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.

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.

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.

Recurrent Positivity of SARS-CoV-2 RNA in a Clinically Recovered COVID-19 Patient with End Stage Renal Disease: A Case Report.

Recurrent or persistent positivity of SARS-CoV-2 RNA in clinically recovered COVID-19 patients have been reported worldwide. However, replication competent live viruses were not recovered beyond two to three weeks from onset of symptoms in mild to severe cases of COVID-19. End stage renal disease is characterized by uremia induced immune dysfunction that increases the risk of infectious diseases including COVID-19. The clinical implications of recurrent or persistently positive SARS-CoV-2 RNA in immunocompromised patients are difficult to be generalized to findings as in immunocompetent patients. We report a case of end stage renal disease with recent history of recovered COVID-19 pneumonia, who again presented with positive reverse transcriptase- polymerase chain reaction (RT-PCR) test for SARS-CoV-2 RNA.

The Grim Reality of Health System Uncovered with COVID-19 Pandemic in Nepal.

With advent of community transmission of COVID-19 in Nepal, the number of cases continues to rise and poses threat to the fragile health system of our country. 'Trace, isolate, test and treat' is the strategy advocated by World Health Organization to fight against COVID-19. Despite the efforts for last nine months, Nepal lacks in some aspect of this strategy. Lack of prompt testing facilities and substandard quarantine and isolation centers, have led to mismanagement of cases. The panic regarding COVID-19, lack of adequate protective measures to healthcare workers in early stage of the pandemic, and nation-wise lockdown, has led to collateral damage in the form of increased morbidity and mortality due to non-COVID related illnesses. COVID-19 pandemic has uncovered the grim reality of the debilitated health system of our country. With mass influx of Nepali migrant workers, the epidemic is expected to grow exponentially. We need to understand that the health system of Nepal must be prepared to function to its maximum capacity in the coming days. Keywords: COVID-19; health; Nepal; pandemic.

The Myriad of Clinical Presentations of COVID-19: a Short Review

The ongoing pandemic of Coronavirus disease- 2019 is yet to be defeated. It is primarily a viral respiratory illness, with a myriad of clinical presentations being reported, since it was first identified towards the end of 2019 in China. Apart from the classical symptoms of fever, cough, and dyspnea, atypical presentations in COVID-19 patients, have puzzled healthcare workers worldwide. Patients with isolated non- respiratory complaints like diarrhea, vomiting, abdominal pain, skin rash, and confusion, have tested positive for severe acute respiratory syndrome coronavirus-2. The symptoms of olfactory and gustatory dysfunction have recently been added to the list for screening suspected cases after their prevalence was found to be high among COVID-19 patients. This article elaborates on the system-wise manifestations of COVID-19 and discusses the clinical implications of these aberrant presentations to healthcare workers.

Stigmatization Towards Healthcare Workers During the COVID-19 Pandemic in Nepal

COVID-19 is a novel disease that accompanies itself with anxiety, fear and social stigma. As the numbers of COVID-19 cases continue to rise in Nepal, many instances of stigmatization towards healthcare workers have come into light. Rather than motivating healthcare workers to work during these adverse times, they are being ostracized as carriers of COVID-19. Despite the risks, healthcare workers are bearing for themselves and for their families, very little has been done to protect them. Stigmas can be counteracted by awareness regarding this novel disease. It is important to aware people about correct practices and makes them realize that this battle against COVID-19, can’t be won without healthcare workers. Ensuring safety of healthcare workers must be the foremost priority of the state. Healthcare workers are the most valuable asset for every country, who must be protected from acts of stigmatization at the earliest.

Knowledge, attitude and practice regarding COVID-19 among healthcare workers in Chitwan, Nepal

Background: The cases of Coronavirus disease-2019 (COVID-19) has been gradually increasing in Nepal. The objective of this study was to evaluate knowledge, attitude and practice regarding COVID-19 among healthcare workers in Chitwan, one of the districts located in central Nepal. Methods: It was a descriptive, cross-sectional study, conducted among healthcare workers from differ­ent health institutions of Chitwan, over the span of two weeks from 1st April, 2020 till 14th April, 2020. Bivariate analyses of knowledge, attitude and practice scores were done with different variables using appropriate tests in SPSS IBM version 25. Results: Out of 353 responses, 166 (47%) were nurses, 102 (28.9%) were doctors, 41 (11.6%) were health assistants, 7 (2%) were community medical assistants, and the remaining 37 (10.5%) were cat­egorized as others. 290 (82.2%) healthcare workers obtained moderate to good knowledge scores, 295 (83.6%) obtained moderate to good practice scores, and 321 (90.9%) had positive attitude scores. Doctors had highest mean knowledge scores (23.70 ± 4.48, p value- 0.000) and health assistants had highest mean practice scores (15.10±3.61, p value- 0.007). Positive correlation was obtained between knowledge and practice scores (r= 0.476, p value- 0.000);and attitude and practice scores (r= 0.238, p value- 0.000). Only 20.4% healthcare workers were confident to handle the pandemic in their health­care setup. Conclusions: The majority of healthcare workers had moderate to good knowledge and practice scores and had a positive attitude toward COVID-19. There was a significant association between knowledge, attitude and practice scores obtained by healthcare workers from Nepal.