Mortality In Nepal Research Articles

Estimating potentially preventable ambient PM2.5-attributable adult deaths by improving air quality in Nepal

Air pollution is an important global environmental health risk factor, with many Asian countries experiencing alarming levels in recent decades. Nepal, a South Asian country, has been facing severe degradation in air quality in recent years, where data are scarce on the health impact of air pollution, especially at sub-national levels. In this study, we investigated ambient fine particulate matter (PM2.5)-attributable adult (≥25 years) premature mortality in Nepal, analyzed its long-term trend, and estimated potentially preventable adult mortality under different improved air quality scenarios defined using the World Health Organization's (WHO) interim targets (IT) and the air quality goal (AQG). Leveraging an open-source high-resolution PM2.5 dataset and an age-specific population dataset, we employed the Global Exposure Mortality Model to estimate mean and 95% confidence intervals of PM2.5-attributable adult mortality using Monte Carlo simulations. We estimated the country-level NCD + LRI (non-communicable diseases and lower respiratory infections) adult deaths attributable to PM2.5 exposure as 48881 (95% CI: 37175−61470), and the PM2.5-attributable NCD + LRI adult mortality rate as 267 (95% CI: 203−335) per 100000 in 2019. The adult mortality burden consistently increased during 2000–2019. Moreover, improving air quality to the WHO ITs and AQG could prevent an estimated 9690 (95% CI: 7698−11812) to 39419 (95% CI: 30311−49277) premature adult deaths across the country in 2019. Our findings suggest that the adult mortality burden due to air pollution in Nepal is substantial, which offers an opportunity to prevent a considerable number of premature adult deaths by mitigating air pollution in the country.

Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021

BackgroundNepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved.MethodsCross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs.ResultsDespite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent.ConclusionsThe slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

COVID-19 mortality and its associated factors in Nepal: A cross-sectional study

ObjectivesReports from other countries have indicated that severe forms and fatal cases of COVID-19 in older adults and people with underlying comorbidities. The aim of this study was to assess the risk factors associated with COVID-19 mortality in Nepal. MethodsA cross-sectional study was conducted from April 12 to July 23, 2021 to identify the underlying factors associated with COVID-19 deaths. Our sample included all cases diagnosed and registered as COVID-19–related deaths at 30 hospitals of Nepal. ResultsA total of 1459 COVID-19 hospital-based death records were collected from 30 hospitals. Mean age at death was 60.2 (±15.6) years. One-third of cases were admitted with fever, cough, and shortness of breath. The computerized tomography Severity Score showed that 7.3% of the individuals who underwent high-resolution computerized tomography chest had a severe form of lung involvement, and 3.6% had mild to moderate involvement. The most common comorbidities were hypertension (43.7%) followed by diabetes mellitus (25.8%). Among the deceased, 37.7% were diagnosed as cases of COVID-19 pneumonia. The most common recorded causes of death were respiratory failure followed by cardio-pulmonary arrest. ConclusionsIndividuals with comorbidities including hypertension and diabetes mellitus were at greater risk of developing complications and had a higher rate of mortality.

Community Advanced First Aid Training for Day-to-Day Emergency and Disaster Response in Nepal

Introduction:Nepal is a country with geographical difficulties in tackling day-to-day emergency healthcare and disaster preparedness. The aim is to develop community preparedness by training for day-to-day emergency and disaster response in Nepal to generate preventive and first aid awareness of consequences and complications of simple to severe emergency conditions during day-to-day emergencies and disasters.Method:It is an analysis of five years of advanced first-aid training at the Nepal Disaster and Emergency Medicine Center from July 2015 to March 2020. In April 2015, the earthquake affected 15 districts of Nepal.Results:During July 2015 to March 2020, NADEM has been training 3,995 Community First Aiders for Male Leaders and Active Community people: 1,315 special mothers’ group–Adolescent Maternity & Child Health First Aiders; 794 Ambulance Drivers–Advanced First Aid Trained of remote districts of Mountain and hilly region’s ambulance’s Drivers and Assistants ; 637 ToT First Aiders for Community School Teachers (Training of Trainers); Total AFAT Trained by NADEM = 6,741 (Province 1 to 5); Total Population AFAT Trained = 52,610 (Province 1 to 5); Total Population Benefit by AFAT = 902,100 and its ongoing. NADEM Study Reports of Nepali community with ‘Incident Rate of First Aid Required’ is 9% per day with First Aid Services for 87.4% minor causes, 5.4% major causes, 0.5% gynecological causes, 1.7% AMCH causes, 4.5% trauma causes, 0.5% Prehospital Cardiac Arrest. With NADEM advanced first-aid training, now we are preventing 70% of deaths in remote parts of those districts before reaching the health care centers.Conclusion:It is a great challenge to train community laypersons to be Community First Aiders who can tackle day-to-day emergencies and disasters in their community with knowledge, skills practice, and attitude to prepare and prevent the increased tendencies of disability, deformity, morbidity, and mortality in Nepal.

Scale-Up of a Newborn Resuscitation Capacity-Building and Skill Retention Program Associated With Improved Neonatal Outcomes in Gandaki Province, Nepal.

Intrapartum events leading to asphyxia at birth are a leading cause of neonatal morbidity and mortality in Nepal. In response, the Nepal Ministry of Health and Population adopted the Helping Babies Breathe (HBB) training curriculum in 2015 as a tool to improve neonatal resuscitation and outcomes. Although the effectiveness of HBB training has been well documented, challenges remain in maintaining skills over time. Safa Sunaulo Nepal (SSN) designed an evidence-based intervention for scaling up newborn resuscitation training and skill retention. We report on its implementation and the changes in newborn outcomes during the program period. The program empowered facility-based trainers in newborn resuscitation and skill retention at 12 facilities in Gandaki Province. Seven of 14 level I hospitals and 5 of 6 level II hospitals were selected. A single external mentor coached the facility-based trainers, provided general support, and monitored progress. Program evaluation tracked changes in newborn metrics over 21 Nepali months (March 2018-November 2019). All deliveries occurring in the health facilities during the program period were included in the evaluation. We assessed program effectiveness by analyzing time trends of neonatal mortality, morbidity, and stillbirths. We gathered data on neonatal health outcomes of 33,417 deliveries, including 23,820 vaginal deliveries and 9,597 cesarean deliveries. During the program, 43 facility-based trainers taught resuscitation skills to 425 medical personnel and supported skill retention. Neonatal deaths within 24 hours of birth (incidence rate ratio [IRR]=0.993, P=.044) and newborn morbidities (IRR=0.996, P<.001) showed a significantly declining trend. Our findings suggest that the SSN program had a substantial influence on critical neonatal outcomes. Future neonatal resuscitation capacity-building and skill retention efforts may benefit from incorporating elements of the program.

Utilization of Maternal Health Care Services and Home or Hospital Delivery of Child Birth Among Women of Deupurkot VDC of Parbat District in Nepal

Background Nepal has made significant improvement in meeting the maternal and child health care services also progress newborn, infant and under mortality over the past two decades. The stark disparities on utilization of health services due to women with lower education, low wealth quintile household, disadvantage cast/ethnic groups and women in remote areas. The utilization of available maternal health care services from public and private service is remarkable to reduce maternal morbidity and mortality in Nepal. Methods The community base descriptive cross sectional study was conducted in 509 households through door to door home visit in Deupurkot VDC covering all first to nine wards. The information was obtained using pretested questionnaire of Pokhara University by Bachelor level students of Public Health. The data was entered into Microsoft excel and analyzed. The data was collected from 19th November to 18th December 2014. Results The nuclear family size was (74.3%). Majority (80%) of the household have their pakka house, (95.7%) household used sanitary latrine and (86.7%) household heads were literate. The major occupation was agriculture (52.55%). The age of marriage before 18 yrs was (25.30%). Majority of women (81%) women used Injection Depo-Provera and less used device was Norplant/Implant user was (3.7%) World Health Organization (WHO) recommended almost (41%) had antenatal care (ANC) visit. Majority (96.70%) had gone for ANC visit and (67%) of them give birth their children at health institution. More than half (51.60%) women had knowledge of postnatal care (PNC) but (32.60%) used this service either in Health post, primary health care center (PHCC) or Hospital. Conclusion The antenatal care (ANC) visit were high in conclusion is high even up to WHO recommendation mark. There is a gap between knowledge of postnatal care (PNC) and its utilization, we need to improve this NPC visit gap utilizing available health services.

Differences in risk factors for head and neck cancer among men and women in Nepal: A case-control study

BackgroundHead and neck cancer (HNC) is a major cause of cancer morbidity and mortality in Nepal. The study aims to investigate differences in risk factors for head and neck cancer by sex in Nepal. MethodsA hospital-based case-control study was conducted at the B.P. Koirala Memorial Cancer Hospital in Nepal from 2016 to 2018. A semi-structured questionnaire consisting of socio-demographic characteristics, dietary habits, reproductive factors, household air pollution, tobacco use (smoking and chewing), alcohol consumption, and second-hand smoking was used to collect the data. Odds ratios (OR) and 95 % confidence intervals (CI) were estimated using unconditional logistic regression adjusting for potential confounders. ResultsA total of 549 HNC cases (438 men and 111 women) and 601 age-matched healthy controls (479 men and 122 women) were recruited in this study. An increased risk of HNC for low education level and family income were observed among men (adjusted odds ratio (AOR) for 3rd grade and less= 1.58, 95 % CI= 1.14–2.18; AOR for family monthly income < 5000 Rupees = 1.64, 95 % CI 1.20–2.24). The AORs among women were higher than the men for known risk factors (AOR for smoking 1.34 (95 % CI 0.96–1.86) for men, 2.94 (95 % CI 1.31–6.69) for women; AOR for tobacco chewing 1.76 (95 % CI 1.27–2.46) for men, 10.22 (95 % CI 4.53–23.03) for women). ConclusionOur results point to an effect modification by sex for HNC risk factors with high AORs observed among women.

Estimation of national and subnational all-cause mortality indicators in Nepal, 2017

BackgroundDespite the civil registration and vital statistics (CRVS) system in Nepal operating for several decades, it has not been used to produce routine mortality statistics. Instead, mortality statistics rely on irregular surveys and censuses that primarily focus on child mortality. To fill this knowledge gap, this study estimates levels and subnational differentials in mortality across all ages in Nepal, primarily using CRVS data adjusted for incompleteness.MethodsWe analyzed death registration data (offline or paper-based) and CRVS survey reported death data, estimating the true crude death rate (CDR) and number of deaths by sex and year for each province and ecological belt. The estimated true number of deaths for 2017 was used with an extension of the empirical completeness method to estimate the adult mortality (45q15) and life expectancy at birth by sex and subnational level. Plausibility of subnational mortality estimates was assessed against poverty head count rates.ResultsAdult mortality in Nepal for 2017 is estimated to be 159 per 1000 for males and 116 for females, while life expectancy was estimated as 69.7 years for males and 73.9 years for females. Subnationally, male adult mortality ranges from 129 per 1000 in Madhesh to 224 in Karnali and female adult mortality from 89 per 1000 in Province 1 to 159 in Sudurpashchim. Similarly, male life expectancy is between 64.9 years in Karnali and 71.8 years in Madhesh and female male life expectancy between 69.6 years in Sudurpashchim and 77.0 years in Province 1. Mountain ecological belt and Sudurpashchim and Karnali provinces have high mortality and high poverty levels, whereas Terai and Hill ecological belts and Province 1, Madhesh, and Bagmati and Gandaki provinces have low mortality and poverty levels.ConclusionsThis is the first use of CRVS system data in Nepal to estimate national and subnational mortality levels and differentials. The national results are plausible when compared with Global Burden of Disease and United Nations World Population Prospects estimates. Understanding of the reasons for inequalities in mortality in Nepal should focus on improving cause of death data and further strengthening CRVS data.

Lower Susceptibility to Fluoroquinolones and a gyrA Gene Mutation in Salmonella Typhi Isolates from Enteric Fever Patients.

Enteric fever remains a major cause of morbidity and mortality in Nepal. The emergence of multi-drug resistant Salmonella is a challenge to the clinician to care for patients with enteric fever. This study assessed the antibiotic susceptibility of Salmonella Typhi isolated from enteric fever and the presence of gyrA? ?gene mutation at ser83 of S. Typhi. Blood samples (n = 834) from suspected enteric fever patients were collected and cultured to identify Salmonella Typhi. Antimicrobial sensitivity test was performed by the modified Kirby Bauer disc diffusion method. The minimum ?inhibitory concentration (MIC) tests for ofloxacin and ciprofloxacin were examined by the agar dilution method. The gyrA gene was amplified by PCR and restriction enzyme digestion was performed to evaluate the ser83 mutation. Among 824 blood samples analyzed, 5.1% (42/824) were culture positive for S. Typhi. First-line antibiotics chloramphenicol and co-trimoxazole showed higher in-vitro efficacy compared to amoxicillin. Macrolides (azithromycin) and third-generation cephalosporins (ceftriaxone, cefixime, and cefotaxime) were highly effective against S. Typhi. Nalidixic acid resistance (NAR) was observed in 95.2% (40/42) isolates, among them, all (40/40) isolates harbored mutant gyrA gene at ser83. However, none of the nalidixic acid-sensitive Salmonella? isolates was positive for gyrA? mutation at ser83. This study showed decreased susceptibility to fluoroquinolones and the presence of gyrA? mutation at ser83 position in majority of S. Typhi isolates which highlights the importance of alternate drugs as empirical therapy for the treatment of enteric fever patients. So, the clinician should focus on prescribing conventional first-line antibiotics for the treatment of typhoid patients after higher cohort and extended follow-up studies.

Assessing the effectiveness of newborn resuscitation training and skill retention program on neonatal outcomes in Madhesh Province, Nepal.

Intrapartum events leading to asphyxia at birth are among the leading causes of neonatal morbidity and mortality in Nepal. In response to this, the Nepal Ministry of Health and Population adopted Helping Babies Breathe (HBB) as a tool to improve neonatal resuscitation competencies. The effectiveness of HBB trainings has been well established. However, challenges remain in maintaining skills over time. Safa Sunaulo Nepal (SSN), with support from Latter-day Saint Charities (LDS Charities) designed an initiative for scaling up newborn resuscitation training and skills maintenance over time. This paper reports on the implementation of the SSN model of newborn resuscitation trainings and skill retention, and the changes in perinatal outcomes that occurred after the program. The program built capacity among facility-based trainers for the scale up and maintenance of resuscitation skills in 20 facilities in Madhesh Province, Nepal. A single external Mentor coached and assisted the facility-based trainers, provided general support, and monitored progress. Prospective outcome monitoring tracked changes in health metrics for a period of 14 months. Data was gathered on the neonatal health outcomes of 68,435 vaginal deliveries and 9,253 cesarean sections. Results indicate decreases in neonatal deaths under 24 hours of life (p<0.001), intrapartum stillbirths (p<0.001), and the number of sick newborns transferred from the maternity unit (p<0.001). During the program, facility-based trainers taught resuscitation skills to 231 medical personnel and supported ongoing skill retention. The SSN model for newborn resuscitation training and skills retention is a low-cost, evidence-based program focusing on facility-based trainers who are mentored and supported to scale-up and sustain resuscitation skills over time. Findings from the report are suggestive that the model had a substantial influence on critical neonatal outcomes. Future programs focused on improving neonatal outcomes may benefit by incorporating program elements of SSN model.

Clinical Profile and Outcome in Patients with Organophosphorous Poisoning

INTRODUCTIONOrganophosphorous poisoning is a prevalent emergency care problem found in Nepal. Nepal being agricultural country and pesticide being easily available, organophorous poisoning is most common cause of poison related morbidity and mortality in Nepal. Main objective of the study is to evaluate the clinical profile and outcome of patients on the basis of demographic profile, type of compound, presenting symptoms and outcome. MATERIAL AND METHODSOur study included 80 patients with organophosphorous ingestion, admitted in ICU and wards of Universal College of Medical Sciences Teaching Hospital (UCMS-TH), Bhairahawa, Rupendehi, Nepal from1th July, 2019 AD to 30th July 2020 AD. Ethical clearance was obtained along with consent from patient. Data was collected from patient’s visitor. RESULTSFemales (63%) were more common than males (37%). Age group 21-30 was most likely to ingest OP compound for suicidal attempts.Chlorpyriphos (80%) was most common compound ingested.41% cases consumed alcohol, 10% cases were smokers, 11% cases had diabetes and 22% cases had hypertension. Vomiting (90% cases) was most common symptom. 54% cases had hospital stay of less than 5 days and 43% cases had hospital stay of 5-10 days.Based on POP scoring 24 cases of moderate severity 1 case died where as 3 cases out of 8 severe cases died.74% had uneventful recovery,11% developed intermediate symptoms,10% needed ventillatory support and 5% died due to poisoning. CONCLUSIONOrganophosphorous poisoning was the most common acute poisoning in young female population.Strict policies against the free availability and sale of insecticides is required to control organophosphorus poisoning.

Poor glycemic control, cardiovascular disease risk factors and their clustering among patients with type 2 diabetes mellitus: A cross-sectional study from Nepal.

Cardiovascular disease (CVD) is the most common complication of diabetes mellitus (DM). To prevent morbidity and mortality among patients with type 2 diabetes mellitus (T2DM), optimization of glycemic status and minimizing CVD risk factors is essential. As Nepal has limited data on these CVD risk parameters, we assessed the prevalence of poor glycemic control, CVD risk factors, and their clustering among patients with T2DM. Using a cross-sectional study design, we collected data of 366 patients with T2DM. We applied a multistage cluster sampling technique and used the WHO STEPS tools. Binary logistic and Poisson regression was applied to calculate odds and prevalence ratio of clustering of risk factors, considering P< 0.05 statistically significant. The mean age of participants was 54.5±10.7 years and 208 (57%) were male. The prevalence of poor glycemic control was 66.4% (95% C.I: 61.5-71.2). The prevalence of smoking, alcohol users, inadequate fruit and vegetables intake and physical inactivity were 18% (95% C.I:14 to 21.9), 14.8% (95% C.I:11.1 to 18.4), 98.1% (95% C.I: 96.7-99.4), and 9.8% (95% C.I:6.7-12.8), respectively. Overall, 47.3% (95% C.I: 42.1-52.4) were overweight and obese, 59% (95% C.I: 52.9-63) were hypertensive, and 68% (95% C.I: 63.2-72.7) had dyslipidemia. Clustering of two, three, four, five and more than five risk factors was 12.6%, 30%, 30%,19%, and 8.7%, respectively. Four or more risk factors clustering was significantly associated with gender, age, level of education, T2DM duration, and use of medication. Risk factors clustering was significantly higher among males and users of anti-diabetic medications with prevalence ratio of 1.14 (95% C.I:1.05-1.23) and 1.09 (95% C.I: 1.09-1.18)], respectively. The majority of the patients with T2DM had poor glycemic control and CVD risk factors. Policies and programs focused on the prevention and better management of T2DM and CVD risk factors should be implemented to reduce mortality in Nepal.

Is routine Vitamin A supplementation still justified for children in Nepal? Trial synthesis findings applied to Nepal national mortality estimates.

The World Health Organization has recommended Vitamin A supplementation for children in low- and middle-income countries for many years to reduce child mortality. Nepal still practices routine Vitamin A supplementation. We examined the potential current impact of these programs using national data in Nepal combined with an update of the mortality effect estimate from a meta-analysis of randomized controlled trials. We used the 2017 Cochrane review as a template for an updated meta-analysis. We conducted fresh searches, re-applied the inclusion criteria, re-extracted the data for mortality and constructed a summary of findings table using GRADE. We applied the best estimate of the effect obtained from the trials to the national statistics of the country to estimate the impact of supplementation on under-five mortality in Nepal. The effect estimates from well-concealed trials gave a 9% reduction in mortality (Risk Ratio: 0.91, 95% CI 0.85 to 0.97, 6 trials; 1,046,829 participants; low certainty evidence). The funnel plot suggested publication bias, and a meta-analysis of trials published since 2000 gave a smaller effect estimate (Risk Ratio: 0.96, 95% CI 0.89 to 1.03, 2 trials, 1,007,587 participants), with the DEVTA trial contributing 55.1 per cent to this estimate. Applying the estimate from well-concealed trials to Nepal's under-five mortality rate, there may be a reduction in mortality, and this is small from 28 to 25 per 1000 live births; 3 fewer deaths (95% CI 1 to 4 fewer) for every 1000 children supplemented. Vitamin A supplementation may only result in a quantitatively unimportant reduction in child mortality. Stopping blanket supplementation seems reasonable given these data.

Declining vulnerability but rising impacts: the trends of climatic disasters in Nepal

The impacts of climatic disasters have been rising globally. Several studies argue that this upward trend is due to rapid growth in the population and wealth exposed to disasters. Others argue that rising extreme weather events due to anthropogenic climate change are responsible for the increase. Hence, the causes of the increase in disaster impacts remain elusive. Disaster impacts relative to income are higher in low-income countries, but existing studies are mostly from developed countries or at the cross-country level. Here we assess the spatiotemporal trends of climatic disaster impacts and vulnerability and their attribution to climatic and socioeconomic factors at the subnational scale in a low-income country, using Nepal as a case study. Loss of life is the most extreme consequence of disasters. Therefore, we employed human mortality as a measure of disaster impacts, and mortality normalized by exposed population as a measure of human vulnerability. We found that climatic disaster frequency and mortality increased in Nepal from 1992 to 2021. However, vulnerability decreased, most likely due to economic growth and progress in disaster risk reduction and climate change adaptation. Disaster mortality is positively correlated with disaster frequency and negatively correlated with per capita income but is not correlated with the exposed population. Hence, population growth may not have caused the rise in disaster mortality in Nepal. The strong rise in disaster incidence, potentially due to climate change, has overcome the effect of decreasing vulnerability and caused the rise in disaster mortality.

Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.

District-Level Risk Factors for COVID-19 Incidence and Mortality in Nepal.

The recent global pandemic of the novel coronavirus disease 2019 (COVID-19) is affecting the entire population of Nepal, and the outcome of the epidemic varies from place to place. A district-level analysis was conducted to identify socio-demographic risk factors that drive the large variations in COVID-19 mortality and related health outcomes, as of 22 January 2021. Data on COVID-19 extracted from relevant reports and websites of the Ministry of Health and Population of Nepal, and the National Population and Housing Census and the Nepal Demographic and Health Survey were the main data sources for the district-level socio-demographic characteristics. We calculated the COVID-19 incidence, recovered cases, and deaths per 100,000 population, then estimated the associations with the risk factors using regression models. COVID-19 outcomes were positively associated with population density. A higher incidence of COVID-19 was associated with districts with a higher percentage of overcrowded households and without access to handwashing facilities. Adult literacy rate was negatively associated with the COVID-19 incidence. Increased mortality was significantly associated with a higher obesity prevalence in women and a higher smoking prevalence in men. Access to health care facilities reduced mortality. Population density was the most important driver behind the large variations in COVID-19 outcomes. This study identifies critical risk factors of COVID-19 outcomes, including population density, crowding, education, and hand hygiene, and these factors should be considered to address inequities in the burden of COVID-19 across districts.

Newborn Resuscitation Scale Up and Retention Program Associated with Improved Neonatal Outcomes in Western Nepal

The adoption of the Helping Babies Breath (HBB) tool has improved the outcomes of neonatal resuscitation following intrapartum events. Perinatal asphyxia however remains a leading cause of neonatal morbidity and mortality in Nepal. HBB training has proven effective, but a major challenge is maintaining resuscitation skills over time.

Perinatal Death Surveillance and Response: A Secondary Analysis of Nepal’s Efforts

This paper presents Nepal’s experience regarding perinatal death surveillance and the country’s response in reducing preventable perinatal deaths. In developing this paper, evidence of perinatal mortality in Nepal is brought from secondary sources, mainly the assessment report of Maternal and Perinatal Death Surveillance and Response (MPDSR) system. As of 2019, this initiative has been implemented in 77 hospitals across Nepal. Challenges and barriers in implementing the MPDSR system need to be brought to attention, as the system is being scaled up to 110 hospitals. Data from the Perinatal Death Review revealed that 72% of the maternal deaths occurred during the post-partum period, due to (i) post-partum haemorrhage, (ii) hypertensive disorder, (iii) pregnancy-related infections, and (iv) non-obstetric causes. In 70% of the cases such deaths could have been prevented. Majority of perinatal deaths, at 71%, were stillbirths, mainly due to low child weight of less than 2500 grams. In conclusion, there is urgent need for the national guidelines for MPDSR system to be amended, additional and continued training provision to the health workforce, improvement in the coordination and feedback mechanism, and strengthening of the information management system. Key words: MPDSR system; Perinatal Death Review; Nepal; Perinatal Mortality; Stillbirth

Stroke patients presenting to the emergency department of a tertiary care hospital

Introduction: Stroke is one of the most common causes of morbidity and mortality in Nepal. It is the 3rd most common cause of death worldwide. In Nepal Non-communicable diseases in Nepal(NCDs) states that stroke accounts for 42% of all deaths and is estimated to reach about 66.3% of all deaths by 2030. Method: A retrospective cross-sectional study of all stroke patients seen in Patan Hospital Emergency Department for a period of 1 y. Demographic data, presenting complaint, time of onset of symptoms, time presenting to the Emergency, patient’s risk factors for stroke, head CT findings (hemorrhagic or ischemic stroke) were analyzed descriptively. Ethical approval was taken. Result: Total 170 patients (96 males i.e.56.5% and 74 females i.e. 43.5%) were analyzed. 130(76.5%) were ischemic CVA and 40 (23.5%) were hemorrhagic CVA. The most common presenting symptoms was hemiparesis and speech changes. Conclusion: Stroke is a common disease seen in Nepal, with higher percentages of hemorrhagic stroke.

Nepal Paediatric Society Clinical Guidance for Management of Sepsis and Septic Shock in the Paediatric Intensive Care Units in Nepal

&#x0D; &#x0D; &#x0D; &#x0D; Justification: Sepsis is a major cause of morbidity and mortality in Nepal. There is a lack of standardisation in the management of severe sepsis and septic shock. Additionally, international guidelines may not be completely applicable to resource limited countries like Nepal.&#x0D; Objective: Create a collaborative standardised protocol for management of severe sepsis and septic shock for Nepal based on evidence and local resources.&#x0D; Process / Methods: Paediatricians representing various paediatric intensive care units all over Nepal gathered to discuss clinical practice and delivery of care of sepsis and septic shock under the aegis of Nepal Paediatric Society. After three meetings and several iterations a standardised protocol and algorithm was developed by modifying the existing Surviving Sepsis Guidelines to suit local experience and resources.&#x0D; Recommendations: Paediatric sepsis and septic shock definitions and management in the early hours of presentation are outlined in text and flow diagram format to simplify and standardise delivery of care to children in the paediatric intensive care setting. These are guidelines and may need to be modified as necessary depending on the resources availability and lack thereof. It is recommended to analyse data moving forward and revise every few years in the advent of additional data.&#x0D; &#x0D; &#x0D; &#x0D;