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.

Prevalence, Pattern, and Factors Associated With Self-reported Disability Among the Bhutanese Population: A Secondary Data Analysis of Population and Housing Census.

We analyzed the Population and Health Census of Bhutan (PHCB) 2017 to assess the prevalence and pattern of self-reported disability among people aged ≥15 years and the associated factors. The PHCB 2017 used the Washington Group Short Set on Functioning questionnaire to assess the disability ("lot of difficulty" or "cannot do at all") in seeing, hearing, mobility, cognition, self-care, and communication. Of the 536 443 persons included in the analysis, 384 101(71.6%) were aged <45 years, 283 453(52.8%) were men, and 206 103(38.4%) were from the rural area. The prevalence of any self-reported disability was 2.8%, among whom 34.2% reported multiple disabilities. The disability prevalence (any) was significantly higher among people aged ≥65 years, illiterate, economically inactive, permanent residents, residing in a rural area, and from central and eastern regions of the country compared with their respective counterparts. Further research on access to rehabilitation and linking with social protection schemes for the disabled is required in this country.

Barriers to Institutional Delivery Services in Districts With the Lowest Institutional Delivery Coverage in Bhutan.

Bhutan aims to achieve 100% institutional delivery coverage. While evidence indicates improved institutional delivery coverage over the years, coverage in some of the districts is only 49%. This study was aimed at exploring barriers to institutional delivery in three low-coverage districts. In-depth qualitative interviews and six focus group discussions were conducted in December 2015. The analysis was done as per the Braun and Clarke's 6-phase guide to doing thematic analysis. This study sheds light on 15 barriers for institutional deliveries, which include hesitancy to seek health care when the pregnancy is out of wedlock, the restriction of alcohol consumption at health centers, fear of hypothermia in cold places, pastoralism, health care providers shortage, lack of maternity waiting home and food, distance, difficult terrain, lack of transportation services, and financial constraints. Some of these barriers could be unique to Bhutan. The coverage could be improved considerably if the recommendations in this article are implemented.

Clinical and Bacteriological Profile of Neonatal Sepsis: A Prospective Hospital-Based Study.

BACKGROUND: Neonatal sepsis remains one of the leading causes of mortality and morbidity in developing countries. With a dearth of data on neonatal sepsis in our country, this study was conducted to determine the incidence of clinical neonatal sepsis and evaluate the clinical, bacteriological, and antimicrobial susceptibility profile of organisms. Material and Methods. A prospective cross-sectional study was conducted in the Neonatal Unit of the National Hospital from 1st January to 31st December 2016. All neonates admitted with suspected clinical sepsis were included. Sepsis screens and cultures were sent under aseptic conditions. Data was analyzed using STATA™ version 12. Clinical features and neonatal and maternal risk factors were analyzed using chi-squared test. Bacteriological profile was analyzed with descriptive statistics. RESULTS: During the study period, incidence of culture positive neonatal sepsis was 19 per 1000 admissions with a blood culture positivity rate of 14%. 54.5% had culture-positive early-onset sepsis (EOS). Prematurity (p = 0.012), APGAR < 6 (p = 0.018), low birth weight (p < 0.001), and maternal intrapartum antibiotics (p = 0.031) significantly increased risk for culture-positive EOS. Prematurity (p < 0.001), low birth weight (p = 0.001), and parental nutrition (p = 0.007) were significantly associated with increased risk of culture-positive late-onset sepsis. A positive screen had sensitivity of 81.8% and negative predictive value of 87.7%. Gram-negative organisms were most commonly isolated (64.6%). Coagulase-negative Staphylococci (31%) were the commonest isolate followed by Klebsiella pneumoniae (27%) and Acinetobacter (18.8%). Ninety percent of Acinetobacter were carbapenem resistant. Gram-negative sepsis had mortality of 88.9%. CONCLUSION: Preterm, low birth weight, low APGAR scores, intrapartum antibiotics, and parental nutrition were significantly associated with neonatal sepsis. Coagulase-negative Staphylococci, Klebsiella pneumoniae, and Acinetobacter were the principal causative organisms. Gram-negative organisms had high resistance to commonly used antibiotics.

Prevalence of Exclusive Breastfeeding and Factors Associated With Exclusive Breastfeeding of Children in Trongsa District, Bhutan.

The World Health Organization estimated that about 800 000 infant deaths could be prevented annually by exclusively breastfeeding infants for the first 6 months of life. This study aimed to examine the prevalence of exclusive breastfeeding and its associated factors. A total of 192 mothers participated. The prevalence of exclusive breastfeeding practice in Trongsa district was 97% at 1 month, declining to 58% at 6 months. Mothers who returned to formal work were less likely to exclusively breastfeed than those who were farmers or housewives. The main reasons stated by the mothers for not exclusively breastfeeding were lack of the mother's self-confidence that the child is getting enough breastmilk and mothers having to return to work, 59% and 22%, respectively. The rate of exclusive breastfeeding in Trongsa district of Bhutan is high, and every effort should be made to maintain and improve this rate.

Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012.

Background: Despite Bhutan's remarkable progress in the area of maternal and child health during the era of the Millennium Development Goals, a large proportion of pregnant women are still delivering at home with no skilled attendant. Limited empirical studies have been carried out to understand the factors associated with delivery at home in Bhutan. Methods: This cross-sectional analytical study used secondary data collected in the nationally representative National Health Survey 2012. The survey included a total of 2213 women aged 15-49 years who had a live birth in the 2 years preceding the survey and were selected using multistage stratified cluster sampling. Weighted analysis was done to evaluate determinants for the place of delivery. Unadjusted and adjusted prevalence ratios with 95% confidence intervals (CIs) were calculated to assess the possible association of factors with home delivery. Results: Out of 2213 women aged 15-49 years who had a live birth in the 2 years preceding the survey, 73.7% had an institutional delivery. Coverage of institutional delivery ranged from 49.4% in Zhemgang district to 96.1% in Paro district. Women in the poorest wealth quintile were 7.35 times more likely to have a birth at home compared to women in the richest quintile (adjusted prevalence ratio [aPR]: 7.35, 95% CI: 2.59-20.9). The older mothers aged 30-49 years were 0.79 times (aPR: 0.79, 95% CI: 0.70-0.88) less likely to have a home delivery than mothers aged 15-19 years. Women who had fewer than four antenatal care visits were 1.50 times (aPR: 1.50, 95% CI: 1.35-1.66) more likely to give birth at home compared to those who had four or more visits. The mothers giving birth for a third or more time were 1.88 times (aPR: 1.88, 95% CI: 1.60-2.22) more likely to give birth at home compared to those giving birth for the first time. Women living in rural areas were 2.87 times (aPR: 2.87, 95% CI: 1.42-5.77) more likely to deliver at home compared to those living in urban areas and women living in the eastern region of the country were 1.35 times (aPR: 1.35, 95% CI: 1.17-1.55) more likely to have a home delivery compared to those living in the western region. Conclusion: Lower socioeconomic status, rural location, eastern location, non- first birth, and having fewer than four antenatal visits were significant factors associated with home delivery. These findings should inform further research and policy to build on Bhutan's progress in promoting institutional delivery as the key strategy towards improving maternal and child health and achieving the relevant targets of Sustainable Development Goal 3.

Emergency Contraceptive Pills (ECP) Knowledge, Attitudes, and Practices Among Women Working in the Entertainment Industry and Men in the Trucking Industry, Bhutan.

Emergency contraceptive pills (ECP) were recently made available over the counter in Bhutan. We evaluated knowledge, attitudes, and practices concerning ECP in 2 populations at risk for HIV and STI (sexually transmitted infections): entertainment women (drayang) and male truck drivers and helpers (truckers). Of 179 drayang and 437 truckers intercepted at venues, 73.7 and 21.1%, respectively, had heard of ECP; 47.0% of drayang had used them. Their concerns about ECP use included harm to the body, impact on future pregnancy, side effects, and HIV/STI risk. Education programs are needed in Bhutan to increase awareness of ECP for unplanned pregnancy and condoms to prevent HIV and STI.

Alarming prevalence and clustering of modifiable noncommunicable disease risk factors among adults in Bhutan: a nationwide cross-sectional community survey.

BACKGROUND: Bhutan is currently facing a double burden of non-communicable (NCDs) and communicable diseases, with rising trends of NCDs. The 2014 STEPS survey identified high prevalence of several NCD risk factors; however, associations with socio-demographic characteristics as well as clustering of risk factors were not assessed. This study aimed to determine the distribution and clustering of modifiable NCD risk factors among adults in Bhutan and their demographic and social determinants. METHODS: This was secondary analysis of data from NCD Risk Factors WHO STEPS Survey 2014 in Bhutan. A weighted analysis was conducted to calculate the prevalence of NCD risk factors, and associations were explored using weighted log-binomial regression models. RESULTS: This study included 2822 Bhutanese aged 18-69 years; 52% were 18-39 years, 62% were female, and 69% were rural resident. Prevalence of high salt intake, unhealthy diet and tobacco use were 99, 67 and 25% respectively. Raised blood pressure was the commonest (36%) modifiable biological risk factor followed by overweight (33%). The median NCD risk factors per person was 3 (Inter Quartile Range: 2-4); 52.5%% had > = 3 risk factors. A statistically significant difference was found between male vs. female in alcohol consumption(aPR 0.71, 95% CI: 0.53-0.97), low physical activity(aPR 2.06, 95% CI: 1.54-2.75), impaired fasting glycaemia(aPR 1.24, 95% CI: 1.01-1.52), and being overweight(aPR 1.46, 95% CI: 1.31-1.63). Low physical activity was more common among those with secondary and above education level vs. those without any formal education(aPR 1.71, 95% CI: 1.24-2.35), and among those residing in urban areas vs. those in rural(aPR 3.43, 95% CI: 2.27-5.18). Older participants and urban residents were more likely to have > = 3 NCD risk factors compared to younger(aPR 1.46, 95% CI: 1.35-1.58) and rural residents(aPR 1.21, 95% CI: 1.10-1.32). CONCLUSION: Lifestyle modifications at the population level are urgently required in Bhutan as several NCD risk factors such as high salt intake, unhealthy diet, overweight, and high blood pressure were alarmingly high and frequently clustered. Moreover there is a need to consider policy and socio-political and economic factors that have undermined global and national progress to address the rise of NCDs and their risk factors in Bhutan as elsewhere.

Current tobacco use and its associated factors among adults in a country with comprehensive ban on tobacco: findings from the nationally representative STEPS survey, Bhutan, 2014.

BACKGROUND: Despite a comprehensive ban on cultivation, manufacture, distribution, and sale of tobacco products since 2004, two nationwide surveys conducted in 2012 and 2013 reported high tobacco use in Bhutan. National Health Survey 2012 reported that 4 % of the population aged 15-75 years used smoked tobacco and about 48 % used smokeless tobacco. Similarly, Global Youth Tobacco Survey (GYTS) of Bhutan reported tobacco use prevalence of 30.3 % in 2013. However, factors associated with this high tobacco use were not systematically studied. Hence, we assessed the prevalence of tobacco use and its associated sociodemographic, behavioral, and environmental factors. METHODS: This cross-sectional analytical study used secondary data collected in a nationally representative Non-communicable Disease Risk Factors Surveillance STEPS Survey 2014 conducted among Bhutanese adults (18-69 years). The survey included a total of 2820 adults; selected using multistage stratified cluster sampling. Weighted analysis was done to calculate the prevalence of tobacco use. Unadjusted and adjusted prevalence ratios were calculated using log binomial regression. RESULTS: The prevalence of current overall tobacco use was 24.8 % (95 % CI: 21.4-28.3) and that of smoked, smokeless, and dual forms (smoked and smokeless forms) were 7.4 % (95 % CI: 5.8-9.0), 19.7 % (95 % CI: 16.5-22.9), and 2.3 % (95 % CI: 1.8-2.9), respectively. Significantly higher prevalence of tobacco use in all forms was found among males, younger age groups, and alcohol users. The prevalence of smoked form was higher in urban areas compared to rural areas (11 % vs 6 %; aPR 1.8, 95 % CI: 1.5-2.0). Among individuals who reported having a non-communicable disease, the prevalence of smoked tobacco use was significantly lower than those who did not have disease (3.5 % vs. 8.3 %; aPR 0.5, 95 % CI: 0.3-0.9). Exposure to health warnings was protective for current tobacco use and smokeless tobacco use, while exposure to tobacco warnings through the media was helpful among smokers and overall tobacco users. CONCLUSIONS: Despite a comprehensive ban on tobacco, tobacco use was high in Bhutan, especially the smokeless form. Males, younger age groups, and alcohol users should be targeted with behavioral interventions along the stricter implementation of tobacco control measures.

Progress and delivery of health care in Bhutan, the Land of the Thunder Dragon and Gross National Happiness.

The Himalayan Kingdom of Bhutan is rapidly changing, but it remains relatively isolated, and it tenaciously embraces its rich cultural heritage. Despite very limited resources, Bhutan is making a concerted effort to update its health care and deliver it to all of its citizens. Healthcare services are delivered through 31 hospitals, 178 basic health unit clinics and 654 outreach clinics that provide maternal and child health services in remote communities in the mountains. Physical access to primary health care is now well sustained for more than 90% of the population. Bhutan has made progress in key health indicators. In the past 50 years, life expectancy increased by 18 years and infant mortality dropped from 102.8 to 49.3 per 1000 live births between 1984 and 2008. Bhutan has a rich medical history. One of the ancient names for Bhutan was 'Land of Medicinal Herbs' because of the diverse medicinal plants it exported to neighbouring countries. In 1967, traditional medicine was included in the National Health System, and in 1971, formal training for Drungtshos (traditional doctors) and sMenpas (traditional compounders) began. In 1982, Bhutan established the Pharmaceutical and Research Unit, which manufactures, develops and researches traditional herbal medicines. Despite commendable achievements, considerable challenges lie ahead, but the advances of the past few decades bode well for the future.