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Introduction and Hypothesis: Risk factors for pelvic floor disorders (PFDs) are not well understood in lower resource settings. The objective of this study is to determine the risk factors associated with stress urinary incontinence (SUI), urge urinary incontinence (UUI), and pelvic organ prolapse (POP) among women of reproductive age in rural Nepal. Methods: This is a case–control study nested within a community-based cross-sectional survey of parous women of reproductive age with PFDs in the Sarlahi District of Nepal. The presence of PFDs was confirmed by clinical assessment. Detailed sociodemographic information and histories were captured. Results: We examined 406 women; the mean (SD, range) age was 32.7 (8.5, 16–49) years, mean BMI (SD) was 19.7 (3.3) kg/m2, and median (range) number of pregnancies was 4 (1–11). Two hundred and three women (50.0%) had either SUI or UUI, 85 (17.8%) had both SUI and UUI, and 71 (17.5%) had POP at or beyond the hymen. After controlling for other variables significant on bivariate analysis, age (adjusted odds ratio [aOR] 1.06 [95% CI 1.03–1.09]), illiteracy (aOR 2.24 [95% CI 1.04–4.80]), and presence of upper gastrointestinal issues (aOR 3.30, [95% CI 1.77–6.16]) were independently associated with SUI/UUI. Age (aOR 1.05 [95% CI 1.02–1.09]), bispinous diameter (aOR 2.88 ([95% CI 1.11–7.47]), and subpubic angle (aOR 2.78 [95% CI 1.55–5.03]) were independently associated with POP. Conclusion: Risk factors for PFDs in a homogenous community of parous women of reproductive age in rural Nepal are similar to those found in parous women in higher income countries. [ABSTRACT FROM AUTHOR]

Introduction: Estimates for cause-specific mortality for neonates are generally available for all countries for neonates overall (0 to 28 days). However, cause-specific mortality is generally not being estimated at higher age resolution for neonates, despite evidence of heterogeneity in the causes of deaths during this period. We aimed to use the adapted log quadratic model in a setting where verbal autopsy was the primary means of determining cause of death. Methods: We examined the timing and causes of death among a cohort of neonates in rural Nepal followed as part of the Nepal Oil Massage Study (NOMS). We adapted methods defined by Wilmoth et al (2012) and Guillot et al. (2022) to estimate age and cause-specific mortality among neonates. We used cross validation to estimate the accuracy of this model, holding out each three month period. We took the average cross validation across hold out as our measure of model performance and compared to a standard approach which did not account for the heterogeneity in cause-specific mortality rate within this age group. Results: There were 957 neonates in the NOMS cohort with known age and cause of death. We estimated an average cross-validation error of 0.9 per 1000 live births for mortality due to prematurity in the first week, and 1.1 for mortality due to birth asphyxia, compared to the standard approach, having error 7.4 and 7.8 per 1000 live births, respectively. Generally mortality rates for less common causes such as congenital malformations and pneumonia were estimated with higher cross-validation error. Conclusions: The stability and precision of these estimates compare favorably with similar estimates developed with higher quality cause-specific mortality surveillance from China, demonstrating that reliably estimating causes of mortality at high resolution is possible for neonates in low resources areas. [ABSTRACT FROM AUTHOR]

Strategies to increase COVID-19 vaccine coverage require an understanding of the extent and drivers of vaccine hesitancy and trust in government related to COVID-19 vaccine programs, especially in low-resource communities. We conducted a cross-sectional household survey post-COVID-19 vaccine introduction among adults (n = 362) in four municipalities in Sarlahi District, Nepal from August to December 2022. The survey included modules on participant demographics and socioeconomic factors and vaccine hesitancy, information seeking, and trust in authorities related to COVID-19 vaccination. Of the study participants, 38.4 % expressed hesitancy related to COVID-19 vaccination. The adjusted odds of being "vaccine hesitant" were significantly lower among the older adults (51+ years) relative to younger (<30 years) (aOR: 0.49, CI: 0.24–0.97) and among males relative to females (aOR: 0.51, CI: 0.26, 0.95). The study population highly trusted the government's handling of the COVID-19 pandemic. While for most, self-reported access to vaccination opportunities was high (88.4 %), 70.4 % of participants did not know if vaccines were in stock at their local vaccination facility. Commonly reported statements of misinformation include the vaccine being developed in a rush or too fast (21.5 %), COVID-19 infection can be effectively treated with ayurvedic medicine(16.3 %) and obtaining immunity from natural infection is better than through vaccination (19.9 %). The primary sources of information on COVID-19 programs were family and friends (98.6 %), healthcare professionals (67.7 %), Female Community Health Volunteers (FCHVs) (61.9 %), television (56.4 %), and radio (43.1 %). Although many respondents expressed concerns about COVID-19 effectiveness and safety, a high proportion trusted COVID-19 information provided by healthcare workers and approved of the government's response to the pandemic. This study highlights an opportunity to design new evidence-based communication strategies to improve vaccine confidence delivered through frontline government healthcare workers. Approaches could be targeted to certain communities in the region shown to have higher vaccine hesitancy, including younger people and women. [ABSTRACT FROM AUTHOR]

Evidence suggests that multiple micronutrient and balanced energy protein (BEP) supplementation during pregnancy can decrease the risk of stillbirth and small‐for‐gestational‐age births and increase birth weight. We conducted a mixed‐methods formative research study to identify the most acceptable among a range of 11 candidates fortified BEP supplements for use in pregnancy and lactation in a rural district in Nepal. Forty pregnant women aged 15–40 years participated in a test meal tasting of 11 different sweet and savoury candidate BEP supplements. Each participant rated the products on organoleptic properties using a 7‐point hedonic scale (1 = Dislike it very much to 7 = Like it very much), ranked her 'top 3' most liked supplements, and subsequently discussed each product with peers in focus group discussions (FGDs). Five supplements (sweet lipid‐based nutrient supplement (LNS), savoury LNS, sweet vanilla biscuits, vanilla instant drinks and seasoned pillows) achieved the maximum overall median hedonic score of 7, with sweet LNS and seasoned pillows ranking as the top 2. This was consistent with the assessments in FGDs. Women in the FGDs expressed dislike of the smell and taste of the cocoa drink, savoury masala bar, sweet mango bar and savoury curry biscuit, which was consistent with the hedonic scale scores. This study provides valuable insights into our understanding of women's acceptance of different BEP supplements during pregnancy in rural Nepal and has helped identify the two most accepted BEP supplements to be used in a two‐month home trial to assess utilisation and compliance in this setting. Key messages: Understanding the acceptability of balanced energy protein supplements by pregnant women along with the potential facilitators and barriers to their use is vital to ensure regular consumption and compliance.Pregnant women in rural Nepal liked both the sweet and savoury products and suggested having the option to choose from more than one type of product would facilitate its daily consumption throughout pregnancy.Concerns regarding the cost of the supplements, strong aversion to smell/taste of certain supplements, and the inability to eat the supplement in private were some of the deterrents for possibly not being able to eat the supplement daily [ABSTRACT FROM AUTHOR]

The delivery of nutrition‐related interventions and counselling during antenatal care is critical for a healthy pregnancy for both mother and child. However, the accuracy of maternal reports of many of these services during household surveys has not yet been examined. Our objectives were to assess the validity of the maternal reports of 10 antenatal nutrition interventions, including counselling, and examine associates between maternal characteristics and accuracy. Maternal report of services received collected during a post‐partum survey was compared to the gold standard, the direct observation of all women's antenatal care visits. Individual‐level validity was assessed by calculating indicator sensitivity, specificity and area under the operating curve (AUC). The inflation factor (IF) measured population‐level bias. For five indicators, the high true coverage limited our ability to assess the validity of the maternal reports. There were no indicators that had both high individual‐level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25). Indicators with greater true coverage estimates had higher sensitivity and lower specificity estimates compared to those indicators with lower true coverage. There were no maternal characteristics associated with the accuracy of the report. Maternal report of antenatal nutrition‐related interventions and counselling during household surveys was found to have variable validity across indicators. Additional research in settings with varying coverage levels should be considered to best inform antenatal care coverage measurement in household surveys. Key Messages: The coverage of nutrition‐related interventions and counselling was high (>89%) for the majority of indicators.Maternal reports resulted in higher coverage estimates than what was observed for all but one indicator.No indicator assessed had high individual level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25).The greater the indicator's true coverage estimate, the greater the sensitivity and lower the specificity values. [ABSTRACT FROM AUTHOR]

Some evidence suggests that balanced energy protein (BEP) supplements taken during pregnancy and lactation can have positive effects on birth outcomes such as small‐for‐gestational age and birthweight, but more evidence is needed on the long‐term use and acceptability of such supplements. We conducted a mixed‐methods formative research study to assess and compare compliance with and acceptability of two BEP supplements, a lipid‐based peanut paste and a biscuit, to identify BEP supplements for subsequent inclusion in an efficacy trial. We conducted an 8‐week feeding trial of daily supplementation among two groups of 40 pregnant women each in rural Nepal. Compliance data were collected and supplements distributed at the weekly visits. Sensory properties of the supplements were assessed using a 7‐point Likert scale. In addition, in‐depth interviews with women (n = 16), family members (n = 6) and health workers (n = 6) and focus group discussions (FGDs) (n = 4) were conducted to explore themes related to general use and intention of future use of the supplement. Overall self‐reported compliance was high: medians of 91.1% in the lipid‐based peanut paste group and 96.4% in the biscuit group. Both supplements were rated highly on overall likability (median score 6/7) and sensory properties. Qualitative findings showed that sustained use of the supplements was attributed to expected health benefits, favourable sensory attributes, and family support. The FGDs suggested providing the option to choose between more than one type/flavour of supplements to improve compliance. Sharing was mostly evident in the first week with higher sharing reported in the biscuit group. Key messages: Both the lipid‐based peanut paste and the vanilla biscuit were well accepted by pregnant women in rural Nepal during an 8‐week home feeding trial.The compliance measurements showed high overall compliance in both supplement groups with the reasons being the perceived health benefits to the mother and baby, favourable sensory properties, enabling environment at home for product consumption (privacy and family support) and ease of product use.Before an efficacy trial of a nutritional food supplement, it is important to conduct a mixed‐methods feeding trial in the study population to understand the contextual factors that enable and prevent the use of supplements to inform ways to improve compliance with the supplements. [ABSTRACT FROM AUTHOR]

Background: The Global Nutrition Target of reducing low birthweight (LBW) by ≥30% between 2012 and 2025 has led to renewed interest in producing accurate, population-based, national LBW estimates. Low- and middle-income countries rely on household surveys for birthweight data. These data are frequently incomplete and exhibit strong "heaping." Standard survey adjustment methods produce estimates with residual bias. The global database used to report against the LBW Global Nutrition Target adjusts survey data using a new MINORMIX (multiple imputation followed by normal mixture) approach: 1) multiple imputation to address missing birthweights, followed by 2) use of a 2-component normal mixture model to account for heaping of birthweights.Objectives: To evaluate the performance of the MINORMIX birthweight adjustment approach and alternative methods against gold-standard measured birthweights in rural Nepal.Methods: As part of a community-randomized trial in rural Nepal, we measured "gold-standard" birthweights at birth and returned 1-24 mo later to collect maternally reported birthweights using standard survey methods. We compared estimates of LBW from maternally reported data derived using: 1) the new MINORMAX approach; 2) the previously used Blanc-Wardlaw adjustment; or 3) no adjustment for missingness or heaping against our gold standard. We also assessed the independent contribution of multiple imputation and curve fitting to LBW adjustment.Results: Our gold standard found 27.7% of newborns were LBW. The unadjusted LBW estimate based on maternal report with simulated missing birthweights was 14.5% (95% CI: 11.6, 18.0%). Application of the Blanc-Wardlaw adjustment increased the LBW estimate to 20.6%. The MINORMIX approach produced an estimate of 26.4% (95% CI: 23.5, 29.3%) LBW, closest to and with bounds encompassing the measured point estimate.Conclusions: In a rural Nepal validation dataset, the MINORMIX method generated a more accurate LBW estimate than the previously applied adjustment method. This supports the use of the MINORMIX method to produce estimates for tracking the LBW Global Nutrition Target. [ABSTRACT FROM AUTHOR]

Background: In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal's success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions. Methods: A verbal autopsy study, led by the Integrated Rural Health Development Training Centre (IRHDTC), conducted interviews for 338 neonatal deaths across six districts in Nepal between April 2012 and April 2013. We conducted a secondary analysis of verbal autopsy data to understand how cause and age of neonatal death are related to health behaviors, care seeking practices, and coverage of essential services in Nepal. Results: Sepsis was the leading cause of neonatal death (n=159/338, 47.0%), followed by birth asphyxia (n=56/338, 16.6%), preterm birth (n=45/338, 13.3%), and low birth weight (n=17/338, 5.0%). Neonatal deaths occurred primarily on the first day of life (27.2%) and between days 1 and 6 (64.8%) of life. Risk of death due birth asphyxia relative to sepsis was higher among mothers who were nulligravida, had <4 antenatal care visits, and had a multiple birth; risk of death due to prematurity relative to sepsis was lower for women who made ≥1 delivery preparation and higher for women with a multiple birth. Conclusions: Our findings suggest cause and age of death distributions typically associated with high mortality settings. Increased coverage of preventive antenatal care interventions and counseling are critically needed. Delays in care seeking for newborn illness and quality of care around the time of delivery and for sick newborns are important points of intervention with potential to reduce deaths, particularly for birth asphyxia and sepsis, which remain common in this population. [ABSTRACT FROM AUTHOR]

Background: Coverage of iron-folic acid (IFA) supplementation is a key indicator for tracking programmatic progress within and across countries. However, the validity of maternal report of this information during household surveys has yet to be determined.Objectives: This study aimed to examine the validity of maternal recall of receipt of IFA supplementation during antenatal care (ANC) and factors associated with accuracy of maternal recall.Methods: A longitudinal cohort design was employed. The direct observation of the IFA received during all ANC visits at the 5 study health posts served as the "gold standard" to the maternal report of IFA received during the postpartum interview. Individual-level validity was assessed by calculating indicator sensitivity, specificity, and AUC. The inflation factor (IF) measured population-level bias. A multivariable log-binomial model was used to assess factors associated with accurate recall.Results: The majority (95.8%) of women were observed receiving IFA during pregnancy. Women overreported the number of IFA tablets received compared with what was observed during ANC visits (mean difference: 45 tablets). Maternal report of any IFA receipt was moderate (AUC = 0.60; 95% CI: 0.50, 0.71), and population bias was low (IF = 1.01). However, the individual-level validity was poor across the 7 IFA tablet count categories; the AUC for categories ranged from misleading to moderate. Driven by the trend of maternal overreport, the IF indicated that maternal report drastically underestimated the coverage of lower tablet categories and overestimated the coverage of higher tablet counts. Accuracy of maternal report was not associated with months since last ANC observation nor any maternal characteristics.Conclusions: Maternal report of the amount of IFA supplementation received during pregnancy produced extremely biased population coverage and performed poorly to moderately for individual-level validity. It is imperative to improve this indicator because it is used in global frameworks and national program planning. [ABSTRACT FROM AUTHOR]

Background Acute respiratory tract infections are a serious clinical burden in infants; human metapneumovirus (HMPV) is an important etiological agent. We investigated genotypic variation and molecular epidemiological patterns among infants infected with HMPV in Sarlahi, Nepal, to better characterize infection in a rural, low-resource setting. Methods Between May 2011 and April 2014, mid-nasal swabs were collected from 3528 infants who developed respiratory symptoms during a longitudinal maternal influenza vaccine study. Sequencing glycoprotein genes permitted genotyping and analyses among subtypes. Results HMPV was detected by reverse-transcriptase polymerase chain reaction (RT-PCR) in 187 (5%) infants, with seasonality observed during fall and winter months. Phylogenetic investigation of complete and partial coding sequences for the F and G genes, respectively, revealed that 3 genotypes were circulating: A2, B1, and B2. HMPV-B was most frequently detected with a single type predominating each season. Both HMPV genotypes exhibited comparable median viral loads. Clinically significant differences between genotypes were limited to increased cough duration and general respiratory symptoms for type B. Conclusions In rural Nepal, multiple HMPV genotypes circulate simultaneously with an alternating predominance of a single genotype and definitive seasonality. No difference in viral load was detected by genotype and symptom severity was not correlated with RT-PCR cycle threshold or genotype. [ABSTRACT FROM AUTHOR]

Objectives: Antiseptic oral rinses have been evaluated as interventions to reduce the risk of adverse pregnancy outcomes associated with periodontal disease in pregnant women. Oral rinse use is not common in Nepal or other countries in South Asia, where the prevalence of adverse pregnancy outcomes is high. Understanding whether pregnant women in rural communities in this region would incorporate rinse use into their daily teeth cleaning routine is an important prerequisite to future research on this topic in South Asia. Methods: We conducted a community‐based pilot randomized controlled trial of three alcohol‐free, antiseptic oral rinses among pregnant women <22 weeks pregnant in rural Nepal with the aim of assessing rinse acceptability, adherence, and effect on clinical periodontal measures. At baseline, participants underwent a clinical periodontal examination, and then were classified as healthy or having at least mild gingivitis (≥1 site with probing depth (PD) 3 mm and bleeding on probing (BOP) or ≥4 mm (PD)). Participants were stratified by periodontal status and randomized within each exposure category to chlorhexidine (CHX) (0.12%), cetylpyridinium chloride (CPC) (0.05%), salt and water (NaCl), or control (no rinse). Rinse participants were followed weekly for 12 weeks, and all participants underwent a second periodontal examination and answered a questionnaire. Results: Pregnant women in the rural Terai region of Nepal showed high adherence to (mean weekly rinse use: 185 mL (standard deviation: 66 mL)) a recommended 210 mL and acceptability of all three rinses. Participants reported greater frequency of tooth brushing with toothpaste and improvements in other recommended oral hygiene behaviours. CHX significantly reduced rates of gingivitis (defined as a participant with BOP ≥ 10% of sites) and the extent of BOP (gingivitis at the end of follow‐up for CHX vs control: RR 0.37, 95% CI: 0.16, 0.84). CPC and NaCl rinse groups had rates of gingivitis and extent of BOP similar to the control group (gingivitis at the end of follow‐up for CPC: RR 0.81, 95% CI: 0.47, 1.38; NaCl: RR 0.92, 95% CI: 0.55, 1.56). Conclusions: Adherence to and acceptability of three alcohol‐free, antiseptic oral rinses were high among pregnant women in rural Nepal. Among participants with mild gingivitis at baseline, CHX rinse was most effective at reducing signs of disease compared to the control group. Oral rinse should be considered as a supplement to current oral self‐care routines for pregnant women in settings where rinse use is uncommon and access to oral health services is limited. [ABSTRACT FROM AUTHOR]

Background: Acute respiratory illnesses are a leading cause of global morbidity and mortality in children. Coinfection with multiple respiratory viruses is common. Although the effects of each virus have been studied individually, the impacts of coinfection on disease severity are less understood. Methods: A secondary analysis was performed of a maternal influenza vaccine trial conducted between 2011 and 2014 in Nepal. Prospective weekly household‐based active surveillance of infants was conducted from birth to 180 days of age. Mid‐nasal swabs were collected and tested for respiratory syncytial virus (RSV), rhinovirus, influenza, human metapneumovirus (HMPV), coronavirus, parainfluenza (HPIV), and bocavirus by RT‐PCR. Coinfection was defined as the presence of two or more respiratory viruses detected as part of the same illness episode. Results: Of 1730 infants with a respiratory illness, 327 (19%) had at least two respiratory viruses detected in their primary illness episode. Of 113 infants with influenza, 23 (20%) had coinfection. Of 214 infants with RSV, 87 (41%) had coinfection. The cohort of infants with coinfection had increased occurrence of fever lasting ≥ 4 days (OR 1.4, 95% CI: 1.1, 2.0), and so did the subset of coinfected infants with influenza (OR 5.8, 95% CI: 1.8, 18.7). Coinfection was not associated with seeking further care (OR 1.1, 95% CI: 0.8, 1.5) or pneumonia (OR 1.2, 95% CI: 0.96, 1.6). Conclusion: A high proportion of infants had multiple viruses detected. Coinfection was associated with greater odds of fever lasting for four or more days, but not with increased illness severity by other measures. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Although pelvic floor disorders (PFDs) are a significant public health issue in higher income countries, less is known about these disorders and associated risk factors in low income countries. We aimed to determine prevalence and associated risk factors for stress urinary incontinence (SUI), urge urinary incontinence (UUI), and pelvic organ prolapse (POP) in reproductive age women in Sarlahi District in rural Nepal. Methods: We conducted a community-based cross-sectional survey of parous, reproductive age women in rural Nepal and screened for pelvic floor disorders using validated screening questions for PFDs. Overall frequency of self-reported symptoms for SUI, UUI, and POP was estimated and compared across demographic and pregnancy history information. Results: Of 14,469 women available for analysis, the mean (SD, range) age was 33.5 (8.2, 13–52) years, and median (range) number of pregnancies was 4 (1–15). The prevalence of SUI was 24.1% (95% CI: 23.3–24.8), of UUI was 13.5% (95% CI: 13.0–14.1), and of POP was 8.0% (95% CI: 7.5–8.4). Bivariate analysis identified the risk of PFD increased incrementally with age and number of vaginal deliveries; these covariates were highly correlated. Multivariable logistic regression revealed age, vaginal deliveries, and previous pelvic surgeries were independently associated with PFD. Conclusions: PFDs are common in a community of parous, reproductive age women in rural Nepal. Risk factors for these conditions are similar to risk factors found in higher income countries. [ABSTRACT FROM AUTHOR]

Background: In many low- and middle-income countries, insufficient human resources limit access to oral health services. Shifting clinical tasks to less specialized health professionals, such as community health workers, has been used as a strategy to expand the health workforce, especially in remote or underserved locations. The objective of this study was to evaluate the validity of periodontal examinations conducted by auxiliary nurse midwives in a rural home setting in Nepal.Methods: Twenty-one pregnant women < 26 weeks gestation from Sarlahi District, Nepal, underwent full mouth periodontal examinations measuring probing depth (PD) and bleeding on probing (BOP) on 6 sites per tooth by one of five auxiliary nurse midwives, who were trained for this study but had no previous training in dentistry. After a 15-min break, each participant was examined again by an experienced dentist. Measures of validity for PD and BOP were calculated comparing the pooled and individual auxiliary nurse midwives to the dentist. A multivariable GEE model estimated the effect of periodontal characteristics on agreement between the auxiliary nurse midwives and the dentist.Results: Participant mean age was 22 years (SD: ±3 years), mean PD was 1.4 mm (SD: 03 mm), and 86% of women had BOP (according to the dentist). Percent agreement, weighted kappa scores, and intraclass correlation coefficients for PD, with an allowance of ±1 mm, exceeded 99%, 0.7, and 0.9, respectively, indicating an acceptable level of agreement. Auxiliary nurse midwives tended to report higher PD scores relative to the dentist, although this over-estimation was small and unlikely to impact population-based estimates of important indicators of oral health status. GEE regression modeling indicated similar agreement for mandible vs. maxilla, left vs. right side, and PD (≤2 mm, > 2 mm), and lower agreement for posterior teeth and lingual and proximal sites.Conclusion: Auxiliary nurse midwives were able to accurately conduct periodontal examinations in a rural home setting, suggesting the potential to shift tasks away from highly trained dentists and periodontal examiners in low-resource communities.Trial Registration: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study); registered on August 6th, 2010. [ABSTRACT FROM AUTHOR]

Background Respiratory viruses cause significant morbidity and death in infants; 99% of such deaths occur in resource-limited settings. Risk factors for initial and repeated respiratory viral infections in young infants in resource-limited settings have not been well described. Methods From 2011 to 2014, a birth cohort of infants in rural Nepal was enrolled and followed with weekly household-based active surveillance for respiratory symptoms until 6 months of age. Respiratory illness was defined as having any of the following: fever, cough, wheeze, difficulty breathing, and/or a draining ear. We tested nasal swabs of infants with respiratory illness for multiple respiratory viruses by using a reverse transcription polymerase chain reaction assay. The risk of primary and repeated infections with the same virus was evaluated using Poisson regression. Results Of 3528 infants, 1726 (49%) had a primary infection, and 419 (12%) had a repeated infection. The incidences of respiratory viral infection in infants were 1816 per 1000 person-years for primary infections and 1204 per 1000 person-years for repeated infection with the same virus. Exposure to other children and male sex were each associated with an increased risk for primary infection (risk ratios, 1.13 [95% confidence interval (CI), 1.06–1.20] and 1.14 [95% CI, 1.02–1.27], respectively), whereas higher maternal education was associated with a decreased risk for both primary and repeated infections (risk ratio, 0.96 [95% CI, 0.95–0.98]). The incidence of subsequent infection did not change when previous infection with the same or another respiratory virus occurred. Illness duration and severity were not significantly different in the infants between the first and second episodes for any respiratory virus tested. Conclusions In infants in rural Nepal, repeated respiratory virus infections were frequent, and we found no decrease in illness severity with repeated infections and no evidence of replacement with another virus. Vaccine strategies and public health interventions that provide durable protection in the first 6 months of life could decrease the burden of repeated infections by multiple respiratory viruses, particularly in low-resource countries. [ABSTRACT FROM AUTHOR]

Background: Natural vegetable oils are widely used for newborn massage in many low resource settings. Animal models indicated that sunflower seed oil (SSO) can accelerate skin barrier recovery following damage, while other oils, including mustard oil (MO), may cause further skin barrier damage. The objective was to compare the effects of two SSO and MO used for routine massage on skin integrity in premature and full-term neonates.Methods: This community-based cluster randomized controlled trial included 995 neonates assigned to full body massage with sunflower seed oil (SSO, intervention) or mustard seed oil (MO, standard practice) from July 2012-May 2014 in Sarlahi, Nepal. Skin integrity measures were evaluated over 28 days, including skin condition (erythema, rash, dryness), skin surface pH, stratum corneum (SC) cohesion/protein concentration, and transepidermal water loss (TEWL). Overall means and rates of change in these skin measures were compared between oil groups using bivariate random-effects models.Results: 500 and 495 live born neonates received repeated massage with MO and SSO, respectively. Skin pH decreased more quickly for SSO than MO in the first week of life, with a difference in mean daily reductions of 0.02 (95% CI: 0.002-0.040). Erythema, rash and dryness increased (worsened) over days 1-14 then decreased by day 28, with no significant oil group differences. TEWL increased over time, with no significant oil group differences. Gestational age did not modify the effect; the slightly faster decrease in skin pH among SSO infants was similar in magnitude between term and preterm infants.Conclusions: Oil type may contribute to differences in skin integrity when neonates are massaged regularly. The more rapid acid mantle development observed for SSO may be protective for neonates in lower resource settings.Trial Registration: ClinicalTrials.gov (NCT01177111); registered August 6th, 2010. [ABSTRACT FROM AUTHOR]

Problem: Rhinoviruses (RVs), the most common causes of acute respiratory infections in young children and infants, are highly diverse genetically. Objective: To characterize the RV types detected with respiratory illness episodes in infants in Nepal. Study methods: Infants born to women enrolled in a randomized trial of maternal influenza immunization in rural, southern Nepal were followed with household‐based weekly surveillance until 180 days of age. Infants with respiratory symptoms had nasal swabs tested for twelve respiratory viruses. A subset with RV alone was selected for sequencing of the VP4/2 gene to identify RV types. Results: Among 547 RV‐only positive illnesses detected from December 2012 to April 2014, 285 samples (52%) were sequenced. RV‐A, B, and C species were detected in 193 (68%), 18 (6%), and 74 (26%) specimens, respectively. A total of 94 unique types were identified from the sequenced samples, including 52 RV‐A, 11 RV‐B, and 31 RV‐C. Multiple species and types circulated simultaneously throughout the study period. No seasonality was observed. The median ages at illness onset were 88, 104, and 88 days for RV‐A, B, and C, respectively. The median polymerase chain reaction cycle threshold values did not differ between RV species. No differences between RV species were observed for reported respiratory symptoms, including pneumonia, or for medical care‐seeking. Conclusions: Among very young, symptomatic infants in rural Nepal, all three species and many types of RV were identified; RV‐A was detected most frequently. There was no association between RV species and disease severity. Highlight: RV infections were common among infants less than six months old in southern Nepal.All three species and 94 types of RV were identified by sequencing the VP4/2 gene.Multiple species and types circulated simultaneously throughout the study period.No symptomatic differences between RV species or types were observed. [ABSTRACT FROM AUTHOR]

In this post-hoc analysis of midnasal pneumococcal carriage in a community-based, randomized prenatal influenza vaccination trial in Nepal with weekly infant respiratory illness surveillance, 457 of 605 (75.5%) infants with influenza, respiratory syncytial virus (RSV), or human metapneumovirus (hMPV) illness had pneumococcus detected. Pneumococcal carriage did not impact rates of lower respiratory tract disease for these 3 viruses. Influenza-positive infants born to mothers given influenza vaccine had lower pneumococcal carriage rates compared to influenza-positive infants born to mothers receiving placebo (58.1% versus 71.6%, P = 0.03). Maternal influenza immunization may impact infant acquisition of pneumococcus during influenza infection. Clinical Trials Registration. NCT01034254. [ABSTRACT FROM AUTHOR]

Background: Quantitative validation studies alone may not be able to distinguish between instances when participants did not accurately report an event vs when participants did not understand a question. We used an explanatory qualitative study design to acquire an in-depth understanding of why some mothers in rural Nepal overestimate birth size of their newborn and their length of pregnancy.Methods: We conducted two focus group discussions (FGDs) with study staff who administered a quantitative questionnaire and 12 in-depth interviews (IDIs) with mothers who had participated in a quantitative validation study. Transcripts were coded and analyzed for themes in patterns of meaning within and across FGDs and IDIs. Using this thematic map, we synthesized our data into common and divergent responses from participants to facilitate our interpretation of the quantitative findings.Results: We identified five themes specific to this analysis: difficulties with the length of pregnancy question, challenges in administering the birth size question, the perceived effect of time since birth on mothers' ability to remember information, the language and style differences specific to this setting, and the study context shaping the relationship between study staff and mothers who participated and how this may have influenced mothers' responses. Visual aids may help to scale the question about birth size within a cultural frame of reference for maternal reports to be more interpretable. Among both study staff and mothers, a longer period of time since the birth of a child was thought to be associated with diminished accuracy of maternal reports, a perception not supported by our previously published quantitative findings.Conclusions: Poor validity of low birth weight (LBW) and preterm birth indicators based on maternal reports may be partly attributed to challenges in maternal understanding of questions assessing birth size and length of pregnancy. Additional research is needed to confirm these findings regarding maternal comprehension and to further evaluate the utility of visual aids developed for this study. [ABSTRACT FROM AUTHOR]

Objective: To assess ethnicity- and age-modified associations between mid-upper arm circumference (MUAC) and mortality in Nepalese children and whether sociodemographic factors explain these associations.Design: Secondary data analysis of children followed until 3 years of age. Estimated mortality hazard ratios (HR) for MUAC<11·5cm (recommended cut-off for identifying severe acute malnutrition among children ≥6 months old) compared with ≥11·5cm in younger (<6 months) and older children (≥6 months) of Pahadi and Madhesi ethnicity, adjusting for sex, socio-economic status (SES) and mother's education using Cox proportional hazard models.Setting: Sarlahi, Nepal (21 October 2001-2 February 2006).Subjects: Children (n 48 492) enrolled in the Nepal Nutrition Intervention Project, Sarlahi-4.Results: Among children aged ≥6 months, MUAC<11·5 cm was associated with increased risk of mortality in both Pahadis (HR=4·01; 95 % CI 1·42, 11·76) and Madhesis (HR=5·60; 95 % CI 3·87, 8·11) compared with those with MUAC≥11·5 cm, after adjusting for sex, SES and maternal literacy. Among children <6 months old, MUAC<11·5 cm was not associated with mortality in Pahadis with (HR=1·12; 95 % CI 0·72, 1·73) or without adjusting (HR=1·17; 95 % CI 0·75, 1·18) as compared with Madeshis (adjusted HR=1·76; 95 % CI 1·35, 2·28).Conclusions: Among older children, MUAC<11·5 cm is associated with subsequent mortality in both ethnicities regardless of other characteristics. However, among children aged <6 months, it predicted mortality only among Madhesis, while sociodemographic factors were more strongly associated with mortality than MUAC<11·5cm among Pahadis. [ABSTRACT FROM AUTHOR]

Background Maternal influenza vaccination protects mothers and their infants in low resource settings, but little is known about whether the protection varies by gestational age at vaccination. Methods Women of childbearing age in rural southern Nepal were surveilled for pregnancy, consented and randomized to receive maternal influenza vaccination or placebo, with randomization stratified on gestational age (17–25 or 26–34 weeks). Enrollment occurred in 2 annual cohorts, and vaccinations occurred from April 2011 through September 2013. Results In sum, 3693 women consented and enrolled, resulting in 3646 live births. Although cord blood antibody titers and the rise in maternal titers were generally greater when women were vaccinated later in pregnancy, this was not statistically significant. The incidence risk ratio (IRR) for maternal influenza in pregnancy through 6 months postpartum was 0.62 (95% confidence interval [CI]: 0.35, 1.10) for those vaccinated 17–25 weeks gestation and 0.89 (95% CI: 0.39, 2.00) for those 26–34 weeks. Infant influenza IRRs were 0.73 (95% CI: 0.51, 1.05) for those whose mothers were vaccinated earlier in gestation, and 0.63 (95% CI: 0.37, 1.08) for those later. Relative risks (RR) for low birthweight were 0.83 (95% CI: 0.71, 0.98) and 0.90 (95% CI: 0.72, 1.12) for 17–25 and 26–34 weeks gestation at vaccination, respectively. IRRs did not differ for small-for-gestational age or preterm. No RRs were statistically different by timing of vaccine receipt. Conclusions Vaccine efficacy did not vary by gestational age at vaccination, making maternal influenza immunization programs easier to implement where women present for care late in pregnancy. Clinical Trials Registration NCT01034254 [ABSTRACT FROM AUTHOR]

Objective: To describe the effect of maternal vaccination on birth outcomes in rural Nepal, modified by timing of vaccination in pregnancy and influenza virus activity.Methods: A secondary analysis was conducted using data from two annual cohorts of a randomized controlled trial. A total of 3693 pregnant women from Sarlahi District were enrolled between April 25, 2011, and September 9, 2013. All participants were aged 15-40 years and received a trivalent inactivated influenza vaccine or placebo. The outcome measures included birth weight, pregnancy length, low birth weight (<2500 g), preterm birth, and small-for-gestational-age birth.Results: Data were available on birth weight for 2741 births and on pregnancy length for 3623 births. Maternal vaccination increased mean birthweight by 42 g (95% confidence interval [CI] 8-76). The magnitude of this increase varied by season but was greatest among pregnancies with high influenza virus circulation during the third trimester. Birth weight increased by 111 g (95% CI -51 to 273) when 75%-100% of a pregnancy's third trimester had high influenza virus circulation versus 38 g (95% CI -6 to 81) when 0%-25% of a pregnancy's third trimester had high influenza virus circulation. However, these results were nonsignificant.Conclusion: Seasonal maternal influenza vaccination in rural Nepal increased birth weight; the magnitude appeared larger during periods of high influenza virus circulation. CLINICALTRIALS.GOV: NCT01034254. [ABSTRACT FROM AUTHOR]

Background: Influenza immunisation during pregnancy is recommended but not widely implemented in some low-income regions. We assessed the safety and efficacy in mothers and infants of year-round maternal influenza immunisation in Nepal, where influenza viruses circulate throughout the year.Methods: In this phase 4, randomised, placebo-controlled trial, we enrolled two consecutive sequential annual cohorts of pregnant women from the Sarlahi district in southern Nepal. We randomised mothers 1:1 to receive seasonally recommended trivalent inactivated influenza vaccine or saline placebo in blocks of eight, stratified by gestational age at enrolment (17-25 weeks vs 26-34 weeks). Women were eligible if they were married, 15-40 years of age, 17-34 weeks' gestation at enrolment, and had not previously received any influenza vaccine that season. We collected serum samples before and after immunisation, and cord blood from a subset of women and infants. Staff masked to allocation made home visits every week from enrolment to 6 months after delivery. Midnasal swabs for respiratory virus PCR testing were collected during maternal acute febrile respiratory infections, and from infants with any respiratory symptom. We assessed vaccine immunogenicity, safety, and three primary outcomes: the incidence of maternal influenza-like illness in pregnancy and 0-180 days postpartum, the incidence of low birthweight (<2500 g), and the incidence of laboratory-confirmed infant influenza disease from 0 to 180 days. This trial is registered with ClinicalTrials.gov, number NCT01034254.Findings: From April 25, 2011, to Sept 9, 2013, we enrolled 3693 women in two cohorts of 2090 (1041 assigned to placebo and 1049 to vaccine) and 1603 (805 assigned to placebo and 798 to vaccine), with 3646 liveborn infants (cohort 1, 999 in placebo group and 1010 in vaccine group; cohort 2, 805 in placebo group and 798 in vaccine group). Immunisation reduced maternal febrile influenza-like illness with an overall efficacy of 19% (95% CI 1 to 34) in the combined cohorts; 9% efficacy (-16 to 29) in the first cohort, and 36% efficacy (9 to 55) in the second cohort. For laboratory-confirmed influenza infections in infants aged 0-6 months, immunisation had an overall efficacy for the combined cohorts of 30% (95% CI 5 to 48); in the first cohort, the efficacy was 16% (-19 to 41), and in the second cohort it was 60% (26 to 88). Maternal immunisation reduced the rates of low birthweight by 15% (95% CI 3-25) in both cohorts combined. The rate of small for gestational age infants was not modified by immunisation. The number of adverse events was similar regardless of immunisation status. Miscarriage occurred in three (0·2%) participants in the placebo group versus five (0·3%) in the vaccine group, stillbirth occurred in 31 (1·7%) versus 33 (1·8%), and congenital defects occurred in 18 (1·0%) versus 20 (1·1%). Five women died in the placebo group and three died in the vaccine group. The number of infant deaths at age 0-6 months was similar in each group (50 in the placebo group and 61 in the vaccine group). No serious adverse events were associated with receipt of immunisation.Interpretation: Year-round maternal influenza immunisation significantly reduced maternal influenza-like illness, influenza in infants, and low birthweight over the entire course of the study, indicating the strategy could be useful in subtropical regions.Funding: Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Human metapneumovirus (HMPV) is a respiratory virus that can cause severe lower respiratory tract disease and even death, primarily in young children. The incidence and characteristics of HMPV have not been well described in pregnant women. As part of a trial of maternal influenza immunization in rural southern Nepal, we conducted prospective, longitudinal, home-based active surveillance for febrile respiratory illness during pregnancy through 6 months postpartum. During 2011-2014, HMPV was detected in 55 of 3,693 women (16.4 cases/1,000 person-years). Twenty-five women were infected with HMPV during pregnancy, compared with 98 pregnant women who contracted rhinovirus and 7 who contracted respiratory syncytial virus. Women with HMPV during pregnancy had an increased risk of giving birth to infants who were small for gestational age. An intervention to reduce HMPV febrile respiratory illness in pregnant women may have the potential to decrease risk of adverse birth outcomes in developing countries. [ABSTRACT FROM AUTHOR]

Objective: To validate a symptom-based fistula screening questionnaire and estimate obstetric fistula (OF) prevalence in rural Nepal.Design: Cross-sectional and nested case-control study.Setting: Sarlahi District, Nepal.Population: Parous, reproductive age women.Methods: The questionnaire assessed symptoms of vesicovaginal and rectovaginal fistula (VVF and RVF, respectively), stress and urge urinary incontinence (SUI and UUI, respectively), fecal incontinence (FI), and included interviewer observations on the smell and presence of urine and/or stool. All women who screened positive for OF and a randomly selected group of women who screened negative for OF were included in a nested case-control study (one case, four normal controls, and four incontinent controls) and underwent confirmatory clinical examinations.Main Outcome Measures: Clinically confirmed OF, and questionnaire sensitivity (Se) and specificity (Sp).Results: Of the 16 893 women who completed cross-sectional screening, 68 were screened-positive cases. Fifty-five (82%) screened-positive cases, 203 screened-negative normal controls, and 203 screened-incontinent controls participated in the case-control study, which confirmed one case of VVF and one case of both VVF and RVF without any false-negative cases. For VVF, the screening tool demonstrated Se 100% (95% CI 34.2-100.0%), Sp 86.9% (95% CI 83.3-89.9%), and estimated VVF prevalence as 12 per 100 000 (95% CI 3-43); for RVF, it demonstrated Se 100% (95% CI 20.7-100.0), Sp 99.8% (95% CI 98.6-100.0), and estimated RVF prevalence as 6 per 100 000 (95% CI 1-34).Conclusions: The OF screening questionnaire demonstrated high sensitivity and specificity in this low-prevalence setting.Tweetable Abstract: Community-based obstetric fistula screening tool validation study, Nepal, n = 16 893: High Se, Sp & feasibility. [ABSTRACT FROM AUTHOR]

Despite increasing recognition that community-level socioeconomic factors are critical to individual health outcomes globally, guidance on their measurement remains limited in low and middle income countries. We outline the steps needed to develop and validate a theory-based, multidimensional index of community-level socioeconomic composition using information that is often available in global settings. Census indicators describing human and social capital were analyzed using principal components analysis to construct a community socioeconomic composition index (CSCI) for 30 communities in the Southern plains of Nepal. The index was validated against subsequent child nutrition, household assets, and village infrastructure using data from 1822 children and their households. At the community-level, the CSCI was positively correlated with child height-for-age, and child weight-for-age, household assets, and community infrastructure (r = 0.54, 0.58, 0.85, 0.67, respectively). In multilevel analyses, +1SD of the CSCI was associated with +0.14SD of the household asset index ( p < 0.01) after adjusting for confounders. These results suggest that an exclusively census-based strategy to measure socioeconomic composition has construct validity in this setting. This approach to measuring community-level socioeconomic composition may be feasibly reproduced in other resource-constrained settings where census data are available, potentially expanding the scope of place and health research globally. [ABSTRACT FROM AUTHOR]

Objective: To assess levels of awareness and use of obstetric ultrasonography in rural Nepal.Methods: Between March 2014 and March 2015, a cross-sectional survey was conducted among married women aged 15-40years residing in rural Sarlahi District, Nepal, regarding their knowledge and use of obstetric ultrasonography during their most recent pregnancy. Regression analyses were conducted to identify reproductive health, socioeconomic, and other characteristics that increased the likelihood of undergoing an obstetric ultrasonographic examination.Results: Among 6182 women, 1630 (26.4%) had undergone obstetric ultrasonography during their most recent pregnancy, of whom 1011 (62.0%) received only one examination. Odds of receiving an ultrasonographic examination were higher among women with post-secondary education than among those with none (≥11years' education: adjusted odds ratio [aOR] 10.28, 95% confidence interval [CI] 5.55-19.04), and among women whose husbands had post-secondary education than among those with husbands with none (≥11years' education: aOR 1.99, 95% CI 1.47-2.69). Odds were lower among women younger than 18years than among those aged 18-34years (aOR 0.72, 95% confidence interval 0.59-0.90).Conclusion: Utilization of obstetric ultrasonography in rural Nepal was very limited. Further research is necessary to assess the potential health impact of obstetric ultrasonography in low-resource settings, while addressing limitations such as cost and misuse. [ABSTRACT FROM AUTHOR]

Objectives: Respiratory syncytial virus (RSV) pneumonia is a leading cause of infant mortality worldwide. The risk of RSV infection associated with preterm birth is not well-characterized in resource-limited settings. We aimed to obtain precise estimates of risk factors and disease burden of RSV in infants in rural southern Nepal.Methods: Pregnant women were enrolled, and along with their infants, followed to six months after birth with active weekly home-based surveillance for acute respiratory illness (ARI). Mid-nasal swabs were obtained and tested for RSV by PCR for all illness episodes. Birth outcomes were assessed at a postpartum home visit.Results: 311 (9%) of 3509 infants had an RSV ARI. RSV ARI incidence decreased from 551/1000 person-years in infants born between 28 and 31 weeks to 195/1000 person-years in infants born full-term (p = 0.017). Of 220 infants (71%) evaluated in the health system, 41 (19%) visited a hospital or physician. Of 287 infants with an assessment performed, 203 (71%) had a lower respiratory tract infection.Conclusions: In a rural south Asian setting with intensive home-based surveillance, RSV caused a significant burden of respiratory illness. Preterm infants had the highest incidence of RSV ARI, and should be considered a priority group for RSV preventive interventions in resource-limited settings. [ABSTRACT FROM AUTHOR]

Background Immunization programs currently measure coverage by assessing the proportion of children 12–24 months who have been immunized but this does not address the important question of when the scheduled vaccines were administered. Data capturing the timing of vaccination in first 6 months, when severe disease is most likely to occur, are limited. Objective To estimate the time to Bacillus Calmette–Guérin (BCG) (recommended at birth), diphtheria-tetanus-pertussis-H, influenza b-hepatitis B (DTP-Hib-HepB), and oral polio vaccine (OPV) (recommended at 6, 10, and 14 weeks) vaccinations and risk factors for vaccination delay in infants <6 months of age in a district in southern Nepal where traditional coverage metrics are high. Design/methods Infants enrolled in a randomized controlled trial of maternal influenza vaccination were visited weekly at home from birth through age 6 months to ascertain if any vaccinations had been given in the prior week. Infant, maternal, and household characteristics were recorded. BCG, DTP-Hib-HepB, and OPV vaccination coverage at 4 and 6 months was estimated. Time to vaccination was estimated through Kaplan–Meier curves; Cox-proportional hazards models were used to examine risk factors for delay for the first vaccine. Results The median age of BCG, first OPV and DTP-Hib-HepB receipt was 22, 21, and 18 weeks, respectively. Almost half of infants received no BCG by age 6 months. Only 8% and 7% of infants had received three doses of OPV and DTP-Hib-HepB, respectively, by age 6 months. Conclusion A significant delay in receipt of infant vaccines was found in a prospective, population-based, cohort in southern Nepal despite traditional coverage metrics being high. Immunization programs should consider measuring time to receipt relative to the official schedule in order to maximize benefits for disease control and child health. [ABSTRACT FROM AUTHOR]

Introduction: The Ten Questions tool was developed in 1984 as a low-cost tool to screen for child disability prior to referral for definitive diagnosis. Iron and zinc contribute to child growth and development, but few studies examine the relationship between supplementation and longer-term neuro-developmental outcomes. Methods: The Ten Questions Plus tool was administered to caregivers of 1410 children between 1-9 years of age from August 2007 to March 2008 in rural Sarlahi, southern Nepal. Participants had been previously enrolled in a randomized 2x2 factorial trial of daily iron and zinc supplementation between October 2001 and January 2006. Results: Nearly 30% of the sample screened positive for disability. The most common problems were learning disability (12.3%) and motor milestone delay (11.3%). Children supplemented with zinc were less likely to screen positive overall, and for motor and learning problems. Children supplemented with smaller doses of iron were more likely to screen positive overall, and for physical, and cognitive problems, but these differences were not statistically significant. There were no differences in children dually supplemented with iron and zinc compared with placebo. Conclusions: The Ten Questions Plus tool can be used in this rural Nepali setting to identify children at increased risk for physical and cognitive disability who should be referred for clinical examination, diagnosis and enrollment in intervention services. We found evidence for a beneficial effect of zinc supplementation in reducing the likelihood of screening positive for disability. [ABSTRACT FROM AUTHOR]

Objectives Self-harm and interpersonal violence are important causes of death among women in Nepal. We analysed prospectively collected data to investigate the extent and nature of injury-related deaths among married women aged 15-49 years, recorded through verbal autopsy in rural Sarlahi District, Nepal. Methods Verbal autopsies were systematically collected on all deaths of married women of reproductive age (15-49 years) over a 3-year period (1994-1997) as part of a randomised community-based trial of maternal vitamin A and β-carotene supplementation. This analysis included a three-way comparison of verbal autopsy data: qualitative free-response narratives, closed-ended responses, and physician-assigned consensus cause of death. Results We focused on 46 of 559 deaths (8.2%) that were determined to be injury-related. Of the 46, 28% were identified as intentionally self-inflicted, and 11% as intentionally inflicted by another. Inconsistencies were noted between verbal autopsy reports of causes of deaths and physician assessments. Conflicts within the family figured prominently in the narratives. Women with unstable family situations and suffering from mental illness were often described as having experienced violent deaths. Conclusions Findings highlight that intervention efforts might be necessary especially in situations where there are poor family dynamics or mental health issues in order to prevent potential intrafamily violence and possible death. Results also point to the need for further documentation of violent deaths in rural Nepal. [ABSTRACT FROM AUTHOR]

Child eating behaviors play an important role in nutrient intake, ultimately affecting child growth and later outcomes in adulthood. The study assessed the effects of iron-folic acid and zinc supplementation on child temperament and child eating behaviors in rural Nepal. Children (N = 569) aged 4–17 months in Sarlahi district, southern Nepal were randomized to receive daily supplements of placebo, iron-folic acid, zinc, or zinc plus iron-folic acid and followed for approximately 1 year. At baseline and four follow-up visits mothers completed questionnaires including information on demographic characteristics and child temperament and eating behaviors. The main effects of zinc and iron-folic acid supplementation on temperament and eating behaviors were assessed through crude and adjusted differences in mean cumulative score changes between visits 1 and 5. The adjusted rate-of-change for these outcomes was modeled using generalized estimating equations. Mean changes in temperament scores and in eating behavior scores between visits 1 and 5 were not significant in either the zinc or non-zinc group. Children in the iron-folic acid group increased temperament scores by 0.37 points over 5 visits (95% CI 0.02, 0.7), which was not significant after adjustment. Neither the adjusted rate-of-change in temperament scores between zinc and non-zinc (β = −0.03, 95% CI −0.3, 0.2) or iron-folic acid and non-iron-folic acid (β = 0.08, 95% CI −0.2, 0.3) were significantly different. Adjusted rate of change analysis showed no significant difference between zinc and non-zinc (β = −0.14, 95% CI −0.3, 0.04) or between iron and non-iron eating behavior scores (β = −0.11, 95% CI −0.3, 0.1). Only among children with iron-deficiency anemia at baseline was there a significant decrease in eating behavior score, indicating better eating behaviors, when supplemented with zinc (β = −0.3, 95% CI −0.6, −0.01), Ultimately, this effect of zinc on eating behaviors was the only effect we observed after approximately one year of micronutrient supplementation. Trial Registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

We investigated the effect of supplementing women weekly with 7000 microg retinol equivalents as preformed vitamin A or beta-carotene vs. a placebo, on the incidence of night blindness during pregnancy and the postpartum period in the rural plains of Nepal. Over a period of approximately 3 y, approximately 29,000 women of child-bearing age, living in 171 wards that were randomized to one of the three supplements, contributed 9932 first pregnancies. A prospective, weekly surveillance identified night blindness in pregnant women, verified further by detailed questioning about nighttime vision. After delivery, women were also interviewed at approximately 3 and approximately 6 mo postpartum to elicit a night blindness history over the preceding 3 mo. Vitamin A supplementation reduced the incidence of night blindness during pregnancy from 10.7% among controls to 6.7% (relative risk 0.62, 95% confidence interval: 0.45-0.85). beta-Carotene supplementation had less of an effect (0. 83, 0.63-1.11). Among women who took >95% of their vitamin A supplements during pregnancy, incidence of verified night blindness was reduced by 67%. Incidence (per 100 person-years) of night blindness during the first 3 mo postpartum was 11.3 in the control, 4.3 in the vitamin A and 8.7 in the beta-carotene groups, yielding corresponding relative risks of 0.38 (0.26-0.55) and 0.77 (0.57-1. 04). In the second 3 mo postpartum, both vitamin A and beta-carotene reduced night blindness by approximately 50%. Vitamin A intakes approaching a recommended amount for pregnancy markedly reduced but did not eliminate night blindness in Nepali women. Greater intakes of vitamin A than provided and/or other nutrients may be needed to prevent maternal night blindness in rural South Asia. [ABSTRACT FROM AUTHOR]

Background: Acute lower respiratory infections (ALRI) are a leading cause of death among children. Low birthweight is prevalent in South Asia and associated with increased risks of mortality, and morbidity, high levels of indoor household air pollution caused by open burning of biomass fuels are common and associated with high rates of ALRI and low birthweight. Alternative stove designs that burn biomass fuel more efficiently have been proposed as one method for reducing these high exposures and lowering rates of these disorders. We designed two randomized trials to test this hypothesis.Methods/design: We conducted a pair of community-based, randomized trials of alternative cookstove installation in a rural district in southern Nepal. Phase one was a cluster randomized, modified step-wedge design using an alternative biomass stove with a chimney. A pre-installation period of morbidity assessment and household environmental assessment was conducted for six months in all households. This was followed by a one year step-wedge phase with 12 monthly steps for clusters of households to receive the alternative stove. The timing of alternative stove introduction was randomized. This step-wedge phase was followed in all households by another six month follow-up phase. Eligibility criteria for phase one included household informed consent, the presence of a married woman of reproductive age (15-30 yrs) or a child < 36 months. Children were followed until 36 months of age or the end of the trial. Pregnancies were identified and followed until completion or end of the trial. Phase two was an individually randomized trial of the same alternative biomass stove versus liquid propane gas stove in a subset of households that participated in phase one. Follow-up for phase two was 12 months following stove installation. Eligibility criteria included the same components as phase one except children were only enrolled for morbidity follow-up if they were less than 24 months.The primary outcomes included: incidence of ALRI in children and birthweight.Discussion: We presented the design and methods of two randomized trials of alternative cookstoves on rates of ALRI and birthweight.Trial Registration: Clinicaltrials.gov (NCT00786877, Nov. 5, 2008). [ABSTRACT FROM AUTHOR]

Background Studies in South Asia have documented increased risk of neonatal mortality among girls, despite evidence of a biological survival advantage. Associations between gender preference and mortality are cited as reasons for excess mortality among girls. This has not, however, been tested in statistical models. Methods A secondary analysis of data from a population-based randomised controlled trial of newborn infection prevention conducted in rural southern Nepal was used to estimate sex differences in early and late neonatal mortality, with girls as the reference group. The analysis investigated which underlying biological factors (immutable factors specific to the newborn or his/her mother) and environmental factors (mutable external factors) might explain observed sex differences in mortality. Results Neonatal mortality was comparable by sex (Ref=girls; OR 1.06, 95% CI 0.92 to 1.22). When stratified by neonatal period, boys were at 20% (OR 1.20, 95% CI 1.02% to 1.42%) greater risk of early and girls at 43% (OR 0.70, 95% CI 0.51% to 0.94%) greater risk of late neonatal mortality. Biological factors, primarily respiratory depression and unconsciousness at birth, explained excess early neonatal mortality among boys. Increased late neonatal mortality among girls was explained by a three-way environmental interaction between ethnicity, sex and prior sibling composition (categorised as primiparous newborns, infants born to families with prior living boys or boys and girls, and infants born to families with only prior living girls). Conclusions Risk of neonatal mortality inverted between the early and late neonatal periods. Excess risk of early neonatal death among boys was consistent with biological expectations. Excess risk for late neonatal death among girls was not explained by overarching gender preference or preferential care-seeking for boys as hypothesised, but was driven by increased risk among Madeshi girls born to families with only prior girls. [ABSTRACT FROM AUTHOR]

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Background Wealth disparities in child developmental outcomes are well documented in developed countries. We sought to (1) describe the extent of wealth-based neurocognitive development disparities and (2) examine potential mediating factors of disparities among a population-based cohort of children in rural Nepal. Methods We investigated household wealth-based differences in intellectual, executive and motor function of n = 1692 children aged between 7 and 9 years in Nepal. Using linear mixed models, wealth-based differences were estimated before and after controlling for child and household demographic characteristics. We further examined wealth-based differences adjusted for three sets of mediators: child nutritional status, home environment, and schooling pattern. Results We observed a positive gradient in child neurocognitive performance by household wealth. After adjusting for child and household control factors, disparities between children in the highest and lowest wealth quintiles persisted in intellectual and motor function, but not executive function. No statistically significant wealth-based differentials in outcomes remained after accounting for nutritional status, home environment, and schooling patterns. The largest differences in neurocognitive development were associated with schooling pattern. Conclusions Household wealth patterns child neurocognitive development in rural Nepal, likely through its influence on nutritional status, the home environment, and schooling. In the current context, improving early and regular schooling in this setting is critical to addressing wealth-based disparities in outcomes. [ABSTRACT FROM AUTHOR]

The provision of essential newborn care through integrated packages is essential to improving survival. We analyzed data on newborn care practices collected among infants who participated in a community-based trial in rural Nepal. Analysis focused on feeding, hygienic, skin/cord care and thermal care practices. Data were analyzed for 23 356 and 22 766 newborns on Days 1 and 14, respectively. About 56.6% of the babies were breastfed within 24 h and 80.4% received pre-lacteal feeds within the first 2 weeks of life. Only 13.3% of the caretakers always washed their hands before caring for their infant. Massage with mustard oil was near universal, 82.2% of the babies slept in a warmed room and skin-to-skin contact was rare (4.5%). Many of these commonly practiced behaviors are detrimental to the health and survival of newborns. Key areas to be addressed when designing a community-endorsed care package were identified. [ABSTRACT FROM PUBLISHER]

Context The Ten Questions tool was developed in 1984 as a low-cost, simple screen for childhood disability and referral for diagnosis in low-resource settings, and its use in Nepal has not been previously evaluated. Preterm birth and intrauterine growth restriction are potential risk factors for child disability and loss of developmental potential, but there are few studies examining this relationship from developing settings. Objective To examine the associations of small for gestational age and preterm birth as predictors of Ten Questions Plus positivity. Design, setting and participants The Ten Questions Plus questionnaire was administered to caregivers of 680 children between 2 and 5 years of age from August 2007 to March 2008 in rural Sarlahi, southern Nepal. Participants had previously been enrolled in a randomized trial of chlorhexidine cleansing at birth. At 1 month of age, children were then enrolled into a randomized 2 × 2 factorial trial of daily iron and zinc supplementation between October 2001 and January 2006. Intervention None. Main outcome measure Positive screen on the Ten Questions Plus tool defined as a positive response to one or more questions. Results Of preterm children, 37 (33.6%) had a positive response to at least one question on the Ten Questions Plus and were considered at risk for disability. One hundred and seventy term children (29.8%) were at risk for disability. Conclusions The Ten Questions Plus tool can be used in this rural Nepali setting to identify children at increased risk for mental and physical disability to be targeted for further examination. The prevalence of parent-reported disabilities is high in this population (almost one-third of children); children who are both preterm and small-for-gestational age are at increased risk for motor milestone delay, reported learning difficulty, speech and behavioural problems. Intrauterine growth restriction may affect child development and result in disabilities later in childhood. [ABSTRACT FROM AUTHOR]

Objective: To assess stillbirth rates and antepartum risk factors in rural Nepal.Methods: Data were collected prospectively during a cluster-randomized, community-based trial in Sarlahi, Nepal, from 2002 to 2006. Multivariate regression modeling was performed to calculate adjusted relative risk estimates.Results: Among 24531 births, the stillbirth rate was 35.4 per 1000 births (term stillbirth rate 21.2 per 1000 births). Most births occurred at home without a skilled birth attendant. The majority (69%) of intrapartum maternal deaths resulted in stillbirth. The adjusted RR (aRR) of stillbirth was 2.74 among nulliparas and 1.47 among mothers with history of a child death. Mothers above the age of 30 years carried a 1.59-fold higher risk for stillbirth than mothers who were 20-24 years old. The stillbirth risk was lower among households where the father had any formal education (aRR 0.70). Land ownership (aRR 0.85) and Pahadi ethnicity (aRR 0.67; reference: Madhesi ethnicity) were associated with significantly lower risks of stillbirth.Conclusion: Stillbirth rates were high in rural Nepal, with the majority of stillbirths occurring at full-term gestation. Nulliparity, history of prior child loss, maternal age above 30 years, Madhesi ethnicity, and socioeconomic disadvantage were significant risk factors for stillbirth. Clinicaltrials.govNCT00 109616. [ABSTRACT FROM AUTHOR]

The article presents information on a study which evaluated intellectual and motor functioning of children whose mothers were given micronutrient supplementation during pregnancy. A brief review of micronutrient inadequacy is presented. Study participants were 676 children aged 7 to 9 years in June 2007 and April 2009 who had been born to women in four of five groups of a community-based, double-blind, randomized controlled trial of prenatal micronutrient supplementation between 1999 and 2001 in rural Nepal. Children's intellectual functioning was assessed using the Universal Nonverbal Intelligence Test (UNIT) tests, among others, while and motor function was assessed using the Movement Assessment Battery for Children (MABC). A discussion on the findings of the report is detailed.

The study was conducted to examine the association between the indicators of malnutrition and disability of children as reported by caregivers. The Ten Questions Plus questionnaire was administered to caregivers of 1,902 children aged 1-9 years, during August 2007-March 2008, in rural Nepal. Height and weight of children were also measured. The main outcome was a positive response to one or more questions. In total, 514 (27%) children had a positive response to at least one question. Moderate stunting [odds ratio (OR)=1.47, 95% confidence interval (CI) 1.02-2.12) and severe (OR=2.39, 95% CI 1.60-3.57) stunting were independently associated with reported delay in sitting, standing, or walking. Severe stunting was also associated with report of delayed learning compared to other children of similar age (OR=2.01, 95% CI 1.27-3.20). Parental report of disability was quite prevalent in this setting, with over a quarter of the sample screening positive. Chronic malnutrition may be associated with delayed motor and mental development. [ABSTRACT FROM AUTHOR]

Demographic household surveys in Nepal between 1996 and 2006 indicate potentially large decreases in the pregnancy-related mortality ratio and raise hopes that Nepal may be on track to meet Millennium Development Goal 5. Between 2002 and 2006, 23,478 pregnant women in Sarlahi District, Nepal, were followed through pregnancy to 42 days postpartum. The pregnancy-related mortality ratio (PRMR) was estimated directly, comparing deaths among women during pregnancy or within 42 days of pregnancy termination to livebirths. In a separate household survey, 13,319 married females reported on the pregnancy history of 28,829 sisters, allowing for a concurrent comparison of estimation methodologies. In the prospective study, there were 121 pregnancy-related deaths and 23,662 livebirths (PRMR = 511, 95% confidence interval: 425, 611). In the household survey, participants reported 396 deaths among sisters, 87 (22.0%) of which were pregnancy related, and 116,491 person-years of exposure (PRMR = 529, 95% confidence interval: 419, 638). Two independent estimates collected with different methods in the same geographic area over similar time periods resulted in similarly high estimates of mortality that are approximately twice the current national estimate. Access to life-saving maternal health interventions remains low in rural Nepal, and continued efforts are necessary to ensure equitable and country-wide progress toward Millennium Development Goal 5. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to examine whether changes in the mid-upper arm circumference (MUAC) in pregnancy and early post-partum varied by maternal age. The MUAC of 3359 nulliparous pregnant women ≤25 years of age in rural Nepal was measured in early pregnancy and at 3 months post-delivery of a live-born infant. Regression was used to model the change in MUAC and prevalence of MUAC < 20 cm by maternal age, adjusted for confounders. A total of 5.2% of the pregnant women were under 16 years of age. The prevalence of MUAC measurements <20 cm was 11.3% in early pregnancy and did not differ by maternal age. The prevalence of low MUAC was 17.7% at post-partum, but those <16 years of age had a significantly higher prevalence of low post-partum MUAC [odds ratio: 2.47, 95% confidence interval (CI) 1.49, 4.10] compared with women 20–25 years of age, adjusted for maternal literacy, caste, meat consumption in early pregnancy and timing of measurements. All women reduced their MUAC from early pregnancy through post-partum. The adjusted loss of the MUAC among those under 16 years of age was 0.97 cm (95% CI: −1.33, −0.60), compared with 0.40 cm (95% CI: −0.70, −0.10) among women 20–25 years of age. In an energy-restricted environment, girls under 16 years contributed to a half centimetre more loss of MUAC than older women of the same parity. Such a loss of fat, muscle or both may put younger women and their breastfed offspring at greater risk of other adverse health and nutritional outcomes. [ABSTRACT FROM AUTHOR]

A community-based, cluster-randomized, placebo-controlled trial of daily zinc and/or iron+folic acid supplementation was conducted in rural southern Nepal to examine motor milestone attainment among 3264 children 1-36 mo of age between 2001 and 2006. Treatment groups included placebo, zinc (10 mg), iron+folic acid (12.5 mg iron + 50 μg folic acid), and zinc+iron+folic acid (10 mg zinc + 12.5 mg iron + 50 μg folic acid). Infants received half of these doses. The iron arms were stopped November 2003 by recommendation of the Data Safety and Monitoring Board; zinc and placebo continued until January 2006. A total of 2457 children had not walked at the time of entry into the trial and 1775 were followed through 36 mo. Mean age at first walking unassisted did not differ among groups and was 444 ± 81 d (mean ± SD) in the placebo group, 444 ± 81 d in the zinc group, 464 ± 85 d in the iron+folic acid group, and 446 ± 87 d in the iron+folic acid+zinc group. Results were similar after adjustment for age at enrollment, asset ownership, maternal literacy, and prior child deaths in the household and in children who consumed at least 60 tablets. Compared with placebo, iron+folic acid was associated with an adjusted mean delay of 28.0 d (95% CI: 11.3, 44.7) in time to walking among infants and the delay was more pronounced with mid-upper arm circumference (MUAC) < 9.5 cm [60.6 d, (95% CI: 28.5, 92.6)]. Risks and benefits of universal iron+folic acid supplementation of infants beyond improved hematologic status deserve further consideration. [ABSTRACT FROM AUTHOR]

A photo essay which documents the past and present of Nepal is presented.

Background: Neonatal hypothermia is associated with an increased mortality risk for 28 days. There are few community-based data on specific risk factors for neonatal hypothermia. Estimates of association between neonatal hypothermia in the community and risk factors are needed to guide the design of interventions to reduce exposure. Methods: A cohort of 23,240 babies in rural southern Nepal was visited at home by field workers who measured axillary temperatures for 28 days (213,316 temperature measurements). The cumulative incidence of hypothermia (defined as < 35.0°C based on an analysis of the hypothermia-mortality risk relationship) was examined for any association with infant characteristics, care practices and parental, household, socioeconomic and demographic factors. Estimates were adjusted for age and ambient temperature. Results: Ten percent of the babies (n = 2342) were observed with temperatures of < 35.0°C. Adjusted prevalence ratios (Adj PR) were increased among those who weighed < 2000 g [Adj PR = 4.32 (3.73, 5.00)] or < 1500 g [Adj PR = 11.63 (8.10, 16.70)] compared to those of normal weight (> 2500 g). Risk varied inversely along the entire weight spectrum: for every 100 g decrement hypothermia risk increased by 7.4%, 13.5% and 31.3%% for babies between 3000 g and 2500 g, 2500 g and 2000 g and < 2000 g, respectively. Preterm babies (< 34 weeks), females, those who had been first breastfed after 24 h and those with hypothermic mothers were at an increased risk. In the hot season the risk disparity between smaller and larger babies increased. Hypothermia was not associated with delayed bathing, hat wearing, room warming or skin-to-skin contact: they may have been practiced reactively and thereby obscured any potential benefit. Conclusions: In addition to season in which the babies were born, weight is an important risk factor for hypothermia. Smaller babies are at higher relative risk of hypothermia during the warm period and do not receive the protective seasonal benefit apparent among larger babies. The need for year-round thermal care, early breastfeeding and maternal thermal care should be emphasized. Further work is needed to quantify the benefits of other simple neonatal thermal care practices. [ABSTRACT FROM AUTHOR]