Why do people purchase antibiotics over-the-counter? A qualitative study with patients, clinicians and dispensers in central, eastern and western Nepal.

INTRODUCTION: Over-the-counter (OTC) use of antibiotics contributes to the burgeoning rise in antimicrobial resistance (AMR). Drawing on qualitative research methods, this article explores the characteristics of OTC sales of antibiotic in Nepal, its drivers and implications for policy. METHODS: Data were collected in and around three tertiary hospitals in eastern, western and central Nepal. Using pre-defined guides, a mix of semi-structured interviews and focus group discussions were conducted with dispensers at drug stores, patients attending a hospital and clinicians. Interviews were audio-recorded, translated and transcribed into English and coded using a combination of an inductive and deductive approach. RESULTS: Drug shops were the primary location where patients engaged with health services. Interactions were brief and transactional: symptoms were described or explicit requests for specific medicine made, and money was exchanged. There were economic incentives for clients and drug stores: patients were able to save money by bypassing the formal healthcare services. Clinicians described antibiotics as easily available OTC at drug shops. Dispensing included the empirical use of broad-spectrum antibiotics, often combining multiple antibiotics, without laboratory diagnostic and drug susceptibility testing. Inappropriately short regimens (2-3 days) were also offered without follow-up. Respondents viewed OTC antibiotic as a convenient alternative to formal healthcare, the access to which was influenced by distance, time and money. Respondents also described the complexities of navigating various departments in hospitals and little confidence in the quality of formal healthcare. Clinicians and a few dispensers expressed concerns about AMR and referred to evadable policies around antibiotics use and poor enforcement of regulation. CONCLUSIONS: The findings point to the need for clear policy guidance and rigorous implementation of prescription-only antibiotics.

Trend and Characteristics of Acinetobacter baumannii Infections in Patients Attending Universal College of Medical Sciences, Bhairahawa, Western Nepal: A Longitudinal Study of 2018.

BACKGROUND: Acinetobacter baumannii is one of the major organisms causing nosocomial infections and is intrinsically resistant to multiple classes of antibiotics. The main objective of this study was to investigate the trend and characteristics of A. baumannii infections including its resistance pattern among patients attending Universal College of Medical Sciences, Teaching Hospital (UCMSTH) in Western Nepal, between January and December 2018. PATIENTS AND METHODS: A total of 4862 clinical samples received at the microbiology laboratory of UCMSTH over a period of a year were analyzed. Following bacterial culture on the samples, culture-positive isolates were tested for antibiotic susceptibility using a modified Kirby-Bauer method. The demographic profile of the patient, information about samples, and the antibiotic profile of the A. baumannii isolated from different samples were recorded and analyzed. RESULTS: A total of 1180 (24.2%; 1180/4862) organisms were isolated from the total samples. Acinetobacter baumannii (12.4%; 147/1180) was the third most common organism. Prevalence of A. baumannii was found to be high in late summer/early winter (July: 15.9%; 18/113 and December: 18.8%; 13/69). The majority 71.4% (n=105) of A. baumannii isolates were multidrug resistant (MDR). None of the isolate was pan-drug resistant. Colistin, polymyxin B, and tigecycline were 100% sensitive to A. baumannii. MDR bacteria were significantly associated with the gender of the patients [female: 51.4% (54/105) versus male: 48.6% (51/105); p=0.05], clinical specimens [swab: 40% (42/105) sputum: 21.9% (23/105) and urine: 10.5% (11/105); p=0.02] and different wards of the hospital [surgery: 30.5% (32/105); ICU: 21.9% (23/105) and medicine: 19.0% (20/105); p< 0.03]. CONCLUSION: The high burden of MDR Acinetobacter isolates in clinical specimens shows an alarming presence of antimicrobial resistance. Two-thirds of the specimens showed MDR and were associated with demographic and clinical characteristics of the patients. In the management of infectious diseases at UCMSTH, there should be a high suspicion of Acinetobacter infection, and isolation and treatment should be carried out based on an antibiotic susceptibility test.

Comparison of glucose-6 phosphate dehydrogenase status by fluorescent spot test and rapid diagnostic test in Lao PDR and Cambodia.

BACKGROUND: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymopathy worldwide. Primaquine is the only licensed drug that effectively removes Plasmodium vivax hypnozoites from the human host and prevents relapse. While well tolerated by most recipients, primaquine can cause haemolysis in G6PD deficient individuals and is, therefore, underused. Rapid diagnostic tests (RDTs) could permit ascertainment of G6PD status outside of laboratory settings and hence safe treatment in remote areas. The performance of the fluorescent spot test (Trinity, Ireland; FST) and a G6PD RDT (Carestart, USA) against spectrophotometry were assessed. METHODS: Participants were enrolled during cross-sectional surveys in Laos and by purposive sampling in Cambodia. FST and RDT were performed during village surveys and 3 mL of venous blood was collected for subsequent G6PD measurement by spectrophotometry. RESULTS: A total of 757 participants were enrolled in Laos and 505 in Cambodia. FST and RDT performed best at 30% cut-off activity and performed significantly better in Laos than in Cambodia. When defining intermediate results as G6PD deficient, the FST had a sensitivity of 100% (95%CI 90-100) and specificity of 90% (95%CI 87.7-92.2) in Laos and sensitivity of 98% (94.1-99.6) and specificity of 71% (95%CI 66-76) in Cambodia (p < 0.001). The RDT had sensitivity and specificity of 100% (95%CI 90-100) and 99% (95%CI 97-99) in Laos and sensitivity and specificity of 91% (86-96) and 93% (90-95) in Cambodia (p < 0.001). The RDT performed significantly better (all p < 0.05) than the FST when intermediate FST results were defined as G6PD deficient. CONCLUSION: The interpretation of RDT results requires some training but is a good alternative to the FST. Trial registration clinicaltrials.gov; NCT01872702; 06/27/2013; https://clinicaltrials.gov/ct2/show/NCT01872702.

Prevalence of methicillin resistant Staphylococcus aureus in Lumbini Medical College and Teaching Hospital, Palpa, Western Nepal.

BACKGROUND: Multidrug resistant Staphylococcus aureus is common in both tertiary and primary health care settings. Emergence of methicillin resistance in S. aureus (MRSA) along with macrolide, lincosamide, streptogramin B (MLSB) has made treatment of Staphylococcal infection more challenging. The main objective of this study was to detect MRSA, MLSB (inducible; MLSBi and constitutive; MLSBc) resistant S. aureus using phenotypic methods and to determine their antibiogram. METHODS: Various samples were collected from 1981 patients who attended Lumbini Medical College and Teaching Hospital (LMCTH) during the period of 6 months from September 2015 to February 2016. Out of a total of 1981 samples, 133 S. aureus were isolated. Cefoxitin was used to detect MRSA by the disk diffusion test. Inducible clindamycin resistance (MLSBi) was detected by the D-zone test. The antibiotic profile of all isolates was tested by a modified Kirby Bauer disk diffusion method. RESULTS: Among 133 S. aureus, there were 58 (43.6%) MRSA, 34 (25.6%) MLSBi and 30 (22.6%) MLSBc. Of a total of 64 MLSB, a significant proportion (62.5%) was MRSA (p < 0.001). Among 11 different antibiotics that were tested for S. aureus, MRSA showed significant resistance to 9 (p < 0.05) with the exception of vancomycin and linezolid. All the isolates were 100% sensitive to linezolid. MLSBi organisms were 100% sensitive to vancomycin and linezolid. Both MLSBi and MLSBc showed a higher degree of resistance to multiple antibiotics (p < 0.05). CONCLUSIONS: Isolation of MRSA, MLSBi and MLSBc were remarkably high. Routine use of simple and cost effective methods such as the disk diffusion test by cefoxitin for MRSA and the D-zone test for MLSBi organisms can easily identify these isolates. Antibiotic resistance profiles from this study can optimize the treatment of multi-drug resistant S. aureus.

Earthquakes, Fuel Crisis, Power Outages, and Health Care in Nepal: Implications for the Future.

Earthquakes are a major natural calamity with pervasive effects on human life and nature. Similar effects are mimicked by man-made disasters such as fuel crises and power outages in developing countries. Natural and man-made disasters can cause intangible human suffering and often leave scars of lifelong psychosocial damage. Lessons from these disasters are frequently not implemented. The main objective of this study was to review the effects of the 2015 earthquakes, fuel crisis, and power outages on the health services of Nepal and formulate recommendations for the future. The impacts of earthquakes on health can be divided into immediate, intermediate, and long-term effects. Power outages and fuel crises have health hazards at all stages. It is imperative to understand the temporal effects of earthquakes, because the major needs soon after the earthquake (emergency care) are vastly different from long-term needs such as rehabilitation and psychosocial support. In Nepal, the inadequate and nearly nonexistent specialized health care at the peripheral level claimed many lives during the earthquakes and left many people disproportionately injured. Preemptive strategies such as mobile critical care units at primary health centers, intensive care training for health workers, and alternative plans for emergency care must be prioritized. Similarly, infrastructural damage led to poor sanitation, and alternative plans for temporary settlements (water supply, food, settlements logistics, space for temporary settlements) must be in place where the danger of disease outbreak is imminent. While much of these strategies are implementable and are often set as priorities, long-term effects of earthquakes such as physical and psychosocial supports are often overlooked. The burden of psychosocial stresses, including depression and physical disabilities, needs to be prioritized by facilitating human resources for mental health care and rehabilitation. In addition, inclusion of mental health and rehabilitation facilities in government health care services of Nepal needs to be prioritized. Similarly, power outages and fuel crises affect health care disproportionately. In the current context where permanent solutions may not be possible, mitigating health hazards, especially cold chain maintenance for essential medicines and continuation of life-saving procedures, are mandatory and policies to regulate all health care services must be undertaken. (Disaster Med Public Health Preparedness. 2017;11:625-632).

Rebuilding Earthquake Struck Nepal through Community Engagement.

Nepal underwent two major earthquakes during 2015 which claimed 9,000 deaths, left more than 23,000 injured, displaced about 2 million people and destroyed about 1,000 health facilities. Emerging health issues and disease outbreaks soon after the earthquakes were major priorities. However, preventive measures such as health education, health promotion and trainings embedded in community engagement remained largely unimplemented. Establishing community preparedness by delivering knowledge about the disasters, preparing contingency plans and conducting disaster drills can be promising in Nepal where geographical inaccessibility invariably impedes the on time management during disasters. The steps that could be taken in Nepal without additional resources include identifying community leaders and volunteers who could participate in health promotion initiatives, training of thus identified community volunteers, formation of community task force, devolvement of responsibilities with continual support (trainings and resources) and supervision of the community task force.

Perceived Stigma towards Leprosy among Community Members Living Close to Nonsomboon Leprosy Colony in Thailand.

BACKGROUND: Interpretation of Leprosy as a sickness differs among society. The set of beliefs, knowledge and perceptions towards a disease play a vital role in the construction of stigma towards a disease. The main purpose of this study was to explore the extent and correlates of the perceived stigma towards leprosy in the community living close to the leprosy colony in Non Somboon region of Khon Kaen Province of Thailand. METHODS: A cross-sectional study was conducted among 257 leprosy unaffected community participants, above the age of 18 who were living close to the Leprosy colony in Non Somboon region of Thailand. Each participant was asked a questionnaire containing characteristics of the participants in terms of socio-demographic background and knowledge regarding the disease. In addition perceived stigma towards leprosy was measured using EMIC (Explanatory Model Interview Catalogue) questionnaire. RESULTS: Among EMIC items, shame or embarrassment in the community due to leprosy was felt by 54.5%, dislike to buy food from leprosy affected persons were 49.8% and difficulty to find work for leprosy affected persons were perceived by 47.1%. Higher total EMIC score was found in participants age 61 years or older (p = 0.021), staying longer in the community (p = 0.005), attending fewer years of education (p = 0.024) and who were unemployed (p = 0.08). Similarly, perceptions about leprosy such as difficult to treat (p = 0.015), severe disease (p = 0.004) and punishment by God (p = 0.011) were significantly associated with higher perceived stigma. CONCLUSIONS: Perceived stigma towards leprosy was found highest among participants with age 61 years or older, longer duration of stay in community close to the leprosy colony, lower duration of education and participants who were unemployed had higher perceived stigma. Similarly, participants with perceptions of leprosy such as difficult to treat, severe disease and punishment by God had higher perceived stigma towards leprosy. There is an urgent need of stigma reduction strategies focused on education and awareness concerning leprosy.

Factors affecting perceived stigma in leprosy affected persons in western Nepal.

BACKGROUND: There are various factors which construct the perception of stigma in both leprosy affected persons and unaffected persons. The main purpose of this study was to determine the level of perceived stigma and the risk factors contributing to it among leprosy affected person attending the Green Pastures Hospital, Pokhara municipality of western Nepal. METHODS: A cross-sectional study was conducted among 135 people affected by leprosy at Green Pastures Hospital and Rehabilitation Centre. Persons above the age of 18 were interviewed using a set of questionnaire form and Explanatory Model Interview Catalogue (EMIC). In addition, two sets of focused group discussions each containing 10 participants from the ward were conducted with the objectives of answering the frequently affected EMIC items. RESULTS: Among 135 leprosy affected persons, the median score of perceived stigma was 10 while it ranged from 0-34. Higher perceived stigma score was found in illiterate persons (p=0.008), participants whose incomes were self-described as inadequate (p=0.014) and who had changed their occupation due to leprosy (p=0.018). Patients who lacked information on leprosy (p=0.025), knowledge about the causes (p=0.02) and transmission of leprosy (p=0.046) and those who had perception that leprosy is a severe disease (p<0.001) and is difficult to treat (p<0.001) had higher perceived stigma score. Participants with disfigurement or deformities (p=0.014), ulcers (p=0.022) and odorous ulcers (p=0.043) had higher perceived stigma score. CONCLUSION: The factors associated with higher stigma were illiteracy, perceived economical inadequacy, change of occupation due to leprosy, lack of knowledge about leprosy, perception of leprosy as a severe disease and difficult to treat. Similarly, visible deformities and ulcers were associated with higher stigma. There is an urgent need of stigma reduction strategies focused on health education and health awareness programs in addition to the necessary rehabilitation support.