rapid diagnostic test and the presence of chigger mite in the right external auditory canal on repeat examination. She responded dramatically to the empirical treatment of ceftriaxone and doxycycline. On follow-up, she did not have any residual hearing loss and her ear pain had resolved completely. CONCLUSION: Acute onset hearing loss or severe otalgia with or without findings should be an important diagnostic clue for suspecting scrub typhus in patients who present with a history of fever especially in endemic areas.

Assessing public financing for nutrition in Bhutan, Nepal and Sri Lanka.

The objective of this study was to assess public financing for nutrition in Bhutan, Nepal and Sri Lanka to identify limitations of available data and to discuss policy implications. A variant of the Scaling Up Nutrition Movement methodology was used. Budget allocations and expenditures for relevant government ministries during 2012-2018 were identified. Nutrition-related line items were tagged using definitions of nutrition-specific and nutrition-sensitive interventions. Data were aggregated by year and calculated in constant United States dollars (USD). Expenditures by year were presented as a proportion of gross domestic product and general government expenditures. The percent utilization of budget allocations and proportion of funding from central government sources were determined. Per capita expenditures on nutrition-specific interventions varied from USD 1.08-8.76 and for nutrition-sensitive interventions varied from USD 20.22-51.20. Nutrition-specific expenditures as a percent of gross domestic product ranged from 0.08% in Sri Lanka in 2017% to 0.34% in Nepal in 2016. The median utilization rate was 64% for nutrition-specific and 84% for nutrition-sensitive interventions. Nutrition-specific funding financed by the central government was 90.7% in Bhutan and 99.4% in Sri Lanka. This study revealed the need to prioritize and invest in evidence-based interventions, including balancing investments in nutrition-specific versus -sensitive interventions. Challenges in estimation of nutrition expenditures and cross-country comparison were also observed, highlighting the need for appropriate nutrition line item tagging and standardized systems for data collection.

Transboundary sources dominated PM2.5 in Thimphu, Bhutan.

This study estimates the potential source regions contributing to PM2.5 in the capital city of Thimphu, Bhutan, during the years 2018-2020 using the ground-based data, followed by the HYSPLIT back trajectory analysis. The average PM2.5 concentration in the entire study period was 32.47 µg/m3 which is three times of the World Health Organization recommended limit of 10 µg/m3. Less than half of the days in pre-monsoon (43.47%) and post-monsoon (46.41%), and no days in winter were within the 24-h average WHO guideline of 25 µg/m3. During the COVID-19 lockdown imposed from August 11 to September 21 in Bhutan, only a marginal reduction of 4% in the PM2.5 concentrations was observed, indicating that nonlocal emissions dominate the PM2.5 concentrations in Thimphu, Bhutan. Most back trajectories in the analysis period were allocated to south or south-west sector. India was the major contributor (~ 44%), followed by Bangladesh (~ 19%), Bhutan itself (~ 19%) and China (~ 16%). This study confirms that there are significant contributions from transboundary sources to PM2.5 concentrations in Thimphu, Bhutan, and the elevated PM2.5 concentrations need to be tackled with appropriate action plans and interventions.

Impact of Human Papillomavirus Vaccination, Rwanda and Bhutan.

Rwanda and Bhutan, 2 low- and middle-income countries, implemented primarily school-based national human papillomavirus (HPV) vaccination in 2011 (Rwanda) and 2010 (Bhutan). We estimated vaccination effectiveness through urine-based HPV prevalence surveys in schools in 2013-2014 and 2017. In Rwanda, 912 participants from baseline surveys and 1,087 from repeat surveys were included, and in Bhutan, 973 participants from baseline surveys and 909 from repeat surveys were included. The overall effectiveness against vaccine-targeted HPV types (i.e., HPV-6/11/16/18) was 78% (95% CI 51%-90%) in Rwanda, and 88% (6%-99%) in Bhutan and against other α-9 types was 58% (21-78) in Rwanda and 63% (27-82) in Bhutan. No effect against other HPV types was detectable. Prevalence of vaccine-targeted HPV types decreased significantly, as well as that of other α-9 types, suggesting cross-protection. These findings provide direct evidence from low- and middle-income countries of the marked effectiveness of high-coverage school-based, national HPV vaccination programs.

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.

Palliative care needs among patients with advanced illnesses in Bhutan.

BACKGROUND: Palliative care improves the quality of lives of patients and families affected by advanced illnesses through the prevention and relief of suffering. While palliative care is well established in developed countries, it is inadequate or non-existent in most developing countries. Palliative care is an emerging concept in Bhutan, a tiny Himalayan Kingdom. A small community palliative care service is available in the national referral hospital with three dedicated inpatient palliative care beds. This study explored the needs for palliative care among patients diagnosed with advanced illnesses and is a component of a larger project aimed to inform a suitable palliative care model for the country. METHODS: This is a cross-sectional descriptive study. A survey, using a structured questionnaire including the EORTC QLQ-C30, was carried out among patients with advanced illness in hospitals, primary care units and communities across the country. Purposeful and snowball sampling strategies were used to recruit study participants. RESULTS: Seventy (76%), out of 93 eligible patients, agreed to participate in the survey. Participants reported low to moderate scores on physical, role, emotional, cognitive and social functioning, a moderate score for the global health/ quality of life scale and moderately high (worse) scores in symptoms including fatigue, pain, insomnia, loss of appetite and the financial impact from the disease. CONCLUSIONS: The symptom burden experienced by patients affected by advanced illnesses demonstrates the need for palliative care in Bhutan. These findings will help inform the development of a public health-focused palliative care model, modified to the Bhutanese context, as recommended by the World Health Organization.

Employing medical anthropology approach as an additional public health strategy in promoting COVID-19 vaccine acceptance in Bhutan.

Bhutan has been commended for their COVID-19 vaccination campaign, in which the country became the fastest in the world to inoculate nearly all of its adult population in just a few weeks. As a profoundly religious Buddhist kingdom in South Asia, the country successfully utilized a very unique strategy in promoting COVID-19 vaccine acceptance nationwide. Bhutan incorporated religion, culture, and tradition in their campaign wherein the royal government collaborated with the Zhung Dratsang, the country's central monastic body, in deciding the most auspicious day for the launch of their vaccination rollout by avoiding the one-month long Dana, selecting the first person to be vaccinated in accordance to the Buddhist astrology, and leading the country in chanting the Sangay Menlha, a mantra believed by many as a powerful prayer in warding off diseases. The launch turned out as a feast for all Bhutanese since it seemingly marked the beginning of the last phase of their COVID-19 struggle. Incorporating medical anthropology in public health approaches can greatly influence the public, especially when the people are deeply rooted in folk beliefs. This unique strategy can be emulated by many localities with strong influence of cultural traditions and folk beliefs.

Outbreak of oral ulcers (glossitis) among the students of three central schools under Tsirang district Bhutan, 2018.

BACKGROUND: Nutritional deficiencies are common worldwide and is most notable in low and middle income countries. In the early weeks of September 2018, oral sores mostly affecting the tongue were reported in three central schools under Tsirang district, Bhutan. A total of 204 students were affected in the three central schools. All the affected students have been assessed on the outbreak and nutritional survey was conducted in the three schools. METHODS: A total of 204 students who complained of different oral lesions in the affected three schools were screened by the dental surgeon for clinical assessment and administered questionnaire for nutritional assessment by the nutritionist. Twenty-one students randomly selected were sent for blood tests for micronutrient assays and complete blood count. 41 students were tested for Exfoliative cell cytology to test for fungal elements. The collected data was double entered and validated using Epi-Data version 3.1 and analysed using Stata 15 IC. The characteristics of the participants are presented as frequencies, percentages, mean and standard deviation (SD). RESULTS: Almost all the affected students in all the three schools had complaints of Burning Sensation (n = 158) followed by Pain (n = 153), Impaired Taste Sensation (n = 100) and Intolerance to Spicy Food (n = 95). Nutritional assessment analysis suggested schools not meeting the Recommended Dietary Allowance (RDA) for all components of Vitamin B complexes and Iron. CONCLUSION: Clinical assessments and nutritional survey analysis found inadequate vitamin rich dietary intakes among all the three schools. Implementation of a strict school feeding program with a balanced diet has been suggested accordingly.

Testing Positive for SARS-CoV-2 in Two Countries 105 Days Apart.

Recovered COVID-19 patients may test positive for SARS-CoV-2 for a long time from intermittent shedding of viral fragments. A 36-year-old man who tested positive for SARS-CoV-2 in the Czech Republic and recovered tested positive again in Bhutan, 105 days beyond his first positive test. He experienced minimal symptoms and recovered without complications. Although no virological test was conducted to rule out reinfection, the repeat positive test after initial recovery likely resulted from prolonged shedding of dead viral particles than a reinfection.

Japanese Encephalitis Virus as Cause of Acute Encephalitis, Bhutan.

In 2011, Bhutan's Royal Centre for Disease Control began Japanese encephalitis (JE) surveillance at 5 sentinel hospitals throughout Bhutan. During 2011-2018, a total of 20 JE cases were detected, indicating JE virus causes encephalitis in Bhutan. Maintaining JE surveillance will help improve understanding of JE epidemiology in this country.

Pneumococcal nasopharyngeal carriage among Bhutanese children hospitalized with clinical pneumonia: serotypes and viral co-infection.

BACKGROUND: Pneumococcal nasopharyngeal colonization (PNC) generally precedes pneumococcal disease. The purpose of this study was to determine the prevalence of PNC and to identify the pneumococcal serotypes circulating among Bhutanese children under five years of age admitted with clinical pneumonia, before the introduction of pneumococcal conjugate vaccine (PCV13) in the country. We also aimed to contribute to the understanding of the interplay between PNC and viral co-infection among this population. METHODS: This was a prospective study conducted at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan over 12 consecutive months. Children aged 2 to 59 months admitted with WHO-defined clinical pneumonia were eligible for recruitment. We collected blood for bacterial culture and molecular identification of S. pneumoniae, and nasopharyngeal washing for screening of respiratory viruses, and for the detection and capsular typing of S. pneumoniae by real-time polymerase chain reaction (RT-PCR). RESULTS: Overall, 189 children were recruited, and PNC was tested in 121 of them (64.0%). PNC was found in 76/121 children (62.8%) and S. pneumoniae was identified in blood (both by culture and RT-PCR) in a single child. Respiratory viruses were detected in a similar proportion among children with (62/70; 88.6%) and without PNC (36/40; 90.0%; p = 1.000), but rhinovirus detection was less common among children with PNC (20/70; 28.6% versus 19/40; 47.5%; p = 0.046). Capsular typing identified 30 different serotypes. Thirty-nine children (51.3%) were colonised with two to five different serotypes. A third of the children presented with serotypes considered highly invasive. Over half of the children (44/76; 57.9%) were carrying at least one serotype included in PCV13. CONCLUSIONS: This study provides baseline information on the status of PNC among Bhutanese children admitted with clinical pneumonia prior to the introduction of PCV13, which is valuable to monitor its potential impact. PCV13 could theoretically have averted up to 58% of the pneumococcal infections among the children in this study, suggesting a future role for the vaccine to significantly reduce the burden associated with S. pneumoniae in Bhutan.

Evaluation of post-exposure prophylaxis practices to improve the cost-effectiveness of rabies control in human cases potentially exposed to rabies in southern Bhutan.

BACKGROUND: Rabies is endemic in southern Bhutan, associated with 1-2 human deaths and high post exposure prophylaxis (PEP) costs annually. Evaluation of clinicians' management of human cases potentially exposed to rabies could contribute to improving PEP prescribing practices to both reduce unnecessary costs associated with PEP and reach the target of zero human deaths due to rabies by 2023. METHODS: A cross-sectional survey of 50 clinicians' management of human cases potentially exposed to rabies was conducted in 13 health centers in high-rabies-risk areas of Bhutan during February-March 2016. RESULTS: Data were collected on clinicians' management of 273 human cases potentially exposed to rabies. The 50 clinicians comprised health assistants or clinical officers (55%) and medical doctors (45%) with a respective median of 19, 21 and 2 years' experience. There was poor agreement between clinicians' rabies risk assessment compared with an independent assessment for each case based on criteria in the National Rabies Management Guidelines (NRMG). Of the 194 cases for which clinicians recorded a rabies risk category, only 53% were correctly classified when compared with the NRMG. Clinicians were more likely to underestimate the risk of exposure to rabies and appeared to prescribe PEP independently of their risk classification.. Male health assistants performed the most accurate risk assessments while female health assistants performed the least accurate. Clinicians in Basic Health Units performed less accurate risk assessments compared with those in hospitals. CONCLUSIONS: This study highlights important discrepancies between clinicians' management of human cases potentially exposed to rabies and recommendations in the NRMG. In particular, clinicians were not accurately assessing rabies risk in potentially exposed cases and were not basing their PEP treatment on the basis of their risk assessment. This has significant implications for achieving the national goal of eliminating dog-mediated human rabies by 2030 and may result in unnecessary costs associated with PEP. Recommendations to improve clinician's management of human cases potentially exposed to rabies include: reviewing and updating the NRMG, providing clinicians with regular and appropriately targeted training about rabies risk assessment and PEP prescription, and regularly reviewing clinicians' practices.

Seroprevalence and risk factors of canine distemper virus in the pet and stray dogs in Haa, western Bhutan.

BACKGROUND: Canine Distemper Virus (CDV) is a highly contagious virus belonging to family Paramyxovirade, genus Morbillivirus and responsible for high morbidity and mortality in dogs worldwide. Infected domestic dogs can cause spillover infections to wild carnivores that are in contact. We conducted a seroprevalence survey of CDV in domestic dogs in two areas of western Bhutan (Haa district) located at the periphery of the Jigme Khesar Strict Nature Reserve, which is home to several endangered wildlife. A total of 238 serum samples, 119 each from the pet and stray dog, were collected during summer and winter seasons. Samples were tested for CDV antibodies using a sandwich enzyme-linked immune-sorbent assay (ELISA) test. RESULTS: The seroprevalence of CDV was found to be 11.3% (95% CI 6.7-14.2). Dogs sampled during winter were less likely to test seropositive against CDV antibodies than those sampled during summer (adjusted odds ratio: -2.6; 95% CI: - 1.2-6.1). Dogs in good body condition were found to be more likely to test seropositive against CDV than dogs in poor condition and obese dogs (adjusted odds ratio: 2.2; 95% CI: 0.1-5.9). There were no significant differences in the seroprevalence of CDV among different sexes, breeds and age classes, pet and stray dogs and between the two study sites. CONCLUSIONS: Our study indicates that CDV seroprevalence was equally distributed among pet and stray dogs. We suggest strengthening the management practices of dogs through responsible dog ownership, dog population management and waste management to minimize the transmission risk of infectious diseases to wildlife.