Months In Nepal Research Articles

Micronutrient Intake and Its Association With Anemia Among Children 6-59 Months In Nepal

Micronutrient Intake and Its Association With Anemia Among Children 6-59 Months In Nepal

Association between Child Nutritional Anthropometric Indices and Iron Deficiencies among Children Aged 6-59 Months in Nepal.

Developmental impairment remains an important public health problem among children in many developing countries, including Nepal. Iron deficiency in children may affect development and lead to anaemia. This study on 1702 children aged 6-59 months aimed to assess the association between nutritional anthropometric indices and iron deficiencies. Data for this study were extracted from the 2016 Nepal National Micronutrient Status Survey. Three nutritional anthropometric indices (stunting, wasting and underweight) and their association with anaemia and iron deficiencies (ferritin and sTfR biomarkers) were assessed by conducting multivariate statistical analyses. The prevalence of stunting, wasting and underweight among children aged 6-59 months was 35.6%, 11.7% and 29.0%, respectively. Most of the children were not stunted (64.4%), not wasted (71.0%) and not underweight (88.3%). Belonging to castes other than the Janajati, Dalit and Brahmin castes increased the odds of anaemia and iron deficiency (ferritin biomarker). Children in the age group 6-23 months were significantly at higher odds of having anaemia and iron deficiency (ferritin and sTfR biomarkers). Stunting significantly increased the odds of anaemia [adjusted odds ratio (OR): 1.55; 95% confidence interval (CI): (1.11, 2.17)], iron deficiency (ferritin biomarker [OR: 1.56; 95% CI: (1.16, 2.08)] and sTfR biomarker [OR: 1.60; 95% CI: (1.18, 2.15)]). Further, underweight significantly increased the odds of anaemia [OR: 1.69; 95% CI: (1.12, 2.54)] and iron deficiency (sTfR biomarker [OR: 1.48; 95% CI: (1.14, 1.93)]). Interventions to minimise the occurrence of anaemia and iron deficiencies among children in Nepal should focus on providing appropriate healthcare services that would reduce the burden of stunting and underweight.

Factors affecting on compliance of childhood immunization in Ilam District of Nepal; A case-control study.

Childhood immunization is one of the most important public health interventions to reduce child morbidity and mortality. Reaching all children with full immunization services is critical to meet Nepal's commitment to Sustainable Development Goals (SDGs). This study aimed to identify factors affecting compliance with childhood immunization in children aged 16 to 36months in Nepal. A community-based unmatched case-control study was conducted with 250 (83 cases and 167 controls) respondents in the Ilam district of Nepal. Respondents were randomly selected using a multi-stage cluster sampling technique. Data were collected using a structured questionnaire and analysed using SPSS version 16 statistical software. Bivariate and multivariate logistic regression analyses were done to identify the factors influencing compliance with childhood immunization of the sampled respondents. More than two-thirds (66.8%) of the sampled children were fully immunized, and 19.3% of the children defaulted to the Measles-Rubella vaccines. Only 19.2% of the respondents had good knowledge about the type of vaccine, and more than half (59.2%) of the respondents had a positive attitude towards immunization. Multivariate logistic regression analysis revealed that lack of knowledge about vaccines (AOR=49.4, 95% CI=12.94 to 188.59), father's level of education (AOR=2.1, 95% CI=1.05 to 4.30), not getting immunization on the day of the appointment (AOR=4.8, 95% CI=2.30 to 9.89), lack of knowledge about immunization schedule (AOR=2.4, 95% CI=1.14 to 4.84), and negative attitude towards immunization (AOR=2.1, 95% CI=1.03 to 4.19) were independently impeded on compliance on the childhood immunization. Targeted intervention in health promotion activities at the household level should be promoted and integrated immunization services into the existing primary health care services.

Methodological choices for an economic evaluation of a combined psychosocial and nutrition treatment intervention for children with severe acute malnutrition: The FUSAM trial in Nepal

As a public health burden, severe acute malnutrition (SAM) among children has been increasingly studied to determine the optimal combination of treatment approaches. Among the new approaches is the addition of early childhood development sessions to standard nutrition-based treatment for SAM which can enhance both nutrition and development outcomes among young children. However, few studies demonstrate the relationship between the costs of such combined programs and the benefits accrued to the children and their caregivers. This article describes our experience of designing and conducting an economic evaluation alongside a cluster randomized controlled trial assessing a combined nutrition and psychosocial intervention for the treatment of SAM in children aged 6–24 months in Nepal. We present key lessons learned regarding methodological choices, the challenges of field data collection, as well as study adjustment when data analysis did not unfold as anticipated. With the view to transparency, this manuscript provides some clarifications on the evaluation processes for funders and policy makers on what economic evaluations entail and what information they convey for the purpose of supporting policy decision-making around limited resource allocation.

Learning and the ‘change enterprise’: inclusion and ambivalences in an educational action research and development project

ABSTRACT Educational action research in development projects applies participative methods to include people with diverse backgrounds, experiencing learning collaboratively. In this article, I explore the learning activities, and their outcomes, unfolding in those settings. Based on project documents, 34 interviews with project staff and smallholder farmers, and participant observations for three months in Nepal, I analyse the action research and development project ‘Strengthening Adaptive Farming in Bangladesh, India and Nepal’ (SAF-BIN), and show how inclusive activities allow for critical reflection, individual experience, and dialogue. I find dialectics in this process of adjustment, such as resistant social and cultural arrangements that are activated. The inclusion of specific social groups, for example, goes along with exclusionary dynamics. This case illustrates that inclusion and action research can be conceptualised at least threefold: from a dialectical, institutional, and learning perspective. I conclude that action research in development provides a fruitful basis for learning, allows for legitimacy, and temporarily leads to social change at a micro-level, for better or worse.

Individual, household and national factors associated with iron, vitamin A and zinc deficiencies among children aged 6-59 months in Nepal.

Iron, vitamin A and zinc deficiencies are the top three micronutrients contributing to disability‐adjusted life years globally. The study assessed the factors associated with iron, vitamin A, and Zinc deficiencies among Nepalese children (n = 1709) aged 6–59 months using data from the 2016 Nepal National Micronutrient Status Survey. The following cut‐off points were applied: iron deficiency [ferritin < 12 μg/L or soluble transferrin receptor (sTfR) > 8.3 mg/L], vitamin A deficiency (retinol‐binding protein < 0.69 μmol/L) and zinc deficiency (serum zinc < 65 μg/dl for morning sample and <57 μg/dl for afternoon sample). We used multiple logistic regression adjusted for sampling weights and clustering to examine the predictors of micronutrient deficiencies. The prevalence of iron depletion (ferritin), tissue iron (sTfR), vitamin A and zinc deficiencies were 36.7%, 27.6%, 8.5% and 20.4%, respectively. Children were more likely to be iron deficient (ferritin) if aged 6–23 months, stunted, and in a middle‐wealth quintile household. Vitamin A deficiency was associated with development region and was higher among children living in severe food‐insecure households and those who did not consume fruits. Zinc deficiency was higher among children in rural areas and the poorest wealth quintile. The Government of Nepal should focus on addressing micronutrient deficiencies in the early years, with emphasis on improving food systems, promote healthy diets, among younger and stunted children and provide social cash transfer targeting high‐risk development regions, poorest and food insecure households.

Accuracy of Using Mid-Upper Arm Circumference to Detect Wasting Among Children Aged 6-59 Months in Nepal.

In countries with a high prevalence of undernutrition, timely, accurate screening at the community level is essential to identify children with wasting. The World Health Organization recommends using either weight-for-height z-scores (WHZ) and mid-upper arm circumference (MUAC) or both measures and signs of edema to be used to identify children with severe acute malnutrition for treatment. We compared WHZ and MUAC cutoffs to identify wasting among children aged 6-59 months in Nepal, using WHZ as the reference standard. We used cross-sectional anthropometric data for 3,169 children aged 6-59 months from a 2017 cross-sectional dataset, representative of 42 of Nepal's 77 districts. We used descriptive statistics, receiver operating characteristic (ROC) curves, and kappa statistics to compare the use of MUAC and WHZ to identify wasting. The Youden index was calculated to determine the optimum MUAC cutoffs. The prevalence of wasting was 3.1% and 10.5% using MUAC and WHZ, respectively. We found 13.6% sensitivity for severe acute malnutrition (SAM) (MUAC <115 mm) and 21.0% sensitivity for moderate acute malnutrition (MAM) (MUAC ≥115 to <125 mm), with specificity of 99.7% and 91.2%, respectively. The sensitivity of MUAC for children aged 6-23 months was higher than for children aged 24-59 months. The total area of the ROC curve was 0.53 for the MUAC cutoff for SAM and 0.56 for MAM. The optimum MUAC cutoffs for SAM and MAM were 125 mm and 132 mm, respectively. Although MUAC can be used as a rapid screening tool to detect wasting in children aged 6-59 months, using the recommended MUAC cutoffs captures only a small proportion of the total number of wasted children. The poor sensitivity and specificity of MUAC compared to WHZ suggests a need to refine admission and discharge criteria for acute malnutrition management programs to ensure that wasting among infants and children in Nepal is consistently and accurately diagnosed and treated.

Factors Associated with Discontinuing Exclusive Breastfeeding among Mothers of Infants Aged 0-6 Months

IntroductionKnowing breastfeeding is one of the easiest and cost-effective ways to maintain a good childhealth, majority infants are not exclusively breastfed for the recommended 6 months of age.Thus, the aim of the study was to find out the factors associated with discontinuing exclusivebreastfeeding (EBF) among mothers of infants’ aged 0-6 months. MethodsA analytical study design was used to find out the factors associated with discontinuing EBFamong mothers of infants’ aged 0-6 months in Nepal. A total of 380 mothers of infants whosechild were 0-6 months old were selected using non-probability purposive sampling techniquethrough online survey as people are advised to stay at home during the Covid-19 outbreak. Datawas collected using structured questionnaire with interview technique. ResultsStudy findings revealed that half (50.5%) of the mothers exclusive breastfed their infants withmother’s mean age being 27.39 ± 3.64 years. Discontinuation of EBF varied with mothers age,ethnicity, mother’s educational level, initiation of breastfeeding and sources of informationregarding EBF as newspaper/articles and relatives/friends/neighbors (p=&lt;0.005). The factorsrelated to mother that are associated with discontinuation of EBF were found to be perceivedinsufficient milk, cesarean section delivery, jobholder mother (p= &lt;0.001) respectively. ConclusionsOnly half of respondents exclusively breastfed their infants for the recommended age in whichonly factors related to mother were significant with discontinuation of EBF rather than infants’.Findings of the study emphasizes on counselling the mothers regarding the benefits of EBF toboth child and mother during hospital visits. Keywords: exclusive breastfeeding; factors; under 6 months; EBF.

COVID-19 Containment Efforts of a Low-Resource Nation: The First Four Months in Nepal.

A novel coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) was identified in hospitalized patients in Wuhan, China, in December 2019. It rapidly spread across the globe within the span of a few months. Nepal is a low-resource country with limited critical care delivery infrastructure. Coronavirus 2019 (COVID-19), the disease caused by the virus, could potentially cause a medical catastrophe in Nepal. We reviewed all pertinent documents published in the public domain by the Ministry of Health and Population of Nepal and other relevant literature. We aimed to describe the key strategies Nepal embraced in the first four months in its attempt to curtail the disease immediately following the identification of its first case and the challenges it faced. In our review, we determined that the key steps taken by Nepal included border control to prevent the importation of cases, strict quarantine in facilities for anyone entering the country, early case detection, and isolation of all infected cases irrespective of symptoms. Testing capabilities, quarantine facilities, and isolation beds were also rapidly increased. We discuss how Nepal achieved some success in the first four months between January 13, 2020, when the first case was identified, to May 13, 2020. However, it faced several challenges that ultimately led to an exponential rise in cases thereafter.

Efficacy, duration of protection, birth outcomes, and infant growth associated with influenza vaccination in pregnancy: a pooled analysis of three randomised controlled trials

SummaryBackgroundMaternal influenza immunisation can reduce morbidity and mortality associated with influenza infection in pregnant women and young infants. We aimed to determine the vaccine efficacy of maternal influenza immunisation against maternal and infant PCR-confirmed influenza, duration of protection, and the effect of gestational age at vaccination on vaccine efficacy, birth outcomes, and infant growth up to 6 months of age.MethodsWe did a pooled analysis of three randomised controlled trials done in Nepal (2011–2014), Mali (2011–2014), and South Africa (2011–2013). Pregnant women, gestational age 17–34 weeks in Nepal, 28 weeks or more in Mali, and 20–36 weeks in South Africa, were enrolled. Women were randomly assigned 1:1 to a study group, in which they received trivalent inactivated influenza vaccine (IIV) in all three trials, or a control group, in which they received saline placebo in Nepal and South Africa or quadrivalent meningococcal conjugate vaccine in Mali. Enrolment at all sites was complete by April 24, 2013. Infants and women were assessed for respiratory illness, and samples from those that met the case definition were tested for influenza by PCR testing. Growth measurements, including length and weight, were obtained at birth at all sites, at 24 weeks in South Africa, and at 6 months in Nepal and Mali. The three trials are registered with ClinicalTrials.gov, numbers NCT01430689, NCT01034254, and NCT02465190.Findings10 002 women and 9800 liveborn infants were included. Pooled efficacy of maternal vaccination to prevent infant PCR-confirmed influenza up to 6 months of age was 35% (95% CI 19 to 47). The pooled estimate was 56% (28 to 73) within the first 2 months of life, 39% (11 to 58) between 2 and 4 months, and 19% (–9 to 40) between 4 and 6 months. In women, from enrolment during pregnancy to the end of follow-up at 6 months postpartum, the vaccine was 50% (95% CI 32–63) efficacious against PCR-confirmed influenza. Efficacy was 42% (12 to 61) during pregnancy and 60% (36 to 75) postpartum. In women vaccinated before 29 weeks gestational age, the estimated efficacy was 30% (–2 to 52), and in women vaccinated at or after 29 weeks, efficacy was 71% (50 to 83). Efficacy was similar in infants born to mothers vaccinated before or after 29 weeks gestation (34% [95% CI 12 to 51] vs 35% [11 to 52]). There was no overall association between maternal vaccination and low birthweight, stillbirth, preterm birth, and small for gestational age. At 6 months of age, the intervention and control groups were similar in terms of underweight (weight-for-age), stunted (length-for-age), and wasted (weight-for-length). Median centile change from birth to 6 months of age was similar between the intervention and the control groups for both weight and length.InterpretationThe assessment of efficacy for women vaccinated before 29 weeks gestational age might have been underpowered, because the point estimate suggests that there might be efficacy despite wide CIs. Estimates of efficacy against PCR-confirmed influenza and safety in terms of adverse birth outcomes should be incorporated into any further consideration of maternal influenza immunisation recommendations.FundingBill & Melinda Gates Foundation.

Age, Ethnicity, Glucose-6-Phosphate Dehydrogenase Deficiency, Micronutrient Powder Intake, and Biomarkers of Micronutrient Status, Infection, and Inflammation Are Associated with Anemia Among Children 6–59 Months in Nepal

Anemia is a major concern for children in Nepal; however, little is known about context-specific causes of anemia. We used cross-sectional data from the 2016 Nepal National Micronutrient Status Survey to evaluate factors associated with anemia in a nationally representative, population-based sample of children 6-59mo (n=1367). Hemoglobin, biomarkers of iron status and other micronutrients, infection, inflammation, and blood disorders were assessed from venous blood samples. Soil-transmitted helminth (STH) and Helicobacter pylori infections were assessed from stool. Anthropometry was measured with standard procedures. Sociodemographic and household characteristics, diet, micronutrient powder (MNP) intake, pica, and morbidity recall were ascertained by caregiver interview. Multivariable logistic regression that accounted for complex sampling design, determined predictors of anemia (hemoglobin <11.0g/dL, altitude adjusted); candidate predictors were variables with P<0.05 in bivariate models. Anemia prevalence was 18.6% (95% CI: 15.8, 21.4). MNP intake [adjusted OR (AOR): 0.25, 95% CI: 0.07, 0.86], log (ln) ferritin (μg/L) (AOR: 0.49, 95% CI: 0.38, 0.64), and ln RBP (μmol/L) (AOR: 0.42, 95% CI: 0.18, 0.95) were associated with reduced odds of anemia. Younger age (6-23 mo compared with 24-59 mo; AOR: 2.29, 95% CI: 1.52, 3.46), other Terai ethnicities (AOR: 2.59, 95% CI: 1.25, 5.35) and Muslim ethnicities (AOR: 3.15, 95% CI: 1.30, 7.65) relative to Brahmin/Chhetri ethnicities, recent fever (AOR: 1.68, 95% CI: 1.08, 2.59), ln C-reactive protein (mg/L) (AOR: 1.23, 95% CI: 1.03, 1.45), and glucose-6-phosphate dehydrogenase deficiency (AOR: 2.84, 95% CI: 1.88, 4.30) were associated with increased odds of anemia. Both nonmodifiable and potentially modifiable factors were associated with anemia. Thus some but not all anemia might be addressed through effective public health policy, programs, and delivery of nutrition and infection prevention and control.

Sociodemographic factors associated with inadequate food group consumption and dietary diversity among infants and young children in Nepal.

Infants and young children need diversified diets to grow healthy. However, there is limited evidence on factors associated with consumption of various food groups. This study aimed to identify the sociodemographic factors associated with inadequate food group consumption and not meeting the minimum dietary diversity (MDD) among infants and young children aged 6–23 months in Nepal. Using cross-sectional data from the 2016 Nepal Demographic and Health Survey, the factors at the individual-, household-, and community-levels associated with not consuming foods from the seven food groups, which are grains, roots and tubers, legumes and nuts, dairy products, flesh foods, eggs, vitamin-A rich fruits and vegetables, and other fruits and vegetables, and not meeting the MDD were examined. The least consumed food group was eggs, followed by flesh foods and 46.5% of children received the MDD. Children aged 6–11 months had higher odds of not consuming foods from the seven food groups and not meeting the MDD than older children. Children from the poorest quintile had higher odds of not consuming legumes and nuts, dairy products, flesh foods, and other fruits and vegetables, and not meeting the MDD. Children from Terai/Madhesi Other had higher odds of not consuming foods from the seven food groups compared to those from the other groups. Children from Province 2 had higher odds of not consuming eggs, vitamin-A rich fruits and vegetables, and other fruits and vegetables, and not meeting the MDD. Dietary diversity among children in Nepal needs improvement. National policies and programs need to promote the consumption of diverse food groups by considering different sociodemographic characteristics.

Preparing for rotavirus vaccine introduction – A retrospective assessment of the epidemiology of intussusception in children below 2 years of age in Nepal

BackgroundRotavirus is the most common cause of severe diarrhea in Nepali children, accounting for 25–33% of childhood diarrhea hospitalizations. Two rotavirus vaccines recommended for inclusion in national immunization programs have been associated with a low risk of intussusception in post-marketing studies conducted in several countries. Data on the epidemiology of intussusception hospitalizations are lacking in Nepal. Thus, we aimed to describe the epidemiology of intussusception-associated hospitalizations among Nepali children in preparation for rotavirus vaccine introduction. MethodsA retrospective review of intussusception hospitalizations for a three year period was conducted at two major pediatric hospitals in Kathmandu, Nepal. Possible intussusception cases were identified through admission, discharge, and operation theater logs and ultrasound registers. Cases with a diagnosis of possible intussusception were selected for medical record review and classified as confirmed if they met the Brighton Collaboration level 1 criteria of diagnostic certainty and the child was aged < 24 months. Data on demographics, clinical course, and outcome were abstracted and analyzed. ResultsEight-five confirmed intussusception cases were identified; most (96%) were confirmed at surgery. The number of intussusception cases peaked between ages 4–7 months; no cases occurred in children 0–2 months. Fifty-nine (64%) case-patients were male. The median duration of symptoms before admission was 2 days (range: 0–14). Abdominal pain, bloody stool, and vomiting were the most common clinical features. All cases underwent surgical treatment; there was only one death. ConclusionsThis is the first study to evaluate the epidemiology of intussusception hospitalizations among children aged < 24 months in Nepal. Because the public health impact of rotavirus vaccination could be substantial in Nepal, where childhood diarrhea-related morbidity and mortality are high, this baseline knowledge of intussusception prior to introduction of rotavirus vaccine in the national immunization schedule will provide useful information for post-vaccine introduction safety monitoring.

Population-Based Pertussis Incidence and Risk Factors in Infants Less Than 6 Months in Nepal.

BackgroundPertussis is estimated to cause 2 percent of childhood deaths globally and is a growing public health problem in developed countries despite high vaccination coverage. Infants are at greatest risk of morbidity and mortality. Maternal vaccination during pregnancy may be effective to prevent pertussis in young infants, but population-based estimates of disease burden in infants are lacking, particularly in low-income countries. The objective of this study was to estimate the incidence of pertussis in infants less than 6 months of age in Sarlahi District, Nepal.MethodsNested within a population-based randomized controlled trial of influenza vaccination during pregnancy, infants were visited weekly from birth through 6 months to assess respiratory illness in the prior week. If any respiratory symptoms had occurred, a nasal swab was collected and tested with a multitarget pertussis polymerase chain reaction (PCR) assay. The prospective cohort study includes infants observed between May 2011 and August 2014.ResultsThe incidence of PCR-confirmed Bordetella pertussis was 13.3 cases per 1000 infant-years (95% confidence interval, 7.7–21.3) in a cohort of 3483 infants with at least 1 day of follow-up.ConclusionsIn a population-based active home surveillance for respiratory illness, a low risk for pertussis was estimated among infants in rural Nepal. Nepal’s immunization program, which includes a childhood whole cell pertussis vaccine, may be effective in controlling pertussis in infants.

An inexpensive device to treat postpartum hemorrhage: a preliminary proof of concept study of health provider opinion and training in Nepal

BackgroundObstetric hemorrhage remains the leading cause of maternal mortality in resource limited areas. An inexpensive pneumatic anti-shock garment was devised of bicycle tubes and tailored cloth which can be prepared from local materials in resource-limited settings. The main purposes of this study were: 1) to determine acceptability of the device by nurses and midwives and obtain suggestions for making the device more suitable for use in their particular work environments, 2) to determine whether a three hour training course provided adequate instruction in the use of this device for the application of circumferential abdominal pelvic pressure, and 3) determine production capability and cost in a resource-limited country.MethodsFifty-eight nurse and midwife participants took part in three sessions over eight months in Nepal. Correct device placement was assessed on non-pregnant participants using ultrasound measurement of distal aortic flow before and after device inflation, and analyzed using confidence intervals. Participants were surveyed to determine acceptability of the device, obtain suggestions for improvement, and to collect data on clinical use.ResultsDevice placement achieved flow decreases with a mean of 39% (95% CI 25%-53%, p < 0.001) in the first session, 28% (95% CI 21%-33%, P < 0.001) after four months and 29% (95% CI 24%-34%, p < 0.001) at 8 months. All nurses and midwives thought the device would be acceptable for use in obstetric hemorrhage and that they could make, clean, and apply it. They quickly learned to apply the device, remembered how to apply it, and were willing and able to use the device clinically. Ten providers used the device, each on one patient, to treat obstetric hemorrhage after routine measures had failed; bleeding stopped promptly in all ten, two of whom were transported to the hospital. Production of devices in Kathmandu using local tailors and supplies cost approximately $40 per device, in a limited production setting.ConclusionsPreliminary data suggest that an inexpensive, easily-made device is potentially an appropriate addition to current obstetric hemorrhage treatment in resource-limited areas and that further study is warranted.

Commentary: Understanding practical lot quality assurance sampling

Commentary: Understanding practical lot quality assurance sampling