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Introduction: Postoperative nausea and vomiting (PONV) are common distressing symptoms experienced after laparoscopic cholecystectomy. We report the rate, and the factors associated with postoperative nausea and vomiting, the patterns of prophylactic antiemetic prescription, and the anesthetic techniques used among patients who underwent laparoscopic cholecystectomy at the Jigme Dorji Wangchuck (JDW) National Referral Hospital, Bhutan. Methods: A cross-sectional study was conducted at the JDW National Referral Hospital, from January to December 2018. All the patients who underwent laparoscopic cholecystectomy under general anesthesia were included in the study. The demographic variables, premedication, induction agents, muscle relaxants, inhalational agents for maintenance, opioid and adjuvant analgesics, the reversal agents used, and the occurrence of PONV within 24 h were recorded. Data were analyzed using SPSS (version 23). Continuous variables were compared using a t-test or Mann-Whitney test, categorical variables were tested using chi-square or Fisher's exact tests. Binary logistic regression analysis was performed to determine the factors associated with postoperative nausea and vomiting. Results: 190 patients underwent laparoscopic cholecystectomy under general anesthesia. The rate of PONV after laparoscopic cholecystectomy was 31.1% (59/190). Over half (53.7%, 102/190) of the study population were within 21–40 years of age, over 80% (157/190) were female, and 2/3rd were overweight and obese. The most frequently used premedication was ranitidine (39%, 34/87) and metoclopramide (31%, 27/87). More than half (57.4%, 109/190) of the patients received morphine as an opioid analgesic before induction. Sodium thiopentone was a commonly used induction agent (65.8%, 125/190). Succinylcholine and atracurium were mostly preferred muscle relaxants. Isoflurane and air were the most used inhalational anesthetic agents for the maintenance of anesthesia. Ondansetron was the most preferred anti-emetics during the intraoperative period. Previous history of motion sickness (OR 5.8, 95%CI 2.9–11.2, p < 0.001), and use of sodium thiopental (OR 4.1, 95%CI 1.9–9.1, p < 0.001) were independent risk factors for PONV. The use of antiemetics (OR 0.1, 95%CI 0.0-0.4, p = 0.002), propofol (OR 0.2, 95%CI 0.1–0.5, p < 0.001), adjuvant analgesic paracetamol (OR 0.4, 95%CI 0.2–0.8, p = 0.026), and adequate hydration with IV fluids (OR 0.9, 95%CI 0.9-1.0, p = 0.042) were preventive factors for PONV. Conclusion: The rate of PONV after laparoscopic cholecystectomy was high. History of motion sickness and use of sodium thiopental for induction were independent risk factors of PONV. The use of multimodal prophylactic antiemetics was robust and superior to monotherapy in preventing PONV. This finding re-emphasizes the need for risk stratification and appropriate use of antiemetics and anesthetic agents to prevent PONV. [ABSTRACT FROM AUTHOR]

Background: Indigenous and non-indigenous people in subtropical and temperate areas of Bhutan share an intricate relationship with stingless bees for diverse purposes including ethno-medicinal uses. Stingless bees hold significant importance in the realms of social, economic, cultural, and spiritual aspects. Bhutan's cultural traditions demonstrate a strong bond with the environment, exemplified by the regular use of honey from stingless bees for remedies such as treating the common cold, cough, and sore throat. Methods: Ethnographic research was conducted to document the ethno-medicinal uses and cultural importance of stingless bees in Bhutan. We deployed semi-structured interviews with stingless beekeepers and honey collectors including traditional healers who perform religious rituals for curing and preventing physical and mental illness. Results: We documented 22 different uses of stingless bee honey in food, medicine, veterinary medicine, crafts, beliefs, and religious purposes. The relative cultural importance (RCI) of stingless bees among Bhutan's ethnic communities was assessed through our calculations. It was determined that these bees hold notably greater significance for the Lhotshampa communities compared to other ethnic groups in Bhutan. This finding demonstrates the dependence of Hindu ethnic communities on natural resources in their everyday life. All participant communities largely exploit these bees through destructive extraction practices. They often find the natural nests in nearby forests, transfer them as a log hive to their backyards, and practice traditional meliponiculture. Conclusion: The ethnic communities of Bhutan use stingless bees for various purposes and the local knowledge are persistent. However, significant efforts should be made to address the ethno-medicinal, ecological, biological, and commercial perspectives of meliponiculture in Bhutan. [ABSTRACT FROM AUTHOR]

Background and objective: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage. [ABSTRACT FROM AUTHOR]

Introduction: Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan. Methods: This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants. Results: Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708–3.765), overweight and obese (OR 1.6 95% CI 0.640–3.945), unemployed (OR 1.7, 95% CI 0.674–1.140), nulliparous (OR 1.7, 95% CI 0.183–15.816), primipara (OR 5.1, 95% CI 0.635–40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449–10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101–12.061), overweight and obesity (OR 1.4, 95% CI 0.490–3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347–13.889), and junior surgeons (OR 1.1, 95%CI 0.463–2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05). Conclusion: The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception. [ABSTRACT FROM AUTHOR]

Background: Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting. Case presentation: A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T10 level. He had hyperaesthesia below T8, hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality. Conclusions: This case called for a serious evaluation of the country's efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases. [ABSTRACT FROM AUTHOR]

Objective: To study the profile, clinical presentation and outcome of hospital stay among patients admitted with warfarin toxicity at the Jigme Dorji Wangchuck National Referral Hospital, Bhutan. This was a cross-sectional study with a review of hospital records of patients admitted between 01 and 2018 and 30 June 2020. Results: There were 22 admissions due to warfarin toxicity. The mean age of patients was 55.9 (± SD 20.2) years, the median duration of warfarin therapy was 30 months (IQR 4.8, 69 months). The indications for warfarin were atrial fibrillation (9, 40.9%), mechanical heart valves (6, 27.3%), deep vein thrombosis (6, 27.3%) and pulmonary thromboembolism (1, 4.5%). The mean of dosage of warfarin was 4.3 (± 2.6) mg and the cumulative dosage in the week prior to admission was 30.9 (± 18.6) mg. The mean of INR at presentation was 7.7 (± 4.3) with the maximum noted at 20. The patients presented with gastrointestinal bleeding, muscle haematomas, epistaxis and oral cavity bleeding. There was no mortality related to warfarin toxicity. The reasons for warfarin toxicity included patient dosing error and drug interactions. Warfarin therapy requires appropriate patient education, adequate facilities for follow-up and avoidance of warfarin wherever possible in clinical settings. [ABSTRACT FROM AUTHOR]

Background: Bhutan has pledged to remain carbon neutral (CN) in perpetuity. Whether they can sustain this is questionable due to the country's increasing economic growth (GDP) and commitment to gross national happiness (GNH) outcomes, both of which can lead to a rise in greenhouse gas (GHG) emissions. The nexus between GHG, GNH and GDP is the essence of the Paris Agreement and Sustainable Development Goals global project. Results: Through scenario modelling using the Long-range Energy Alternative Planning (LEAP) model, the study finds that the carbon neutral declaration will derail between 2037 and 2050 without mitigation measures. By putting in place mitigation measures especially in the industry and transport sectors, CN can be retained even under high growth pressure, which may cost just 2% of GDP. CN can be easily retained under low economic growth, but this could undermine GNH. High growth will require immediate interventions to enable electrification of industry and transport. Conclusions: The options to remain CN will require Bhutan to adopt more efficient technologies and electrify industry and transport under both low and high growth scenarios. The additional cost to the Bhutanese economy is feasible through low and high growth opportunities. The options are similar to those confronting emerging nations struggling with issues of climate commitments under economic growth pressures. All will need to adapt their specific economic contexts to achieve the simultaneous objectives of the Sustainable Development Goals whilst addressing the net zero Paris agenda. Bhutan shows it is possible. [ABSTRACT FROM AUTHOR]

Background: The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan. Methods: We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data. Results: The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments. Conclusion: There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with "One Health" public health sectors. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Ethno-medicinal Uses and Cultural Importance of Stingless Bees and Their Hive Products in Several Ethnic Communities in Bhutan," which appeared in the 2024 issue of the magazine.

Background: Assessment of occupational exposures is an integral component of population-based studies investigating the epidemiology of occupational diseases. However, all the available methods for exposure assessment have been developed, tested and used in high-income countries. Except for a few studies examining pesticide exposures, there is limited research on whether these methods are appropriate for assessing exposure in LMICs. The aim of this study is to compare a task-specific algorithm-based method (OccIDEAS) to a job-specific matrix method (OAsJEM) in the assessment of asthmagen exposures among healthcare workers in a high-income country and a low- and middle- income country (LMIC) to determine an appropriate assessment method for use in LMICs for future research.Methods: Data were obtained from a national cross-sectional survey of occupational asthmagens exposure in Australia and a cross-sectional survey of occupational chemical exposure among Bhutanese healthcare workers. Exposure was assessed using OccIDEAS and the OAsJEM. Prevalence of exposure to asthmagens and inter-rater agreement were calculated.Results: In Australia, the prevalence was higher for a majority of agents when assessed by OccIDEAS than by the OAsJEM (13 versus 3). OccIDEAS identified exposures to a greater number of agents (16 versus 7). The agreement as indicated by κ (Cohen's Kappa coefficient) for six of the seven agents assessed was poor to fair (0.02 to 0.37). In Bhutan, the prevalence of exposure assessed by OccIDEAS was higher for four of the seven agents and κ was poor for all the four agents assessed (-0.06 to 0.13). The OAsJEM overestimated exposures to high-level disinfectants by assigning exposures to all participants from 10 (Bhutan) and 12 (Australia) ISCO-88 codes; whereas OccIDEAS assigned exposures to varying proportions of participants from these ISCO-codes.Conclusion: There was poor to fair agreement in the assessment of asthmagen exposure in healthcare workers between the two methods. The OAsJEM overestimated the prevalence of certain exposures. As compared to the OAsJEM, OccIDEAS appeared to be more appropriate for evaluating cross-country exposures to asthmagens in healthcare workers due to its inherent quality of assessing task-based determinants and its versatility in being adaptable for use in different countries with different exposure circumstances. [ABSTRACT FROM AUTHOR]

Background: Star anise fruit has been used in spice in Asian cuisine, ingredient for traditional medicines, component for antiviral drugs and as parts of tea and beverage across the globe. Toxicity from these plants has been reported due to adulteration with similar toxic species and from consumption with high toxic dose. Most physician and public are unaware of these adverse effects., Cases: We present two cases of star anise toxicity. Both of the patients presented with gastrointestinal and neurological symptoms after consumption of the said fruit. All of the labs and imaging test was negative for other causes and star anise toxicity diagnosis was made after detailed history, events and related symptoms. They were managed supportively and discharged after 24 h of observation., Conclusion: Emergency department doctors should be vigilant about possible star anise toxicity in patient presenting with suggestive symptoms, negative investigation for other possible cause and in area where these plant species is available. A detailed drug and ingestion history is essential., (© 2024. The Author(s).)

Background: Cervical cancer in pregnancy is a rare event. Diagnosis and management of cervical cancer in pregnancy is complicated and challenging in a low resource setting., Case Presentation: Herein, we present a case of cervical cancer (FIGO stage IB3) diagnosed at 28 + 5 weeks and successfully managed at 37 + 2 weeks of gestation in a 27-year-old woman., Conclusion: This is the first case report on cervical cancer in pregnancy from Bhutan. It highlights the diagnostic and management challenges in a low resource country., (© 2024. The Author(s).)

Background: In the past, wild edible fruits (WEFs) were a significant source of food and nutrition in Bhutan. These nutrient-rich species can enhance food security and alleviate poverty in Bhutan. However, recent developments like the introduction of improved fruit varieties, changes in dietary choices, and infrastructure development are expected to influence indigenous knowledge and consumption of WEFs. We aimed to document the species diversity of WEFs and their uses in eastern Bhutan and examine how the knowledge and consumption of WEFs vary with socio-demographic factors. Methods: A total of 97 households in two districts were selected to participate in the survey. A semi-structured questionnaire was used to interview a selected adult from each household. Comparative analysis of indigenous knowledge and consumption of WEFs among the socio-demographic factors was performed using one-way ANOVA and a Chi-square test on R software. Results: The present study reported 52 species of WEFs belonging to 35 families. The prevalence of WEF consumption was found to be 42%. WEF consumption differed significantly between districts, age groups, and indigenous knowledge levels. Similarly, indigenous knowledge of WEFs was significantly associated with districts and age groups. Conclusions: Eastern Bhutan has a rich diversity of WEFs, but their consumption has been decreasing. Recent agricultural and infrastructure developments may have impacted the consumption and indigenous knowledge of WEFs in this region. Thus, domestication and agro-processing of WEFs should become a major focus in Bhutan to utilize their nutritional value and potential economic benefits to enhance food security in the country. Additionally, incorporating WEF-related knowledge in the school curriculum is essential to educate younger generations on WEFs. [ABSTRACT FROM AUTHOR]

Objective: To describe the clinical profile of minimal invasive procedures performed in gynecology at the national referral hospital in Bhutan. A review of such procedures performed in gynecology was needed to assess the baseline information and generate our own experience. We conducted a descriptive study with a review of hospital records of minimal invasive procedures performed from 1st January to 31st December 2020 at the Department of Gynecology. Data were extracted into a structured pro forma. Descriptive statistics were used to express the results. Results: The mean age of the patients was 33.9 ± 8.6 years of which the maximum was in the age group 25–34 years. 28 (17.5%) and 132 (82.5%) patients underwent emergency and elective procedures respectively. 142 (88.8%) and 18 (11.2%) patients underwent laparoscopic and hysteroscopic procedures respectively. Ovarian cystectomy was the most commonly performed procedure. The median operating time was 100 min (IQR 62.5–157.5). The overall complication rate was 2.5%. The median postoperative length of hospital stay was 24 h (IQR 3–24). Using our data and experience, we recommend a new health policy to recognize MIS in gynecology as a subspecialty and strengthen the existing service in gynecological MIS. [ABSTRACT FROM AUTHOR]

Background: Scrub Typhus (ST) is an acute, febrile zoonotic disease caused by the bacterium Orientia tsutsugamushi which is endemic to the Asia-Pacific region. Infected adults rarely present with sensorineural hearing loss and otalgia. Though few cases of pediatric cases are known to present with otalgia, no pediatric cases of sensorineural deafness complicating ST have been reported to date.Case Presentation: A 5-year-old, previously healthy girl presented with a one-week history of high-grade intermittent fever, Headache and right ear pain with a recent onset of reduced hearing. She had a fever up to 39 °C, cervical lymphadenopathy, bilateral pleural effusion with diffuse infiltrations, and mild hepatosplenomegaly with no evidence of rash. Her initial examination was normal except for mildly enlarged tonsils. Unilateral right ear hearing loss was noted using Weber's test. Evidence of progressive, mild anemia, and raised inflammatory markers was noted. Diagnosis of scrub typhus was confirmed by positive detection of Orentia tsutsugamushi IgM antibodies on rapid diagnostic test and the presence of chigger mite in the right external auditory canal on repeat examination. She responded dramatically to the empirical treatment of ceftriaxone and doxycycline. On follow-up, she did not have any residual hearing loss and her ear pain had resolved completely.Conclusion: Acute onset hearing loss or severe otalgia with or without findings should be an important diagnostic clue for suspecting scrub typhus in patients who present with a history of fever especially in endemic areas. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Alcohol use is a major public health problem in Bhutan. Compliance with regulations at the point of sale is an important strategy in alcohol control. Retail outlets were briefed on sale regulations and provided notification of rules, which they were directed to display on the premises. The extent to which licensed alcohol outlets responded to possible alcohol purchases was assessed through the use of young proxy-purchasers, adults feigning alcohol intoxication and sober adults. A total of 854 visits (pre versus post visits) were made across four district towns. Two towns (Damphu town in Tsirang district and Pema Gatshel town in Pema Gatshel district) received pre- and post-intervention purchase surveys, while the other two neighbouring towns (Khuruthang town in Punakha and Bajo town in Wangdue) were administered only baseline surveys.Method: We used a pre- and post-test community intervention design covering all alcohol retailers both on premise (bar, hotel, restaurant, karaoke bars) and off premise (grocery shops). Compliance with alcohol regulations at the point of sale was assessed through the use of young proxy-purchasers, adults feigning alcohol intoxication and sober adults.Results: Retailers rarely checked the age and/or identification (ID) of the proxy-purchasers before the intervention. There was a 22.7% (8.6, 37) percent increase in compliance with laws after the intervention. While some strategies are suggested, the strongest and most effective measure to prevent under-age drinking and service to intoxicated individuals is more rigorous enforcement of existing liquor laws.Conclusion: Alcohol control requires ongoing government enforcements, supplemented by public awareness and knowledge. [ABSTRACT FROM AUTHOR]

Background: Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan.Methods: This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital.Results: For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%).Conclusion: Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections. [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary perioperative care program to optimize and enhance postoperative recovery. It has a beneficial role in decreasing the length of hospital stay and improving the quality of care. This study aims to observe the successful implementation of ERAS in reducing the length of hospital stay (LOS) among caesarean deliveries.Methods: A pre-and post-implementation study of ERAS protocol was conducted, among cohort of women who underwent caesarean deliveries from January to December 2020 in the Department of Obstetrics and Gynaecology, Mongar Regional Referral hospital. Data collected retrospectively and analyzed in SPSS (IBM SPSS trial version); and comparison of length of hospital stay between the two groups were tested by t-test.Results: One hundred seventy-one patients were included in the study: 87 in the pre-ERAS and 84 in the post-ERAS cohort. Post implementation, LOS decreased by an average of 21.0 (CI 16.11-24.64; p-value < 0.001) hours in the postoperative period. A greater proportion of patients were discharged on day-2 (2.3% in pre-ERAS and 81% in ERAS; p-value < 0.001).Conclusion: Implementation of ERAS protocol can significantly decrease the postoperative length of hospital stay without increasing the complications and readmission rates. [ABSTRACT FROM AUTHOR]

Background: Nutritional deficiencies are common worldwide and is most notable in low and middle income countries. In the early weeks of September 2018, oral sores mostly affecting the tongue were reported in three central schools under Tsirang district, Bhutan. A total of 204 students were affected in the three central schools. All the affected students have been assessed on the outbreak and nutritional survey was conducted in the three schools. Methods: A total of 204 students who complained of different oral lesions in the affected three schools were screened by the dental surgeon for clinical assessment and administered questionnaire for nutritional assessment by the nutritionist. Twenty-one students randomly selected were sent for blood tests for micronutrient assays and complete blood count. 41 students were tested for Exfoliative cell cytology to test for fungal elements. The collected data was double entered and validated using Epi-Data version 3.1 and analysed using Stata 15 IC. The characteristics of the participants are presented as frequencies, percentages, mean and standard deviation (SD). Results: Almost all the affected students in all the three schools had complaints of Burning Sensation (n = 158) followed by Pain (n = 153), Impaired Taste Sensation (n = 100) and Intolerance to Spicy Food (n = 95). Nutritional assessment analysis suggested schools not meeting the Recommended Dietary Allowance (RDA) for all components of Vitamin B complexes and Iron. Conclusion: Clinical assessments and nutritional survey analysis found inadequate vitamin rich dietary intakes among all the three schools. Implementation of a strict school feeding program with a balanced diet has been suggested accordingly. [ABSTRACT FROM AUTHOR]

Physiotherapy and rehabilitative services are an integral part of patient care, but in many developing countries they are not considered a priority and are either not available or not easily accessible to those who need them. Bhutan is one such country where healthcare is provided free of cost to all, but as of 2021 physiotherapy services were available only in 26 of 48 hospitals and 19 of 20 districts. The number of physiotherapy professionals per 10,000 population is 1.4 with significant rates of attrition. There is lack of awareness among patients and other health professionals about physiotherapy and rehabilitation services. The country needs to integrate physiotherapy and rehabilitation services into the overall health policy framework and develop proper planning of human resources and infrastructure to meet the current and future demands. [ABSTRACT FROM AUTHOR]

Background: Palliative care improves the quality of lives of patients and families affected by advanced illnesses through the prevention and relief of suffering. While palliative care is well established in developed countries, it is inadequate or non-existent in most developing countries. Palliative care is an emerging concept in Bhutan, a tiny Himalayan Kingdom. A small community palliative care service is available in the national referral hospital with three dedicated inpatient palliative care beds. This study explored the needs for palliative care among patients diagnosed with advanced illnesses and is a component of a larger project aimed to inform a suitable palliative care model for the country. Methods: This is a cross-sectional descriptive study. A survey, using a structured questionnaire including the EORTC QLQ-C30, was carried out among patients with advanced illness in hospitals, primary care units and communities across the country. Purposeful and snowball sampling strategies were used to recruit study participants. Results: Seventy (76%), out of 93 eligible patients, agreed to participate in the survey. Participants reported low to moderate scores on physical, role, emotional, cognitive and social functioning, a moderate score for the global health/ quality of life scale and moderately high (worse) scores in symptoms including fatigue, pain, insomnia, loss of appetite and the financial impact from the disease. Conclusions: The symptom burden experienced by patients affected by advanced illnesses demonstrates the need for palliative care in Bhutan. These findings will help inform the development of a public health-focused palliative care model, modified to the Bhutanese context, as recommended by the World Health Organization. [ABSTRACT FROM AUTHOR]

Emergency medicine in Bhutan has made significant progress in the past few decades and continues to evolve. In this article, we provide valuable insights into the history of emergency medicine at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and in Bhutan and highlight some of the future challenges we face as we move forward to meet the demands of increased patient volume and complexity., (© 2024. Crown.)

Background: Pneumococcal nasopharyngeal colonization (PNC) generally precedes pneumococcal disease. The purpose of this study was to determine the prevalence of PNC and to identify the pneumococcal serotypes circulating among Bhutanese children under five years of age admitted with clinical pneumonia, before the introduction of pneumococcal conjugate vaccine (PCV13) in the country. We also aimed to contribute to the understanding of the interplay between PNC and viral co-infection among this population.Methods: This was a prospective study conducted at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan over 12 consecutive months. Children aged 2 to 59 months admitted with WHO-defined clinical pneumonia were eligible for recruitment. We collected blood for bacterial culture and molecular identification of S. pneumoniae, and nasopharyngeal washing for screening of respiratory viruses, and for the detection and capsular typing of S. pneumoniae by real-time polymerase chain reaction (RT-PCR).Results: Overall, 189 children were recruited, and PNC was tested in 121 of them (64.0%). PNC was found in 76/121 children (62.8%) and S. pneumoniae was identified in blood (both by culture and RT-PCR) in a single child. Respiratory viruses were detected in a similar proportion among children with (62/70; 88.6%) and without PNC (36/40; 90.0%; p = 1.000), but rhinovirus detection was less common among children with PNC (20/70; 28.6% versus 19/40; 47.5%; p = 0.046). Capsular typing identified 30 different serotypes. Thirty-nine children (51.3%) were colonised with two to five different serotypes. A third of the children presented with serotypes considered highly invasive. Over half of the children (44/76; 57.9%) were carrying at least one serotype included in PCV13.Conclusions: This study provides baseline information on the status of PNC among Bhutanese children admitted with clinical pneumonia prior to the introduction of PCV13, which is valuable to monitor its potential impact. PCV13 could theoretically have averted up to 58% of the pneumococcal infections among the children in this study, suggesting a future role for the vaccine to significantly reduce the burden associated with S. pneumoniae in Bhutan. [ABSTRACT FROM AUTHOR]

Background: Several plant-pathogenic bacteria are transmitted by insect vector species that often also act as hosts. In this interface, these bacteria encounter plant endophytic, insect endosymbiotic and other microbes. Here, we used high throughput sequencing to examine the bacterial communities of five different psyllids associated with citrus and related plants of Rutaceae in Bhutan: Diaphorina citri, Diaphorina communis, Cornopsylla rotundiconis, Cacopsylla heterogena and an unidentified Cacopsylla sp. Results: The microbiomes of the psyllids largely comprised their obligate P-endosymbiont 'Candidatus Carsonella ruddii', and one or two S-endosymbionts that are fixed and specific to each lineage. In addition, all contained Wolbachia strains; the Bhutanese accessions of D. citri were dominated by a Wolbachia strain first found in American isolates of D. citri, while D. communis accessions were dominated by the Wolbachia strain, wDi, first detected in D. citri from China. The S-endosymbionts from the five psyllids grouped with those from other psyllid taxa; all D. citri and D. communis individuals contained sequences matching 'Candidatus Profftella armatura' that has previously only been reported from other Diaphorina species, and the remaining psyllid species contained OTUs related to unclassified Enterobacteriaceae. The plant pathogenic 'Candidatus Liberibacter asiaticus' was found in D. citri but not in D. communis. Furthermore, an unidentified 'Candidatus Liberibacter sp.' occurred at low abundance in both Co. rotundiconis and the unidentified Cacopsylla sp. sampled from Zanthoxylum sp.; the status of this new liberibacter as a plant pathogen and its potential plant hosts are currently unknown. The bacterial communities of Co. rotundiconis also contained a range of OTUs with similarities to bacteria previously found in samples taken from various environmental sources. Conclusions: The bacterial microbiota detected in these Bhutanese psyllids support the trends that have been seen in previous studies: psyllids have microbiomes largely comprising their obligate P-endosymbiont and one or two S-endosymbionts. In addition, the association with plant pathogens has been demonstrated, with the detection of liberibacters in a known host, D. citri, and identification of a putative new species of liberibacter in Co. rotundiconis and Cacopsylla sp. [ABSTRACT FROM AUTHOR]

Background: Bhutan is committed to eliminating hepatitis B and hepatitis C, though recent baseline estimates of disease burden in the general population are unknown. In 2017, we carried out a biomarker survey in the general population to estimate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) biomarkers to evaluate the impact of immunization and guide further efforts.Methods: In 2017, a cross-sectional, population-based, three-stage cluster survey was undertaken of the general population (1-17 and 20+ years of age). We visited households, collected blood specimens and administered a standard questionnaire. Specimens were collected for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We calculated prevalence of infection and selected characteristics, along with confidence intervals (CIs).Results: Of 1372 individuals approached, 1358 (99%) participated. Of those, 1321 (97%) had a specimen tested for HBsAg, and among 1173 enrolled individuals 5 years of age or older, 1150 (98%) individuals were tested for anti-HCV. The prevalence of HBsAg was 2.0% in 775 persons 20 years of age or older (95% CI: 1.0-4.0) and 0.5% in 546 persons 1-17 years of age (95% CI: 0.1-1.8). The prevalence of anti-HCV was 0.3% (95% CI: 0.1-0.8) among persons ≥5 years.Conclusions: Universal hepatitis B immunization of infants has resulted in a low prevalence of chronic HBV infection in persons 1-17 years of age and the prevalence of anti-HCV is low among persons aged ≥5 years. Efforts should continue to reach high coverage of the timely birth dose along with completion of the hepatitis B vaccine series. To reduce the chronic liver disease burden among adults, HBV and HCV testing and treatment as indicated might be restricted to pregnant women, blood donors, individuals with chronic liver diseases, and other groups with history of high-risk exposures. [ABSTRACT FROM AUTHOR]

Background: Rabies kills approximately 59,000 people each year worldwide. Rapid and accurate diagnosis of rabies is important for instituting rapid containment measures and for advising the exposed people for postexposure treatment. The application of a rapid diagnostic tests in the field can greatly enhance disease surveillance and diagnostic activities, especially in resource poor settings. In this study, a total of 179 brain tissue samples collected from different rabies suspect animal species (113 dogs, 50 cattle, 10 cats, 3 goats, 2 horses, and 1 bear) were selected and tested using both rapid immunochromatographic kit and the reference standard fluorescent antibody test (FAT). We evaluated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of a rapid antigen detection test kit produced by BioNote, Inc. (Hwaseong-si, Korea) relative to a FAT for its fit-for-purpose for confirmation of clinical cases of rabies for early response and enhancing rabies surveillance. Results: Among 179 samples examined in this study, there was a concordance in results by the rapid test and FAT in 115 positive samples and 54 negative samples. Test results were discordant in 10 samples which were positive by FAT, but negative (false negative) by rapid kit. The rapid test kit showed a sensitivity of 92% (95% CI: 85.9–95.6) and specificity of 100% (95% CI: 93.4–100) using FAT as the reference standard. The positive and negative predictive values were found to be 100% (95% CI:96.7–100) and 84.4% (95% CI: 73.6–91.3), respectively. Overall, there was 94.4% (95% CI: 90–96.9) test agreement between rapid test and FAT (Kappa value = 0.874) with a positive percent agreement and negative percent agreement of 92 and 100%, respectively. Conclusions: Our finding demonstrated that the rapid test kit (BioNote) can be used for rabies surveillance and confirming clinical case of rabies in animals for making rapid decisions particularly controlling rabies outbreaks in resource poor settings. [ABSTRACT FROM AUTHOR]

Background: Oral cancer is a growing problem worldwide, with high incidence rates in South Asian countries. With increasing numbers of South Asian immigrants in developed countries, a possible rise in oral cancer cases is expected given the high prevalence in their source countries and the continued oral cancer risk behaviours of immigrants. The aim of this review is to synthesise existing evidence regarding knowledge, attitudes and practices of South Asian immigrants in developed countries regarding oral cancer.Methods: Five electronic databases were systematically searched to identify original, English language articles focussing on oral cancer risk knowledge, attitudes and practices of South Asian immigrants in developed countries. All studies that met the following inclusion criteria were included: conducted among South Asian immigrants in developed countries; explored at least one study outcome (knowledge or attitudes or practices); used either qualitative, quantitative or mixed methods. No restrictions were placed on the publication date, quality and setting of the study.Results: A total of 16 studies involving 4772 participants were reviewed. These studies were mainly conducted in the USA, UK, Italy and New Zealand between 1994 and 2018. Findings were categorised into themes of oral cancer knowledge, attitudes and practices. General lack of oral cancer risk knowledge (43-76%) among participants was reported. More than 50% people were found engaging in one or more oral cancer risk practices like smoking, betel quid/pan/gutka chewing. Some of the participants perceived betel quid/pan/gutka chewing habit good for their health (12-43.6%).Conclusion: This review has shown that oral cancer risk practices are prevalent among South Asian immigrants who possess limited knowledge and unfavourable attitude in this area. Culturally appropriate targeted interventions and strategies are needed to raise oral cancer awareness among South Asian communities in developed countries. [ABSTRACT FROM AUTHOR]

Background: Canine Distemper Virus (CDV) is a highly contagious virus belonging to family Paramyxovirade, genus Morbillivirus and responsible for high morbidity and mortality in dogs worldwide. Infected domestic dogs can cause spillover infections to wild carnivores that are in contact. We conducted a seroprevalence survey of CDV in domestic dogs in two areas of western Bhutan (Haa district) located at the periphery of the Jigme Khesar Strict Nature Reserve, which is home to several endangered wildlife. A total of 238 serum samples, 119 each from the pet and stray dog, were collected during summer and winter seasons. Samples were tested for CDV antibodies using a sandwich enzyme-linked immune-sorbent assay (ELISA) test. Results: The seroprevalence of CDV was found to be 11.3% (95% CI 6.7–14.2). Dogs sampled during winter were less likely to test seropositive against CDV antibodies than those sampled during summer (adjusted odds ratio: -2.6; 95% CI: − 1.2–6.1). Dogs in good body condition were found to be more likely to test seropositive against CDV than dogs in poor condition and obese dogs (adjusted odds ratio: 2.2; 95% CI: 0.1–5.9). There were no significant differences in the seroprevalence of CDV among different sexes, breeds and age classes, pet and stray dogs and between the two study sites. Conclusions: Our study indicates that CDV seroprevalence was equally distributed among pet and stray dogs. We suggest strengthening the management practices of dogs through responsible dog ownership, dog population management and waste management to minimize the transmission risk of infectious diseases to wildlife. [ABSTRACT FROM AUTHOR]

Background: Direct observed treatment (DOT) has been implemented in Bhutan since 1997 and currently, it is offered in various model of delivery including a combination of hospital based, home based DOT and ambulatory DOT. Overall, treatment success rate for tuberculosis cases is higher than the global target; however, it is still need to be improved. Evaluation to the implementation fidelity of DOT is important to identify potential rooms for improvement. This study aimed to assess two major components of the program's implementation fidelity: to assess patient's adherence to DOT and explore factors for adherence; to assess provider's compliance with DOT guideline and explore factors for compliance.Methods: This research used a sequential explanatory mixed method. The conceptual framework of implementation fidelity was adopted to guide this study design. The cross-sectional study of TB patients was enrolled in two hospitals with highest TB load, between September to November 2017 in Bhutan. Interviewer assisted survey was conducted with 139 TB patients who visited the hospital in continuation phase. In-depth interview was then conducted with nine TB patients and four health staffs to explore the barriers and enablers of DOT.Results: Total of 61.9% (86/139) of patients has received DOT at intensive phase. Proportion was higher among MDR-TB cases (100%), and smear sputum positive TB cases (84.7%). In the continuation phase, 5.8% of patients took medicine at hospital, 48.9% at home and the rest 45.3% no longer practiced DOT. More than 90% of patient received correct dosage and standard regimen of anti-TB drugs according to the guideline. The key factors affecting poor adherence to DOT as perceived by patients were; lack of willingness to visit the clinic on daily basis due to long distance, financial implications and family support. However, patient's satisfaction to the quality of TB treatment service delivery was high (98.6%). Providing incentives to the patient was most agreed enabler felt by both health workers and patients.Conclusion: In the selected hospital sites, the patient's adherence to DOT and provider's compliance with DOT guideline is partially implemented; the coverage and the duration of DOT is very low, therefore, need to revise and improve DOT model and structure. [ABSTRACT FROM AUTHOR]

Background: Knowing the pattern and presentation of the diseases is critical for management strategies. To inform eye-care policy we quantified the pattern of vitreo-retinal (VR) diseases presenting at the national referral hospital in Bhutan.Methods: We reviewed all new patients over three years from the retinal clinic of the Jigme Dorji Wangchuck National Referral Hospital. Demographic data, presenting complaints and duration, treatment history, associated systemic diseases, diagnostic procedures performed, and final diagnoses were quantified. Comparisons of the expected and observed frequency of gender used Chi-squared tests. We applied a sampling with replacement based bootstrap analysis (10,000 cycles) to estimate the population means and the standard errors of the means and standard error of the 10th, 25th, 50th, 75th and 90th percentiles of the ages of the males and females within 20-year cohorts. We then applied t-tests employing the estimated means and standard errors. The 2913 subjects insured that the bootstrap estimates were statistically conservative.Results: The 2913 new cases were aged 47.2 ± 21.8 years. 1544 (53.0%) were males. Housewives (953, 32.7%) and farmers (648, 22.2%) were the commonest occupations. Poor vision (41.9%), screening for diabetic and hypertensive retinopathy (13.1%), referral (9.7%), sudden vision loss (9.3%), and trauma (8.0%) were the commonest presenting symptoms. Coexistent diabetes and hypertension were the most common associated systemic diseases. Haematological tests (blood sugar, HbA1c and lipid profile, 31.8%), OCT (27.4%), refraction (9.9%), B-scan (8.7%), fundus photography (8.0%) were the most commonly performed diagnostic tests. Hypertensive retinopathy (18.9%) was the commonest VR disease, followed by refractive errors referred for retinal evaluation (16.7%), diabetic retinopathy with macular oedema (15.8%), and AMD (11.0%). Retinal detachment was more prevalent in females (83 vs. 41, p = 0.007). Rare vision-threatening diseases like seasonal hyper-acute pan-uveitis also presented.Conclusions: The developing VR service in Bhutan is challenged by the spectrum of diseases, limited human resources (e.g. one retinal surgeon during the study), and accessibility to tertiary eye-care services, all amidst difficult terrain. Sustained effort and robust coordination among the eye-care professionals, government and non-governmental organisations are critical for optimising VR services, especially as rates of diseases such as diabetes and hypertension grow. [ABSTRACT FROM AUTHOR]

Background: Soon after Bhutan's first medical university was established in 2012, Faculty Development Programmes (FDPs) were adopted for efficient delivery of postgraduate medical curriculum. Medical education was an additional responsibility for the clinicians who already had multi-dimensional roles in the healthcare system where there is acute shortage of healthcare professionals. We studied the impact of FDPs on postgraduate medical education in Bhutan. Methods: This was a mixed-methods study with a quantitative (cohort study – quasi-experimental with 18 participants) and concurrent explanatory qualitative component (focused group discussion (FGD) with 11 teaching faculty members). The 18 participants were given a structured FDP designed by the University. The FGD assessed teacher self-efficacy and competency using standard tools before and after the FDP. Thematic analysis of the FGD explored the impact of FDPs in the delivery of postgraduate residency programmes. Results: There were significant increase in the teacher self-efficacy (31 vs 34, p = 0.009) and competency scores (56 vs 64, p = 0.011). There were significant improvements in self-efficacy in the domain of the teaching relevant subject contents and developing creative ways to cope with system constraints. In teaching-learning assessments, there was a significant appreciation of the effectiveness of lectures and tutorials and the use of essay questions. The FGD demonstrated the acceptance of FDPs and its importance in quality improvement of postgraduate medical education, professional development of teachers and improvement of their communication skills. The teachers have now migrated from the conventional methods of teaching to workplace-based teaching and assessment. The FDPs also resulted in review and revision of postgraduate medical curriculum soon after the first batch graduated in 2018. Lack of adequate support from relevant stakeholders and lack of a medical education centre in the University were seen as major challenges. Conclusions: The FDPs have brought tangible professionalization of postgraduate medical education at an early stage of the medical university. There is a need for continued efforts to strengthen, sustain and consolidate the gains made thus far. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has resulted in massive global disruptions with considerable impact on the delivery of health services and national health programmes. Since the detection of the first COVID-19 case on 5th March 2020, the Royal Government of Bhutan implemented a number of containment measures including border closure and national lockdowns. Against the backdrop of this global COVID-19 pandemic response, there was a sudden surge of locally-transmitted malaria cases between June to August 2020. There were 20 indigenous cases (zero Plasmodium falciparum and 20 Plasmodium vivax) from a total of 49 cases (seven P. falciparum and 42 P. vivax) in 2020 compared to just two from a total of 42 in 2019. Over 80% of the cases were clustered in malaria endemic district of Sarpang. This spike of malaria cases was attributed to the delay in the delivery of routine malaria preventive interventions due to the COVID-19 pandemic. As a result, Bhutan is unlikely to achieve the national goal of malaria elimination by 2020. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Autism spectrum disorders (ASD) are a group of complex neurodevelopmental disorders. The prevalence of ASD in many South Asian countries is still unknown. The aim of this study was to systematically review available epidemiological studies of ASD in this region to identify gaps in our current knowledge. Methods: We searched, collected and evaluated articles published between January 1962 and July 2016 which reported the prevalence of ASD in eight South Asian countries. The search was conducted in line with the PRISMA guidelines. Results: We identified six articles from Bangladesh, India, and Sri Lanka which met our predefined inclusion criteria. The reported prevalence of ASD in South Asia ranged from 0.09% in India to 1.07% in Sri Lanka that indicates up to one in 93 children have ASD in this region. Alarmingly high prevalence (3%) was reported in Dhaka city. Study sample sizes ranged from 374 in Sri Lanka to 18,480 in India. The age range varied between 1 and 30 years. No studies were found which reported the prevalence of ASD in Pakistan, Nepal, Bhutan, Maldives and Afghanistan. This review identifies methodological differences in case definition, screening instruments and diagnostic criteria among reported three countries which make it very difficult to compare the studies. Conclusions: Our study is an attempt at understanding the scale of the problem and scarcity of information regarding ASD in the South Asia. This study will contribute to the evidence base needed to design further research and make policy decisions on addressing this issue in this region. Knowing the prevalence of ASD in South Asia is vital to ensure the effective allocation of resources and services. [ABSTRACT FROM AUTHOR]

Background: To describe spatiotemporal patterns of diarrhoea in Bhutan, and quantify the association between climatic factors and the distribution and dynamics of the disease.Methods: Nationwide data on diarrhoea were obtained for 2003 to 2013 from the Health Information and Management System (HIMS), Ministry of Health, Bhutan. Climatic variables were obtained from the Department of Hydro Met Services, Ministry of Economic Affairs, Bhutan. Seasonal trend decomposition was used to examine secular trends and seasonal patterns of diarrhoea. A Bayesian conditional autoregressive (CAR) model was used to quantify the relationship between monthly diarrhoea, maximum temperature, rainfall, age and gender.Results: The monthly average diarrhoea incidence was highly seasonal. Diarrhoea incidence increased by 0.6% (95% CrI: 0.5-0.6%) for every degree increase in maximum temperature; and 5% (95 Cr I: 4.9-5.1%) for a 1 mm increase in rainfall. Children aged <5 years were found to be 74.2% (95% CrI: 74.1-74.4) more likely to experience diarrhoea than children and adults aged ≥5 years and females were 4.9% (95% CrI: 4.4-5.3%) less likely to suffer from diarrhoea as compared to males. Significant residual spatial clustering was found after accounting for climate and demographic variables.Conclusions: Diarrhoea incidence was highly seasonal, with positive associations with maximum temperature and rainfall and negative associations with age and being female. This calls for public health actions to reduce future risks of climate change with great consideration of local climatic conditions. In addition, protection of <5 years children should be prioritize through provision of rotavirus vaccination, safe and clean drinking water, and proper latrines. [ABSTRACT FROM AUTHOR]

Background: A questionnaire survey was conducted to assess the biosecurity and other practices of backyard poultry holdings and knowledge and practices of poultry keepers following an outbreak of highly pathogenic avian influenza (H5N1) virus in poultry in Thimphu city area, Bhutan. Results: The study identified 62 backyard poultry holdings in 12 settlement areas, and the owners were subsequently interviewed. The birds are kept in a low-input low-output system, fed locally available scavenging feed base, and supplemented with food scraps and some grain. Although the birds are housed at night in a small coop to protect them against theft and predators, they are let loose during the day to scavenge in the homestead surroundings. This invariably results in mixing with other poultry birds within the settlement and wild birds, creating favorable conditions for disease spread within and between flocks. Moreover, the poultry keepers have a low level of knowledge and awareness related to the importance of biosecurity measures, as well as veterinary care of the birds and reporting systems. Of particular concern is that sick birds within backyard holdings may not be detected rapidly, resulting in silent spread of disease and increased risk of humans contacting the virus (e.g. HPAI) from infected poultry. Nevertheless, all the respondents have indicated that they know and practice hand washing using soap and water after handling poultry and poultry products, but rarely use face-masks and hand gloves while handling poultry or cleaning poultry house. Conclusions: This study highlights the importance of educating poultry keepers to improve the housing and management systems of poultry farming within the backyard holdings in the Thimphu city area in order to prevent future disease outbreaks. [ABSTRACT FROM AUTHOR]

Background: Rabies is a highly fatal disease transmitted through the bite of a rabid animal. Human deaths can be prevented by prompt administering of rabies vaccine and rabies immunoglobulin following the exposure. An assessment of community knowledge, awareness and practices on rabies is important during outbreak to understand their preparedness and target educational messages and response activities by the rapid response team.Methods: A rabies outbreak has occurred in Rangjung town, eastern Bhutan on 4 October 2016. A rapid response team was activated to investigate outbreak and to establish a control program. A community-based questionnaire survey was conducted from 20 to 21 October 2016 to assess the community knowledge of rabies to guide outbreak preparedness and also target educational messages and response activities by the RRT.Results: A total of 67 respondents were interviewed, of which 61% were female and 39% male. All the respondents have heard of rabies (100%), have knowledge on source of rabies (dog) and its mode of transmission in animals and humans. Most (61%) respondents were aware and also indicated that they would wash the animal bite wound with soap and water and seek medical care on the same day of exposure (100%). Majority (94%) of the respondents have indicated that they would report to the government agencies if they see any suspected rabid dogs in the community and suggested various control measures for dog population management and rabies in Rangjung including neutering procedure and mass dog vaccination. Although only few (10%) of the respondents households owned dogs and cats, but 50% of them have indicated that their dogs were allowed to roam outside the home premises posing risk of contracting rabies through rabid dog bites.Conclusions: Although this study indicates a high level of knowledge and awareness on rabies among the community, there exists some knowledge gaps about rabies and therefore, an awareness education should be focused on the source of rabies and rabies virus transmission route to reduce public concern on nonexposure events thereby reducing the cost on unnecessary postexposure treatment. [ABSTRACT FROM AUTHOR]

Background: Urine sampling may offer a less invasive solution than cervical sampling to test for human papillomavirus (HPV) for HPV vaccine impact monitoring. Methods: Paired samples of urine and exfoliated cervical cells were obtained for 89 women with history of high-risk (HR) HPV-positive normal cytology in Bhutan. Urine sampling protocol included self-collection of first-void urine immediately into a conservation medium and procedures to optimize DNA yield. Colposcopical abnormalities were biopsied. Two HPV assays were used: a multiplex type-specific PCR (E7-MPG) and a less analytically sensitive GP5+/6+ PCR followed by reverse line blot. Results: HPV positivity for 21 types common to both assays was similar in urine and cells by E7-MPG (62.9% and 57.3%, respectively, p = 0.32) but lower in urine by GP5+/6+ (30.3% and 40.4%, p = 0.05). HPV6/11/16/18 positivity did not significantly differ between urine and cells by either assay. Sensitivity of urine (using cells as gold standard) to detect 21 HPV types was 80% and 58% for E7-MPG and GP5+/6+, respectively, with specificity 61% and 89%. HPV type distribution in urine and cells was similar, regardless of assay. The 5 detected CIN3+ were HR-HPV positive in cells by both assays, compared to 4 and 3 by E7-MPG and GP5+/6+, respectively, in urine samples. Conclusion: For the monitoring of vaccine impact, we demonstrate validity of a urine sampling protocol to obtain HPV prevalence data that are broadly comparable to that from cervical cells. However, detection of HPV in urine varies according to assay sensitivity, presumably because low level infections are frequent. [ABSTRACT FROM AUTHOR]

Biocultural knowledge provides valuable insight into ecological processes, and can guide conservation practitioners in local contexts. In many regions, however, such knowledge is underutilized due to its often-fragmented record in disparate sources. In this article, we review and apply ethnobiological knowledge to biodiversity conservation in the Eastern Himalayas. Using Sikkim, India as a case study, we: (i) traced the history and trends of ethnobiological documentation; (ii) identified priority species and habitat types; and, (iii) analyzed within and among community differences pertaining to species use and management. Our results revealed that Sikkim is a biocultural hotspot, where six ethnic communities and 1128 species engage in biocultural relationships. Since the mid-1800s, the number of ethnobiological publications from Sikkim has exponentially increased; however, our results also indicate that much of this knowledge is both unwritten and partitioned within an aging, gendered, and caste or ethnic group-specific stratum of society. Reviewed species were primarily wild or wild cultivated, native to subtropical and temperate forests, and pend IUCN Red List of Threatened Species assessment. Our results demonstrate the value of engaging local knowledge holders as active participants in conservation, and suggest the need for further ethnobiological research in the Eastern Himalayas. Our interdisciplinary approach, which included rank indices and geospatial modelling, can help integrate diverse datasets into evidence-based policy. [ABSTRACT FROM AUTHOR]

Background: Cervical cancer is the leading cause of cancer morbidity and mortality among women in Nepal and Bhutan. Data on high-risk human papillomavirus (HR-HPV) infection and cervical abnormalities among Nepali and Bhutanese women are sparse. The objectives of this study were to assess and compare the prevalence of HR-HPV infection and cervical abnormalities among Nepali and Bhutanese women living in Jhapa District in eastern Nepal; and examine the risk factors for HR-HPV infection and cervical abnormalities in those women.Methods: Study participants were recruited from a women's health camp organized by NFCC-International, a Nepal-based non-governmental organization, in 2014. Consenting participants were administered a demographic and health questionnaire and cervico-vaginal specimens collected. Both self-collected and clinician-collected cervico-vaginal specimens were tested for HR-HPV infection. Cytologic exam was performed on clinician-collected samples and cervical cytology results were categorized according to the Bethesda classification. A participant was classified as a Bhutanese if they were either born in Bhutan or currently lived in one of the United Nations administered Bhutanese refugee camps in Jhapa; otherwise, the participant was classified as a Nepali.Results: Of the 647 study participants, 15.9% were Bhutanese women living in refugee camps and the overall age (± standard deviation) was 38.8 ± 8.2 years. The prevalence of HR-HPV infection was 8.9% and abnormal cervical cytology was 7.1% respectively, with no significant difference in HR-HPV positivity (p = 0.399) or abnormal cervical cytology (p = 0.698) between Nepali and Bhutanese women. Compared to women whose husbands had not migrated for employment, women whose husbands had migrated outside of the district had 3.30 times (95% Confidence Interval [CI]: 1.13-9.64) the odds of being HR-HPV positive and women whose husbands had migrated outside the country had 2.92 times (95% CI: 1.32-6.49) the odds of having abnormal cervical cytology.Conclusions: HR-HPV positivity and abnormal cervical cytology were similar among Nepali and Bhutanese women. Husbands migrating for employment within or outside the country was a significant risk factor for high-risk HPV infection and cervical cytology, indicating the important role spousal behavior may play in HR-HPV acquisition and cervical abnormalities among these women. [ABSTRACT FROM AUTHOR]

Background: Human beings use plants for a multitude of purposes of which a prominent one across the globe is for their medicinal values. Medicinal plants serve as one of the major sources of income for high altitude inhabitants in the Himalaya, particularly in countries like Nepal, and Bhutan. People here harvest huge volumes of medicinal plants indiscriminately, risking their sustainability. This paper attempts to identify some of the priority medicinal plant species harvested in the wild and assess their ecological status for their judicious utilization, and to help provide policy guidance for possible domestication and support strategic conservation frameworks. Results: Out of the 16 priority species identified by the expert group, collectors' perception on ecological status of the priority species differed from survey findings. Chrysosplenium nudicaule (clumps) ranked as most threatened species followed by Corydalis dubia, and Meconopsis simplicifolia. Onosma hookeri, Corydalis crispa and Delphinium glaciale were some of the species ranked as threatened species followed by Halenia elliptica (not in priority list). Percent relative abundance showed irregular pattern of species distribution. High species evenness was recorded among Nardostachys grandiflora, Chrysosplenium nudicaule, Saussurea gossypiphora and Aconitum orochryseum with average species density of 8 plant m-2. Rhodiola crenulata, and Dactylorhiza hatagirea followed by Meconopsis horridula and Meconopsis simplicifolia were ranked as most threatened species with average species density of 0.4, 0.4, 5.6 and 6.0 plant m-2, respectively. The most abundant (common) species was Onosma hookeri (plant m-2). Species composition and density also differed with vegetation, altitude, slope and its aspects. Conclusion: Priority species identified by expert group were found vulnerable and patchy in distribution. Survey results and collectors' perceptions tally to an extent. Some of the species (Dactylorhiza hatagirea, Rhodiola crenulata, Meconopsis simplicifolia and Meconopsis horridula) were critically low in plant density with less than a plant per m² while Delphinium glaciale, Fritillaria delavayi and Aconitum orochryseum were confined to narrow altitude range. Collectors were aware that most species identified in priority list are threatened and existing harvesting plan are hardly implemented as it is not pragmatic. Moreover, major chunk of medicinal plants harvested remain unaccounted as illegal harvest and marketing seemed to occur across the borders. Policing and monitoring would continue to be a challenge given the rugged terrain and harsh climate. In-depth study and further monitoring of low density species is suggested to ensure its sustainability through long term strategy development. [ABSTRACT FROM AUTHOR]

Background: The Bhutanese So-wa-rig-pa medicine (BSM) was integrated with the allopathic (modern) health care system in 1967. Ever since the health care integration policy was implemented, the BSM has gone through many phases of quality improvement and changes including the establishment of one university-based institute, 58 hospitals and Basic Health Units (BHU)-based health care services, and one traditional medicine factory. The BSM provides primary health care services to more than 20-30 % of patients who visit hospitals and BHU on a daily basis. However, there has been no study covering the quality assurance system of BSM. Our paper addresses this information gap. Methods: This study was an observational ethnographic study supported by phenomenological understanding and content analysis of the data. The information was triangulated through consultation with the BSM practitioners (discussion (N = 8)) and personalized in-depth question-answer sessions using electronic protocols (N = 5). These participants comprised BSM educationists, clinical physicians, researchers, production and the quality assurance staff who were selected using convenience and purposive sampling method. The relevant So-wa-rig-pa information and literature were obtained from the government policy documents, official websites, scientific papers and the traditional medical texts. This study is enhanced by our practical observations and first-hand experience with BSM while working as the researchers at the Ministry of Health in Bhutan. In addition, the information in this paper is crosschecked and authenticated by five So-wa-rig-pa practitioners of Bhutan. Results: The study highlights the following: a) The BSM receives both the government and people's support, b) The quality assurance system have been developed by integrating the traditional empirical knowledge and modern scientific protocols, c) There exist three administrative and functional organizations responsible for providing the quality BSM health care services in Bhutan, d) Extensive standard treatment guidelines and Quality documentation system exist for BSM as required by the regulatory bodies in Bhutan. The paper also recommends appropriate future directions for BSM. Conclusions: The BSM plays significant role in the primary health care system of the country. Consequently, the quality, safety and efficacy of BSM has been given priority by the Bhutan government. Many scientific protocols were integrated with the traditional quality approaches and further scientific studies are still required to improve its quality. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The traditional g.so-ba-rig-pa hospitals in Bhutan uses more than 100 polyingredient medicines that are manufactured by the Menjong Sorig Pharmaceuticals (MSP). The MSP has been collecting medicinal plants from Lingzhi region for about 48 years and therefore the ecological pressure on these plants have increased. It is MSP's top priority to identify an alternative collection site to ease the problem. Therefore, this study was carried out to determine whether Dagala region could potentially be an alternative collection site for MSP. Methods: First the multidisciplinary research team generated a tentative plant list by reviewing a body of ancient g.so-ba-rig-pa literature, current formulations, and the MSP medicinal plants inventory documents. Second, the research team visited the study areas in Dagala region for spot identification of medicinal plants. Third, we confirmed our traditional and botanical identification by crosschecking the descriptions with the series of books on traditional texts, Flora of Bhutan, scientific papers on medicinal plants, and the plant databases. Results: We have identified 100 species of high altitude medicinal plants from Dagala region. Of these, 24 species grow abundantly, 29 species grow in moderate numbers and 47 species were scarce. More than 85 species belonged to the herbaceous life form and 51 of them are used as a whole plant. A total of 68 species grow in between 4000 and 4999 meter above sea level. These 100 medicinal plants represented 39 different families and 80 genera and the maximum number of plants belonged to the family Asteraceae. Of 60 species that are currently used for formulating medicines at MSP, 16 species have economic importance with potential for commercial collection. Out of seven areas covered by the survey, Kipchen hosted maximum number of medicinal plants (21 species). Conclusions: Our survey identified 100 medicinal plants from Dagala region and of these, 16 species has economic potential that could benefit both MSP and Dagala communities. It is feasible to establish an alternative medicinal plants collection center in Dagala Gewog. [ABSTRACT FROM AUTHOR]

Background: Bhutan has made substantial progress in reducing malaria incidence. The national guidelines recommend chloroquine (CQ) and primaquine (PQ) for radical cure of uncomplicated Plasmodium vivax, but the local efficacy has not been assessed. The impact of cases imported from India on the genetic make-up of the local vivax populations is currently unknown. Methods: Patients over 4 years of age with uncomplicated P. vivax mono-infection were enrolled into a clinical efficacy study and molecular survey. Study participants received a standard dose of CQ (25 mg/kg over 3 days) followed by weekly review until day 28. On day 28 a 14-day regimen of PQ (0.25 mg/kg/day) was commenced under direct observation. After day 42, patients were followed up monthly for a year. The primary and secondary endpoints were risk of treatment failure at day 28 and at 1 year. Parasite genotyping was undertaken at nine tandem repeat markers, and standard population genetic metrics were applied to examine population diversity and structure in infections thought to be acquired inside or outside of Bhutan. Results: A total of 24 patients were enrolled in the clinical study between April 2013 and October 2015. Eight patients (33.3 %) were lost to follow-up in the first 6 months and another eight patients lost between 6 and 12 months. No (0/24) treatment failures occurred by day 28 and no (0/8) parasitaemia was detected following PQ treatment. Some 95.8 % (23/24) of patients were aparasitaemic by day 2. There were no haemolytic or serious events. Genotyping was undertaken on parasites from 12 autochthonous cases and 16 suspected imported cases. Diversity was high (HE 0.87 and 0.90) in both populations. There was no notable differentiation between the autochthonous and imported populations. Conclusions: CQ and PQ remains effective for radical cure of P. vivax in Bhutan. The genetic analyses indicate that imported infections are sustaining the local vivax population, with concomitant risk of introducing drug-resistant strains. [ABSTRACT FROM AUTHOR]

Non-timber Forest Products (NTFPs), an important provisioning ecosystem services, are recognized for their contribution in rural livelihoods and forest conservation. Effective management through sustainable harvesting and market driven commercialization are two contrasting aspects that are bringing challenges in development of NTFPs sector. Identifying potential species having market value, conducting value chain analyses, and sustainable management of NTFPs need analysis of their use patterns by communities and trends at a regional scale. We analyzed use patterns, trends, and challenges in traditional use and management of NTFPs in the southern slope of Kangchenjunga Landscape, Eastern Himalaya and discussed potential implications for conservation and livelihoods. A total of 739 species of NTFPs used by the local people of Kangchenjunga Landscape were reported in the reviewed literature. Of these, the highest number of NTFPs was documented from India (377 species), followed by Nepal (363) and Bhutan (245). Though the reported species were used for 24 different purposes, medicinal and edible plants were the most frequently used NTFP categories in the landscape. Medicinal plants were used in 27 major ailment categories, with the highest number of species being used for gastro-intestinal disorders. Though the Kangchenjunga Landscape harbors many potential NTFPs, trade of NTFPs was found to be nominal indicating lack of commercialization due to limited market information. We found that the unsustainable harvesting and lack of marketing were the major constraints for sustainable management of NTFPs sector in the landscape despite of promising policy provisions. We suggest sustainable harvesting practices, value addition at local level, and marketing for promotion of NTFPs in the Kangchenjunga Landscape for income generation and livelihood improvement that subsequently contributes to conservation. [ABSTRACT FROM AUTHOR]

Background: Bhutan has reduced its malaria incidence significantly in the last 5 years, and is aiming for malaria elimination by 2016. To assist with the management of the Bhutanese malaria elimination programme a spatial decision support system (SDSS) was developed. The current study aims to describe SDSS development and evaluate SDSS utility and acceptability through informant interviews. Methods: The SDSS was developed based on the open-source Quantum geographical information system (QGIS) and piloted to support the distribution of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) in the two sub-districts of Samdrup Jongkhar District. It was subsequently used to support reactive case detection (RACD) in the two sub-districts of Samdrup Jongkhar and two additional sub-districts in Sarpang District. Interviews were conducted to ascertain perceptions on utility and acceptability of 11 informants using the SDSS, including programme and district managers, and field workers. Results: A total of 1502 households with a population of 7165 were enumerated in the four sub-districts, and a total of 3491 LLINs were distributed with one LLIN per 1.7 persons. A total of 279 households representing 728 residents were involved with RACD. Informants considered that the SDSS was an improvement on previous methods for organizing LLIN distribution, IRS and RACD, and could be easily integrated into routine malaria and other vector-borne disease surveillance systems. Informants identified some challenges at the programme and field level, including the need for more skilled personnel to manage the SDSS, and more training to improve the effectiveness of SDSS implementation and use of hardware. Conclusions: The SDSS was well accepted and informants expected its use to be extended to other malaria reporting districts and other vector-borne diseases. Challenges associated with efficient SDSS use included adequate skills and knowledge, access to training and support, and availability of hardware including computers and global positioning system receivers. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, Bhutan has made substantial progress in controlling malaria. The country is now in an elimination phase, aiming to achieve no locally transmitted malaria by 2018. However, challenges remain and innovative control strategies are needed to overcome these. The evaluation and user acceptance of a robust surveillance tool applicable for informing malaria elimination activities is reported here. Methods: The Bhutan Febrile and Malaria Information System (BFMIS) is a combination of web-based and mobile technology that captures malariometric surveillance data and generates real time reports. The system was rolled out at six sites and data uploaded regularly for analysis. Data completeness, accuracy and data turnaround time were accessed by comparison to traditional paper based surveillance records. User acceptance and willingness for further roll out was assessed using qualitative and quantitative data. Results: Data completeness was nearly 10 % higher using the electronic system than the paper logs, and accuracy and validity of both approaches was comparable (up to 0.05 % in valid data and up to 3.06 % inaccurate data). Data turnaround time was faster using the BFMIS. General user satisfaction with the BFMIS was high, with high willingness of health facilities to adopt the system. Qualitative interviews revealed several areas for improvement before scale up. Conclusions: The BFMIS had numerous advantages over the paper-based system and based on the findings of the survey the Vector-Borne Disease Control Programme has taken the decision to incorporate the BMFIS and expand its use throughout all areas at risk for malaria as a key surveillance tool. [ABSTRACT FROM AUTHOR]