Threat of Dengue Outbreak in Nepal in Context of COVID-19 Pandemic

The world has been chained with Corona Virus Disease (COVID-19) pandemic today. It has affected more than 200 countries in just about a few months since December 2019. The virus has engulfed the world at a momentum never seen before. Considering the chances of disease being spread through asymptomatic transmission, social distancing has become a norm. This has brought a huge shift in how we live, work or interact with each other. It is feared that after the pandemic is over, the world would suffer a period of economic loss, as huge as the greatest depression of the 1930s or even more. With the world making medievalinventions and science doing wonders, we seem helpless to fight this pandemic. It has also drawn usto a realization that pandemic response cannot be extemporaneous

Spatial heterogeneity of enteric fever in 2 diverse communities in Nepal

Background: Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear.Methods: We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence.Results: Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence \u3e200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities.Conclusions: In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever

Diagnostic value of clinical features to distinguish enteric fever from other febrile illnesses in Bangladesh, Nepal, and Pakistan

Background: Enteric fever, a bacterial infection caused by Salmonella enterica serotypes Typhi and Paratyphi A, frequently presents as a nonlocalizing febrile illness that is difficult to distinguish from other infectious causes of fever. Blood culture is not widely available in endemic settings and, even when available, results can take up to 5 days. We evaluated the diagnostic performance of clinical features, including both reported symptoms and clinical signs, of enteric fever among patients participating in the Surveillance for Enteric Fever in Asia Project (SEAP), a 3-year surveillance study in Bangladesh, Nepal, and Pakistan.Methods: Outpatients presenting with ≥3 consecutive days of reported fever and inpatients with clinically suspected enteric fever from all 6 SEAP study hospitals were eligible to participate. We evaluated the diagnostic performance of select clinical features against blood culture results among outpatients using mixed-effect regression models with a random effect for study site hospital. We also compared the clinical features of S. Typhi to S. Paratyphi A among both outpatients and inpatients.Results: We enrolled 20 899 outpatients, of whom 2116 (10.1%) had positive blood cultures for S. Typhi and 297 (1.4%) had positive cultures for S. Paratyphi A. The sensitivity of absence of cough was the highest among all evaluated features, at 65.5% (95% confidence interval [CI], 55.0-74.7), followed by measured fever at presentation at 59.0% (95% CI, 51.6-65.9) and being unable to complete normal activities for 3 or more days at 51.0% (95% CI, 23.8-77.6). A combined case definition of 3 or more consecutive days of reported fever and 1 or more of the following (a) either the absence of cough, (b) fever at presentation, or (c) 3 or more consecutive days of being unable to conduct usual activity--yielded a sensitivity of 94.6% (95% CI, 93.4-95.5) and specificity of 13.6% (95% CI, 9.8-17.5).Conclusions: Clinical features do not accurately distinguish blood culture-confirmed enteric fever from other febrile syndromes. Rapid, affordable, and accurate diagnostics are urgently needed, particularly in settings with limited or no blood culture capacity

Antibiotic use prior to hospital presentation among individuals with suspected enteric fever in Nepal, Bangladesh, and Pakistan

Background: Antibiotic use prior to seeking care at a hospital may reduce the sensitivity of blood culture for enteric fever, with implications for both clinical care and surveillance. The Surveillance for Enteric Fever in Asia Project (SEAP) is a prospective study of enteric fever incidence in Nepal, Bangladesh, and Pakistan. Nested within SEAP, we evaluated the accuracy of self-reported antibiotic use and investigated the association between antibiotic use and blood culture positivity.Methods: Between November 2016 and April 2019, we collected urine samples among a subset of SEAP participants to test for antibiotic use prior to the hospital visit using an antibacterial activity assay. All participants were asked about recent antibiotic use and had a blood culture performed. We used mixed-effect logit models to evaluate the effect of antimicrobial use on blood culture positivity, adjusted for markers of disease severity.Results: We enrolled 2939 patients with suspected enteric fever. Antibiotics were detected in 39% (1145/2939) of urine samples. The correlation between measured and reported antibiotic use was modest (κ = 0.72). After adjusting for disease severity, patients with antibiotics in their urine were slightly more likely to be blood culture positive for enteric fever; however, the effect was not statistically significant (prevalence ratio, 1.22 [95% confidence interval, .99-1.50]).Conclusions: The reliability of self-reported prior antibiotic use was modest among individuals presenting with fever to tertiary hospitals. While antibiotics are likely to reduce the sensitivity of blood culture, our findings indicate that there is still considerable value in performing blood culture for individuals reporting antibiotic use

Utilization of blood culture in south Asia for the diagnosis and treatment of febrile illness

Background: Blood culture is the current standard for diagnosing bacteremic illnesses, yet it is not clear how physicians in many low- and middle-income countries utilize blood culture for diagnostic purposes and to inform treatment decisions.Methods: We screened suspected enteric fever cases from 6 hospitals in Bangladesh, Nepal, and Pakistan, and enrolled patients if blood culture was prescribed by the treating physician. We used generalized additive regression models to analyze the probability of receiving blood culture by age, and linear regression models to analyze changes by month to the proportion of febrile cases prescribed a blood culture compared with the burden of febrile illness, stratified by hospital. We used logistic regression to analyze predictors for receiving antibiotics empirically. We descriptively reviewed changes in antibiotic therapy by susceptibility patterns and coverage, stratified by country.Results: We screened 30 809 outpatients resulting in 1819 enteric fever cases; 1935 additional cases were enrolled from other hospital locations. Younger outpatients were less likely to receive a blood culture. The association between the number of febrile outpatients and the proportion prescribed blood culture varied by hospital. Antibiotics prescribed empirically were associated with severity and provisional diagnoses, but 31% (1147/3754) of enteric fever cases were not covered by initial therapy; this was highest in Pakistan (50%) as many isolates were resistant to cephalosporins, which were commonly prescribed empirically.Conclusions: Understanding hospital-level communication between laboratories and physicians may improve patient care and timeliness of appropriate antibiotics, which is important considering the rise of antimicrobial resistance

Practice of Breastfeeding and its Barriers among Women Working in Tertiary Level Hospitals

Introduction: Breastfeeding provides ideal food for newborns and prevents recurrent infection and malnutrition in infants. In Nepal, breastfeeding is a universal practice but exclusive breastfeeding is low. As there is increased involvement of women in workforce, practice of breastfeeding may have been compromised. The main objective of the study was to examine the practice and barriers of breastfeeding among women working in tertiary level hospitals of Nepal. Methods: This was a hospital based descriptive cross-sectional study. Study participants were wom- en working in Dhulikhel Hospital and Kathmandu Medical College and Teaching Hospital and was conducted from December 2017 to June 2018. Ethical approval was taken from institutional review committee of both institutions. Total of 208 women were included in the study and face to face interview was conducted. Data entry and analysis was done using statistical package of social sciences (SPSS). Results: Breastfeeding practice was universal and colostrum was fed by 195 (94%) women. Pre- lacteal feeding was given by 14 (7%) women and 119 (57%) initiated breastfeeding within one hour of birth. Total of 93 (45%) children were exclusively breastfed for any duration while 10 (11%) were exclusively breastfed for six months. The mean duration of breastfeeding was 14.57 months and 90 (43%) started complementary feeding before six months. Total of 97 (51%) women and 42 (47%) women stated work as barrier for not exclusively breastfeeding and early complementary feeding respectively. Conclusions: Exclusive breastfeeding was very low and children were breastfed for less than two years. Complementary feeding was also started earlier and work was stated as the main barrier for poor breastfeeding practice. Keywords: breastfeeding; complementary feeding; working women

A questionnaire of knowledge, attitude and practices on tuberculosis among medical interns in Nepal

Background Tuberculosis (TB) remains a major health problem worldwide, including in Nepal where around 33,000 new cases of TB were diagnosed in 2018 and 5400 patients died. There are challenges in the diagnostic process, treatment, and follow-up. Deaths, increased transmission and development of multi- drug resistant TB could be the consequences. Young doctors play an important role in this struggle, and therefore, their knowledge of and attitudes towards TB are crucial. Objective We surveyed medical interns in Nepal regarding their knowledge, attitude and practices on TB and their adherence to the National Tuberculosis Programmes’ guidelines. The objective was to determine the associations between TB knowledge, and attitude and the factors that influence them. Methods A WHO cross-sectional questionnaire template was modified and piloted. It was distributed anonymously among medical interns at three private medical colleges. Statistical analyses were performed to establish possible associations between TB knowledge and attitude, and the investigated variables, and to investigate differences between the medical colleges. Results Of 270 interns, 185 (69%) interns were included. The mean knowledge score was 13,3 (SD: 2,12) of a maximum of 19. The possible attitude scores ranged from zero to 14 points, whereas the mean attitudes score was 9,4 (SD: 1,89). Some unacceptable attitudes and knowledge gaps were identified, including disease detection and management. There was an association between the knowledge score and attitude score and between the number of TB patients seen and knowledge/attitude. Conclusion The surveyed interns had an adequate level of TB related knowledge, and acceptable attitudes. However, some unacceptable knowledge gaps and attitudes were detected. This survey underlines the considerable need of closing these knowledge gaps, and improving the attitudes, for which it is important for medical students to practice at a TB clinic and see a certain number of TB patient

Comparative Analysis of Current Control Techniques to Support Virtual Inertia Applications

The rapid transition towards an inverter-dominated power system has reduced the inertial response capability of modern power systems. As a solution, inverters are equipped with control strategies, which can emulate inertia by exchanging power with the grid based on frequency changes. This paper discusses the various current control techniques for application in these systems, known as virtual inertia systems. Some classic control techniques like the proportional-integral, the proportional-resonant, and the hysteresis control are presented first, followed by the design and discussion of two more advanced control techniques based on model prediction and machine learning, respectively. MATLAB/Simulink-based simulations are performed, and results are presented to compare these control techniques in terms of harmonic performance, switching frequency, and transient response

Genomic analysis of SARS-CoV-2 Circulating during Second and Third Wave of COVID-19 in Nepal

Background: In Nepal, since the first detection of COVID-19 case in January 2020, the total cases have rose to almost a million with more than 12,000 deaths. Till now, WHO has classified 5 variants of SARS-Cov2 as variant of concerns at different time points causing many waves in different countries and regions at different time points. Nepal had also faced three distinct waves of COVID-19 caused by different variant of COVID 19. The objective of this study was to perform whole-genome sequencing of SARS-CoV-2 circulating in different waves of COVID-19 in Nepal and investigate its variant or lineage. Methods: In this study, samples from 49 SARS-CoV-2 infected subjects from May 2021 to January 2022, were investigated. The methodology followed RNA extraction, real-time PCR for confirmation and whole-genome sequencing. The consensus genomes were interpreted with appropriate bioinformatics tools and databases. Results: Sequence analysis of 49 genomes revealed to be of Delta (n=27) and Omicron Variant (n=22). The mutations in the consensus genomes contained the defining mutations of the respective lineages/variants. There were 20 genomes of Omicron sub-lineage BA.2, 1 of BA.1.1 and 1 of B.1.1.529. Conclusions: This study provides concise genomic evidence of presence of Delta and Omicron variant of COVID-19 in Nepal. Delta and Omicron variants were driving the second wave and the third wave of COVID-19 respectively in Nepal. Therefore, the genomic surveillance must be increased to clearly map out the pandemic and strategize vaccination approaches in the country. Keywords: COVID-19; delta, omicron; Nepal;SARS-CoV-2; whole-genome sequencin