The role of Diabetes mellitus comorbidity on Tuberculosis treatment outcomes in Nepal: A prospective cohort study

Aim: The Objective of this study was to assess the effect of Diabetes Mellitus (DM) on treatment outcomes of tuberculosis (TB) patients in the Central Development Region of Nepal. Methods: A prospective cohort study was conducted in central Nepal. The study population of n=408 was consecutively recruited from treatment centers of all 19 districts of central Nepal. The TB cases (n=306) and TB with DM (n=102) cases were followed up for the estimation of blood glucose level, HbA1c level, and sputum examination on 2, 5, and 6 months after TB treatment started. The Generalized Estimating Equation (GEE) was performed to identify the risk ratio among TB and TB with DM cases on treatment outcome. Results: Our study identified that the magnitude of treatment failure among the tuberculosis cases was 19.7% (95% CI: 17.44-21.95). The GEE analysis observed that factors associated with the treatment failure had uncontrolled DM (HbA1C ≥7 %) (adj.RR=5.24, 95% CI: 2.58-10.62, P value <0.001), aged ≥ 45 (adj.RR= 6.13, 95% CI: 2.55-14.76, P value <0.001), had inadequate financial status (adj.RR= 2.33, 95% CI: 1.07-5.06, P value 0.033) and had prior TB (adj.RR=2.33, 95% CI: 1.09-4.97, P value 0.028) respectively.  Conclusion: The prevalence of worsening TB treatment among patients with TB and DM was significantly higher than those who had TB only. Poor glycaemic control, increasing age, inadequate financial status, and previous history of tuberculosis were strong predictors of worsening tuberculosis treatment outcomes

Estimating prevalence and burden of major disorders of the brain in Nepal: cultural, geographic, logistic and philosophical issues of methodology

BACKGROUND: Headache, anxiety and depression are major disorders of the brain in terms of their prevalence and the burdens and costs they impose on society. Nationwide population-based studies of these disorders are necessary to inform health policy but, in research-naïve and resource-poor countries such as Nepal, a host of methodological problems are encountered: cultural, geographic, logistic and philosophical. METHODS: Expert consensus was sought among researchers from different professional and cultural backgrounds in planning and conceptualizing an epidemiological study and adapting established methods to the special situation and circumstances of Nepal. RESULTS: The methodological problems were sorted into different themes: study design; climate; geography, access and transport; sociocultural issues; safety of interviewers. Each of these was dealt with separately, and their inter-relationships explored, in finding solutions that were sometimes pragmatic. A cross-sectional questionnaire-based study, with teams of interviewers visiting households across the three physiographic divisions (with extremes in altitude) in each of the five development regions of the country, would enable national sampling with sociocultural representativeness. However, the study instruments and interviews would be in Nepali only. Transport and access challenges were considerable, and their solutions combined travel by air, bus, river and foot, with allowances for rain-damaged roads, collapsed bridges and cancelled scheduled flights. The monsoon would render many routes impassable, and therefore set an absolute time limitation. Engaging participants willingly in the enquiry would be the key to success, and several tactics would be employed to enhance the success of this, most importantly enlisting the support of local community volunteers in each study site. CONCLUSION: Anticipating problems in advance of investing substantial resources in a large nationwide epidemiological study in Nepal was a sensible precaution. The difficulties could be resolved or circumvented without expected compromise in scientific quality. Expert consensus was an effective means of achieving this outcome

KEY FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT AT TERM IN NEPAL: A CASE CONTROL STUDY

Background:Low Birth Weight (LBW) is a major public health problem in developing countries including Nepal. Nepal has a prevalence of LBW of 21%. There are various factors associated to high prevalence of LBW. This study aimed to identify specific factors associated to LBW at term in hospital settings in Nepal. Methodology: This study used a hospital based case control design. Hospital nurses interviewed mothers aged 15-45 years who had delivered a full term, single and live baby. Results: A total of 1533 respondents (511 cases and 1022 controls) were taken which is slightly more than the estimated sample size. The mean weight of newborns among case group was 2215 gm (SD:203); and among control group was 3012gm (SD:367). This study revealed that factors such as mothers under 20 years old (OR=1.436, 95% CI:1.074-1.920); height below 145cm (OR=1.504, 95% CI:1.087 -2.083); primigravida (OR=1.423, 95% CI:1.132-1.788); illiterate (OR=1.407 95% CI:1.011-1.957); <4 ANC visits (OR=1.534, 95% CI:1.202-1.957); and iron supplement <180 tabs (OR=1.434, 95% CI:1.152-1.786) were associated with LBW. However, variables like <20 years at the first pregnancy (OR=1.139, 95% CI: 0.904-1.433), disadvantaged ethnicity (OR=1.077, 95% CI: 0.861-1.347) were not associated with LBW in this study.Conclusion: Maternal height, education, number of ANC visits, and iron consumption were strong predictors for LBW in Nepal. It would benefit the country to develop effective strategies on maternal nutrition, female education, and quality ANC to overcome LBW.KEYWORDS: Low Birth Weight; Socio-demographic and antenatal care, Case control design

KEY FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT AT TERM IN NEPAL: A CASE CONTROL STUDY

Background:Low Birth Weight (LBW) is a major public health problem in developing countries including Nepal. Nepal has a prevalence of LBW of 21%. There are various factors associated to high prevalence of LBW. This study aimed to identify specific factors associated to LBW at term in hospital settings in Nepal. Methodology: This study used a hospital based case control design. Hospital nurses interviewed mothers aged 15-45 years who had delivered a full term, single and live baby. Results: A total of 1533 respondents (511 cases and 1022 controls) were taken which is slightly more than the estimated sample size. The mean weight of newborns among case group was 2215 gm (SD:203); and among control group was 3012gm (SD:367). This study revealed that factors such as mothers under 20 years old (OR=1.436, 95% CI:1.074-1.920); height below 145cm (OR=1.504, 95% CI:1.087 -2.083); primigravida (OR=1.423, 95% CI:1.132-1.788); illiterate (OR=1.407 95% CI:1.011-1.957); <4 ANC visits (OR=1.534, 95% CI:1.202-1.957); and iron supplement <180 tabs (OR=1.434, 95% CI:1.152-1.786) were associated with LBW. However, variables like <20 years at the first pregnancy (OR=1.139, 95% CI: 0.904-1.433), disadvantaged ethnicity (OR=1.077, 95% CI: 0.861-1.347) were not associated with LBW in this study.Conclusion: Maternal height, education, number of ANC visits, and iron consumption were strong predictors for LBW in Nepal. It would benefit the country to develop effective strategies on maternal nutrition, female education, and quality ANC to overcome LBW.KEYWORDS: Low Birth Weight; Socio-demographic and antenatal care, Case control design

The burden of chronic respiratory diseases in adults in Nepal:A systematic review

While chronic lung disease causes substantial global morbidity and mortality, global estimates have primarily been based on broad assumptions. Specific country data from low-income countries such as Nepal are limited. This review assessed primary evidence on chronic respiratory disease burden among adults in Nepal. A systematic search was performed in June 2019 (updated May 2020) for studies through nine databases. High levels of heterogeneity deemed a narrative synthesis appropriate. Among 27 eligible studies identified, most were low-moderate quality with cross-sectional and retrospective study design. Chronic lung diseases identified were chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis and restrictive lung diseases. Studies were categorised as: (i) community-based, (ii) hospital-based and (iii) comorbidity-related and disease burden. Reported disease prevalence varied widely (COPD, 1.67–14.3%; asthma, 4.2–8.9%). The prevalence of airflow obstruction was higher among rural dwellers (15.8%) and those exposed to household air pollution from domestic biomass burning as opposed to liquid petroleum gas users (Odds Ratio: 2.06). Several comorbidities, including hypertension and diabetes mellitus added to the disease burden. The review shows limited literature on lung disease burden in Nepal. Publications varied in terms of overall quality. Good quality research studies with prospective cohorts related to respiratory conditions are required

Nutritional and health status of children 15 months after integrated school garden, nutrition, and water, sanitation and hygiene interventions: a cluster-randomised controlled trial in Nepal

It has been suggested that specific interventions delivered through the education sector in low- and middle-income countries might improve children's health and wellbeing. This cluster-randomised controlled trial aimed to evaluate the effects of a school garden programme and complementary nutrition, and water, sanitation and hygiene (WASH) interventions on children's health and nutritional status in two districts of Nepal.; The trial included 682 children aged 8-17 years from 12 schools. The schools were randomly allocated to one of three interventions: (a) school garden programme (SG; 4 schools, n = 172 children); (b) school garden programme with complementary WASH, health and nutrition interventions (SG+; 4 schools, n = 197 children); and (c) no specific intervention (control; 4 schools, n = 313 children). The same field and laboratory procedures were employed at the baseline (March 2015) and end-line (June 2016) surveys. Questionnaires were administered to evaluate WASH conditions at schools and households. Water quality was assessed using a Delagua kit. Dietary intake was determined using food frequency and 24-h recall questionnaire. Haemoglobin levels were measured using HemoCue digital device and used as a proxy for anaemia. Stool samples were subjected to a suite of copro-microscopic diagnostic methods for detection of intestinal protozoa and helminths. The changes in key indicators between the baseline and end-line surveys were analysed by mixed logistic and linear regression models.; Stunting was slightly lowered in SG+ (19.9 to 18.3%; p = 0.92) and in the control (19.7 to 18.9%). Anaemia slightly decreased in SG+ (33.0 to 32.0%; p < 0.01) and markedly increased in the control (22.7 to 41.3%; p < 0.01), a minor decline was found in the control (43.9 to 42.4%). Handwashing with soap before eating strongly increased in SG+ (from 74.1 to 96.9%; p = 0.01, compared to control where only a slight increase was observed from 78.0 to 84.0%). A similar observation was made for handwashing after defecation (increase from 77.2 to 99.0% in SG+ versus 78.0 to 91.9% in control, p = 0.15).; An integrated intervention consisting of school garden, WASH, nutrition and health components (SG+) increased children's fruit and vegetable consumption, decreased intestinal parasitic infections and improved hygiene behaviours.; ISRCTN17968589 (date assigned: 17 July 2015)

Intestinal parasite infections and associated risk factors among schoolchildren in Dolakha and Ramechhap districts, Nepal: a cross-sectional study

Infections with soil-transmitted helminths and pathogenic intestinal protozoa pose a considerable public health burden, particularly in low- and middle-income countries, including Nepal. We assessed the extent of intestinal parasite infections among schoolchildren in two districts of Nepal and determined underlying risk factors.; A cross-sectional survey was conducted between March and May 2015 in the districts of Dolakha and Ramechhap, Nepal. A total of 708 children, aged 8-16 years from 16 purposively selected schools, were enrolled. Each child provided a single stool sample that was subjected to a suite of copro-microscopic diagnoses for intestinal protozoa and helminths. Drinking water samples from different sources at schools (n = 29), community places (n = 43) and households (n = 562) were analysed for contamination with thermotolerant coliforms (TTC). A questionnaire was administered to determine individual- and household-level risk factors of intestinal parasite infections. Self-reported symptoms were assessed and a clinical examination was undertaken by a physician. Haemoglobin was measured and used as a proxy for anaemia. Mixed logistic regression models were applied to investigate associations.; The overall prevalence of intestinal parasite infections was 39.7%. Trichuris trichiura (30.9%), Giardia intestinalis (30.5%) and hookworm (30.2%) were the predominant intestinal parasite infections. Children from households lacking soap for handwashing were at higher odds of intestinal parasite infections than children who had soap [adjusted odds ratio (aOR) 1.81; 95% confidence interval (CI): 1.13-2.89; P = 0.01]. Children from households without freely roaming domestic animals showed lower odds of G. intestinalis compared to children from households with freely roaming animals (aOR 0.52; 95% CI: 0.33-0.83; P = 0.01). One out of three (31.0%) children suffered from fever and 22.4% had watery diarrhoea within a two-week recall period. Anaemia was diagnosed in 23.6% of the children. Water contamination with TTC showed no clear association with intestinal parasite infection.; Intestinal parasites are common among schoolchildren in the two surveyed districts of Nepal. An important risk factor was lack of soap for handwashing. Our findings call for efforts to control intestinal parasite infection and emphasis should be placed on improvements in water, sanitation and hygiene interventions.; ISRCTN17968589 (date assigned: 17 July 2015)

The role of Diabetes mellitus comorbidity on Tuberculosis treatment outcomes in Nepal: A prospective cohort study

Aim: The Objective of this study was to assess the effect of Diabetes Mellitus (DM) on treatment outcomes of tuberculosis (TB) patients in the Central Development Region of Nepal. Methods: A prospective cohort study was conducted in central Nepal. The study population of n=408 was consecutively recruited from treatment centers of all 19 districts of central Nepal. The TB cases (n=306) and TB with DM (n=102) cases were followed up for the estimation of blood glucose level, HbA1c level, and sputum examination on 2, 5, and 6 months after TB treatment started. The Generalized Estimating Equation (GEE) was performed to identify the risk ratio among TB and TB with DM cases on treatment outcome. Results: Our study identified that the magnitude of treatment failure among the tuberculosis cases was 19.7% (95% CI: 17.44-21.95). The GEE analysis observed that factors associated with the treatment failure had uncontrolled DM (HbA1C ≥7 %) (adj.RR=5.24, 95% CI: 2.58-10.62, P value &lt;0.001), aged ≥ 45 (adj.RR= 6.13, 95% CI: 2.55-14.76, P value &lt;0.001), had inadequate financial status (adj.RR= 2.33, 95% CI: 1.07-5.06, P value 0.033) and had prior TB (adj.RR=2.33, 95% CI: 1.09-4.97, P value 0.028) respectively.&nbsp; Conclusion: The prevalence of worsening TB treatment among patients with TB and DM was significantly higher than those who had TB only. Poor glycaemic control, increasing age, inadequate financial status, and previous history of tuberculosis were strong predictors of worsening tuberculosis treatment outcomes. Conflict of interest: None declared. Ethical approval: The Ethics Committee in Human Research of Khon Kaen University, Khon Kaen, Thailand (HE612209), the Nepal Health Research Council (2640) and Institutional Review Committee (Protocol approved number 01/18), Kathmandu University School of Medical Sciences, Dhulikhel, Nepal had approved to conduct this study. Acknowledgment: The author wishes to thank the National Tuberculosis Centre, Nepal, for providing the approval to conduct this study. We would like to express our sincere gratitude to the Faculty of Public Health, Khon Kaen University, for their sincere guidance and support during the study period

Delay for First Consultation and Its Associated Factors among New Pulmonary Tuberculosis Patients of Central Nepal

Tuberculosis (TB) is still a major public health challenge in Nepal and worldwide. Most transmissions occur between the onset of symptoms and the consultation with formal health care centers. This study aimed to determine the duration of delay for the first consultation and its associated factors with unacceptable delay among the new sputum pulmonary tuberculosis cases in the central development region of Nepal. An analytical cross-sectional study was conducted in the central development region of Nepal between January and May 2015. New pulmonary sputum positive tuberculosis patients were interviewed by using a structured questionnaire and their medical records were reviewed. Among a total of 374 patients, the magnitude of patient delay was 53.21% (95% CI: 48.12–58.28%) with a median delay of 32 days and an interquartile range of 11–70 days. The factors associated with unacceptable patient delay (duration ≥ 30 days) were residence in the rural area (adj. OR = 3.10, 95% CI: 1.10–8.72; p value = 0.032) and DOTS center located more than 5 km away from their residences (adj. OR = 5.53, 95% CI: 2.18–13.99; p value < 0.001). Unemployed patients were more likely to have patient delay (adj. OR = 7.79, 95% CI: 1.64–37.00; p value = 0.010) when controlled for other variables

Perception of obesity and overweight among adults living in suburban Nepal: a qualitative study

Objective To explore the perception of obesity and overweight among Nepalese adults living in a suburban community.Design A qualitative study composed of focus group discussion (FGD) and in-depth interview (IDI).Setting Community and healthcare facilities in Dhulikhel, Nepal.Participants Four FGDs were conducted with community members (n=22) and four IDIs were conducted with healthcare providers (HCPs).Results Obesity is a rising problem in this suburban community. Participants had inadequate knowledge regarding the consequences of obesity, and they perceived overweight as normal, healthy and attractive. The participants above 40 years of age did not perceive themselves to be overweight or obese. Despite participants’ awareness of the importance of diet control and exercise to prevent obesity, these were not translated into practice.Conclusions This study provided insight into perceptions of obesity in a suburban Dhulikhel community through both community members’ and HCPs’ perspective. Misconceptions and inadequate knowledge of obesity among people in this community indicate the need for health education and intervention programme to increase health awareness and preventive practices