Human Rabies in the WHO Southeast Asia Region: Forward Steps for Elimination

There are eleven Member States in the WHO southeast Asia region (Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste) of which eight are endemic for rabies. More than 1.4 billion people in the Region are at risk of rabies infection, and approximately 45% of worldwide rabies deaths occur in Asia. Dog bites account for 96% of human rabies cases. Progress in preventing human rabies through control of the disease in dogs has been slow due to various factors. Innovative control tools and techniques have been developed and standardized in recent years. The introduction of cost-effective intradermal rabies vaccination regimens in Asian countries has increased the availability and affordability of postexposure prophylaxis. Elimination of rabies is not possible without regional and intersectoral cooperation. Considering the importance of consolidating achievements in rabies control in Member countries, the WHO Regional Office for southeast Asia has developed a regional strategy for elimination of human rabies transmitted by dogs in the Region. They have committed to provide technical leadership, to advocate national health authorities to develop major stakeholder consensus for a comprehensive rabies elimination programme, and to implement national strategies for elimination of human rabies

Population based need assessment of palliative care in rural Nepal

Introductions: Developing palliative care in rural Nepal is essential to integrate the service into the national health system. This study was done with the aim of assessing the need of patients requiring palliative care in rural Nepal. Methods: This was a cross-sectional population based study in Thaha Municipality using a 30-cluster sampling method and employing the Supportive and Palliative Care Indicators Tool (SPICT) to identify patients with palliative care need. Assessment of symptom burden was done for patients identified to have palliative care need. Results: Out of 330 households with a population of 2168, we found 139 (6.4%) suffering from chronic non-communicable diseases and 66 (3.04%) met the SPICT criteria for palliative care need and 60% were elderly above the age of 60. The disease of respiratory system followed by frailty and dementia were common condition requiring palliative care. Conclusions: This study showed a high level of need for palliative care in a rural population in Nepal. This needs to be considered in further planning of health services in the country. Keywords: need assessment, palliative care, rural, SPIC

How will the urban ring impact airport related economic activities and low income communities in Chelsea?

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 1999.Includes bibliographical references (leaf 51).There are two actions that are currently most relevant to the future economic development of Chelsea. One is the Compact signed by Six Cities - Chelsea, Everett, Somerville, Cambridge, Brookline and Boston in support of the Urban Ring. This led Massachusetts Bay Transportation Authority (MBTA) to conduct the Major Investment Study of the Urban Ring Proposal. Second is the agreement signed in August 1998 between the City of Chelsea and the Massachusetts Port Authority (Massport) to attract airport-related businesses to locate in Chelsea. In the context of these two agreements, my thesis sought to answer two questions. 1) How will the Urban Ring impact the low-income communities in Chelsea? and 2) How will the Urban Ring Impact the Airport Related Business? This thesis evaluates the impact of the Urban Ring Proposal mainly in terms of employment for the low income residents of Chelsea. I used maps produced by combining the census data with the spatial and network analysis tools in Arcview (Geographic Information System) to draw a picture of Chelsea. Additionally, I applied information obtained from interviews with local community organizations, and the information from the city office and the Massport. I looked at how the Urban Ring addresses Chelsea's oldest problem of poor public transportation connection to the rest of Boston. The lack of reliable public transportation has serious implications for the low-income communities in Chelsea. One third of the population do not own automobiles and more than two-thirds work outside Chelsea. Based on my finding, this thesis concludes that the Urban Ring would increase the opportunities for employment for Chelsea residents, by improving the connection to other cities and major employment centers along the Urban Ring Corridor. My thesis suggests that the Urban Ring will not impact the location of Airport related business. It also establishes that the location of airport related businesses will not necessarily provide a high number of new jobs for Chelsea residents. Most Chelsea residents will continue to work outside Chelsea and a large proportion of them will depend on public transportation. For these reasons, I argue that the Urban Ring would benefit Chelsea. Finally, I establish a set of recommendations that the City of Chelsea and community organizations can take to increase employment opportunities for Chelsea's low-income residents until the Urban Ring becomes a reality.by Shailesh N. Gongal.M.C.P

Palliative care need among inpatients in acute general hospitals in Nepal: a point prevalence survey

Introductions:  Developing palliative care services in acute hospitals is important to address the need of patients dying from malignant and non-malignant diseases. This study is carried out to assess the need of palliative care in Patan Hospital to inform the planning process for starting palliative care services.Methods: A cross-sectional, point prevalence survey of in-patient beds occupied in Patan Hospital was carried out using Supportive and Palliative Care Indicators Tool. For patients who met the criteria, symptom burden was noted.Results: Of the 116 patients admitted on the day of surveillance, 30% met the criteria for palliative care need; 60% were aged 60 or above. The most common conditions requiring palliative care need was lung disease (46%) followed by cardio vascular (23%) and neurological diseases (23%). The most common symptoms patients were suffering from were fatigue (60%) followed by shortness of breath (51%), inability to move (35%), abdominal distension (31%), anorexia (31%) and pain (25%).Conclusions: Almost one third of patients admitted to Patan Hospital need palliative care with majority of them being above sixty years. This highlights the need to develop palliative care services in the hospital to address the need of such patients and families to improve the quality of life in the last years of life.Keywords: acute hospital, need assessment, palliative care, SPICT too

Reconciling surveillance systems with limited resources: an evaluation of passive surveillance for rabies in an endemic setting

Surveillance systems for rabies in endemic regions are often subject to severe constraints in terms of resources. The World Organisation for Animal Health (OIE) and the World Health Organisation (WHO) propose the use of an active surveillance system to substantiate claims of disease freedom, including rabies. However, many countries do not have the resources to establish active surveillance systems for rabies and the testing of dead dogs poses logistical challenges. This paper explores the potential of using a scenario tree model parameterised with data collected via questionnaires and interviews to estimate the sensitivity of passive surveillance, assessing its potential as a viable low-cost alternative to active surveillance systems. The results of this explorative study illustrated that given a large enough sample size, in this case the entire population of Colombo City, the sensitivity of passive surveillance can be 100% even at a low disease prevalence (0.1%), despite the low sensitivity of individual surveillance components (mean values in the range 4.077×10(-5)-1.834×10(-3) at 1% prevalence). In addition, logistic regression was used to identify factors associated with increased recognition of rabies in dogs and reporting of rabies suspect dogs. Increased recognition was observed amongst dog owners (OR 3.8 (CI, 1.3-10.8)), people previously bitten by dogs (OR 5.9 (CI, 2.2-15.9)) and people who believed they had seen suspect dogs in the past (OR 4.7 (CI, 1.8-12.9)). Increased likelihood of reporting suspect dogs was observed amongst dog owners (OR 5.3 (CI, 1.1-25)). Further work is required to validate the data collection tool and the assumptions made in the model with respect to sample size in order to develop a robust methodology for evaluating passive rabies surveillance

Epidemiology, impact and control of rabies in Nepal : a systematic review

Background: Rabies is a vaccine-preventable viral zoonosis belonging to the group of neglected tropical diseases. Exposure to a rabid animal may result in a fatal acute encephalitis if effective post-exposure prophylaxis is not provided. Rabies occurs worldwide, but its burden is disproportionately high in developing countries, including Nepal. We aimed to summarize current knowledge on the epidemiology, impact and control of rabies in Nepal. Methods: We performed a systematic review of international and national scientific literature and searched grey literature through the World Health Organization Digital Library and the library of the National Zoonoses and Food Hygiene Research Centre, Nepal, and through searching Google and Google Scholar. Further data on animal and human rabies were obtained from the relevant Nepalese government agencies. Finally, we surveyed the archives of a Nepalese daily to obtain qualitative information on rabies in Nepal. Findings: So far, only little original research has been conducted on the epidemiology and impact of rabies in Nepal. Per year, rabies is reported to kill about 100 livestock and 10–100 humans, while about 1,000 livestock and 35,000 humans are reported to receive rabies post-exposure prophylaxis. However, these estimates are very likely to be serious underestimations of the true rabies burden. Significant progress has been made in the production of cell culture-based anti-rabies vaccine and rabies immunoglobulin, but availability and supply remain a matter of concern, especially in remote areas. Different state and non-state actors have initiated rabies control activities over the years, but efforts typically remained focalized, of short duration and not harmonized. Communication and coordination between veterinary and human health authorities is limited at present, further complicating rabies control in Nepal. Important research gaps include the reporting biases for both human and animal rabies, the ecology of stray dog populations and the true contribution of the sylvatic cycle. Interpretation: Better data are needed to unravel the true burden of animal and human rabies. More collaboration, both within the country and within the region, is needed to control rabies. To achieve these goals, high level political commitment is essential. We therefore propose to make rabies the model zoonosis for successful control in Nepal

Review of oral rabies vaccination of dogs and its application in India

Oral rabies vaccines (ORVs) have been in use to successfully control rabies in wildlife since 1978 across Europe and the USA. This review focuses on the potential and need for the use of ORVs in free-roaming dogs to control dog-transmitted rabies in India. Iterative work to improve ORVs over the past four decades has resulted in vaccines that have high safety profiles whilst generating a consistent protective immune response to the rabies virus. The available evidence for safety and efficacy of modern ORVs in dogs and the broad and outspoken support from prominent global public health institutions for their use provides confidence to national authorities considering their use in rabies-endemic regions. India is estimated to have the largest rabies burden of any country and, whilst considerable progress has been made to increase access to human rabies prophylaxis, examples of high-output mass dog vaccination campaigns to eliminate the virus at the source remain limited. Efficiently accessing a large proportion of the dog population through parenteral methods is a considerable challenge due to the large, evasive stray dog population in many settings. Existing parenteral approaches require large skilled dog-catching teams to reach these dogs, which present financial, operational and logistical limitations to achieve 70% dog vaccination coverage in urban settings in a short duration. ORV presents the potential to accelerate the development of approaches to eliminate rabies across large areas of the South Asia region. Here we review the use of ORVs in wildlife and dogs, with specific consideration of the India setting. We also present the results of a risk analysis for a hypothetical campaign using ORV for the vaccination of dogs in an Indian state

Laparoscopic Cholecystectomy in Situs Inversus Totalis with Stage 5 Chronic Kidney Disease: A Case Report

Situs inversus totalis is a rare congenital anomaly in which the abdominal and thoracic organs are transposed in a mirror image. Diagnosis and management of cholelithiasis in patients with situs inversus totalis pose a challenge due to the anatomical variation. A laparoscopic cholecystectomy in such a case can be technically challenging, especially for a right-handed surgeon. In this case report, we present a case of a 38-year-old male with symptomatic cholelithiasis in a chronic kidney disease stage five patient under maintenance hemodialysis planned for recipient renal transplant. A laparoscopic cholecystectomy considered the gold standard for symptomatic cholelithiasis was performed with a three-port technique. The technical challenges anticipated due to anatomical variation were managed by intraoperative modifications. In conclusion, laparoscopic cholecystectomy in patients with situs inversus totalis can be done with technical modifications and re-orientation of visual motor skills

A Global Collaboration to Develop and Pilot Test a Mobile Application to Improve Cancer Pain Management in Nepal

INTRODUCTION: Quality palliative care, which prioritizes comfort and symptom control, can reduce global suffering from non-communicable diseases, such as cancer. To address this need, the Nepalese Association of Palliative Care (NAPCare) created pain management guidelines (PMG) to support healthcare providers in assessing and treating serious pain. The NAPCare PMG are grounded in World Health Organization best practices but adapted for the cultural and resource context of Nepal. Wider adoption of the NAPCare PMG has been limited due to distribution of the guidelines as paper booklets. METHODS: Building on a long-standing partnership between clinicians and researchers in the US and Nepal, the NAPCare PMG mobile application (“app”) was collaboratively designed. Healthcare providers in Nepal were recruited to pilot test the app using patient case studies. Then, participants completed a Qualtrics survey to evaluate the app which included the System Usability Scale (SUS) and selected items from the Mobile App Rating Scale (MARS). Descriptive and summary statistics were calculated and compared across institutions and roles. Regression analyses to explore relationships (α = 0.05) between selected demographic variables and SUS and MARS scores were also conducted. RESULTS: Ninety eight healthcare providers (n = 98) pilot tested the NAPCare PMG app. Overall, across institutions and roles, the app received an SUS score of 76.0 (a score > 68 is considered above average) and a MARS score of 4.10 (on a scale of 1 = poor, 5 = excellent). 89.8% (n = 88) “agreed” or “strongly agreed” that the app will help them better manage cancer pain. Age, years of experience, and training in palliative care were significant in predicting SUS scores (p-values, 0.0124, 0.0371, and 0.0189, respectively); institution was significant in predicting MARS scores (p = 0.0030). CONCLUSION: The NAPCare PMG mobile app was well-received, and participants rated it highly on both the SUS and MARS. Regression analyses suggest end-user variables important to consider in designing and evaluating mobile apps in lower resourced settings. Our app design and pilot testing process illustrate the benefits of cross global collaborations to build research capacity and generate knowledge within the local context