Laboratory and clinico-demographic profile of patients investigated for tuberculosis in the National Referral Hospital of Bhutan

Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, is an important public health problem in Bhutan. Microscopy is the primary method of diagnosis of TB in developing countries including Bhutan. Performance of microscopy in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), has never been assessed. A retrospective review of laboratory records for three years (2014-2016) was performed to determine the laboratory profile of patients investigated for different types of TB at the JDWNRH. A total of 10,821 sputum and 3,495 non-sputum samples were examined for pulmonary TB (PTB) and extrapulmonary TB (EPTB) respectively. The commonest EPTB samples were Fine Needle Aspiration Cytology (FNAC), urine and sterile fluids. About 6% (127/2163), 5 % (130/2390) and 5% (289/5310) were positive for PTB in 2014, 2015 and 2016 respectively and EPTB positivity was about 7% in all years. During follow-up a significant number of patients remained sputum positive. Sputum sample satisfactory rate (quality) varied between 51 % to 79% in the primary samples. Sample completeness (number) ranged between 62.3% to 94.6% but dropped sequentially in the follow-up cases. Sample completeness of urine samples for EPTB ranged between 75-90%. EPTB positivity rate was highest in FNAC, followed by urine, pleural fluid and ascitic fluid samples. Higher number of patients were investigated for TB in subsequent years from 2014 to 2016. TB positivity rates for PTB and EPTB remained consistent over three years at about 5-6% and 7% respectively. There was a significant variation in sputum sample adequateness (by quality and number). Sputum conversion in the follow-up cases was lower than other countries. Educating the patients on the importance of providing adequate samples can improve TB diagnosis, enhance early treatment, reduce transmission and contribute significantly towards TB elimination

Exposure to Leptospira spp. and associated risk factors in the human, cattle and dog populations in Bhutan

Leptospirosis is a neglected worldwide zoonotic bacterial disease with a high prevalence in subtropical and tropical countries. The prevalence of Leptospira spp. in humans, cattle and dogs is unknown in Bhutan. Therefore, we sought to find out whether humans, cattle or dogs had been infected in the past with leptospires by measuring antibodies in the serum. We therefore collected blood from 864 humans >/=13 years of age, 130 bovines and 84 dogs from different rural and urban areas in Bhutan and tested the serum for antibodies specific for leptospires with a screening of enzyme-linked immunosorbent assays (ELISA) and a confirmatory microscopic agglutination test (MAT). In humans, 17.6% were seropositive by ELISA and 1.6% by MAT. The seropositivity was stronger in bovines (36.9%) and dogs (47.6%). "Having had a fever recently" (OR 5.2, p = 0.004), "working for the military" (OR 26.6, p = 0.028) and "being unemployed" (OR 12.9, p = 0.041) (reference category = housemaker) were statistically significantly associated with seropositivity when controlled for the effects of other risk factors. However, due to the small number of positive test results, the findings on risk factors should be interpreted with caution. Based on the serogroups found in the three species, dogs could be a source of infection for humans, or dogs and humans are exposed to the same environmental risk factors Clinical leptospirosis in humans and domestic animals should be investigated by testing blood and urine for the presence of leptospires by molecular methods (qPCR)

Performance of an Emergency Road Ambulance Service in Bhutan: Response Time, Utilization, and Outcomes

Background: An efficient ambulance service is a vital component of emergency medical services. We determined the emergency ambulance response and transport times and ambulance exit outcomes in Bhutan. Methods: A cross-sectional study involving real-time monitoring of emergency ambulance deployments managed by a central toll-free (112) hotline (20 October 2021 to 20 January 2022) was carried out. Results: Of 5092 ambulance deployments, 4291 (84%) were inter-facility transfers, and 801 (16%) were for emergencies. Of the latter, 703 (88%) were for non-pregnancy-related emergencies (i.e., medical, surgical, and accidents), while 98 (12%) were for pregnancy-related emergencies. The median ambulance response and patient transport times were 42 (IQR 3–271) and 41 (IQR 2–272) minutes, respectively. The median round-trip distance travelled by ambulances was 18 km (range 1–186 km). For ambulance exit outcomes that were pregnancy-related (n = 98), 89 (91%) reached the health facility successfully, 8 delivered prior to ambulance arrival at the scene or in the ambulance during transport, and 1 had no outcome record. For the remaining 703 non-pregnancy deployments, 29 (4.1%) deployments were deemed not required or refusals, and 656 (93.3%) reached the health facility successfully; 16 (2.3%) died before the ambulance’s arrival at the scene, and 2 (0.3%) were not recorded. Conclusions: This first countrywide real-time operational research showed acceptable ambulance exit outcomes. Improving ambulance response and transport times might reduce morbidities and mortalities further

The trend of tuberculosis case notification and predictors of unsuccessful treatment outcomes in Samdrup Jongkhar district, Bhutan:A fourteen-year retrospective study

Tuberculosis (TB) continues to be an important public health issue in Bhutan. This study aims to describe the trend of tuberculosis and investigate factors associated with a unsuccessful treatment outcome in Samdrup Jongkhar District in Bhutan. A fourteen-year (2004-2017) case records in two TB centres of Dewathang and Samdrup Jongkhar Hospitals were reviewed and analyzed to examine trends in case notification and treatment outcomes. Univariable and multivariable logistic regression analysis was undertaken to identify covariates of unsuccessful TB treatment. Of the total of 820 TB cases registered in surveillance record, 729 cases were analysed. Males made up 53.8% (397) of total cases and the median age was 29 years (range: 2-87 years). A gradual downward trend in TB case notification was noticed in the district with overall case notification rate of 139/100,000 during the study period. The annual treatment success rate was over 90% except for years 2013-2015 with overall treatment success rate for the study period at 93%. A re-treatment TB patient, sputum-positive at the second month of treatment and being of Indian nationality were significant correlates of unsuccessful treatment outcomes. The overall TB inclidence has declined and TB treatment success rate was above WHO recommended 90% in Samdrup Jongkhar District during the study period. A special attention should be paid to the poor treatment outcome predictors including re-treatment cases and failed sputum conversion at the second month of treatment.</p

Assessing the Knowledge, Attitudes, and Practices onAntibiotics Among the General Public Attending the Outpatient Pharmacy Units of Hospitals in Bhutan: A Cross-Sectional Survey

We assessed the level of knowledge, attitudes, and practices on antibiotics through a questionnaire-based cross-sectional survey among the general public in Bhutan. Of the 692 participants, 52.6% (364) were females with a mean age of 34.2 years. More than half of the respondents showed unsatisfactory knowledge varying significantly from 23.1% to 69.6%. Cotrimoxazole (septran) was the least known while amoxicillin was the most known antibiotics assessed. Two-thirds of the responsents (267) knew that inappropriate use of antibiotics could lead to antimicrobial resistance and 89% (319) were aware of the need to complete the antibiotic courses. In bivariate analysis, satisfactory knowledge was associated with the education level of graduate and higher as compared with no education. This study revealed unsatisfactory knowledge and attitude but satisfactory practices on antibiotics use among participants. Efforts are needed to improve public awareness on antibiotics. Enforcement of regulations on sale of antibiotics over the counter needs a revamp

Assessing Knowledge, Attitudes and Practices on Antibiotics amongst University Graduates in Bhutan: A Cross-Sectional Survey

Introduction: Concerns about antibiotic resistances is increasing. Antibiotic misuses mostly result from inadequate knowledge impacting attitudes and practices. The literature on this subject is limited in Bhutan.  It is of immense importance to understand the gap and target interventions. Therefore, we assessed the knowledge, attitudes and practices (KAP) on antibiotics amongst Bhutanese university graduates in 2016. Methods: The survey was conducted through a self-administered online questionnaire after seeking consent. The questionnaire was developed by the investigators using past literature.   Results: Of the 2,229 invited graduates, only 220 (≈10%), 52.3% (115) males, completed the survey. Internet was the commonest source of information on antibiotics. Only 51% (113) showed good knowledge with a mean score of 15.5 (range 2-30). Penicillin, amoxicillin and cotrimoxazole were correctly identified as antibiotics by 63.6%, 78.7% and 21.4% but 11.4%, 35% and 31.8% misidentified atenolol, paracetamol and ibuprofen as antibiotics respectively. Side effects of antibiotics were poorly recognized. Fifty-four percent (119) showed good attitude score. About 39% (85), 35% (76) and 46% (101) misconceived that antibiotics would be required for common cold, all fevers and all small clean-cut wounds respectively. Almost 91% knew that antibiotic courses should be completed, 12% thought that antibiotics can be stopped when patients improve and 31.8% repeated antibiotics for similar illnesses. Although 76% knew that antibiotics shouldn’t be bought without a prescription, 28% were able to get them. About 44.1% revealed that the dispensing pharmacists did not explain adequately about antibiotics. Unfortunately, 43.6% suggested others to take antibiotics during illnesses and 60% used topical antibiotics. Conclusion: KAP on antibiotics amongst Bhutanese graduates was unsatisfactory except few good specific practices. Health authorities should educate public on antibiotics and other medicines

Knowledge, attitude and practice towards COVID-19 among college students in Bhutan: a web-based cross-sectional analysis.

Bhutan has reopened schools and colleges after an initial closure to contain coronavirus disease 2019 (COVID-19) transmission. However, the risk of transmissions is higher in the schools and colleges due to crowding. Therefore, this study aimed to assess the level of knowledge, attitude, and practice (KAP) toward COVID-19 among the students of Sherubtse College in Bhutan. A cross-sectional study using a questionnaire was conducted in September 2020 among the students of Sherubtse College, Bhutan. The questionnaire was made in the Google Forms and administered through a social forum WeChat app. The KAP scores were calculated that include mean scores. The association between the KAP was assessed using the Pearson's correlation coefficient. A total of 613 students participated in the survey. The majority of the participants (57%) were female and 56% were from the third year. The mean knowledge score was 10.7 (SD = 1.7; range 0–14), mean attitude score of 3.67 (SD = 1.0; range: 0–5), and mean practice score of 5.19 (SD = range: 0–6). A majority of the students had good knowledge (98%) and practice (93.5%) scores, and a positive attitude (86.6%) toward COVID-19. A positive but weak correlation between good knowledge and practice (r = 0.1, p = 0.0126) was observed. Having a positive attitude led to practicing appropriately most of the time (r = 0.1866, p &lt; 0.001). The students had good KAP scores and followed the COVID-19 prevention protocols advocated by the government. Good knowledge and a positive attitude were translated into good practice. Therefore, the education campaign of the Bhutan government seems to be effective in the students

Scrub Typhus Outbreak in a Remote Primary School, Bhutan, 2014

Scrub typhus in Bhutan was first reported in 2009. We investigated an outbreak of scrub typhus in a remote primary school during August–October 2014. Delay in recognition and treatment resulted in 2 deaths from meningoencephalitis. Scrub typhus warrants urgent public health interventions in Bhutan