The burgeoning rise of non-communicable diseases (NCDs) is posing serious challenges in resource constrained health facilities of Nepal. The main objective of this study was to assess the readiness of health facilities for cardiovascular diseases (CVDs), diabetes and chronic respiratory diseases (CRDs) services in Nepal. This study utilized data from the Nepal Health Facility Survey 2015. General readiness of 940 health facilities along with disease specific readiness for CVDs, diabetes, and CRDs were assessed using the Service Availability and Readiness Assessment manual of the World Health Organization. Health facilities were categorized into public and private facilities. Out of a total of 940 health facilities assessed, private facilities showed higher availability of items of general service readiness except for standard precautions for infection prevention, compared to public facilities. The multivariable adjusted regression coefficients for CVDs (β = 2.87, 95%CI: 2.42–3.39), diabetes (β =3.02, 95%CI: 2.03–4.49), and CRDs (β = 15.95, 95%CI: 4.61–55.13) at private facilities were higher than the public facilities. Health facilities located in the hills had a higher readiness index for CVDs (β = 1.99, 95%CI: 1.02–1.39). Service readiness for CVDs (β = 1.13, 95%CI: 1.04–1.23) and diabetes (β = 1.78, 95%CI: 1.23–2.59) were higher in the urban municipalities than in rural municipalities. Finally, disease-related services readiness index was sub-optimal with some degree of variation at the province level in Nepal. Compared to province 1, province 2 (β = 0.83, 95%CI: 0.73–0.95) had lower, and province 4 (β =1.24, 95%CI: 1.07–1.43) and province 5 (β =1.17, 95%CI: 1.02–1.34) had higher readiness index for CVDs. This study found sub-optimal readiness of services related to three NCDs at the public facilities in Nepal. Compared to public facilities, private facilities showed higher readiness scores for CVDs, diabetes, and CRDs. There is an urgent need for policy reform to improve the health services for NCDs, particularly in public facilities.

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Health system’s readiness to provide cardiovascular, diabetes and chronic respiratory disease related services in Nepal: analysis using 2015 health facility survey

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case–control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger’s test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

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Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become the pandemic. Since its first report in late December from Wuhan, China, it has spread in 211 countries and has infected more than a million population claiming more than 81,000 lives until 7th April 2020. Although heterogeneous between countries, the recent trend shows that almost 10% of the infected persons are at the risk of death. The case-fatality has been reported to be at 2.3% in China, 7.2% in Italy, 1.73% in South Korea. One of the dreadful characteristics of the COVID-19 is that it is highly efficient at transmission from human to human. SARS-CoV-2 transmits from one human to another through respiratory droplets and close physical contact. Droplet transmission may also occur through fomites in the immediate environment around the infected person. Although there have been multiple studies and trials, no effective vaccines or anti-viral treatments have been effective to prevent or treat SARS-CoV-2 infection and can take another 12-18 months for the evidence to be generated. In this context, the only remained options would be to explore the epidemiological trend and learn from countries who have controlled the infection successfully. The early detection of cases and community containment have been some of the successful strategies. South Korea was able to lower the COVID-19 cases by an extensive and concerted community testing. The traditional strategies of isolation, quarantine, social distancing and community containment helped China to hold its level of infection after the second half of March 2020. With the increasing number of cases, Italy, the United State and the United Kingdom have increased their testing facilities. Germany, for instance, started mass testing and community surveillance quite early on (proactive community testing) reflected on its low fatality rate.
In Nepal by 5 April 2020, only 1,521 tests have been performed only among the suspected cases (a reactive testing method) who attend the hospital and so far 9 has been confirmed cases. Though the case was identified in January, the country-wide lockdown came into effect only on 24 March 2020. Based on the report provided by the Ministry of Health and Population, Nepal is trying its best to increase the number of isolation and quarantine facilities along with the provision of essential PPE. Nepal is at stage II (evidence of local transmission as opposed to imported cases only) of a pandemic but it is difficult to say how the disease is circulating in our population due to poor testing coverage and no proactive community testing. Current public health measures that are cost-effective, although not ideal would be to stringently follow social distancing. Social distance alone would be futile unless, other measures are in place that includes proactive community testing, providing essential medical equipment such as personal protective equipment (PPE), isolation and quarantine spaces, medical logistics such as infection control gears, and ICU facilities with adequate ventilators. While social distancing is the best measure, for now, community outreach for proactive testing with mobilization of community health workers and the use of technologies to inform the preventive measures and to dispel the fears, and rumors can be promising. Including the general public, health workers and policymakers require a strong collaborative platform to work together to consolidate the measures ahead to prevent the COVID-19 disaster in Nepal.
Keywords: COVID-19, SARS-CoV-2 pandemic, surveillance, social distancing

https://jkahs.org.np/jkahs/index.php/jkahs/article/download/213/133

COVID-19 Pandemic: What can Nepal do to Curb the Potential Public Health Disaster?

Introduction Over-the-counter (OTC) use of antibiotics contributes to the burgeoning rise in antimicrobial resistance (AMR). Drawing on qualitative research methods, this article explores the characteristics of OTC sales of antibiotic in Nepal, its drivers and implications for policy. Methods Data were collected in and around three tertiary hospitals in eastern, western and central Nepal. Using pre-defined guides, a mix of semi-structured interviews and focus group discussions were conducted with dispensers at drug stores, patients attending a hospital and clinicians. Interviews were audio-recorded, translated and transcribed into English and coded using a combination of an inductive and deductive approach. Results Drug shops were the primary location where patients engaged with health services. Interactions were brief and transactional: symptoms were described or explicit requests for specific medicine made, and money was exchanged. There were economic incentives for clients and drug stores: patients were able to save money by bypassing the formal healthcare services. Clinicians described antibiotics as easily available OTC at drug shops. Dispensing included the empirical use of broad-spectrum antibiotics, often combining multiple antibiotics, without laboratory diagnostic and drug susceptibility testing. Inappropriately short regimens (2–3 days) were also offered without follow-up. Respondents viewed OTC antibiotic as a convenient alternative to formal healthcare, the access to which was influenced by distance, time and money. Respondents also described the complexities of navigating various departments in hospitals and little confidence in the quality of formal healthcare. Clinicians and a few dispensers expressed concerns about AMR and referred to evadable policies around antibiotics use and poor enforcement of regulation. Conclusions The findings point to the need for clear policy guidance and rigorous implementation of prescription-only antibiotics.

https://gh.bmj.com/content/bmjgh/6/5/e005829.full.pdf

Why do people purchase antibiotics over-the-counter? A qualitative study with patients, clinicians and dispensers in central, eastern and western Nepal

Background Tuberculosis (TB) is a major public health problem and at 48%, Karamoja in North-Eastern Uganda has the lowest treatment success rate nationally. Addressing the social determinants of TB is crucial to ending TB. This study sought to understand the extent and ways in which socio-economic factors affect TB treatment outcomes in Karamoja. Methods We conducted a convergent parallel mixed methods study in 10 TB Diagnostic and Treatment Units. The study enrolled former TB patients diagnosed with drug-susceptible TB between April 2018 and March 2019. Unit TB and laboratory registers were reviewed to identify pre-treatment losses to follow-up. Four focus group discussions with former TB patients and 18 key informant interviews with healthcare workers were conducted. Principle component analysis was used to generate wealth quintiles that were compared to treatment outcomes using the proportion test. The association between sociodemographic characteristics and TB treatment outcomes was evaluated using the chi-square test and multiple logistic regression. Results A total of 313 participants were randomly selected from 1184 former TB patients recorded in the unit TB registers. Of these, 264 were contacted in the community and consented to join the study: 57% were male and 156 (59.1%) participants had unsuccessful treatment outcomes. The wealthiest quintile had a 58% reduction in the risk of having an unsuccessful treatment outcome (adj OR = 0.42, 95% CI 0.18-0.99, p = 0.047). People who were employed in the informal sector (adj OR = 4.71, 95% CI 1.18-18.89, p = 0.029) and children under the age of 15 years who were not in school or employed (adj OR = 2.71, 95% CI 1.11-6.62, p = 0.029) had significantly higher odds of unsuccessful treatment outcome. Analysis of the pre-treatment loss to follow-up showed that 17.2% of patients with pulmonary bacteriologically confirmed TB did not initiate treatment with a higher proportion among females (21.7%) than males (13.5%). Inadequate food, belonging to migratory communities, stigma, lack of social protection, drug stock-outs and transport challenges affected TB treatment outcomes. Conclusions This study confirmed that low socio-economic status is associated with poor TB treatment outcomes emphasizing the need for multi- and cross-sectoral approaches and socio-economic enablers to optimise TB care.

Impact of socio-economic factors on Tuberculosis treatment outcomes in north-eastern Uganda: a mixed methods study.

Background Nepal has achieved a significant reduction of TB incidence over the past decades. Nevertheless, TB patients continue to experience barriers in access, diagnosis and completion of the treatment. The main objective of this study was to explore the factors affecting the access to the health services, diagnosis and the treatment completion for TB patients in central and western Nepal. Methods Data were collected using in-depth interviews (IDI) with the TB patients (n = 4); Focus Group Discussions (FGDs) with TB suspected patients (n = 16); Semi Strucutred Interviews (SSIs) with health workers (n = 24) and traditional healers (n = 2); and FGDs with community members (n = 8). All data were audio recorded, transcribed and translated to English. All transcriptions underwent thematic analysis using qualitative data analysis software: Atlas.ti. Results Barriers to access to the health centre were the long distance, poor road conditions, and costs associated with travelling. In addition, lack of awareness of TB and its consequences, and the belief, prompted many respondents to visit traditional healers. Early diagnosis of TB was hindered by lack of trained health personnel to use the equipment, lack of equipment and irregular presence of health workers. Additional barriers that impeded the adherence and treatment completion were the need to visit health centre daily for DOTS treatment and associated constraints, complex treatment regimen, and the stigma. Conclusions Barriers embedded in health services and care seekers’ characteristics can be dealt by strengthening the peripheral health services. A continuous availability of (trained) human resources and equipment for diagnosis is critical. As well as increasing the awareness and collaborating with the traditional healers, health services utilization can be enhanced by compensating the costs associated with it, including the modification in current DOTS strategy by providing medicine for a longer term under the supervision of a family member, peer or a community volunteer.

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Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers

Roshan Kumar Mahato

Papers

Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers