Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Knowledge and practice of Nepalese doctors on reutilization of medical/surgical tools from developed nations: a national level online cross-sectional survey

Background:
A manifold cause of global disparity in medical and surgical care exists, among which lack of access to proper biomedical equipment including surgical tools are a recurrent theme. Use and reuse of such donated tools are common in low resource settings including countries like Nepal; however, there is a lack of adequate data and less has been explored. Through this nationwide study, we aimed to discover the knowledge of donated medical and surgical devices and the practice of reusing single-use equipment by Nepalese medical practitioners and surgeons.

Methods:
An online, questionnaire-based cross-sectional study was conducted using SurveyMonkey from October 2020 through January 2021. The link was sent to target respondents via email and social media and responses were recorded. Data processing and analysis were done using the same platform.

Results:
Among 466 respondents, 349 completed the survey. Around 81.5% recorded that their institute has never received medical devices or donations in the past, while 18.34% believed they had received such commodities. Most of the donations were received from countries like the United States, China, Japan, and India. Around 24% of the respondents reused the tools meant for single-use and only 5% communicated with the donors. Commodities like laparoscopic sets, sutures, dialysis machines, magnetic resonance imaging machines, surgical retractors, face masks, sanitizers, personal protective equipment, endoscopy apparatus, etc., were received. The majority of them were concerned about national guidelines regarding donating reusable tools which might not be acceptable through custom rules of the country, although the facilitation of functional yet unused tools is always welcome in the underserved regions of Nepal.

Conclusion:
Nepalese medical professionals had adequate knowledge about the donated medical devices and only a few of them had practiced reusing single-use equipment. Mutual cooperation between donors and recipients is one of the most important aspects of safe medical/surgical tools delivery.

Evaluation of an Artificial Intelligence System for Retinopathy of Prematurity Screening in Nepal and Mongolia

Objective
The purpose of this study is to evaluate the performance of a deep learning algorithm for retinopathy of prematurity (ROP) screening in Nepal and Mongolia.

Design
This was a retrospective analysis of prospectively collected clinical data.

Subjects
Clinical information and fundus images were obtained from infants in two ROP screening programs in Nepal and Mongolia.

Methods
Fundus images were obtained using the Forus 3nethra neo in Nepal and RetCam® Portable in Mongolia. The overall severity of ROP was determined from the medical record using the International Classification of ROP (ICROP). The presence of plus disease was independently determined in each image using a reference standard diagnosis. The Imaging and Informatics for ROP (i-ROP) deep learning (DL) algorithm, which was trained on images from the RetCam® was used to classify plus disease, as well as assign a vascular severity score (VSS) from 1-9.

Main outcome measures
The main outcome measures were area under the receiver operating characteristic (AUC-ROC) and area under the precision recall curve (AUC-PR) for the presence of plus disease or type 1 ROP, and association between VSS and ICROP disease category.

Results
The prevalence of type 1 ROP was found to be higher in Mongolia (14.0%) than in Nepal (2.2%, p < 0.001) in these data sets. In Mongolia (Retcam images), the AUC-ROC for exam-level plus disease detection was 0.968 and AUC-PR was 0.823. In Nepal (Forus images), the AUC-ROC for exam-level plus disease detection was 0.999 and AUC-PR was 0.993. The ROP vascular severity score was associated with ICROP classification in both datasets (p < 0.001). At the population level, the median [interquartile range] VSS was found to be higher in Mongolia (2.7 [1.3–5.4]) as compared to Nepal (1.9 [1.2–3.4], p < 0.001). Conclusions These data provide preliminary evidence of the effectiveness of the i-ROP DL algorithm for ROP screening in neonatal populations in Nepal and Mongolia, using multiple camera systems, and provide useful data for consideration in future clinical implementation of AI-based ROP screening in low- and middle-income countries.

Causes of perinatal mortality and associated maternal factors in a tertiary referral hospital of Gandaki province of Nepal: a cross-sectional study from a hospital-based surveillance

Background
Perinatal and neonatal death rates have decreased recently but it still poses a major challenge to the health system of Nepal. The study was conducted to explore the pattern and causes of perinatal deaths.

Methods
This was a descriptive cross-sectional study conducted from September 2020 to June 2021 using the data of perinatal mortality of three years from June 15, 2017, to June 14, 2020. The demographic parameters of the mother consisted of maternal age, place of residence, ethnicity, antenatal care, the number of antenatal visits, gravida, gestational weeks, and the mode of delivery. The causes of death were categorized into fetal and early neonatal deaths. Fetal deaths were further classified as macerated stillbirth and fresh stillbirth. The attribution of the causes of deaths to fetal/neonatal and maternal conditions was done as per the guidelines of the WHO application of ICD-10 to deaths during the perinatal period.

Results
There were a total of 145 perinatal deaths from 144 mothers among which 92 (63.5%) were males. Ten mothers (6.9%) had not sought even single antenatal care, whereas 32 (22.9%) had visited for antenatal care one to three times. At least one cause of death was identified in 114 (78.6%) and remained unknown in 31(21.4%) cases. Among the 28 cases of macerated stillbirths, the cause of death was not identified in 14 (50%), whereas preterm labor was attributed to the cause of death in four (14.3%). In 53 of the fresh stillbirths, intrapartum hypoxia was identified as the cause of death in 20 (37.7%) cases, preterm labor in nine (17%), and was left unknown in 15 (28.3%) cases. Among the 64 early neonatal deaths, prematurity was attributed as the cause of death in 32 (50%) cases, birth asphyxia, and infections each in 11 (17.2%).

Conclusions
The perinatal mortality surveillance system identified the causes of death in most of the cases in our observation. Prematurity was identified as the commonest cause of early neonatal deaths and preterm labor was the commonest cause responsible for perinatal deaths overall. The perinatal deaths should be investigated to establish exact causes of deaths which can be useful to develop prevention strategies.

Evaluation of Quality Indicators of Breast Cancer Management at a Tertiary Cancer Center in Nepal

PURPOSE
Breast cancer is the second commonest cancer among female in Nepal. This is our first attempt to audit breast cancer management in our institute and compare with standard quality indicators (QIs) available.

METHODS
The retrospective study included 104 female patients with breast cancer who had taken treatment at Bhaktapur Cancer Hospital in 1 year. Participants were selected on the basis of convenience sampling. Of 33 QIs in breast cancer management according to European Society of Breast Cancer Specialists guidelines, 19 QIs were chosen relevant to our setup. These QIs were calculated for all patients and compared with the European Society of Breast Cancer Specialists standard target. Frequencies and percentages were calculated and presented in tables. Binomial 95% of the rates for QI adherence were also calculated for each QI.

RESULTS
One hundred four patients had a median age of 47.5 years (range 24-70 years). Applicable QIs were in the range of 5-15 with a mean of 9.66 per patient. Of 19 evaluable QIs, very high adherence rates were observed in six QIs, high adherence in three Qis, and low adherences in 10 QIs. High adherence rates were for QI 5 and QI 10a, which were 88.46% and 94.73%, respectively. The low compliance was for QI 1, QI 4a, QI 8, QI 9d, QI 10b, QI 11a, QI 11b, QI 13b, QI 13e, and 14b, which were 53.84%, 78.21%, 0%, 83.16%, 76.92%, 36.0%, 33.33%, 4.76%, 30.55%, and 10.81%, respectively.

CONCLUSION
There are several QIs that have low levels of adherence in our setting and suggest that there is significant room for improvement. We will be continuing auditing these QIs regularly to improve our quality of care.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal

Background
A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking.
Objective
This study attempted to assess Nepal’s health system gap on organization and delivery of cardiovascular disease prevention and management services.
Method
This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery.
Result
We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking.
Conclusion
Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverag

Needs Assessment of Leadership and Governance in Cardiovascular Health in Nepal

Background
Good governance and leadership are essential to improve healthy life expectancy particularly in low and middle-income countries (LMICs). This study aimed to epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases (CVD) in Nepal.
Objective
The objective of this study was to understand and document CVD programs and policy formulation processes and to identify the government capacity to engage stakeholders for planning and implementation purposes.
Method
A national-level task force was formed to coordinate and steer the overall need assessment process. A qualitative study design was adopted using “The Health System Assessment Approach”. Eighteen indicators under six topical areas in leadership and governance in cardiovascular health were assessed using desk review and key informant interviews.
Result
Voice and accountability exist in planning for health from the local level. The government has shown a strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination has not been effective. There are strong rules in place for regulatory quality, control of corruption, and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been minimum. There is a scarcity of cardiovascular disease-specific protocols.
Conclusion
Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research, and work towards developing CVD-specific guidelines, protocols, and capacity building.

Knowledge, awareness, attitudes and screening practices towards breast and cervical cancer among women in Nepal: a scoping review

Aim
Breast and cervical cancers have emerged as major global health challenges and disproportionately affect women in low- and middle-income countries, including Nepal. This scoping review aimed to map the knowledge, attitudes and screening practices for these cancers among Nepali women to improve cancer outcomes and reduce inequality.

Methods
Five electronic databases (CINAHL, Embase, Global Health, PsycINFO and PubMed), grey literature, and reference and citation lists were searched for articles published in English up to June 2021. Articles were screened against inclusion/exclusion criteria, and data from eligible studies were extracted. Results were summarised narratively.

Results
The search yielded 615 articles, 38 of which were included in this scoping review (27 cervical cancer, 10 breast cancer, 1 both cancers). Levels of knowledge regarding breast and cervical varied widely. The main knowledge gaps were misconceptions about symptoms and risk factors, and poor understanding of screening behaviours. Screening practices were mostly inadequate due to socio-cultural, geographical or financial barriers. Positive attitudes towards cervical screening were associated with higher education and increased knowledge of screening modalities. Higher levels of knowledge, (health) literacy and participation in awareness campaigns facilitated breast cancer screening.

Conclusion
Knowledge and screening practices for breast and cervical cancer among Nepali women were poor and highlight the need for awareness and education programmes. Future research should explore community health worker-led awareness and screening interventions for cervical cancer, and programmes to increase the practice of breast self-examination and clinical breast examinations to support early diagnosis of breast cancer.

Building Capacity and Infrastructure at Hospitals Implementing Minimally Invasive Tissue Sampling: Experience and Lessons Learned From Nepal, Rwanda, and Tanzania

Background
Minimally invasive tissue sampling (MITS) is a useful tool to determine cause of death in low- and middle-income countries (LMICs). In 2019 the MITS Surveillance Alliance supported the implementation of small-scale postmortem studies using MITS in several LMICs.

Methods
In this article we describe the preparations, challenges, and lessons learned as part of implementing MITS across 4 study sites in 3 countries: Nepal, Rwanda, and Tanzania. We describe the process for building capacity to conduct MITS, which consisted of training in MITS sample collection, individual site assessment to determine readiness and gaps prior to implementation, site visits as sites began implementation of MITS, and feedback based on remote evaluation of histology slides via an online portal.

Results
The 4 study sites each conducted 100 MITS, for a total of 400. All 4 sites lacked sufficient infrastructure and facilities to conduct MITS, and upgrades were required. Common challenges faced by sites included that clinical autopsies were neither routinely conducted nor widely accepted. Limited clinical records made cause of death determination more difficult. Lessons learned included the importance of sensitization of the community and medical staff to MITS to enhance understanding and increase consent.

Conclusions
The study sites accomplished MITS and utilized the available support systems to overcome the challenges. The quality of the procedures was satisfactory and was facilitated through the organized capacity-building programs