Managing essential healthcare services during the first nationwide lockdown: experiences from a Regional Referral Hospital in Bhutan

The current COVID -19 pandemic has brought unprecedented burden on healthcare system throughout the world. While the pandemic has hijacked all attention and priorities, there is a significant concern that non-COVID essential healthcare services  may be negleccted. Lockdowns have become an important public health measure to contain local outbreaks. We describe  our experiences  in ensuring the provision of essential healthcare services during the first nationwide lockdown. Adequate preparations with a well-thought of contingency plan , identification of roles,  good communication system,  24 -hour hotline and a  mobile clinic with the most essential services,  form important components of essential healthcare services. &nbsp

Climate change and childhood diarrhoea in Kathmandu, Nepal: a health risk assessment and exploration of surveillance capacity

There is substantial evidence that the onset and transmission of infectious diseases, particularly vector-borne diseases and diarrheal diseases, are influenced by many factors including climate change. Improving the understanding of the impacts of climate change on infectious diseases is important to inform policy decision making on disease control and prevention, as well as predicting the trends in the infectious diseases burden. Epidemiological analysis of long-term surveillance data on infectious diseases and meteorological factors are instrumental in establishing the association between infectious disease incidence and climate change. Advanced epidemiological techniques are now available to precisely estimate the nature of association (linear, non-linear) as well as the delayed effect: this means that it is possible to plan and design climate-based early warning systems to predict conditions that are likely to be favourable for an outbreak of climate-sensitive infectious disease. However, the association between infectious diseases and climate change varies, depending upon the pathogens responsible for infection. Similarly, the ability of infectious disease surveillance systems or disease control divisions to generate this evidence and utilise the knowledge to cope or adapt to the impacts of climate change is contingent upon the social, economic, political and other contextual problems. In the Nepalese context, the impacts of climate change on infectious diseases, in particular diarrheal disease, remains unknown: similarly, there has been no exploration of the contextual factors associated with the integration of climate change-related risk in Nepalese infectious diseases surveillance systems. Given this background, the first aim of this PhD thesis is to characterize the association between diarrhoea among children below five years of age and climate variables in Kathmandu, Nepal and then project the future burden of diarrhoea due to climate change. The second aim is to understand the association between rotavirus infection among children below five years of age and temperature variability in Kathmandu and compute the fraction of rotavirus infection that is attributable to temperature. The third aim is to explore the extant research on climate change and infectious diseases in Nepal and to identify the reasons behind sparse evidence on the topic. The final aim is to explore social, economic and cultural factors associated with infectious diseases surveillance in Nepal in the context of climate change. A mixed method study design was employed to achieve the goals of this project. There are four analytical chapters in this thesis: two quantitative studies; a study that reviews evidence of the impacts of climate change on infectious disease and policy documents related to infectious disease control and prevention in Nepal; and a qualitative study. Two quantitative studies were carried out to estimate the association between climate variability and childhood diarrhoea, and childhood rotavirus infection in Kathmandu. Study 1 and study 2 utilised time series design involving Poisson regression equations fitted with distributed lag models to characterise exposure-response and possible lagged association between climate variables and diarrhoea, and rotavirus infection. A qualitative research study was undertaken to explore the social, economic, cultural and political factors associated with infectious diseases surveillance in the context of climate change in Nepal. In study 4, semi-structured interviews were conducted with key informants and stakeholders from the Department of Health Services Nepal, World Health Organization Nepal, the Department of Hydrology and Meteorology Nepal and infectious disease experts working in both public and private sectors in Nepal. The interviews and subsequent thematic analysis of data were conducted from a critical realist perspective. Study 1 established a significant positive association between childhood diarrhoea and temperature, and rainfall. A 1°C increase in maximum temperature above the monthly average was found to be associated with 8.1% (RR: 1.081; 95% CI: 1.02-1.14) increase in the monthly count of diarrhoea among children below five years of age living in Kathmandu, Nepal. Similarly, a 10mm increase in monthly cumulative rainfall above the mean value was associated with 0.09% (RR: 1.009; 95% CI: 1.004-1.015) increase in childhood diarrhoea. It was further projected that 1357 (UI: 410–2274) additional cases of childhood diarrhoea could be experienced by 2050 given the projected change in climate under low-risk scenario (0.9°C increase in maximum temperature). Study 2 established a nonlinear negative association between temperature (maximum, mean and minimum) and weekly rotavirus infection cases among children below five years of age in Kathmandu. Compared to the median value of mean temperature, an increased risk (RR: 1.52; 95% CI: 1.08–2.15) of rotavirus infection was detected at the lower quantile (10th percentile) and a decreased risk (RR: 0.64; 95% CI: 0.43–0.95) was detected at the higher quantile (75th percentile). Similarly, an increased risk [(RR: 1.93; 95% CI: 1.40–2.65) and (RR: 1.42; 95% CI: 1.04–1.95)] of infection was detected for both maximum and minimum temperature at their lower quantile (10th percentile). It was further estimated that 47.01% of the rotavirus infection cases reported between 2013 and 2016 in Kathmandu could be attributed to minimum temperature. Study 3 identified that there was little evidence describing the impacts of climate change on infectious diseases and no evidence describing the projected burden under climate change scenarios. I explored the reasons behind paucity in the evidence and challenges faced by epidemiologists in Nepal. The challenges identified included poor quality infectious disease datasets, shortage of trained human resources, inadequate funding and political instability. As such, it was recommended that an integrated digital network of interdisciplinary experts be established and increased collaboration among different stakeholders be promoted to advance the evidence base on the impacts of climate change on infectious diseases in Nepal. The fourth and final study outlined that climate change and its impacts on infectious disease surveillance is treated as a less serious issue than other more ‘salient’ public health risks in the context of Nepal. The study further illustrates how climate change is variably constructed as a contingent risk for infectious diseases transmission and public health systems. The analysis exposes a weaker alliance among different stakeholders, particularly policymakers and evidence generators that leads to the continuation of traditional practices of infectious diseases surveillance without consideration of the impacts of climate change. In summary, this thesis brings to prominence important progress in understanding the link between climate change and infectious diseases, in particular childhood diarrhoea, in a subtropical highland climate from a low and middle income South Asian country. So far, we have not found any other study that explores the contextual factors (social, economic, cultural and political) that impede the integration of climate change-related risk in the disease surveillance systems. Therefore, this thesis illustrates a novel facet of infectious disease surveillance and climate change. This thesis makes an important contribution to address the gap on information related to climate change and infectious diseases in Nepal and can have significant implications towards building a climate-resilient public health system in Nepal.Thesis (Ph.D.) -- University of Adelaide, School of Public Health, 202

Containment of a local outbreak of COVID-19 through community isolation and quarantine in rural Bhutan: An experience

ABSTRACTIntroduction: Bhutan experienced the third and a larger outbreak of COVID-19 in the summer of 2021, with huge surge of cases from several districts on the southern border. A remote sub-district of Jomotshangkha in Samdrup Jongkhar district, was suddenly caught with a large number of cases in May 2021. All the COVID-19 cases during the outbreak were successfully managed at the community level or with home isolation without the need for sophisticated infrastructure and specialized manpower. In this article, we discuss the advantages of community-level management of COVID-19 in the context of Bhutan’s health system.

Postpartum Depression: Prevention strategies in South East Asia and its possibility of replication in Nepal

Aims: To identify existing interventions in South East Asian countries implemented to prevent postpartum depression (PPD) and explore the possibility of replication of such interventions in Nepal to reduce it. Methods: The paper reviewed the risk factors and preventive strategies implemented in South East Asian countries to prevent PPD. Results: Enough actions have not been taken to address PPD despite of high prevalence in the reviewed countries (Bangladesh, India, Pakistan, Srilanka and Nepal). However, some of the interventions used such as cognitive behavior therapy, education for girls, poverty alleviation program, participatory approach for empowerment and involvement of community health workers have shown positive impact on reducing PPD. Conclusions: The interventions used in South East Asian countries were simple in design intervention and mostly conducted through community health workers; it showed a possibility of replication in Nepal as it already has sufficient community workforces working in maternal and child health

Late presentation of congenital diaphragmatic hernia: A diagnostic dilemma

Congenital diaphragmatic hernias are commonly symptomatic within 24 hours after birth, but late presentation is not uncommon. Late presentation of congenital diaphragmatic hernia poses diagnostic difficulties as clinical picture are vague, and more commonly presented with non-specific gastrointestinal and respiratory symptoms. Due to the vague and non-specific clinical presentation, clinician faces a diagnostic dilemma resulting in delay in diagnosis and many a times an inappropriate management. This article reports 2 cases of late-presenting congenital diaphragmatic hernia (over the period of 6 months from September 2014 to February 2015) in National Institute of Disease of Chest and Hospital (NIDCH). In first case, she was diagnosed as right-sided tubercular pleural effusion and was treated with CAT-1 anti-tubercular therapy for 6 months without any clinical improvement. Later CT scan of chest was done and diagnosed as a case of congenital diaphragmatic hernia. The second case was diagnosed as a left-sided hydropneumothorax and treated with left tube thoracostomy. During removal of the intercostal chest tube, some fatty tissue was pulled out of the thoracostomy site. In NIDCH, she was diagnosed as a case of diaphragmatic hernia by barium follow-through. Both cases were diagnosed as Bochdalek hernia during the repair of the hernia defect via thoracotomy

Detection of Pyuria by Microscopic Urinalysis as a Marker of Pediatric Urinary Tract Infection

Globally, different diagnostic tests of urinary tract infection (UTI) are in clinical practices. A reliable test can increase the efficiency of the healthcare system, especially in a developing country like Nepal, reducing cost and time. Thus, we accessed the possibility of pyuria detected by microscopic urinalysis as a marker of pediatric UTI. The prospective study was conducted fromJuly2014 to January 2015 at Alka hospital, Lalitpur. Microscopic urinalysis of 353clean-catch urine samples was done by the wet mount method, followed by urine culture by a semi-quantitative method. We confirmed 64 (18.1%) UTI cases by culture, the gold standard for UTI diagnosis. Fever was the most common clinical manifestation in UTI cases. The sensitivity, specificity, positive predictive value and negative predictive value of pyuria detected by microscopic urinalysis to identify UTI were 50%, 70.9%, 27.6% and 86.5% respectively. In 318 febrile cases, the sensitivity, specificity, positive predictive value and negative predictive value of pyuria detected by microscopic urinalysis to identify UTI were 73.2%, 72.6%, 28.3% and 94.8% respectively. The findings suggest pyuria detected by microscopic urinalysis as not a worth while marker of pediatric UTI. But it is a trust worthy marker in febrile pediatric cases

Real Time Spectroscopic Ellipsometry Analysis of First Stage CuIn1-xGaxSe2 Growth: Indium-Gallium Selenide Co-Evaporation

Real time spectroscopic ellipsometry (RTSE) has been applied for in-situ monitoring of the first stage of copper indium-gallium diselenide (CIGS) thin film deposition by the three-stage co-evaporation process used for fabrication of high efficiency thin film photovoltaic (PV) devices. The first stage entails the growth of indium-gallium selenide (In1-xGax)₂Se₃ (IGS) on a substrate of Mo-coated soda lime glass maintained at a temperature of 400 °C. This is a critical stage of CIGS deposition because a large fraction of the final film thickness is deposited, and as a result precise compositional control is desired in order to achieve the optimum performance of the resulting CIGS solar cell. RTSE is sensitive to monolayer level film growth processes and can provide accurate measurements of bulk and surface roughness layer thicknesses. These in turn enable accurate measurements of the bulk layer optical response in the form of the complex dielectric function ε = ε₁ - iε₂, spectra. Here, RTSE has been used to obtain the (ε₁, ε₂) spectra at the measurement temperature of 400 °C for IGS thin films of different Ga contents (x) deduced from different ranges of accumulated bulk layer thickness during the deposition process. Applying an analytical expression in common for each of the (ε₁, ε₂) spectra of these IGS films, oscillator parameters have been obtained in the best fits and these parameters in turn have been fitted with polynomials in x. From the resulting database of polynomial coefficients, the (ε₁, ε₂) spectra can be generated for any composition of IGS from the single parameter, x. The results have served as an RTSE fingerprint for IGS composition and have provided further structural information beyond simply thicknesses, for example information related to film density and grain size. The deduced IGS structural evolution and the (ε₁, ε₂) spectra have been interpreted as well in relation to observations from scanning electron microscopy, X-ray diffractometry and energy-dispersive X-ray spectroscopy profiling analyses. Overall the structural, optical and compositional analysis possible by RTSE has assisted in understanding the growth and properties of three stage CIGS absorbers for solar cells and shows future promise for enhancing cell performance through monitoring and control

Pseudomonas aeruginosa interactions with drinking water biofilm after an acute spike in annular bioreactors—attachment, persistence, release, and reattachment

The potential of DWDS pipewall biofilms to shelter and propagate opportunistic pathogens is currently poorly understood. Here, we use an annular biofilm reactor approach to quantify the fate of the opportunistic pathogen Pseudomonas aeruginosa when introduced to a simulated DWDS environment. We found that P. aeruginosa was capable of swift attachment to surfaces and able to persist for up to 14 days under shear stress conditions. Further, we demonstrate that P. aeruginosa is capable of detachment/reattachment and mobilisation through the bulk water, potentially acting as a source of inoculum to drinking water