Outbreak of Extended Spectrum Beta Lactamase Producing Klebsiella Species Causing Neonatal Sepsis at Patan Hospital in Nepal

Introductions: Klebsiella sepsis is the most important nosocomial infection in neonates. The objectives of this study were to review an outbreak in a neonatal unit caused by Klebsiella species, to identify the source of the infections, and to identify infection control measures for eradication and prevention of these infections.Methods: The case notes and investigation reports of all sepsis cases admitted in neonatal units of Patan hospital from July to December 2011 caused by Klebsiella species were retrospectively reviewed. The demographic profile, risk factors along with clinical features and management of sepsis were reviewed.Results: Twenty three out of 37 neonatal blood cultures grew Klebsiella species. Thirty one were K. pneumoniae and six K. oxytoca. Seventeen of the 31 (55%) K. pneumoniae isolates were multidrug resistant and extended spectrum beta lactamase producers. Eighteen of 23 (78%) neonates with Klebsiella sepsis died. After extensive cleaning methods and identifying an intermittently leaking roof in one of the nurseries below a vescicovaginal fistula room of gynecological ward above, the infection outbreak was finally controlled.Conclusions: Infections with extended spectrum beta lactamase producing Klebsiella spp. are a threat in neonatal units because of limited treatment options for these multidrug resistant organisms. Identification of the source and control of the outbreak can be a challenge.Keywords: extended spectrum beta lacatamase, Klebsiella, multi drug resistant, neonate

Attempting affirmative political ecologies: Collective transformative learning for social justice in Nepal's community forestry

Whilst political ecology scholarship has contributed much to articulating social injustices associated with Nepal's community forestry, here we took a different approach, by attempting an 'affirmative political ecology.' We drew on feminist and activist scholarship to inspire collective action that engaged directly with challenges of social justice and those charged with delivering it through their work. Guided by theories and practices of 'transformative learning' and a range of associated reflective practices, our participatory action research involved 4 facilitators and (up to) 25 participants who work across Nepal's forest bureaucracy (and for some, the wider community-based natural resource management sector). Together physically, remotely and through our writing, we reflect upon the operation of power in our professional – and personal – lives, exploring how that may enable a more informed and meaningful engagement with social justice within the workplace, and beyond. This article presents the process of our collective reflection and learning, and shares some of its initial outcomes based on the experiences of the 15 co-authors. Whilst 'simply' having the time and space to come together was hugely important, it was the form and feel of that space that was particularly significant, as we focused on co-creating a safe space which was non-judgmental and based on mutual respect, enabling comfortable and open discussion of often unspoken and uncomfortable issues. Ultimately, this article argues that collective practices of reflection and transformative learning can create shared learning, understanding, empathy and solidarity, and thus that it offers hope in the face of on-going social injustices. It therefore urges political ecologists to work towards such caring and affirmative collective engagements with practitioners as one way in which to affect change

Assessment of hospitalization costs and its determinants in infants with clinical severe infection at a public tertiary hospital in Nepal

Sepsis, an important and preventable cause of death in the newborn, is associated with high out of pocket hospitalization costs for the parents/guardians. The government of Nepal’s Free Newborn Care (FNC) service that covers hospitalization costs has set a maximum limit of Nepalese rupees (NPR) 8000 i.e. USD 73.5, the basis of which is unclear. We aimed to estimate the costs of treatment in neonates and young infants fulfilling clinical criteria for sepsis, defined as clinical severe infection (CSI) to identify determinants of increased cost. This study assessed costs for treatment of 206 infants 3–59 days old, enrolled in a clinical trial, and admitted to the Kanti Children’s Hospital in Nepal through June 2017 to December 2018. Total costs were derived as the sum of direct costs for bed charges, investigations, and medicines and indirect costs calculated by using work time loss of parents. We estimated treatment costs for CSI, the proportion exceeding NPR 8000 and performed multivariable linear regression to identify determinants of high cost. Of the 206 infants, 138 (67%) were neonates (3–28 days). The median (IQR) direct costs for treatment of CSI in neonates and young infants (29–59 days) were USD 111.7 (69.8–155.5) and 65.17 (43.4–98.5) respectively. The direct costs exceeded NPR 8000 (USD 73.5) in 69% of neonates with CSI. Age <29 days, moderate malnutrition, presence of any sign of critical illness and documented treatment failure were found to be important determinants of high costs for treatment of CSI. According to this study, the average treatment cost for a newborn with CSI in a public tertiary level hospital is substantial. The maximum limit offered for free newborn care in public hospitals needs to be revised for better acceptance and successful implementation of the FNC service to avert catastrophic health expenditures in developing countries like Nepal. Trial Registration: CTRI/2017/02/007966 (Registered on: 27/02/2017).publishedVersio

Dark and bright spots in the shadow of the pandemic: Rural livelihoods, social vulnerability, and local governance in India and Nepal

The global COVID-19 pandemic has brought unprecedented disruption to lives and livelihoods around the world. These disruptions have brought into sharp focus experiences of vulnerability but also, at times, evidence of resilience as people and institutions gear up to respond to the crisis. Drawing on intensive qualitative enquiry in 16 villages of Himalayan India and Nepal, this paper documents both dark and bright spots from the early days of the pandemic. We find intense experiences of fear and uncertainty, heightened food insecurity, and drastic reductions in livelihood opportunities. However, we also find a wide range of individual and collective responses as well as a patchwork of policy support mechanisms that have provided at least some measure of basic security. Local elected governments have played a critical role in coordinating responses and delivering social support, however the nature of their actions varies as a result of different institutional arrangements and state support systems in the two countries. Our findings highlight the changing nature of vulnerability in the present era, as demographic shifts, growing off-farm employment and dependence on remittances, and increasing market integration have all brought about new kinds of exposure to risk for rural populations in the context of the present disruption and beyond. Most importantly, our research shows the critical importance of strong systems of state support for protecting basic well-being in times of crises. Based on these findings, we argue that there is a need for greater knowledge of how local institutions work in tandem with a broader set of state support mechanisms to generate responses for urgent challenges; such knowledge holds the potential to develop governance systems that are better able to confront diverse shocks that households face, both now and in the future. (C) 2020 The Author(s). Published by Elsevier Ltd

Outbreaks of Serratia marcescens and Serratia rubidaea bacteremia in a central Kathmandu hospital following the 2015 earthquakes.

BACKGROUND: Human infections with Serratia spp. are generally limited to Serratia marcescens and the Serratia liquefaciens complex. There is little data regarding the infections caused by the remaining Serratia spp., as they are seldom isolated from clinical specimens. METHODS: In this health care setting in Kathmandu, Nepal routine blood culture is performed on all febrile patients with a temperature >38°C or when there is clinical suspicion of bacteremia. During 2015 we atypically isolated and identified several Serratia spp. We extracted clinical data from these cases and performed whole genome sequencing on all isolates using a MiSeq system (Ilumina, San Diego, CA, USA). RESULTS: Between June and November 2015, we identified eight patients with suspected bacteremia that produced a positive blood culture for Serratia spp., six Serratia rubidaea and five Serratia marcescens. The S. rubidaea were isolated from three neonates and were concentrated in the neonatal intensive care unit between June and July 2015. All patients were severely ill and one patient died. Whole genome sequencing confirmed that six Nepalese S. rubidaea sequences were identical and indicative of a single-source outbreak. CONCLUSIONS: Despite extensive screening we were unable to identify the source of the outbreak, but the inferred timeline suggested that these atypical infections were associated with the aftermath of two massive earthquakes. We speculate that deficits in hygienic behavior, combined with a lack of standard infection control, in the post-earthquake emergency situation contributed to these unusual Serratia spp. outbreaks

Evaluation of hydroxychloroquine or chloroquine for the prevention of COVID-19 (COPCOV): A double-blind, randomised, placebo-controlled trial

Background: Hydroxychloroquine (HCQ) has proved ineffective in treating patients hospitalised with Coronavirus Disease 2019 (COVID-19), but uncertainty remains over its safety and efficacy in chemoprevention. Previous chemoprevention randomised controlled trials (RCTs) did not individually show benefit of HCQ against COVID-19 and, although meta-analysis did suggest clinical benefit, guidelines recommend against its use. Methods and findings: Healthy adult participants from the healthcare setting, and later from the community, were enrolled in 26 centres in 11 countries to a double-blind, placebo-controlled, randomised trial of COVID-19 chemoprevention. HCQ was evaluated in Europe and Africa, and chloroquine (CQ) was evaluated in Asia, (both base equivalent of 155 mg once daily). The primary endpoint was symptomatic COVID-19, confirmed by PCR or seroconversion during the 3-month follow-up period. The secondary and tertiary endpoints were: asymptomatic laboratory-confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection; severity of COVID-19 symptoms; all-cause PCR-confirmed symptomatic acute respiratory illness (including SARS-CoV-2 infection); participant reported number of workdays lost; genetic and baseline biochemical markers associated with symptomatic COVID-19, respiratory illness and disease severity (not reported here); and health economic analyses of HCQ and CQ prophylaxis on costs and quality of life measures (not reported here). The primary and safety analyses were conducted in the intention-to-treat (ITT) population. Recruitment of 40,000 (20,000 HCQ arm, 20,000 CQ arm) participants was planned but was not possible because of protracted delays resulting from controversies over efficacy and adverse events with HCQ use, vaccine rollout in some countries, and other factors. Between 29 April 2020 and 10 March 2022, 4,652 participants (46% females) were enrolled (HCQ/CQ n = 2,320; placebo n = 2,332). The median (IQR) age was 29 (23 to 39) years. SARS-CoV-2 infections (symptomatic and asymptomatic) occurred in 1,071 (23%) participants. For the primary endpoint the incidence of symptomatic COVID-19 was 240/2,320 in the HCQ/CQ versus 284/2,332 in the placebo arms (risk ratio (RR) 0.85 [95% confidence interval, 0.72 to 1.00; p = 0.05]). For the secondary and tertiary outcomes asymptomatic SARS-CoV-2 infections occurred in 11.5% of HCQ/CQ recipients and 12.0% of placebo recipients: RR: 0.96 (95% CI, 0.82 to 1.12; p = 0.6). There were no differences in the severity of symptoms between the groups and no severe illnesses. HCQ/CQ chemoprevention was associated with fewer PCR-confirmed all-cause respiratory infections (predominantly SARS-CoV-2): RR 0.61 (95% CI, 0.42 to 0.88; p = 0.009) and fewer days lost to work because of illness: 104 days per 1,000 participants over 90 days (95% CI, 12 to 199 days; p < 0.001). The prespecified meta-analysis of all published pre-exposure RCTs indicates that HCQ/CQ prophylaxis provided a moderate protective benefit against symptomatic COVID-19: RR 0.80 (95% CI, 0.71 to 0.91). Both drugs were well tolerated with no drug-related serious adverse events (SAEs). Study limitations include the smaller than planned study size, the relatively low number of PCR-confirmed infections, and the lower comparative accuracy of serology endpoints (in particular, the adapted dried blood spot method) compared to the PCR endpoint. The COPCOV trial was registered with ClinicalTrials.gov; number NCT04303507. Interpretation: In this large placebo-controlled, double-blind randomised trial, HCQ and CQ were safe and well tolerated in COVID-19 chemoprevention, and there was evidence of moderate protective benefit in a meta-analysis including this trial and similar RCTs. Trial registration: ClinicalTrials.gov NCT04303507; ISRCTN Registry ISRCTN10207947

An Ensemble Model for Co-Seismic Landslide Susceptibility Using GIS and Random Forest Method

The Mw 7.8 Gorkha earthquake of 25 April 2015 triggered thousands of landslides in the central part of the Nepal Himalayas. The main goal of this study was to generate an ensemble-based map of co-seismic landslide susceptibility in Sindhupalchowk District using model comparison and combination strands. A total of 2194 co-seismic landslides were identified and were randomly split into 1536 (~70%), to train data for establishing the model, and the remaining 658 (~30%) for the validation of the model. Frequency ratio, evidential belief function, and weight of evidence methods were applied and compared using 11 different causative factors (peak ground acceleration, epicenter proximity, fault proximity, geology, elevation, slope, plan curvature, internal relief, drainage proximity, stream power index, and topographic wetness index) to prepare the landslide susceptibility map. An ensemble of random forest was then used to overcome the various prediction limitations of the individual models. The success rates and prediction capabilities were critically compared using the area under the curve (AUC) of the receiver operating characteristic curve (ROC). By synthesizing the results of the various models into a single score, the ensemble model improved accuracy and provided considerably more realistic prediction capacities (91%) than the frequency ratio (81.2%), evidential belief function (83.5%) methods, and weight of evidence (80.1%)

An Ensemble Model for Co-Seismic Landslide Susceptibility Using GIS and Random Forest Method

The Mw 7.8 Gorkha earthquake of 25 April 2015 triggered thousands of landslides in the central part of the Nepal Himalayas. The main goal of this study was to generate an ensemble-based map of co-seismic landslide susceptibility in Sindhupalchowk District using model comparison and combination strands. A total of 2194 co-seismic landslides were identified and were randomly split into 1536 (~70%), to train data for establishing the model, and the remaining 658 (~30%) for the validation of the model. Frequency ratio, evidential belief function, and weight of evidence methods were applied and compared using 11 different causative factors (peak ground acceleration, epicenter proximity, fault proximity, geology, elevation, slope, plan curvature, internal relief, drainage proximity, stream power index, and topographic wetness index) to prepare the landslide susceptibility map. An ensemble of random forest was then used to overcome the various prediction limitations of the individual models. The success rates and prediction capabilities were critically compared using the area under the curve (AUC) of the receiver operating characteristic curve (ROC). By synthesizing the results of the various models into a single score, the ensemble model improved accuracy and provided considerably more realistic prediction capacities (91%) than the frequency ratio (81.2%), evidential belief function (83.5%) methods, and weight of evidence (80.1%)

Acute reversible monoparesis in multiple neurocysticercosis: A case report and review of literature

Abstract Focal neurological deficit like monoparesis due to cortical lesions is a rare entity. In spite of the common presentations like seizures and headaches in neurocysticercosis, occurrence of reversible monoparesis is an atypical phenomenon. Even in the absence of infarct or hemorrhages, manifestation of neural deficit due to compressive effect only is an interesting finding. And on top of that, reversible nature of the deficit in space occupying lesion is a rare occurrence in the existing literature. Here, we describe a known case of neurocysticercosis with reversible acute monoparesis secondary to multiple neurocysticercosis. The variations with which neurocysticercosis can present broaden our understanding in its pathophysiology and management protocol