Impact of intensified case-finding strategies on childhood TB case registration in Nepal.

SETTING: Seven intervention districts with intensified childhood tuberculosis (TB) case-finding strategies implemented by a non-governmental organisation and seven control districts under the National Tuberculosis Programme, Nepal. OBJECTIVES: To assess the differences in childhood TB case registrations and case registration rates per 100 000 population between two time periods (Year 1 = March 2012-March 2013 and Year 2 = March 2013-March 2014) in intervention and control districts. DESIGN: Retrospective record review using routinely collected data. RESULTS: Childhood TB cases increased from 271 to 360 between Years 1 and 2 in the intervention districts (case registration rate from 18.2 to 24.2/100 000) and from 97 to 113 in the control districts (13.4 to 15.6/100 000): the increases were significantly higher in the intervention districts compared with the control districts. The increases were also significantly higher in children aged 0-4 years and in those with smear-negative pulmonary TB and extra-pulmonary TB. Of the various case-finding strategies, household contact screening, private-public mix services and mobile health chest camps produced the highest yield of TB. CONCLUSION: A package of intensified case-finding strategies in children was associated with an increase in childhood TB case registrations in Nepal. Additional diagnostic approaches to increase case registrations also need to be considered

Throat carriage rate and antimicrobial resistance trend of Streptococcus pyogenes among the asymptomatic Nepalese school children

Abstract Background: Streptococcus pyogenes or Group A streptococcus (GAS) causes several suppurative and non suppurative infections. Since the 1980s there has been re-emergence in the incidence of invasive S. pyogenes infections and rheumatic heart disease all over the world and hence throat carriage has assumed of great importance. Objectives: We carried out this preliminary study to determine the throat carriage rate and antimicrobial resistance trend of Streptococcus pyogenes or Group A streptococcus (GAS) among the Nepalese school children. Materials and methods: Four schools situated at different locations of Kathmandu valley were included in the study. Throat swabs from 350 students of age group 5-15 years were collected, immediately transported to the laboratory and were processed for S. pyogenes following standard microbiological procedures. Antimicrobial susceptibility testing of the isolates was performed by Kirby Bauer disc diffusion method following CLSI guidelines. Results: S. pyogenes was isolated from 10.9% (38/350) of the screened children. The GAS colonisation rate was statistically insignifi cant (P>0.05) with sex and age subgroups, although the rate was slightly higher among girls and age subgroup 9-12 years. No signifi cant difference in carrier rate was observed among different schools (P>0.05). Highest resistance rate was observed for Cotrimoxazole (71.05%) followed by Chloramphenicol (7.8%), Ciprofl oxacin (5.2%) and Erythromycin (5.2%). All isolates were susceptible to Azithromycin. No resistance was detected for penicillin and its derivative and Azithromycin. Conclusion: Antibiotic resistant GAS isolated from asymptomatic Nepalese children is a concern. When screened and appropriately treated with antibiotics, carriers can be prevented from spreading of streptococcal infections in the community. This would ultimately reduce the incidence of life-threatening sequelae which are debilitating and diffi cult to treat. It is recommended to conduct regular screening programs and GAS surveillance, and maintain rational use of antibiotics to keep GAS carriage/ infections and resistance in check

The implementation of Xpert MTB/RIF assay for diagnosis of tuberculosis in Nepal: A mixed-methods analysis

BACKGROUND: Tuberculosis (TB) is a major public health problem in low and middle-income countries. Early detection and enrolment of TB cases is a challenge for National TB Programs. OBJECTIVE: To understand the performance and feasibility for scale-up of Xpert MTB/RIF assay for the TB diagnosis in Nepal. DESIGN: Implementation research employed mixed-method sequential explanatory design. The results of Xpert MTB/RIF assay were analysed in 26 TB diagnostic centres where Xpert machines had been installed before 2015. In-depth interviews and focus group discussions were conducted with stakeholders, purposively selected to represent experiences in centres that were functioning well, poorly or not functioning. RESULTS: During a one-year period in 2015/16, 23,075 Xpert MTB/RIF assays were performed in 21 diagnostic centres with 22,288 people also tested by sputum microscopy. Among these, 77% had concordant (positive or negative) results, demonstrating fair agreement (Kappa score, 0.3) between test results. Test failure and positivity rates in diagnostic centres ranged from 2.6% to 13.4% and 6.5% to 49%, respectively. The number of cartridges per positive result varied from 2.3 to 10.2. Xpert assay was positive in 3314 (15% of all cases) sputum smear microscopy negative cases. Of 4280 bacteriologically confirmed cases by Xpert assay, 355 (8%) were rifampicin resistant. Xpert machines were no longer functioning regularly throughout the year in 5 diagnostic centres. The main barriers for effective implementation of Xpert in Nepal were the lack of: timely supply of cartridges; replacement of damaged modules; maintenance of Xpert machines; and stock verification for timely procurement of cartridges. Inadequate laboratory infrastructure for maintaining functional Xpert equipment further challenges implementation and scale-up. CONCLUSION: The implementation of Xpert MTB/RIF assay has increased case-finding of TB and MDR-TB in Nepal. However, there is a need to improve laboratory performance and strengthen laboratory infrastructure for optimal utilisation and scale-up of Xpert

Modifiable predictors of severe heart failure in Morocco: a descriptive study using routinely collected health data

Introduction: Heart Failure (HF) is a growing public health concern in Morocco and there is a striking paucity on determinants of severe HF (SHF) in this population. The aim of this study was to identify patients admitted with HF at Ibn Rochd Hospital, Casablanca from 2011 onwards, when electronic record keeping began.Methods: a total of 105 patients underwent a series of cardiological examinations between July 2011 and January 2014. The New York Heart Association (NYHA) criteria was used to evaluate the severity of HF. Patients with NYHA classification gradings of I and II were defined as having moderate HF (MHF) and those graded as III and IV were defined as having a SHF. Univariable and multivariable risk factors associated with SHF were explored using logistic regression. The results were reported following the RECORD (Reporting of studies Conducted using Observational Routinely-collected Data) statement.Results: a total of 24 (33%) patients were identified as having a SHF. Four predictors of SHF were identified in univariate analysis: haemoglobin &lt;12g/dL, neutrophil-to-lymphocyte ratio (NLR) &gt;3, mean corpuscular haemoglobin concentration (MCHC) &lt;32 picolitre, and high density lipoprotein (HDL) &lt;0.35 (mmol/L). Only NLR&gt;3 and HDL &lt;0.35 mmol/L remained independent predictors in multivariable analysis. Patients with NLR &gt;3 were at 6-fold increased odds of SHF [adjusted odds ratio (AOR): 6.78, 95% confidence interval (CI): 1.40-32.80, p=0.017], and those with HDL&lt;0.35 (mmol/L) were at 10-fold increased odds of SHF [AOR: 10.11, 95% CI: 2.26-45.27, p=0.002].Conclusion: the independent biomarkers of SHF identified in this study provide valuable information to ward clinicians in resourceconstrained facilities to identify patients vulnerable to developing severe heart complications.</br

Micro-stratification of malaria risk in Nepal: implications for malaria control and elimination

Background:A significant reduction in malaria cases over the recent years in Nepal has encouraged the government to adopt a goal of "malaria-free nation by 2025." Nevertheless, to achieve this goal, it is critical to identify the epidemiological burden of malaria by specific regions and areas for an effective targeted intervention. The main objective of this study was to estimate the risk of malaria at Village Development Committee (VDC) level in Nepal based on disease, vector, parasite, and geography. Methods:In 2012, the micro-stratification of malaria risk was carried out in 75 districts of Nepal. Instruments such as a questionnaire, case record forms, and guidelines for malaria micro-stratification were developed and pre-tested for necessary adaptations. Village Development Committee (VDC)-wise malaria data were analyzed using exploratory statistics and were stratified by geographical variables that contributed to the risk of malaria. To understand the transmission risk at VDC level, overlay analysis was done using ArcGIS 10. To ensure transparent, reproducible, and comprehensible risk assessment, standard scoring method was selected and utilized for data from 2009 to 2011. Thus identified, three major variables (key determinants) were given weights (wt.) accordingly to stratification of the malaria risk (disease burden, "0.3" wt.; ecology/vector transmission, "0.5" wt.; and vulnerability-population movement, "0.2" wt.). Malaria risk in a VDC was determined based on the overall scores and classified into four categories: no risk, low risk, moderate risk, and high risk. Results:Analyzing the overall risk based on scoring of the total VDCs (n = 3976), 54 (1.36%), 201 (5.06%), 999 (25.13%), and 2718 (68.36%) were identified as high-, moderate-, low-, and no-risk categories for malaria, respectively. Based on the population statistics, 3.62%, 9.79%, 34.52%, and 52.05% of the country's total population live in high-risk, moderate-risk, low-risk, and no-risk VDCs for malaria, respectively. Our micro-stratification study estimates are 100,000 population at high risk. Regional distribution showed that the majority of the high-risk VDCs were identified in the Far- and Mid-western regions (19 and 18 VDCs) followed by Central and Western regions (10 and 7 VDCs) with no high-risk VDCs in the Eastern region. Similarly, 77, 59, 27, 24, and 14 VDCs of the Central, Mid-western, Western, Eastern, and Far-western regions, respectively, were found under moderate malaria risk. Of the low-risk VDCs, 353, 215, 191, 148, and 92 were respectively from the Central, Eastern, Western, Far-western, and Mid-western regions. Conclusions:The current micro-stratification study provides insights on malaria risk up to the VDC level. This will help the malaria elimination program to target interventions at the local level thereby ensuring the best utilization of available resources to substantially narrowed-down target areas. With further updates and refinement, the micro-stratification approach can be employed to identify the risk areas up to smaller units within the VDCs (ward and villages)

Modifiable predictors of severe heart failure in Morocco: a descriptive study using routinely collected health data

Introduction: Heart Failure (HF) is a growing public health concern in Morocco and there is a striking paucity on determinants of severe HF (SHF) in this population. The aim of this study was to identify patients admitted with HF at Ibn Rochd Hospital, Casablanca from 2011 onwards, when electronic record keeping began.Methods: a total of 105 patients underwent a series of cardiological examinations between July 2011 and January 2014. The New York Heart Association (NYHA) criteria was used to evaluate the severity of HF. Patients with NYHA classification gradings of I and II were defined as having moderate HF (MHF) and those graded as III and IV were defined as having a SHF. Univariable and multivariable risk factors associated with SHF were explored using logistic regression. The results were reported following the RECORD (Reporting of studies Conducted using Observational Routinely-collected Data) statement.Results: a total of 24 (33%) patients were identified as having a SHF. Four predictors of SHF were identified in univariate analysis: haemoglobin &lt;12g/dL, neutrophil-to-lymphocyte ratio (NLR) &gt;3, mean corpuscular haemoglobin concentration (MCHC) &lt;32 picolitre, and high density lipoprotein (HDL) &lt;0.35 (mmol/L). Only NLR&gt;3 and HDL &lt;0.35 mmol/L remained independent predictors in multivariable analysis. Patients with NLR &gt;3 were at 6-fold increased odds of SHF [adjusted odds ratio (AOR): 6.78, 95% confidence interval (CI): 1.40-32.80, p=0.017], and those with HDL&lt;0.35 (mmol/L) were at 10-fold increased odds of SHF [AOR: 10.11, 95% CI: 2.26-45.27, p=0.002].Conclusion: the independent biomarkers of SHF identified in this study provide valuable information to ward clinicians in resourceconstrained facilities to identify patients vulnerable to developing severe heart complications

Study Protocol for a Global Survey: Awareness and Preparedness of Hospital Staff Against Coronavirus Disease (COVID-19) Outbreak

Background: The outbreak of Coronavirus disease (COVID-19) caused by a novel coronavirus (named SARS-CoV-2) has gained attention globally and has been recognized as a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) due to the rapidly increasing number of deaths and confirmed cases. Health care workers (HCWs) are vulnerable to this crisis as they are the first frontline to receive and manage COVID-19 patients. In this multicenter multinational survey, we aim to assess the level of awareness and preparedness of hospital staff regarding COVID-19 all over the world.Methods: From February to March 2020, the web-based or paper-based survey to gather information about the hospital staff\u27s awareness and preparedness in the participants\u27 countries will be carried out using a structured questionnaire based on the United States Centers for Disease Control and Prevention (CDC) checklist and delivered to participants by the local collaborators for each hospital. As of March 2020, we recruited 374 hospitals from 58 countries that could adhere to this protocol as approved by their Institutional Review Boards (IRB) or Ethics Committees (EC).Discussion: The awareness and preparedness of HCWs against COVID-19 are of utmost importance not only to protect themselves from infection, but also to control the virus transmission in healthcare facilities and to manage the disease, especially in the context of manpower lacking and hospital overload during the pandemic. The results of this survey can be used to inform hospitals about the awareness and preparedness of their health staff regarding COVID-19, so appropriate policies and practice guidelines can be implemented to improve their capabilities of facing this crisis and other future pandemic-prone diseases.</jats:p