Bhutan has attained universal child immunization since 1991. Since then, immunization coverage is maintained at high level through routine immunization, periodic National Immunization Days, and mop up campaigns. Despite high immunization coverage, every year, significant numbers of clinically suspected measles cases were reported.
In-vitro susceptibility distributions to antibiotics can evolve over time because of emerging resistance determinants. This can affect clinical drug efficacy and interpretation of laboratory susceptibility tests. In January 2019, the Clinical Laboratory Standards Institute (CLSI) analyzed Neisseria gonorrhoeae (Ng) susceptibility parameters for ceftriaxone (CRO), cefixime (CFX) and azithromycin (AZI) to review interpretive criteria for laboratory tests.
Methods
GISP (Gonococcal Isolate Surveillance Project) is a United States national surveillance project at approximately 25 sentinel STD clinics, collecting about 5,000 yearly urethral isolates from symptomatic men. From 1987–2017, minimal inhibitory drug concentrations (MIC) of 164,506 isolates were determined by agar dilution using CLSI-recommended protocols. Susceptibility parameters were calculated with R software, and included mean MIC, 98.5% MIC indicating end of wild-type distribution, and percent isolates meeting 2019 CLSI susceptibility (S) criteria (CRO, CFX, AZI <= 0.25, 0.25, 1 μg/mL, respectively) or current GISP alert definitions (CRO, CFX, AZI ≥=0.125, 0.25, 2 μg/mL, respectively).
Results
Since 1987, only 5 isolates did not meet CRO S criteria. CRO alerts peaked at 1.05% in 1991. Mean MICs were highest in 2016 (0.013 μg/mL; 95% CI: 0.013–0.013), but compared to the mean MIC when GISP began (0.011 μg/mL; 95% CI: 0.010–0.011) the difference was less than a full drug dilution. Isolates not meeting CFX S criteria, 76 since 1987, were at a 0.17% peak in 1992, as were mean MICs. Isolates not meeting AZI S criteria were highest at 3.6% and 4.4% in 2016 and 2017, respectively, as were mean MICs.
Conclusion
Ng CRO and CFX in-vitro susceptibilities have not uniformly decreased since GISP began, while most indicators suggest declining AZI in-vitro susceptibility. CLSI reviewed these data in conjunction with clinical, pharmacokinetic/-dynamic and other international susceptibility data and kept steady (CRO, CFX) or established new (AZI) 2019 laboratory testing susceptibility criteria.
Self-criticism focuses on what traits others may have that is missing in oneself. Bhutan’s cultural gender differences and gross national happiness measure uniquely define their population. This mixed-method study describes the social media-based self-criticism among Bhutanese university students and considered significant differences according to gender, and, country of study. A total of 352 students responded. Descriptive statistics, t-test, and thematic analysis were done. There is a moderate level of social media-based self-criticism among Bhutanese university students in Thailand and Bhutan. There are also significant differences in terms of gender and country of study. Written narratives were coded into positive and negative comparatives versus neutral comparative, which also served as a guide in formulating the interview questions for 6 key informants, recruited from the respondents. Digital freedom and self-enhancement surfaced as the themes of the study. The study concludes the Bhutanese university students are responsive to the increasing influence of social media. Gender and studying in a country with more access to social media determine their propensity towards social media-based self-criticism. Social media-based self-criticism after graduation, gender differences, and inclusion of more variables are recommended for further studies.
Abstract Background Alcohol use has impacts on several dimensions of health, including physical health and mental health, particularly in college-age populations. Therefore, this study aimed to estimate the prevalence and to determine factors associated with alcohol use behaviors among college students in Bhutan. Methods A cross-sectional design was applied to collect data from the participants. A simple random method was used to select the participants from the lists of students who were attending the four selected colleges in Bhutan in the academic year of 2019. A questionnaire was developed, and validity and reliability were verified before use. Descriptive statistics were applied to describe the general characteristics of participants, while logistic regression was used to detect the associations between variables at the significance level of α = 0.05. Results A total of 432 college students were recruited into the study, of whom 62.0% were females. The average age was 20.0 years, 40.7% were the third-year students, and 79.9% lived in college dormitories. The prevalence of current drinking was 51.6% and that of binge drinking was 19.4%. After controlling for all potential confounder factors, three variables were found to be associated with current drinking: students who had low income were more likely to be current drinkers than those who had high income (AOR = 2.59, 95% CI = 1.29–5.21); students who did not use tobacco were more likely to be current drinkers than those students who used tobacco (AOR = 6.99, 95% CI = 2.90–16.81); and students who had close friends who did not use alcohol were more likely to be current drinkers than those who had close friends who used alcohol (AOR = 5.14, 95% CI = 3.04–8.69). Four factors were found to be associated with binge drinking after controlling for all possible confounder factors: students who had high income were more likely to be binge drinkers than those who had low income (AOR = 3.03, 95% CI = 1.72–5.31); students who used tobacco were more likely to be binge drinkers than those students who did not use tobacco (AOR = 2.28, 95% CI = 1.35–3.87); students whose parents used alcohol were more likely to be binge drinkers than those students whose parents did not use alcohol (AOR = 1.75, 95% CI = 1.02–3.01); and students whose close friends used alcohol were more likely to be binge drinkers than those who had close friends who did not use alcohol (AOR = 2.26, 95% CI = 1.05–4.87). Conclusions There is a high prevalence in alcohol use among the college students in Bhutan. Effective health promotion programs should be implemented by focusing on reducing the alcohol consumption among college students.
Abstract Background There are few reports on the nutritional status of Bhutanese children. The objective of this paper is to summarize results from the 2008 National Nutrition Survey and to describe progress achieved during the last two decades. Methods A cross-sectional survey of 2376 children aged 6 to 59 months was conducted during November-December 2008 to provide national and regional estimates. A multi-stage cluster sampling method was applied and 40 gewogs/thromdes were selected from each region (Western, Central, Eastern). Guidelines on how to measure length/height and weight followed WHO standardized procedures. Data were analysed for consistency and validation using the software WHO Anthro and the WHO SPSS macro. Underweight, stunting, overweight, wasting and thinness were defined based on the WHO Child Growth Standards. Data from 1986-88 and 1999 national surveys were reanalysed using the WHO standards to describe trends in nutritional status. Results Nationally, 34.9% Bhutanese preschool children are stunted and 10.4% are underweight. Wasting is 4.7%, with severe wasting close to 2% in rural areas, while overweight affects 4.4% of preschool children. While underweight rates are similar across regions, wasting is substantially more prevalent in the Western region and stunting in the Eastern region. Stunting shows a steep rise during the first two years of life, as high as 40%, and levels off thereafter, while wasting is greatest among children aged 6-24 months and subsequently decreases. The prevalence of stunting fell from 60.9% in 1986-88 to 34.9% in 2008, and underweight declined from 34.0% to 10.4% during same period. The percentage of wasted children dropped from 5.2% in 1986-88 to 2.5% in 1999 but then increased to 4.7% in 2008. Conclusions There have been major improvements in the nutritional status of Bhutanese children over the past two decades, however, linear growth retardation remains a significant concern. Early identification of growth faltering is essential for improving the effectiveness of public health programs to prevent stunting. Similarly, wasting rates indicate the need for a system to identify children with severe malnutrition in the isolated communities so that they can receive appropriate care.
During September-November 2016, a number of measles cases were reported from Trashigang District, Bhutan. The outbreak was investigated to determine epidemiological characteristics and risk factors, and recommend control measures. Hospital records of measles cases were reviewed. An active case finding was conducted in the affected communities and schools. Vaccination records were also reviewed. A case-control study was conducted to determine risk factors for measles infection. Tests for measles and rubella immunoglobulin M (IgM) antibodies, viral identification in throat swabs by polymerase chain reaction, and viral genotyping were performed. Total 62 suspected cases were identified, with no reported deaths. The first case developed symptoms on 15 Sep 2016 and 72.2% of the cases occurred in October 2016. The majority (85.0%) were 14 years old and younger (median 8.2 years, interquartile range 6.5-12.0). Cases were from Sakteng (87.1%) and Merak (12.9%) Subdistricts, the latter being a common place where nomads lived. Among 40 cases tested for measles IgM and viral identification, 33 (82.5%) were found to have measles IgM antibodies. All positive samples were genotyped and 11 (33%) were identified as D8 strains which circulated in India during 2016. The measles vaccine efficacy was 82.0%. Significant risk factors were having previous contact with a measles case (OR = 8.46, 95% CI = 2.08-34.41) and not receiving measles vaccination (OR = 6.61, 95% CI = 2.60-16.82). Immunization for outbreak response, case-based investigation and supplementary immunization activities were recommended.
Purpose To estimate the nationwide prevalence of visual impairment and associated refractive error in school children in Bhutan. Methods The sample of this prospective cross-sectional national survey comprised of randomly selected classes in levels IV-IX (age 10 to 15 years) from schools throughout Bhutan. The examination included measurement of visual acuity (VA), evaluation of ocular motility, refraction under cycloplegia, examination of the external eye, media and fundus. The principal cause of impairment was determined for eyes with uncorrected VA ≤6/12. The main outcome measures were distance VA and cycloplegic refractive error. Results With a sampling frame of 1967 class-based clusters from 190 schools, 160 classes in 103 schools were randomly selected; 4985 (98.5%) of 5060 enumerated children were examined. The prevalence of uncorrected, presenting, and best-corrected visual impairment (VA≤6/12) in the better eye was 14.5%, 12.8%, and 0.34%, respectively. Refractive error was the principal cause (94.2%) of impaired vision and 88% of children who could achieve VA ≥6/9 with best correction were without necessary spectacles. The prevalence of myopia (≤ -0.5 D) was 6.64% and was associated with female gender (P = 0.004), urban schooling (P = 0.002), and greater parental education (P<0.001). The prevalence of hyperopia (≥ +2.0 D) was 2.17% and was significantly associated with lower class-level (P = 0.033), and female gender (P = 0.025). The overall prevalence of astigmatism (≥ 0.75 D) was 9.75%. Conclusions Reduced vision because of uncorrected refractive error is a public health problem among school-age children in Bhutan. Effective school eye health strategies are needed to eliminate this easily treatable cause of visual impairment.
There is an increasing trend of non-communicable diseases in Bhutan including Diabetes Mellitus (DM). To address this problem, a National Diabetes Control Programme was launched in 1996. There is anecdotal evidence that many patients do not visit the DM clinics regularly, but owing to lack of cohort monitoring, the magnitude of such attrition from care is unknown. Knowledge of the extent of this problem will provide a realistic assessment of the situation on the ground and would be helpful to initiate corrective actions. In this first country-wide audit, we thus aimed to determine among type 2 DM patients registered for care the i) pre-treatment attrition ii) one-year programme outcomes including retention in care, died and Lost-to-follow-up (LTFU, defined as not having visited the clinic at least once within a year of registration) iii) factors associated with attrition from care (death + LTFU) and iv) quality of follow-up care, measured by adherence to recommended patient-monitoring protocols including glycaemic control.A retrospective cohort study involving a review of records routinely maintained under the National Diabetes Control Programme. All type 2 DM patients registered between 1st January and 31st December 2012 in 18 district hospitals of Bhutan were included. Glycaemic control was defined as glycosylated haemoglobin of <7% or [Fasting Blood Sugar of <130 mg/dl and, Post-prandial Blood Sugar of <180 mg/dl].Of 350 registered DM patients (52% female, median age 55 years), 63(18%) were LTFU before treatment initiation (pre-treatment attrition). Of the remaining 287 individuals who started treatment, 226(79%) were retained in care while 61(21%) either died or were LTFU. Glycaemic control was achieved in 85(38%) patients retained in care. Between 7 and 98% of monitoring parameters had missing data.Nearly one-third of DM patients were LTFU and there were short comings in monitoring. Qualitative research is urgently needed to find out the reasons for high attrition. Given the high political commitment by the Royal Government of Bhutan, the findings provide ample grounds for instituting corrective measures and propelling DM care further. It is time to do better!
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