An Epidemiological Study of Snake Bite Cases in Children of Nepal.

Introduction: Snakebite is common in the Terai region of Nepal. Injury and mortality of humans due to Snake envenomation is a serious pubic health problem in Southeast Asia and Nepal. It has been thought that at least 50,000 people in the region die of snake bites (this includes India, Bangladesh and Nepal and Pakistan) per year. There are abundant venomous snakes present in the region. Studies in Nepal have identified 4 species of snake responsible for the majority of fatal bites. These are the Indian cobra (Naja naja), common krait (Bungaris caeruleus) Russell's viper (Viper ressellii) and greenpit viper. The incidence of snakebite varies from 300-500 bites per 100,000 human populations in forested regions to 50-100 bites per 100,000 in Sahara. Objective: To study the epidemiology of snakebite in the endemic regions of the terai, to analyse the morbidity and mortality data of snakebite cases in children for the year 2008. Method: National Zoonoses and Food Hygiene Research Centre (NZFHRC) started collection of secondary and primary information on snakebite cases in children recorded and reported by different media and hospitals, health post in Nepal during the year 2008. The data had been compiled, tabulated and analysed. This is the regular surveillance study carried out on snakes in general and venomous snakebite human cases recorded in Nepal. The team visited in 6 mid, hill districts and 24 terai districts of Nepal. Results: Total snakebite cases in children were 540 during the year 2008. Of which 10 cases were from six mid hill districts and 530 were from 24 terai and inner terai districts of Nepal. Total morbidity was 406 (75.19%) and mortality 134 (24.81%). Seasonal incidence of snakebite cases recorded in Bheri zonal hospital and medical college Banke district. Highest morbidity were recorded during the month of Jestha (May) to Aswin (August). Morbidity 12 (25%) and mortality 3 (20%) were recorded in the month of May/June 2008. Conclusions: Snakebite cases in children and deaths were recorded and reported along with adult cases of snakebite. Total adult cases were 2190 of which children were 540 (24.66%) during the year 2008. This means that about 25% of all cases of snakebites were seen in children every year in the endemic areas of snakes. Mass awareness school education programme about snakebite especially in endemic area of terai and inner districts should be advocated regularly so that parents along with children will take necessary precautions.

Japanese Encephalitis Vaccination in Children Population of Nepal During the year 2005, 2006 and 2008.

Japanese Encephalitis (JE) is caused by a Flavivirus that, in a proportion of human cases, causes severe encephalitis leading to death or sometimes permanent disablement. It is a zoonotic disease, transferred from animals (commonly pigs or wild birds) by a mosquito vector to humans. In Southeast Asia it is thought to cause up to 50000 clinical cases and 10000 deaths per year. JE vaccination programme was carried out in high risk districts of Nepal. Japanese encephalitis vaccination was carried out during the years 2005, 2006, 2008 and 2009. The data collected from primary and secondary sources from the District Health Offices and other concerned central offices of the Department of Health Services, was tabulated and analysed. Thirty-five lakh of JE vaccine doses was procured by the Ministry of Health during the year 2006/2007. This vaccine was used in children under 15 years of age of 12 districts of JE risk and high-risk areas of Nepal. It was found that during the year 2005; 85% children in Banke and 81% in Kailali were vaccinated against JE. In Kailali and Banke districts it was found to be about 103% coverage in children population targeted, in Dang district it was 100% coverage, and in Bardiya district it was 73% coverege but in Rupandehi and Kanchanpur districts it was only about 40% and 41% respectively. JE vaccine coverage was very low in two Rupandehi and Kanchanpur districts during 2005 and 2006 and very high coverage during the year 2008. JE vaccination coverage results for the year 2009 have not been made available yet due to unavailability of data. This type of mass vaccination campaign needs regularlity, mass awareness and health education programme should be carried out before JE vaccination campaign in the children in the future.

Study of Visceral Leishmaniasis (Kala-azar) in Children of Nepal.

Introduction: Visceral leishmaniasis (VL) or Kala-azar is a potentially fatal vector-borne (sand fly phlebotomies spp) zoonotic disease caused by a protozoan parasite, Leishmania donovani. In Nepal, the disease is restricted to the Eastern Terai region which lies adjacent to the Bihar state of India. Although leishmaniasis is regarded as a significant health problem in Nepal by the Ministry of Health, there is no active case detection programme in the country. Objective: Objectives of this study were to determine the up-to-date morbidity and mortality trend for VL in children of Nepal. Method: The epidemiological surveillance team from the NZFHRC visited to eight zonal hospitals in Terai region during the month from September to December of each year 2003 to 2007. The morbidity and mortality data up to the year 2007 were collected every year. The team has also collected 66 blood serum samples of which 18 samples from children were collected for the diagnosis. Results: A total 25890 cases with 599 deaths were reported during the year 1980-2006. The case fatality rate (CFR) varied from 0.23% to 13.2%. Districtwise analysis showed that, during 2003, highest incidence was in Mahottari district (184/100,000), followed by Sarlahi (100/100,000) and Sunsari (96/100,000). The highest CFR was in Dhanusha (2.9%) followed by Bara (2.4%) and Saptari (2.0%). Majority (70.9%) of persons affected by VL were aged 15 years and above, followed by 10-14 years (13.9%), 5-9 years (11.9%) and 1-4 years (3.3%). VL cases recorded from different district of Nepal for the year 2004, 2005, 2006 and 2007 are recorded. CFR for the year 2004, 2005, 2006 and 2007 were 3.2%, 3.7%, 16.67% and 11.42% respectively. Conclusions: There should be regular surveillance research work to be carried out in endemic area. Mass public health education, to make the people aware about preventive aspects of the disease is important. The possibility of the existence of animal reservoirs as zoonotic disease should also be considered. This disease is very much serious in children below 15 years of age both in male and female, therefore it is essential to have paediatrician post at least in all VL six endemic districts.

Prevalence of pulmonary tuberculosis in far Western Nepal.

Keeping in view of high prevalence of tuberculosis in far western development region in different reports, a door to door survey of 125 household was carried out randomly in Mahendra Nagar municipality ward no 13 of Kanchanpur district to pick up symptomatics suggestive of pulmonary tuberculosis and find the prevalence in the target population. A total of 200 sputum specimens from 70 symptomatics within the age range of 10-80 years were collected and subjected to smear microscopy by Ziehl - Neelsen's method. Out of 10 positive cases (14.28%), infection in males and females was 80% and 20% respectively. The infection was found in the productive age group 20-69. The highest prevalence was obtained in 20-29 age group (25%) followed by 40-49 (11%), 30-39 (9%), 50-59 (8%) and 60-69 (8%). The diagnostic yield of single sputum specimen examined was insufficient in field condition, especially where the sputum positivity was low. Of the three sputum smears examined, the early morning specimen had the best result.

Health promotion approach for the control of food-borne parasitic zoonoses in Nepal: emphasis on an environmental assessment.

Green and Kreuter define health promotion as the use of both education and ecology to encourage and support living conditions conducive to good health. Their PRECEDE-PROCEED model delineates a practical way to cope with health problems using this definition. Applying PRECEDE to Nepal helps identify the steps needed to control the ever-increasing incidence of food-borne parasitic zoonoses (FBPZ) there and in other South Asian countries. In executing the first five steps of the model, we focused on behavioral and environmental assessments to find a method for controlling FBPZ. Through these two assessments, we identified the following behavioral and environmental objectives: establish a meat inspection system by 2003, establish training programs on safe meat production and selling practices by 2003, improve slaughterhouses and slaughtering practices by 2003. The educational and ecological assessments revealed that the necessary predisposing, reinforcing and enabling factors for appropriate control of FBPZ are present in Nepal, while an administration and policy assessment shows Nepal meets PRECEDE requirements through its recent meat inspection legislation. Although the data for each element of the PRECEDE-PROCEED model are limited in Nepal, they clearly tell us to move forward to the PROCEED stage to control FBPZ there as well as in all of South Asia.

Controlling Taenia solium in Nepal using the PRECEDE-PROCEED model.

Taenia solium is a predominant food-borne parasitic zoonosis (FBPZ) in Nepal. Using the PRECEDE framework, as defined by Green and Kreuter, we can identify the factors behind the high incidence of this disease. Armed with this information, we can define the actions necessary to control T. solium. In accordance with the first step of PRECEDE, social assessment, we set the goal of decreasing the potential for T. solium transmission in Nepal by the year 2003. This goal has yet to be endorsed by policy makers. However, an epidemiological assessment based on hospital data alone showed that T. solium is an endemic problem in urban Nepal that must be addressed. Based on behavioral and environmental assessments (Steps 1 and 2 of PRECEDE-PROCEED), we defined the following action objectives to be achieved by 2003: 1) Train meat producers and sellers to detect contaminated pork and avoid selling it, 2) Improve pig husbandry to limit the animals' access to human feces, 3) Construct hygienic model slaughterhouses. These improvements could control the meat-producing environment, thus limiting the potential for cross-carcass contamination and other hygiene deficiencies associated with the spread of T. solium. An educational and ecological assessment shows all predisposing, reinforcing and enabling factors are present in Nepal, consistent with PRECEDE requirements. While T. solium is clearly defined as a health problem according to PRECEDE, there remain significant hurdles to controlling it. These hurdles lie in administration and policy, where standardized law-enforcement and meat inspection practices are needed. Finally, the government of Nepal must assign high priority to T. solium control, as it is a preventable, yet prevalent disease.

Epidemiology of echinococcosis in Nepal.

Echinococcosis and hydatidosis is a parasitic zoonotic disease of human and animals. This disease has created public health and environment problems in all urban areas of Nepal. Based on the three year study (1993-1995) it has been revealed that the epidemiological cycle (indigenous) of Echinococcus granulosus parasite is dog-pig-dog cycle and human acquire infection accidentally through infected dog stool. However, this study has proved also the epidemiological cycle like dog-sheep-dog, dog-goat-dog and dog-buffalo-dog. This study was supported by International Development Research Centre (IDRC), Ottawa, Canada.