Knowledge, Attitude, and Practice towards COVID-19 among Patients Attending Phuentsholing Hospital, Bhutan: A Cross-Sectional Study.

Bhutan is one of the few countries in the world to take unprecedented steps to control the spread of COVID-19 in the country. This study aimed to investigate knowledge, attitude, and practice (KAP) and their associated covariates among patients attending Phuentsholing Hospital, Bhutan. Therefore, a cross-sectional study was conducted among patients attending Phuentsholing Hospital in Bhutan between March 17 and April 9, 2021, using an interview-administered questionnaire. The multivariable logistic regression was used to identify statistically significant covariates of good KAP. Further, the association between levels of KAP scores was assessed using Pearson's correlation coefficient. Of the 441 participants, 54.6% (241) were female. Knowledge, attitude, and practice score were reported by 55.3%, 51.8%, and 83.7% of participants, respectively. Higher education, secondary education, monastic education, and non-formal education were 9 [adjusted odds ratio (AOR) = 9.23; 95% confidence interval (CI) 3.438, 24.797], 3.5 (AOR = 3.5; 95% CI 1.425, 8.619), and 4 (AOR = 3.8; 95% CI 1.199, 12.141) times more likely to report good knowledge than illiterates. A positive attitude was associated with higher (AOR = 2.97; 95% CI 1.154, 7.66) and secondary (AOR = 3.53; 95% CI 1.454, 8.55) education compared to illiteracy. The good practice was associated with higher (AOR = 12.31; 95% CI 2.952, 51.318) and secondary (AOR = 11.5; 95% CI 3.439, 38.476) education compared to illiteracy. Participants in the age groups 26-35 years (AOR = 0.11; 95% CI 0.026, 0.484) and >45 years (AOR = 0.12; 95% CI 0.026, 0.588) were less likely to exhibit good practice compared to those aged 18-25 years. Those working in the private or business sectors were 9 (AOR = 8.81; 95% CI 1.165, 41.455) times more likely to have good practice compared to civil servants. There was a weak but positive correlation between knowledge-attitude (r = 0.228), knowledge-practice (r = 0.220), and attitude-practice scores (r = 0.338). The need for health education on COVID-19 to increase knowledge and attitude is highly recommended, and should be focused on the less educated and other vulnerable groups such as farmers and students, as well as those older than 25 years.

Hand Hygiene, Face Mask Use, and Associated Factors during the COVID-19 Pandemic among the Students of Mongar Higher Secondary School, Bhutan: A Cross-Sectional Study.

Non-pharmacological measures, such as hand hygiene and face mask use, continue to play an important role in the fight against the COVID-19 pandemic. However, there is a paucity of studies on the adherence to these measures among students in Bhutan. Therefore, we aimed to investigate hand hygiene and face mask-wearing behaviours, as well as their associated factors, among the students of Mongar Higher Secondary School, Bhutan. We conducted a cross-sectional study amongst the students of Mongar Higher Secondary School in Bhutan. The students self-answered the questionnaire on web-based Google Forms. Multivariable logistic regression for good hand washing and face mask use was conducted in order to identify statistically significant socio-demographic covariates. The correlation between hand hygiene and mask use was investigated using Pearson's correlation coefficient. A total of 533 students completed the survey questionnaire, 52.9% (282) of whom were female students. Facebook (44.3%, 236) and TV (35.5%, 189) were the two most popular sources of information on COVID-19 prevention and control. Good (scores of ≥80% of total scores) hand hygiene and face mask use were reported in 33.6% (179) and 22.1% (118) of students. In multivariable logistic regression, male students presented 79% (adjusted odds ratio [AOR] = 1.79, 95% confidence interval [CI] = 1.23−2.613) odds of engaging in good hand hygiene, compared to female students. Compared to grade 9, those in grade 10 were 60% (AOR = 0.4, 95% CI 0.158−0.998) less likely to engage in good hand hygiene. Boarding students presented 68% (AOR = 1.68, 95% CI 1.001, 2.813) higher odds of wearing a face mask compared to day students. There was a significant positive correlation between good hand hygiene and face mask use (r = 0.3671, p-value < 0.001). Good hand hygiene and face mask use were reported in less than one-third of the study participants. It is recommended to continue educating students on good hand hygiene and face mask use through popular information sources.

Exploring the Digital Divide among the Bhutanese Refugee Community during COVID-19: Engaged Research in Action.

The digital divide proved a critical barrier to accessing information and healthcare during the COVID-19 pandemic and negatively impacted the Bhutanese refugee community. Moving beyond a technological model of the digital divide that highlights a lack of access to computers and the internet, we engaged the community to co-produce a dynamic approach that identifies the impact of socio-cultural and socio-environmental factors as well. Our paper reports on our community-academic research partnership and explores how the digital divide exacerbates health disparities in a midwestern Bhutanese refugee community. Combining the efforts of the community, anthropologists and social workers, this paper reports on the health disparities that confront the community as well as interventions designed to mitigate social inequities.

Household Transmission of SARS-CoV-2 in Bhutan.

Introduction: The transmission trend of SARS-CoV-2 is continuously evolving. Understanding the dynamics in different settings is crucial for any effective containment measures. We aimed to study the characteristics of household transmission of SARS-CoV-2 in Bhutanese households by determining the transmissibility within household contacts of confirmed COVID-19 index cases and their factors of infectivity. Methods: We conducted a retrospective observational study on household transmission in 306 household contacts of 93 COVID-19 positive index cases diagnosed from April 16, 2021, to June 30, 2021. A pro forma was used to collect data on the epidemiological, demographic, and clinical profile of all recruited individuals. Secondary attack rates (SAR) were calculated, and risk factors for transmission were estimated. Results: 180 of 306 household contacts developed secondary household transmission (SAR 58.8%; 95% CI: 53.2-64.2). The median age of household contacts was 22 years. The median household size was 4 (mean 4.3 ± 2.199) members. Contacts exposed to adult index cases (aPR 1; 95% CI 1, 1.02, p = 0.01) and vaccinated index cases (uPR 0.41, 95% CI 0.25, 0.66, p < 0.001) had a higher SAR and prevalence of secondary infections. Conclusions: Our findings suggest substantial evidence of secondary infections among household contacts, especially in the context of public health mandated lockdowns. Aggressive early contact tracing and case identification with subsequent case isolation from other household members remains a crucial step in preventing secondary transmission.

Risk Factors of Symptomatic COVID-19 in Samtse District, Bhutan.

Introduction: All Coronavirus disease 2019 (COVID-19) positive cases in Samtse District, Bhutan were isolated in the isolation facilities managed by the government hospitals. This study aimed to identify the socio-demographic risk factors for developing COVID-19 symptoms amongst these patients. Methods and Materials: A secondary data of the COVID-19 positive cases from isolation facilities of Samtse District from 5 May to 7 September 2021 was used for this study. Survival analysis was carried out to estimate the cumulative probability of symptom onset time by each risk factor. Kaplan-Meier curves were used to estimate the probabilities for the onset of symptoms at different time points and a log-rank test was employed to assess the differences between covariates. Results: A total of 449 patients were included, of which 55.2% were males and 73.3% (328) were aged >18 years. The mean age was 42 years with a range of 3 months to 83 years. Forty-seven percent (213) reported at least one symptom. Common symptoms were fever (32.3%, 145), headache (31.6%, 142), and cough (30.1%, 135), respectively. Males were 64% less likely to be symptomatic than females [adjusted hazard ratio (aHR) = 0.36, 95% confidence interval (CI) 0.183-0.917]. Farmers (aHR = 3.17, 95% CI 1.119-8.953), and drivers and loaders (aHR = 3.18, 95% CI 1.029-9.834) were 3 times more likely to be symptomatic compared to housewives. Residents of Samtse sub-districts were 5 times more likely to be symptomatic than those living in other sub-districts (aHR = 5.16, 95% CI 2.362-11.254). Conclusion: The risk of developing COVID-19 symptoms was being fe male, farmers, drivers and loaders, and residents of the Samtse sub-district. These high-risk groups should be provided additional care when in isolation facilities.

COVID-19 vaccinations in Bhutan - Mix-and-Match to Boosters: An experience.

Bhutan - a landlocked least developed country in the Himalayas - vaccinated 94% of its adults with the first dose of COVID-19 vaccine in March-April 2021, 90.2% with second dose in July 2021, and 89.1% with booster (third) dose by March 2022. The country used COVISHIELD (Oxford-Astrazeneca) vaccine for the first dose but decided to pursue a heterologous prime-boost strategy ("mix-and-match") for the second dose using Moderna's mRNA vaccine for adults. Bhutan rapidly rolled out Pfizer and Moderna vaccines for 12 to 17-year-olds through a school-based vaccination strategy followed by booster doses: 78.6% of adolescents aged 12-17 years were vaccinated with the first dose by August 2021, 92.8% with second dose by November 2021, and 79.7% with booster (third) dose by March 2022. More than 97% of children aged 5 to 11 years have received Pfizer's Comirnaty vaccine for their first dose. Bhutan is steadily vaccinating its population and might soon become one of the few least developed countries to achieve herd immunity-level vaccination coverage with more than 80% of its population fully vaccinated.

Psychological impact during COVID-19 pandemic: A web-based cross-sectional study among students studying at College of Science and Technology (CST), Phuentsholing, Bhutan.

The unprecedented experience of national lockdowns and uncertainty of academic career due to the COVID-19 pandemic has multifaceted impacts on mental health among university students worldwide. This study determined its impact on depression and anxiety level, and associated risk factors among engineering students studying at College of Science and Technology (CST), Phuentsholing, Bhutan during the first lockdown in the country. Self-reported depression and anxiety levels were assessed using Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) respectively. Data was collected using an e-questionnaire link generated in Google form and the link was shared with students via the student's official email group. A total of 278 students (response rate, 26.9%) completed the questionnaire. The majority of respondents were male (69.8%) and were aged from 18 to 30 (Mean: 21.7 ±SD 2.07) years. The prevalence of self-reported moderate to severe depression and anxiety were 44.2% (95% CI, 38.5-49.6) and 27.3% (95% CI, 22.3-32.4) respectively. Participants having their family members as frontline workers reported a significantly higher level of anxiety (χ2 = 4.85, p = 0.028). In multivariable logistic regression analysis, students who were academically lagging showed a higher risk of depression (AOR = 5.36, 95% CI = 2.86-10.04) and anxiety (AOR = 3.83, 95%CI = 1.86-7.88) as compared to students who were not academically behind. A high percentage of depression and anxiety was reported by students of CST during the COVID-19 pandemic. Findings from the study highlight the importance of adopting appropriate online-based teaching and learning methods to ensure timely academic and professional achievements. Moreover, the relevant stakeholders should put health system strategies in place to provide psychological support to university students during the COVID-19 pandemic.

Factors influencing COVID-19 testing: a qualitative study in Bhutan.

BACKGROUND: The COVID-19 pandemic has reaffirmed an all-knowing truth-that health is central in the 2030 Sustainable Development Agenda. To fully control the infection in a community, accurate testing of suspected cases along with effective tracing and appropriate treatment (3Ts) is still crucial to slowing transmission of COVID-19 virus This study explored factors that influenced COVID-19 testing in Bhutan. The lessons learned from this study could serve as a roadmap to strengthen the current respond to COVID-19 and for future outbreaks, particularly in low- and middle-income countries. METHODS: The study employed an exploratory qualitative design. Data collection methods included interviews with key informants with a purposively selected sample of 20 participants. The interview findings were augmented by reviewing both published literature and unpublished documents.For the analysis of qualitative interviews, a hybrid approach of inductive and deductive coding and theme development was conducted to analyze findings. A tailored version of the WHO Health System Framework incorporating the Essential Public Health Function was used to guide data interpretation. RESULTS: Political will through the influence and leadership of the King of Bhutan played a crucial role in raising attention to the problem, and provision of adequate financial and technical relief to ensure that all people irrespective of their socioeconomic status do not pay to get tested of COVID-19. A compassionate leadership, Whole of Society approach is backed by the scientific community, functional health systems and community-based approaches, use of information technology for awareness creation and improved surveillance system, and fast-tracked COVID-19 testing service delivery. CONCLUSION: Bhutan's success relied greatly on multi-sectoral and systematic approach during policy design, implementation and monitoring, and active collaborative efforts involving consultation and engagements with a broad range of local (community members), national and global actors for accelerated COVID-19 testing. These efforts were made possible through improved health governance and leadership at all levels of the society.

The Nepali-speaking Bhutanese Immigrants: A Population Overlooked amidst the COVID-19 Crisis.

The Nepali-speaking Bhutanese (NSB) community living in Central Pennsylvania has been significantly affected by COVID-19 due to various biopsychosocial determinants of health. In this paper, we discuss interventions developed by a tertiary care health system in Central Pennsylvania to provide immediate support to the NSB community.

The COVID-19 vaccination campaign in Bhutan: strategy and enablers.

Bhutan has reported a total of 2596 COVID-19 cases and three deaths as of September 15, 2021. With support from India, the United States, Denmark, the People's Republic of China, Croatia and other countries, Bhutan was able to conduct two rounds of nationwide vaccination campaign. While many countries struggle to overcome vaccine refusal or hesitancy due to complacency, a lack of trust, inconvenience and fear, escalated in some countries by anti-vaccine groups, Bhutan managed to inoculate more than 95% of its eligible populations in two rounds of vaccination campaign. Enabling factors of this successful vaccination campaign were strong national leadership, a well-coordinated national preparedness plan, and high acceptability of vaccine due to effective mass communication and social engagement led by religious figures, volunteers and local leaders. In this short report, we described the national strategic plan and enabling factors that led to the success of this historical vaccination campaign.

Knowledge, Attitude, and Practice Toward COVID-19 Among Sherubtse College Students in Bhutan: A Web-Based Cross-Sectional Study.

Bhutan has reopened schools and colleges after an initial closure to contain coronavirus disease 2019 (COVID-19) transmission. However, the risk of transmissions is higher in the schools and colleges due to crowding. Therefore, this study aimed to assess the level of knowledge, attitude, and practice (KAP) toward COVID-19 among the students of Sherubtse College in Bhutan. A cross-sectional study using a questionnaire was conducted in September 2020 among the students of Sherubtse College, Bhutan. The questionnaire was made in the Google Forms and administered through a social forum WeChat app. The KAP scores were calculated that include mean scores. The association between the KAP was assessed using the Pearson's correlation coefficient. A total of 613 students participated in the survey. The majority of the participants (57%) were female and 56% were from the third year. The mean knowledge score was 10.7 (SD = 1.7; range 0-14), mean attitude score of 3.67 (SD = 1.0; range: 0-5), and mean practice score of 5.19 (SD = range: 0-6). A majority of the students had good knowledge (98%) and practice (93.5%) scores, and a positive attitude (86.6%) toward COVID-19. A positive but weak correlation between good knowledge and practice (r = 0.1, p = 0.0126) was observed. Having a positive attitude led to practicing appropriately most of the time (r = 0.1866, p < 0.001). The students had good KAP scores and followed the COVID-19 prevention protocols advocated by the government. Good knowledge and a positive attitude were translated into good practice. Therefore, the education campaign of the Bhutan government seems to be effective in the students.

Twenty Months Into the Pandemic: No SARS-CoV-2 Infections Among Health Care Workers Managing COVID-19 Cases in Bhutan.

There is no international reporting of SARS-CoV-2 infections in health care workers (HCWs). Estimates suggest that a HCW dies every thirty minutes from COVID-19. This worsened the shortages and burnout of HCWs worldwide. Twenty months into the pandemic, Bhutan recorded over 2600 COVID-19 positive cases and three deaths. About 906 HCWs were directly involved in managing these laboratory confirmed cases but no infections occured amongst this group. This zero infection was possible through the clustered management of positive cases in four national COVID-19 centers, strategic deployment of HCWs, the uninterrupted provision of quality personal protective equipment (PPE) and repeated training on the correct use of PPE. This is an exemplary achievement for a small country with limited expertise and resources.

Repatriation of Bhutanese During COVID-19 Pandemic: The Unspoken Economic Burden of COVID-19 on the Bhutanese Government.

Protecting the citizens who are living abroad has been a challenge for many countries during the current COVID-19 pandemic. In Bhutan, since the start of the pandemic, it has repatriated its citizens living and working abroad and putting them into a 21-day state-sponsored quarantine. They were also tested for COVID-19 on reverse transcription polymerase chain reaction (RT-PCR) that was funded by the government. While this measure is a blessing for its people, for the government it is a huge economic challenge.

Bhutan's COVID-19 Vaccination Efforts and the Evolution of COVID-19 Cases in the Aftermath.

The COVID-19 pandemic is continuing to ravage countries across the world. It has displaced families and impacted economies around the world. Our fight against the pandemic is never ending, but COVID-19 vaccines offer unique promises and opportunities to win this war. As more and more vaccines are approved for use, many countries including Bhutan have started vaccinating their population against the SARS-CoV2 disease. Bhutan has fully vaccinated 61.5% of its people and 11.2% partially including children aged between 12 and 17 years. The country used many strategies to increase vaccine accessibility and availability such as government's exhaustive efforts to secure enough vaccine doses, careful preparations, use of international partners, and integration of its tradition and culture for wider vaccine acceptance. The protection from vaccines coupled with other public health measures has helped keep the number of COVID-19 cases to a manageable number without straining its health system too much. The success story is a "beacon of hope for the region" as the world looks to rebuild itself from this long exhausting fight against the COVID-19 pandemic.

Survival Analysis of Symptomatic COVID-19 in Phuentsholing Municipality, Bhutan.

COVID-19 is a disease that is caused by a highly transmissible and pathogenic novel coronavirus: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). All of the COVID-19 positive cases in Bhutanese travellers returning via the Phuentsholing point of entry, the local population, and Indian nationals were isolated in the Phuentsholing COVID-19 isolation ward, Bhutan. This study aimed to identify the risk factors for developing symptoms among COVID-19 positive patients in this ward. A retrospective cohort study was conducted using the data regarding COVID-19 positive cases in the Phuentsholing COVID-19 isolation ward from 28 May 2020 to 31 May 2021. The Cox proportional hazards regression model was used to identify the risk factors of developing COVID-19 symptoms. There were 521 patients in the study; 368 (70.6%) were males and 153 (29.4%) were females. The mean age was 32 years (with a range of 1-78 years), and 290 (56.0%) reported at least one symptom. The median length of isolation was eight days (with a range of 3-48 days). The common symptoms were: cough (162, 31.0%), fever (135, 26.0%), and headache (101, 19.0%). In the multivariable Cox regression, vaccinated patients were 77.0% (p = 0.047) less likely to develop symptoms compared to those who were not vaccinated. The front line workers and the mini-dry port (MDP) workers were 15 (p = 0.031) and 41 (p < 0.001) times more likely to be symptomatic compared to returning travellers. The young and economically active population group was most commonly affected by COVID-19. The presence of risk factors, such as being front line workers, MDP workers, or not being vaccinated against COVID-19, meant that patients had a higher probability of developing symptoms of COVID-19.

Are doctors protected enough during COVID-19 in South Asia?

BACKGROUND: The highly contagious nature of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) places physicians in South Asia at high risk of contracting the infection. Accordingly, we conducted this study to provide an updated account of physician deaths in South Asia during the COVID-19 pandemic and to analyze and compare the different characteristics associated with physician mortality amongst the countries of the region. METHODS: We performed a cross-sectional study by using published news reports on the websites of news agencies from 9 selected countries in South Asia. Our study included only those physicians and doctors who died after contracting COVID-19 from their respective workplaces. All available data about the country of origin, type of, sex, age, medical or surgical specialty, and date of death were included. RESULTS: The total number of physician deaths reported due to COVID-19 in our study was 170, with half (87/170, 51%) of the deaths reported from Iran. Male physician deaths were reported to be 145 (145/170 = 85%). Internal Medicine (58.43%) was the most severely affected sub-specialty. The highest physician mortality rate in the general population recorded in Afghanistan (27/1000 deaths). General physicians from India [OR = 11.00(95% CI = 1.06-114.08), p = 0.045] and public sector medical practitioners from Pakistan [aOR = 4.52 (95% CI = 1.18-17.33), p = 0.028] were showing significant mortality when compared with other regions in multivariate logistic regression. CONCLUSION: An increased number of physician deaths, owing to COVID-19, has been shown in South Asia. This could be due to decreased personal protective equipment and the poor health care management systems of the countries in the region to combat the pandemic. Future studies should provide detailed information of characteristics associated with physician mortalities along with the main complications arising due to the virus.