Audit of Clinical Care Received by COVID-19 Patients Treated at a Tertiary Care Hospital of Nepal in 2021.

Like the world over, Nepal was also hard hit by the second wave of COVID-19. We audited the clinical care provided to COVID-19 patients admitted from April to June 2021 in a tertiary care hospital of Nepal. This was a cohort study using routinely collected hospital data. There were 620 patients, and most (458, 74%) had severe illness. The majority (600, 97%) of the patients were eligible for admission as per national guidelines. Laboratory tests helping to predict the outcome of COVID-19, such as D-dimer and C-reactive protein, were missing in about 25% of patients. Nearly all (>95%) patients with severe disease received corticosteroids, anticoagulants and oxygen. The use of remdesivir was low (22%). About 70% of the patients received antibiotics. Hospital exit outcomes of most (>95%) patients with mild and moderate illness were favorable (alive and discharged). Among patients with severe illness, about 25% died and 4% were critically ill, needing further referral. This is the first study from Nepal to audit and document COVID-19 clinical care provision in a tertiary care hospital, thus filling the evidence gap in this area from resource-limited settings. Adherence to admission guidelines was excellent. Laboratory testing, access to essential drugs and data management needs to be improved.

The impact of COVID-19 pandemic on rabies post-exposure prophylaxis services in Asia.

Human rabies is a preventable disease through post-exposure prophylaxis (PEP) in rabies endemic countries where enzootic cycle of dog rabies occurs. The COVID­19 pandemic has induced an unprecedented challenge for under-funded and already stretched health­care systems particularly in low- and middle-income countries, which are unfortunately bearing a huge burden of human rabies. An analysis of hospital-based PEP data in India, Nepal, Sri Lanka, and Thailand, focus group discussion and key informant interview have been carried out to better understand the impact of Covid-19 pandemic in human rabies prophylaxis. It is necessary to better prepare for human rabies prophylaxis in future pandemics based on lesson learnt from current pandemic. The PEP should be categorized as an emergency medical service, and it should be part of the hospital medical emergency. Mass dog vaccination against rabies should be accelerated to reduce the risk of potential bite of roaming dogs and pet dogs in communities. It is a wise decision to invest in cost-effective preparedness, i.e., mass dog vaccination rather than costly response, i.e., human rabies prophylaxis.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study.

INTRODUCTION: The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient's experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening's implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal. METHODS: In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization's six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines. RESULTS: Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients' thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system. CONCLUSION: This study approached a unique way to strengthen the health system by exploring patients' feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government's role to continue its efforts to strengthen the health system.

Experience of Treating COVID-19 With Remdesivir and Convalescent Plasma in a Resource-Limited Setting: A Prospective, Observational Study.

BACKGROUND: Convalescent plasma therapy (CPT) and remdesivir (REM) have been approved for investigational use to treat coronavirus disease 2019 (COVID-19) in Nepal. METHODS: In this prospective, multicentered study, we evaluated the safety and outcomes of treatment with CPT and/or REM in 1315 hospitalized COVID-19 patients over 18 years in 31 hospitals across Nepal. REM was administered to patients with moderate, severe, or life-threatening infection. CPT was administered to patients with severe to life-threatening infections who were at high risk for progression or clinical worsening despite REM. Clinical findings and outcomes were recorded until discharge or death. RESULTS: Patients were classified as having moderate (24.2%), severe (64%), or life-threatening (11.7%) COVID-19 infection. The majority of CPT and CPT + REM recipients had severe to life-threatening infections (CPT 98.3%; CPT + REM 92.1%) and were admitted to the intensive care unit (ICU; CPT 91.8%; CPT + REM 94.6%) compared with those who received REM alone (73.3% and 57.5%, respectively). Of 1083 patients with reported outcomes, 78.4% were discharged and 21.6% died. The discharge rate was 84% for REM (n = 910), 39% for CPT (n = 59), and 54.4% for CPT + REM (n = 114) recipients. In a logistic model comparing death vs discharge and adjusted for age, gender, steroid use, and severity, the predicted margin for discharge was higher for recipients of remdesivir alone (0.82; 95% CI, 0.79-0.84) compared with CPT (0.58; 95% CI, 0.47-0.70) and CPT + REM (0.67; 95% CI, 0.60-0.74) recipients. Adverse events of remdesivir and CPT were reported in <5% of patients. CONCLUSIONS: This study demonstrates a safe rollout of CPT and REM in a resource-limited setting. Remdesivir recipients had less severe infection and better outcomes.ClinicalTrials.gov identifier. NCT04570982.

Clinical Mortality Review of COVID-19 Patients at Sukraraj Tropical and Infectious Disease Hospital, Nepal; A Retrospective Study.

Coronavirus Disease 2019 (COVID-19) has challenged the health system worldwide, including the low and middle income countries like Nepal. In view of the rising number of infections and prediction of multiple waves of this disease, mortalities due to COVID-19 need to be critically analyzed so that every possible effort could be made to prevent COVID-19 related mortalities in future. Main aim of this research was to study about the mortalities due to COVID-19 at a tertiary level hospital, in Nepal. This was a retrospective, observational study that included all inpatients from Sukraraj Tropical and Infectious Disease Hospital, who were reverse transcriptase polymerase chain reaction positive for SARS-COV-2 and died during hospital stay from January 2020 till January 2021. Medical records of the patients were evaluated. Out of 860 total admissions in a year, there were 50 mortalities in the study center. Out of 50 mortalities, majority were males (76%) with male to female ratio of 3.17:1. Most were above 65 years of age (72%) and had two or more comorbidities (64%). The most common comorbidities among the patients who had died during hospital stay were hypertension (58%) followed by diabetes mellitus (50%) and chronic obstructive airway disease (24%). The median duration from the symptom onset to death was 18 days, ranged from the minimum of 2 days till maximum of 39 days. D-dimer was found to be >1 mg/L in 58% cases and ferritin was >500 ng/ml in 42% patients at presentation. A total of 42% patients had thrombocytopenia, 80% patients had lymphocytopenia and 60% had Neutrophil to Lymphocyte ratio >11.75 with the mean NLR of 18.38. Of total mortalities, 16% patients also showed microbiological evidence of secondary infection; Male gender, age more than 65 years, multiple comorbidities with lymphocytopenia, elevated Neutrophil lymphocyte ratio and elevated inflammatory markers were risk factors found in majority of mortalities in our study. These findings could be utilized for early triage and risk assessment in COVID-19 patients so that aggressive treatment strategies could be employed at the earliest to reduce mortalities due to COVID-19 in future.

Persistent Symptoms in Post-COVID-19 Patients Attending Follow-Up OPD at Sukraraj Tropical and Infectious Disease Hospital (STIDH), Kathmandu, Nepal.

The long-term effects of COVID-19 among survivors is a matter of concern. This research aimed to study persistent symptoms in post-COVID-19 patients attending a follow-up clinic at a tertiary care hospital in Nepal. All patients, presenting to the outpatient clinic during the study duration of six weeks, with history of positive reverse transcriptase- polymerase chain reaction for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at least two weeks prior to presentation, were included. The duration of follow-up ranged from 15 till 150 days with the mean duration of 28 days after diagnosis of COVID-19. Of 118 patients, 43 (36.4%) had a history of mild COVID-19, 15 (12.8%) had moderate, and 60 (50.8%) had severe. At the time of presentation, 97 (82.2%) patients reported that they had at least one persistent/new symptom beyond two weeks from the diagnosis of COVID-19. Dyspnea, fatigue, chest heaviness, and cough were the commonest persistent complaints in 48 (40.7%), 39 (33.1%), 33 (28%), and 32 (27.1%) patients, respectively. The findings in our study highlight the need for extended monitoring of post-COVID-19 patients following discharge, in order to understand and mitigate long-term implications of the disease.

Complete Genome Sequence of a 2019 Novel Coronavirus (SARS-CoV-2) Strain Isolated in Nepal.

A complete genome sequence was obtained for a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strain isolated from an oropharyngeal swab specimen of a Nepalese patient with coronavirus disease 2019 (COVID-19), who had returned to Nepal after traveling to Wuhan, China.

Bell's palsy as a possible neurological complication of COVID-19: A case report.

COVID-19 has been associated with several neurological complications. We presented a case of Bell's palsy as a possible neurological complication of COVID-19 infection. Further research should be conducted to clarify the association, correlation, or causality between COVID-19 and neuroimmunological diseases.

Dermatological Practice in Nepal during COVID-19 Crisis: Recommendations of National Panel of Experts

Introduction: Novel Coronavirus disease has caused a substantial halt to the ongoing world in every aspect. There are medical and social implications of the disease. Cutaneous manifestations have been reported to be a part of the disease as well. Dermatologists globally are in dilemma with the clinical practice because of the fear of acquiring the disease. Objectives: This article aims to recommend best practice measures that can be followed in local scenario for re-opening up of dermatological services in the context of Nepal. Materials and Methods: A preliminary draft for guidance on Dermatological services based on recommendations of American Academy of Dermatology, International league of Dermatological societies, National recommendations from Ministry of Health, Nepal was sent to a panel of national experts to determine the level of consensus in first week of April, 2020.  A preliminary survey was sent to all the members of Society of Dermatologists, Venereologists, and leprologists of Nepal on first week of June and a second draft was subsequently formed which was sent again to experts and revised based on the opinions of national experts. Results: A total of 19 experts participated in the preparation of draft and reached a national consensus after a series of revisions in preliminary draft. Conclusion: Agreements regarding the opening of practice in dermatology discipline have been summarized. Recommendations have been made for opening of dermatological services – opening of outpatient department, performing dermatosurgical and cosmetic procedures as well as strategies on triage of patients and use of masks.