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.

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.

Survey and Phylogenetic Analysis of Rodents and Important Rodent-Borne Zoonotic Pathogens in Gedu, Bhutan.

Rodents are well-known reservoirs and vectors of many emerging and re-emerging infectious diseases, but little is known about their role in zoonotic disease transmission in Bhutan. In this study, a cross-sectional investigation of zoonotic disease pathogens in rodents was performed in Chukha district, Bhutan, where a high incidence of scrub typhus and cases of acute undifferentiated febrile illness had been reported in people during the preceding 4-6 months. Twelve rodents were trapped alive using wire-mesh traps. Following euthanasia, liver and kidney tissues were removed and tested using PCR for Orientia tsutsugamushi and other bacterial and rickettsial pathogens causing bartonellosis, borreliosis, human monocytic ehrlichiosis, human granulocytic anaplasmosis, leptospirosis, and rickettsiosis. A phylogenetic analysis was performed on all rodent species captured and pathogens detected. Four out of the 12 rodents (33.3%) tested positive by PCR for zoonotic pathogens. Anaplasma phagocytophilum, Bartonella grahamii, and B. queenslandensis were identified for the first time in Bhutan. Leptospira interrogans was also detected for the first time from rodents in Bhutan. The findings demonstrate the presence of these zoonotic pathogens in rodents in Bhutan, which may pose a risk of disease transmission to humans.

Social and behavioral factors related to blood pressure measurement: A cross-sectional study in Bhutan.

Cardiovascular disease is a leading cause of death in the Kingdom of Bhutan, and early detection of hypertension is critical for preventing cardiovascular disease. However, health-seeking behavior, including blood pressure measurement, is infrequently investigated in Bhutan. Therefore, this study investigated factors related to blood pressure measurement in Bhutan. We performed a secondary data analysis of a target population of 1,962 individuals using data from the "2014 Bhutan STEPS survey data"as a cross-sectional study. Approximately 26% of those with hypertension who were detected during the STEPS survey had never had their blood pressure measured. Previous blood pressure measurement was significantly associated with age and working status in men (self-employed [odds ratio (OR): 0.219, 95% CI: 0.133-0.361], non-working [OR: 0.114, 95% CI: 0.050-0.263], employee [OR: 1.000]). Previous blood pressure measurement was significantly associated with higher income in women (Quartile-2 [OR: 1.984, 95% CI: 1.209-3.255], Quartile-1 [OR: 2.161, 95% CI: 1.415-3.299], Quartile-4 [OR: 1.000]). A family history of hypertension (OR: 2.019, 95% CI: 1.549-2.243) increased the likelihood of having experienced a blood pressure measurement in both men and women. Multivariate logistic regression showed that people with unhealthy lifestyles (high salt intake [adjusted odds ratio (AOR): 0.247, 95% confidence interval (CI): 0.068-0.893], tobacco use [AOR: 0.538, 95% CI: 0.380-0.761]) had a decreased likelihood of previous blood pressure measurement. To promote the early detection of hypertension in Bhutan, we suggest that more attention be paid to low-income women, non-working, self-employed, and low-income men, and a reduction of barriers to blood pressure measurement. Before the STEPS survey, a substantial number of hypertensive people had never had their blood pressure measured or were unconcerned about their health. As a result, we propose that early blood pressure monitoring and treatment for people with hypertension or at higher risk of hypertension be given increased emphasis.

Gender with marital status, cultural differences, and vulnerability to hypertension: Findings from the national survey for noncommunicable disease risk factors and mental health using WHO STEPS in Bhutan.

Cardiovascular disease is the leading cause of death in the Kingdom of Bhutan. Thus, the early detection and prevention of hypertension is critical for reducing cardiovascular disease. However, the influence of sociocultural factors on vulnerability to hypertension needs further investigation. This study performed secondary data analysis on 1,909 individuals in a cross-sectional study (the National survey for noncommunicable disease risk factors and mental health using World Health Organization (WHO) STEPS approach in Bhutan- 2014). Multivariate logistic regression demonstrated a significant association between gender with marital status and hypertension. Women had a higher odds ratio than men (Ref) when married (AOR: 1.27, 95% confidence intervals (CI): 1.23-1.31), and when separated, divorced, or widowed (AOR: 1.18, 95% CI: 1.12-1.26). People who speak the Tshanglakha language scored the highest odds (AOR: 1.24, 95% CI: 1.20-1.27), followed by Lhotshamkha (AOR: 1.09, 95% CI: 1.06-1.12) and Dzongkha (Ref) after adjusting for various social and biomedical factors. Additionally, tobacco use displayed decreased odds for hypertension. To promote the early detection and prevention of hypertension, these cultural factors should be considered even within small geographic areas, such as Bhutan. It is necessary to strengthen hypertension preventive strategies for people who speak Tshanglakha and Lhotshamkha. Furthermore, careful consideration should be given to preventing hypertension among adults aged 40 years or more, women who are married, separated, divorced, or widowed, and men who never married in Bhutan.

Clinical and Epidemiological Patterns of Scrub Typhus, an Emerging Disease in Bhutan.

Scrub typhus (ST) is a vector-borne rickettsial infection causing acute febrile illness. The re-emergence of ST in the Asia-Pacific region represents a serious public health threat. ST was first detected in Bhutan in 2008. However, the disease is likely to be under-diagnosed and under-reported, and the true impact is difficult to estimate. At the end of 2014, the SD Bioline Tsutsugamushi TestTM rapid diagnostic test (RDT) kits became available in all hospitals to assist clinicians in diagnosing ST. We conducted a retrospective descriptive study, reviewing records from all hospitals of Bhutan to identify all RDT-positive clinical cases of ST in Bhutan in 2015. The aim was to evaluate the burden of ST in Bhutan, describe the demographic, spatial and temporal patterns of disease, and identify the typical clinical presentations. The annual incidence of RDT-positive cases of ST reporting to Bhutanese hospitals in 2015 was estimated to be 62 per 100,000 population at risk. The incidence of disease was highest in the southern districts with a subtropical climate and a high level of agricultural production. The highest proportion of cases (87%) was rural residents, with farmers being the main occupational category. The disease was strongly seasonal, with 97% of cases occurring between June and November, coinciding with the monsoon and agricultural production seasons. Common ST symptoms were not specific, and an eschar was noted by clinicians in only 7.4% of cases, which is likely to contribute to an under-diagnosis of ST. ST represents an important and neglected burden, especially in rural communities in Bhutan. The outcomes of this study will inform public health measures such as timely-awareness programmes for clinicians and the public in high-risk areas, to improve the diagnosis, treatment and clinical outcomes of this disease.