Anup Ghimire

Tobacco use and associated factors among adolescent students in Dharan, Eastern Nepal: a cross-sectional questionnaire survey

Introduction The tobacco use among the youth, in both smoking and smokeless forms, is quite high in the South East Asian region. Tobacco use is a major proven risk factor and contributes substantially to the rising epidemic of non-communicable diseases. Objectives To estimate the prevalence of tobacco use and determine associated factors among adolescent students of Dharan municipality. Design Cross-sectional study. Setting Secondary and higher secondary schools of Dharan municipality in Sunsari district of Nepal. Participants Students in middle (14–15 years) and late adolescence (16–19 years) from grades 9, 10, 11 and 12 were included. Primary outcome measure Ever tobacco use which was defined as one who had not used any form of tobacco in the past 1 month but had tried in the past. Methodology Self-administered questionnaire adapted from Global Youth Tobacco Survey was used to assess tobacco use among the representative sample of 1312 adolescent students selected by stratified random sampling from July 2011 to July 2012. Results Out of 1454 students, 1312 students completed the questionnaires with a response rate of 90.23%. Prevalence of ever use of any tobacco product was 19.7% (95% CI 17.7 to 21.6). More than half of the tobacco users (51.9%) consumed tobacco in public places whereas almost a third (75.6%) of the consumers purchased tobacco from shops. Multivariate analysis showed that tobacco use was associated with late adolescence (OR: 1.64; 95% CI 1.17 to 2.28), male gender (OR: 12.20; 95% CI 7.78 to 19.14), type of school (OR=1.72; 95% CI 1.01 to 2.94), Janajati ethnicity (OR: 2.05; 95% CI 1.39 to 3.01) and receiving pocket money ≥Nepalese rupees 500/month (OR: 1.45; 95% CI 1.04 to 2.03). Conclusions Tobacco-focused interventions are required for school/college going students to promote cessation among users and prevent initiation, focussing on late adolescence, male gender, government schools, Janajati ethnicity and higher amount of pocket money.

Use of Molecular Diagnostic Tools for the Identification of Species Responsible for Snakebite in Nepal: A Pilot Study.

Snakebite is an important medical emergency in rural Nepal. Correct identification of the biting species is crucial for clinicians to choose appropriate treatment and anticipate complications. This is particularly important for neurotoxic envenoming which, depending on the snake species involved, may not respond to available antivenoms. Adequate species identification tools are lacking. This study used a combination of morphological and molecular approaches (PCR-aided DNA sequencing from swabs of bite sites) to determine the contribution of venomous and non-venomous species to the snakebite burden in southern Nepal. Out of 749 patients admitted with a history of snakebite to one of three study centres, the biting species could be identified in 194 (25.9%). Out of these, 87 had been bitten by a venomous snake, most commonly the Indian spectacled cobra (Naja naja; n = 42) and the common krait (Bungarus caeruleus; n = 22). When both morphological identification and PCR/sequencing results were available, a 100% agreement was noted. The probability of a positive PCR result was significantly lower among patients who had used inadequate “first aid” measures (e.g. tourniquets or local application of remedies). This study is the first to report the use of forensic genetics methods for snake species identification in a prospective clinical study. If high diagnostic accuracy is confirmed in larger cohorts, this method will be a very useful reference diagnostic tool for epidemiological investigations and clinical studies.

Dose of antivenom for the treatment of snakebite with neurotoxic envenoming: Evidence from a randomised controlled trial in Nepal

Background Currently, there is inadequate evidence on which to base clinical management of neurotoxic snakebite envenoming, especially in the choice of initial antivenom dosage. This randomised controlled trial compared the effectiveness and safety of high versus low initial antivenom dosage in victims of neurotoxic envenoming. Methodology/ Principal findings This was a balanced, randomised, double-blind trial that was conducted in three health care centers located in the Terai plains of Nepal. Participants received either low (two vials) or high (10 vials) initial dosage of Indian polyvalent antivenom. The primary composite outcome consisted of death, the need for assisted ventilation and worsening/recurrence of neurotoxicity. Hourly evaluations followed antivenom treatment. Between April 2011 and October 2012, 157 snakebite victims were enrolled, of which 154 were analysed (76 in the low and 78 in the high initial dose group). Sixty-seven (43·5%) participants met the primary outcome definition. The proportions were similar in the low (37 or 48.7%) vs. high (30 or 38.5%) initial dose group (difference = 10·2%, 95%CI [-6·7 to 27·1], p = 0·264). The mean number of vials used was similar between treatment groups. Overall, patients bitten by kraits did worse than those bitten by cobras. The occurrence of treatment-related adverse events did not differ among treatment groups. A total of 19 serious adverse events occurred, including seven attributed to antivenom. Conclusions This first robust trial investigating antivenom dosage for neurotoxic snakebite envenoming shows that the antivenom currently used in Nepal performs poorly. Although the high initial dose regimen is not more effective than the low initial dose, it offers the practical advantage of being a single dose, while not incurring higher consumption or enhanced risk of adverse reaction. The development of new and more effective antivenoms that better target the species responsible for bites in the region will help improve future patients’ outcomes. Trial registration The study was registered on clinicaltrials.gov (NCT01284855) (GJ 5/1)

CARDIOVASCULAR RISK REDUCTION COMMUNITY BASED APPROACH

Background: Due to lack of resources, treatment options for cardiovascular disease is limited in Nepal. A community based volunteer program may help early detection and management of cardiovascular risk factors leading to reduction in cardiovascular disease burden. Methods: A network of primary

Tobacco Use during Pregnancy and Its Associated Factors in a Mountain District of Eastern Nepal: A Cross-Sectional Questionnaire Survey

Background Tobacco using among women is more prevalent in Nepal as compared to other South-East Asian countries. The effect of its use is seen not only on the pregnant women, but also health of the growing fetus is compromised. Currently, little is known about the tobacco use among women especially during pregnancy in Nepal. This study explored the tobacco use prevalence and its associated factors during pregnancy. Materials and methods A cross-sectional study was conducted in Sankhuwasabha, a mountain district of eastern Nepal. Representative sample of 436 women of reproductive age group with infant were selected by stratified simple random sampling. Data were collected by face-to-face interviews of selected participants. Data were analyzed with SPSS version 16.0. Binary logistic regression was used to analyze the relationship among variables. Results The study revealed that the prevalence of tobacco use during pregnancy was 17.2%. Only one fifth of the research participants were asked to quit tobacco by health workers during last pregnancy. Multivariable analyses revealed that illiteracy (AOR: 2.31, CI: 1.18–4.52), more than two parity (AOR: 2.45, CI: 1.19–5.07), alcohol use during last pregnancy (AOR: 3.99, CI: 1.65–9.68), and having tobacco user within family (AOR: 2.05, CI: 1.11–3.78) are more likely to use tobacco during pregnancy. Conclusion Tobacco use during pregnancy was widely prevalent. Tobacco-focused interventions are required for antenatal women to promote cessation among user and prevent initiation with focus on overcoming problems like illiteracy, high parity, alcohol use, and having other tobacco user family members in family.