Prakash Ghimire

Identification of all dengue serotypes in Nepal.

To the Editor: Nepal is situated on the southern slopes of the Himalayas, surrounded by India on 3 sides and China to the north. Nepal’s altitude ranges from 8,848 m in the Himalayas to 90 m in the Terai, the southern, low, flatland bordering India. Nepal is a disease-endemic area for many vector-borne diseases, including malaria, kala-azar, Japanese encephalitis, and lymphatic filariasis. Because of the porous border between Nepal and India, social, cultural, and economic activities in cross-border areas are common. Dengue is an emerging disease in Nepal; presumably transmission is moving north from India into the Terai (1–5). The first report of dengue virus isolation or RNA (serotype 2 with nucleotide homology closest to a dengue virus type 2 isolate from India) was in 2008 involving a Japanese patient returning from Nepal in October 2004 (5). Entomologic investigations from the 1980s showed Aedes albopictus in the Terai plains, but Ae. aegypti has not been previously reported. After Indian outbreaks now known to include all 4 dengue serotypes (6), a team from the Epidemiology and Disease Control Division, Kathmandu, investigated suspected cases of dengue fever during September–October 2006 in Banke, the district bordering Uttar Pradesh, India. The team collected blood samples from persons in Banke and, subsequently, from persons in a number of other districts and sent them to the National Public Health Laboratory in Kathmandu or the Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand for analysis with ELISA, reverse transcription–PCR, (RT-PCR), or both. Case definitions for dengue fever were adopted based on World Health Organization guidelines (7). Blood samples were obtained from patients with an acute febrile illness of 2–7 days’ duration and with >2 of the following manifestations: headache, retro-orbital pain, muscular or joint pain, and rash. If laboratory tests were positive, cases were confirmed. Results were confirmed by ELISA performed at the Armed Forces Research Institute of Medical Sciences as previously described (8). Positive results were immunoglobulin (Ig) M >40 units or IgG >100 units. RT-PCR was performed by extracting RNA from 140 μL of each serum sample using QIAGEN Viral RNA Extraction Kit per manufacturer’s instructions (QIAGEN, Germantown, MD, USA). RT-PCR and nested PCR were conducted according to the Lanciotti protocol (9) with the following modifications. Reverse transcriptase from avian myeloblastosis virus (Promega, Madison, WI, USA) was used in the first round RT-PCR. The concentrations of the primers used in the RT-PCR and nested reactions were reduced from 50 pmol to 12.5 pmol per reaction, and the number of nested PCR amplification cycles was increased to 25. Serum specimens were obtained from 70 suspected case-patients from 16 districts from October 13 through December 3, 2006; 25 confirmed cases (13 by ELISA, 10 by RT-PCR, and 2 by both tests) came from 9 districts (Table). The average age was 29 years (range 5–65 years); 80% of the case-patients were men. Three patients had a history of travel to India, but clusters of dengue fever cases reported in October (Banke and Dang districts) indicated local transmission was occurring among patients with no travel history. The Terai districts accounted for 80% of cases. Entomologic collections done indoors and outside at 5 different sites reporting suspected cases identified Ae. albopictus and Ae. aegypti in all 5 districts. Table Dengue laboratory test results, National Public Health Laboratory, Nepal, and AFRIMS, Bangkok, 2006* These clinical and laboratory test results confirmed the presence of all 4 dengue serotypes. Notably, patients from the Dang district had no travel history outside the Dang valley. Because Aedes spp. have been identified in Dang, the data strongly suggest the existence of an endemic cycle of dengue. Underreporting is expected in the absence of diagnostic facilities at the field level. It is unclear whether the predominance of male patients is indicative of greater outdoor as opposed to indoor transmission. Of note, Ae. albopictus has been found in the country since the 1980s; in this study, we found Ae. aegypti in Nepal. Men typically wear short-sleeved clothes due to hot and humid conditions and, therefore, are frequently exposed to mosquito bites. However, men may also access the healthcare system more frequently. The ages of case-patients point to a relative lack of dengue immunity among the older population, and this finding is consistent with a new introduction of dengue. Because dengue hemorrhagic fever appears when >1 serotype becomes endemic to an area (10), the presence of all 4 serotypes portends the emergence of more severe dengue disease in Nepal.

Dengue Virus and Japanese Encephalitis Virus Epidemiological Shifts in Nepal: A Case of Opposing Trends

We report on the changing epidemiology of two important flaviviruses in Nepal: Japanese encephalitis (JE) and dengue viruses. Morbidity and mortality in Nepal is in the thousands since JE was introduced in 1978. Nepal launched an extensive laboratory-based JE surveillance in 2004. Nepal experienced a remarkable reduction in disease burden after mass immunizations from 2005 to 2010, when 2,040 JE infections and 205 JE-related deaths were confirmed. With its emergence in 2006, dengue has become a significant challenge in the country, highlighted by a sudden outbreak in 2010 that resulted in 359 confirmed dengue infections. Currently, both viruses cocirculate in Nepal. Here, we document the remarkable expansion of dengue in Nepal, which urgently requires national surveillance to refine the burden and make recommendations regarding control and prevention programs. We believe that the use of existing JE surveillance network for integrated dengue surveillance may represent the most appropriate alternative.

Seroprevalence of human immunodeficiency virus in Nepalese blood donors: A study from three regional blood transfusion services

Background and Objective: The likelihood of human immunodeficiency virus (HIV) infection occurring in recipients of HIV seropositive blood is close to 100%. Transmission during window period is still possible even each unit of blood is tested for anti-HIV 1 and 2 antibodies. The possibility of window period transmission would be minimized if blood is collected from low risk targeted general public. A continuous surveillance data might prove valuable for concerned authorities to assess their service and plan for further improvements in transfusion safety. Our aim was to determine the seroprevalence of HIV in regional blood transfusion services located at three developmental regions of Nepal and compare the results. Materials and Methods: A total of 16,557 blood donors were screened for anti-HIV 1 and 2 antibodies in three blood transfusion services viz. 5,351 donors in Morang, 5,211 in Banke, 5,995 in Kaski by using rapid anti HIV 1 and 2 Test. The statistical significance of difference in seroprevalence was tested by Fisher’s Exact Test using the statistical software ‘Winpepi ver 3.8’. Results: The overall seroprevalence of HIV among blood donors in the regional blood transfusion services was 0.054% (9/16557) and 100% seropositivity was among male donors. The individual seroprevalence in Morang was 0.019%, in Banke was 0.095% and in Kaski was 0.05%. The HIV seroprevalence was not significantly different in regional blood transfusion services of Nepal (Fisher Exact Test, P = 0.2096). Conclusion: The seroprevalence in the regional blood transfusion service of Nepal was quite low and the seroprevalence rate was not significantly different.

HBsAg serosurveillance among Nepalese blood donors

Context: Hepatitis B virus (HBV) is highly infectious and can be transmitted covertly by percutaneous routes and overtly by blood transfusion. Earlier studies among Nepalese blood donors have shown a high seroprevalence of HBV. Regarding this problem Blood Transfusion Service in Nepal has focused seriously for improving its service by various motivation and education programs. Aims: The study was aimed to reveal the seroprevalence of HBV among different category of blood donors, in relation to their sex and age. Settings and Design: Descriptive cross-sectional Study. Materials and Methods: A total of 33,255 blood samples were screened from donors using enzyme-linked immunosorbent assay kits from December 1, 2006 to September 1, 2007 in Central Blood Transfusion Service, Nepal Red Cross Society, Exhibition Road, Kathmandu. Statistical Analysis: Chi-square test was used for significance testing by using the software SPSS ver. 11.5. Results: The seroprevalence of HBsAg among total blood donors was 0.53% (95% confidence interval [CI] = 0.46-0.62%). Significantly, higher seroprevalence was observed among male donors than in females (0.58% vs. 0.18%, respectively) ( P 0.05). The hepatitis C virus coinfection rate among HBV-infected donors was 1.67%. Conclusions: On the basis of this study, we concluded that the seroprevalence of HBV among Nepalese blood donors in Kathmandu Valley, is decreasing compared to recent past years and is relatively lower than as described for most of the major cities in South Asia. However, similar seroprevalence rate among first time and repeat donors suggests that further improvements are essential.

Seroprevalence of HBV and HCV in blood donors: A study from regional blood transfusion services of Nepal

Background and Objective: Hepatitis B and hepatitis C are significant health problems that might involve the late sequel of liver cirrhosis and hepatocellular carcinoma. A high prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) in blood donors poses an increased risk of window period transmission through blood transfusion. The present study aimed to know the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) among blood donors in regional blood transfusion services of Nepal. Materials and Methods: This was a retrospective study conducted among blood donors in Banke (5,211), Morang (5,351), and Kaski (5,995) blood transfusion services. Serum samples were tested for hepatitis B surface antigen (HBsAg) and anti-HCV antibodies using rapid enzyme immunoassays. The donors information was collected via the donor record register through their respective blood transfusion services. The software “Winpepi ver 3.8” was used for statistical analysis. Results: The seroprevalence rate of HBV was highest in the Banke (1.2%) followed by Biratnagar (0.87%) and Kaski (0.35%) (P < 0.0001). The seroprevalence of HCV was highest in the Morang (0.26%) followed by Kaski (0.16%) and Banke (0.11%) (P > 0.05). The seroprevalence of HBV was significantly higher than HCV in all three blood transfusion services. The burden of HBV as well as HCV seems to be higher in male donors (P > 0.05). Conclusion: The study revealed that the seroprevalence of HBV was alarmingly higher in two of the three blood transfusion services. Implementation of community-based preventive measures and improved strategies for safe blood supply might prove useful to decrease the seroprevalence.

Intestinal parasitic infection among the HIV-infected patients in Nepal.

INTRODUCTION Intestinal parasitic infection has been a significant problem in HIV patients, worldwide. In this study, we aimed to measure the prevalence and identify the factors associated with intestinal parasitic infection in people infected with HIV and attending National Public Health Laboratory in Kathmandu, Nepal, for CD4 T-cell count. METHODOLOGY An analytical cross-sectional study in 745 HIV-infected people attending for CD4 T-cell count was conducted. RESULTS The prevalence of intestinal parasitic infection was 22.4% (95% CI 19.5 to 25.5). In univariate analysis, age, sex, longer time since diagnosis of HIV, CD4 T-cell count of <200/µL, diarrhoea, marital status, and being under tuberculosis (TB) treatment were significantly associated with increased odds of intestinal parasite infection. However, in the logistic regression model, only the CD4 T-cell count of <200/µL (adjusted OR=4.2, 95% CI 2.5 to 7.0), diarrhoea (adjusted OR=2.8, 95% CI 1.8 to 4.3) and being under TB treatment (adjusted OR=2.9, 95% CI 1.8 to 4.6) remained as significant predictors. On stratification, CD4 T-cell count of <200/ µL was independently associated with higher odds of protozoal as well as helminthes infection. The parasites Cryptosporidium and Cyclospora were observed only in participants with CD4 T-cell counts <200/µL. CONCLUSIONS Both protozoal and helminthic intestinal parasitic infections are common in HIV-infected people seeking care in healthcare facilities. The poor immune status as indicated by low CD4 T-cell count and TB may account for such a high risk of parasitic infection.

Co-infection rate of HIV, HBV and Syphilis among HCV seropositive identified blood donors in Kathmandu, Nepal

Background: HIV, HBV, Syphilis and HCV share common modes of transmission. Objective: The study was aimed to determine the co-infection rate of HIV, HBV and Syphilis among HCV seropositive identified blood donors. Methods: The study was conducted on blood samples screened as HCV seropositive at Nepal Red Cross Society, Central Blood Transfusion Service, Kathmandu, Nepal. HCV seropositive samples were further tested for HIV, HBV and Syphilis. Results: Eight co-infections were observed in 139 HCV seropositives with total co-infection rate of 5.75% (95% CI = 2.52-11.03). Conclusion: Co-infection of HIV, HBV and Syphilis with HCV is prevalent in the healthy looking blood donors of Kathmandu, Nepal.

Burden estimation of dengue at National Public Health Laboratory, Kathmandu

Abstract Objective To determine the burden of dengue in the patients visiting National Public Health Laboratory, Kathmandu. Methods A cross sectional study was carried out at National Public Health Laboratory, Kathmandu from May to December, 2013. Serum samples were collected from patients suspected of dengue virus infection and tested by ELISA. Results Among 266 patients suspected of dengue virus infection, 45 (16.9%) showed anti-dengue immunoglobulin M antibodies in serum. Males and economically active people were more infected and the maximum number of cases was during the month of October. Conclusions This study revealed that the proportion of dengue was more in Kathmandu, especially among the economically active males. So, the control measures should be initiated targeting these groups of people.

Epidemiology of Plasmodium vivax Malaria Infection in Nepal

Abstract. Malaria is endemic in the southern plain of Nepal which shares a porous border with India. More than 80% cases of malaria in Nepal are caused by Plasmodium vivax. The main objective of this study was to review the epidemiology of P. vivax malaria infections as recorded by the national malaria control program of Nepal between 1963 and 2016. National malaria data were retrieved from the National Malaria program in the Ministry of Health, Government of Nepal. The epidemiological trends and malariometric indicators were analyzed. Vivax malaria has predominated over falciparum malaria in the past 53 years, with P. vivax malaria comprising 70–95% of the annual malaria infections. In 1985, a malaria epidemic occurred with 42,321 cases (82% P. vivax and 17% Plasmodium falciparum). Nepal had experienced further outbreaks of malaria in 1991 and 2002. Plasmodium falciparum cases increased from 2005 to 2010 but since then declined. Analyzing the overall trend between 2002 (12,786 cases) until 2016 (1,009 cases) shows a case reduction by 92%. The proportion of imported malaria cases has increased from 18% of cases in 2001 to 50% in 2016. The current trends of malariometric indices indicate that Nepal is making a significant progress toward achieving the goal of malaria elimination by 2025. Most of the cases are caused by P. vivax with imported malaria comprising an increasing proportion of cases. The malaria control program in Nepal needs to counter importation of malaria at high risk areas with collaborative cross border malaria control activities.

Factors associated with high prevalence of pulmonary tuberculosis in HIV-infected people visiting for assessment of eligibility for highly active antiretroviral therapy in Kathmandu, Nepal

Background: Tuberculosis is the leading cause of deaths among HIV patients. In this study, we estimated the prevalence of pulmonary tuberculosis (PTB) and identified the factors/co-morbidities associated with active PTB in HIV-infected people visiting the national public health laboratory to assess their eligibility to receive highly active antiretroviral therapy. Methods: A cross-sectional study was conducted to measure the prevalence of pulmonary tuberculosis. Data on probable risk factors in patients with and without PTB were compared, calculating the odds ratio as a measure of association. Factors showing significant association in univariate analyses were included in a stepwise backward logistic regression model to adjust for confounding. Results: The prevalence of pulmonary tuberculosis was 32.4 % (95% confidence interval (CI) 30.25–34.56). In the univariate analysis, patients with PTB were more likely to be older, married, and have a longer duration since the diagnosis of HIV, diarrhoea, parasitic infection, lower CD4 T-cell counts, and lower CD4/CD8 ratio. However, the backward stepwise logistic regression revealed that only the CD4 T-cell count < 200/μL (AOR 11.69, 95% CI 6.23–21.94), CD4 T-cell count 200–350/μL (AOR 2.52, 95% CI 1.30–4.89), diarrhoea (AOR 2.77, 95% CI 1.78–4.31), parasitic infection (AOR 3.34, 95% CI 2.02–5.50) and ‘sex with partner’ as probable modes of transmission (AOR 0.44, 95% CI 0.20–0.93) were independently associated with pulmonary tuberculosis. Conclusion: A high prevalence of pulmonary tuberculosis was observed. Participants with tuberculosis were significantly more likely to have lower CD4 counts, diarrhoea, and parasitic infections. HIV treatment programmes should consider these factors for better outcomes.