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Background: Recently, extra-pulmonary tuberculosis (EPTB) has been increasingly reported in Bhutan, rising from 26% in 2001 to 39% in 2010. In 2016, almost half (49%) of all reported TB cases were classified as EPTB. Thus, this study was conducted to understand the epidemiology and identify risk factors contributing to increasing notification of EPTB in Bhutan., Methods: A case-control study was conducted by recruiting all 110 cases of nationally notified EPTB (Extrapulmonary bacteriologically confirmed/EPBC) as cases and 235 Pulmonary TB (Pulmonary bacteriologically confirmed/PBC) as controls. Data were collected on socio-demography, clinical and diagnostic, behavioral and lifestyle and environmental exposures using a structured questionnaire between April and September, 2018., Results: The median age of the cases was 25 years, ranged 9-79 years. Lymphatic TB was predominant (n = 78; 70.91%) followed by genitourinary TB (n = 4 (3.64%). The likelihood of EPTB decreased with increase in age (p = 0.023). The odds of EPTB in females was 1.65 times higher than the males (p = 0.038). Increase in Body Mass Index (adjusted odds ratio (AOR): 1.1; 95% confidence interval (CI): 1.052-1.200) and urban residency were (AOR 1.6; 95% CI 1.016-2.805) were found to have higher odds of developing EPTB., Conclusion: Females, urban residents, and those with higher BMI are at increased risk of developing EPTB. These at-risk groups can be used to target limited public health resources to control EPTB in Bhutan., Competing Interests: Conflict of interest The authors have none to declare., (Copyright © 2023 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Leishmaniases are a group of diseases under the category of neglected tropical diseases targeted for global elimination. However, they continue to pose major clinical and public health problems, especially among those living in poor socioeconomic conditions. Here, we summarize leishmaniasis elimination efforts in Bhutan. Between 1994 and 2022, Bhutan recorded 54 cases of leishmaniasis across 14 of its 20 districts. There are seven species of Phlebotomus and three species of Sergentomyia sand flies documented in the country. At a subnational level, all endemic districts recorded a visceral leishmaniasis annual incidence <1 per 10,000 population, meeting the regional elimination targets. Serological testing with ELISA and molecular testing with polymerase chain reaction were established at the Royal Center for Disease Control in 2022. A leishmaniasis prevention and management guideline was adopted in 2023 to aid clinicians in diagnosis and management. Active and passive case surveillance was integrated with the national infectious disease early warning and response system. Risk-based entomological surveillance and control have also been prioritized. Climate change may play a major role in rendering districts in the temperate zone favorable for vector proliferation. The country's medical university introduced a diploma course in medical entomology in 2023 to augment the human resources needed for vector surveillance efforts. However, leishmaniasis elimination lacks dedicated programmatic management amid competing priorities for resources against other infectious diseases. Leishmaniasis elimination requires a targeted and programmatic approach in Bhutan, including cross-border collaborative efforts with neighboring Indian states. Bhutan remains highly committed to achieving leishmaniasis elimination targets.

Background: The Thai Rural ENT foundation has been conducting ear camps in Bhutan for many years to address the shortage of ENT specialists in the kingdom where patients are examined and treated for various ear illnesses. However, there has been no study conducted to assess the outcomes of such camps. This is the first study of its kind to be carried out in Bhutan., Objective: To study the spectrum of ear cases seen during the mobile ear camp, the intervention done and treatment outcomes., Materials and Methods: The study enrolled patients with ear disorders who presented to the mobile ear camp at Monggar Regional Referral Hospital, Bhutan, from January 6, 2020, to January 8, 2020. The following data were recorded: demographic details, preoperative clinical symptoms and otoscopic findings, preoperative audiogram, treatment or surgery done, postoperative middle ear and mastoid infection, wound infection, graft condition, any complications, and postoperative audiogram of operated cases. Patients who underwent surgery were followed up at 1 day, 6 weeks, and 2 months postoperatively., Results: Two hundred ten patients presented with otologic conditions and 43 underwent surgeries. Otitis media was the commonest disease detected, and tympanoplasty was the commonest surgery performed. The tympanic membrane closure rate was 92.1%, and the rate of hearing improvement was 63.2%., Conclusion: The ear camp had beneficial effect and showed good results., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To report the first series of Seasonal Hyperacute Pan Uveitis (SHAPU) from Bhutan., Methods: We retrospectively analyzed the patients with clinically diagnosed SHAPU treated in the referral center in the last 5 years. Data included demographics (age, sex, laterality), region, time of presentation (year, season) and treatment received., Results: The series included 3 males and 2 females. The mean age was 16 years. Three patients had presented in autumn of 2021, and two in autumn of 2019. Four patients presented within 2 weeks of the onset of symptoms. All patients had either exposure or contact with white moths. All patients presented with unilateral sudden painless reduction in vision and low Intraocular pressure. Four patients required vitrectomy. The final visual acuity of 3 patients was >6/36, and one patient was 6/60., Conclusions and Importance: The time of presentation and early treatment intervention are crucial in achieving good visual prognosis in SHAPU.

Introduction: Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infections worldwide, particularly in young children. In Bhutan, respiratory disease continues to be among the top 10 diseases of morbidity for several years. This study aimed to estimate the prevalence of RSV among hospitalized patients with severe acute respiratory infection (SARI) in Bhutan., Method: Respiratory specimens were collected from SARI patients of all ages in 2016 and 2018 following influenza surveillance guidelines. Specimens were tested for influenza and RSV, human metapneumovirus, adenovirus, and human parainfluenza virus types 1, 2, and 3 using real-time reverse-transcription polymerase chain reaction assay. Descriptive statistics were used to analyze the result in STATA 16.1., Result: Of the 1339 SARI specimens tested, 34.8% were positive for at least one viral pathogen. RSV was detected in 18.5% of SARI cases, followed by influenza in 13.4% and other respiratory viruses in 3%. The median age of SARI cases was 3 (IQR: 0.8-21 years) years. RSV detection was higher among children aged 0-6 (Adj OR: 3.03; 95% CI: 1.7-5.39) and 7-23 months (Adj OR: 3.01; 95% CI: 1.77-5.12) compared with the children aged 5-15 years. RSV was also associated with breathing difficulty (Adj OR: 1.73; 95% CI: 1.17-2.56) and pre-existing lung disease, including asthma (Adj OR: 2.78; 95% CI: 0.99-7.8)., Conclusion: Respiratory viruses were detected in a substantial proportion of SARI hospitalizations in Bhutan., Competing Interests: All authors declared that they have no conflict of any financial interest to disclose., (© 2024 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

The World Health Organization (WHO) recommends the use of color-coded cardiovascular disease (CVD) risk charts for CVD management. This study evaluated the agreement between the laboratory and non-laboratory 10-year CVD risks based on 2019 WHO CVD risk-prediction charts. The agreement of CVD risk scores among 40- to 69-year-old Bhutanese population stratified by gender and age groups (<60 and ≥60 years) was determined via weighted kappa statistics. In the general population, there was substantial agreement between the two CVD risk score charts for all ages and <60 years but a moderate agreement for participants aged ≥60 years. In males, substantial agreement was observed in all ages and in <60 years and moderate agreement in ≥60 years. In females, both the predictions showed substantial agreement in all ages and <60, but a moderate agreement for ≥60 years. The non-laboratory-based risk charts can be used interchangeably with laboratory-based charts for predicting 10-year CVD risk in resource-constrained countries like Bhutan., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Bhutan successfully introduced multiple vaccines since the establishment of the Vaccine Preventable Disease Program in 1979. Surveillance and subsequent introduction of influenza vaccination became a public health priority for the Ministry of Health following the influenza A(H1N1)pdm09 pandemic. Sentinel surveillance for influenza in Bhutan began in 2008, and a study of severe acute respiratory infection was conducted in 2017, which found the highest influenza burden in children aged <5 years and adults ≥50 years. Following review of surveillance and burden of disease data, the National Technical Advisory Group presented recommendations to Bhutan's Ministry of Health which approved influenza vaccine introduction for all five high-risk groups in the country. Upon the official launch of the program in June 2018, the Vaccine Preventable Disease Program began planning, budgeting, and procurement processes with technical and financial support from the Partnership for Influenza Vaccine Introduction, the United States Centers for Disease Control and Prevention, the Bhutan Health Trust Fund, and the World Health Organization. Influenza vaccination for high-risk groups was integrated into Bhutan's routine immunization services in all health care facilities beginning in November 2019 and vaccinated all populations in 2020 in response to the COVID-19 pandemic. Coverage levels between 2019 and 2022 were highest in children aged 6-24 months (62.5%-96.9%) and lowest in pregnant women (47.7%-62.5%). Bhutan maintained high coverage levels despite the COVID-19 pandemic by continued provision of influenza vaccine services at health centers during lockdowns, conducting communication and sensitization efforts, and using catch-up campaigns. Bhutan's experience with introducing and scaling up the influenza vaccine program contributed to the country's capacity to rapidly deploy its COVID-19 vaccination program in 2021., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Many popular tourist attractions and trekking routes in Bhutan and Nepal are situated between 3000 and 6000 m in elevation. High-altitude emergencies are becoming more common and medical providers must be aware of the practical and medical issues in managing these disorders. We reflect on the challenges in providing high-altitude emergency medical services in Bhutan and Nepal., Competing Interests: Declaration of competing interest The authors have no disclosures to report., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting., Case Presentation: A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T 10 level. He had hyperaesthesia below T 8 , hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality., Conclusions: This case called for a serious evaluation of the country's efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases., (© 2023. National Institute of Parasitic Diseases.)

Background: The study aimed to evaluate trends in the prevalence and correlates of risk factors for non-communicable diseases (NCDs; low physical activity, insufficient fruit/vegetable intake, current tobacco use, problem alcohol use, diabetes, hypertension, increased total cholesterol, and obesity) in Bhutan., Methods: Three repeat cross-sectional Bhutan STEPS surveys ( N  = 9,281) in 2007, 2014, and 2019 were analyzed., Results: The proportion of people with 3-8 NCD risk factors significantly decreased from 62.8% in 2007 to 32.6% in 2019 ( p  < 0.001), and the mean number of NCD risk factors significantly decreased from 3.0 in 2007 to 2.1 in 2019 ( p  < 0.001). In linear regression analyses by study year, older age ( p  < 0.001) was positively associated with eight NCD risk factors across all study years. Furthermore, male subjects were negatively ( p  < 0.01) and positively ( p  < 0.001) associated with eight NCD risk factors, respectively. Higher education levels ( p  < 0.05) were positively associated with eight NCD risk factors in 2007 and negatively associated with eight NCD risk factors in 2019 ( p  < 0.05). Employment ( p  < 0.001) and urban residence ( p  < 0.001) were positively associated with eight risk factors for NCD in 2019, while urban residence ( p  < 0.001) was negatively associated with eight NCD risk factors in 2014., Conclusion: The prevalence of eight NCD risk factors decreased in Bhutan over the past 13 years. Inadequate fruit and vegetable intake, problem alcohol use, and hypertension increased, current tobacco use, low physical activity, obesity, diabetes, and elevated total cholesterol decreased from 2007 to 2019. Several factors associated for eight and each individual NCD risk factor were identified, which can help guide interventions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Pengpid and Peltzer.)

Diabetes has become a major cause of morbidity and mortality in South Asia. Using the data from the three STEPwise approach to Surveillance (STEPS) surveys conducted in Bangladesh, Bhutan, and Nepal during 2018-2019, this study tried to quantify the gaps in diabetes screening, awareness, treatment, and control in these three South Asian countries. Diabetes care cascade was constructed by decomposing the population with diabetes (diabetes prevalence) in each country into five mutually exclusive and exhaustive categories: (1) unscreened and undiagnosed, (2) screened but undiagnosed, (3) diagnosed but untreated, (4) treated but uncontrolled, (5) treated and controlled. In Bangladesh, Bhutan, and Nepal, among the participants with diabetes, 14.7%, 35.7%, and 4.9% of the participants were treated and controlled, suggesting that 85.3%, 64.3%, and 95.1% of the diabetic population had unmet need for care, respectively. Multivariable logistic regression models were used to explore factors associated with awareness of the diabetes diagnosis. Common influencing factors for awareness of the diabetes diagnosis for Bangladesh and Nepal were living in urban areas [Bangladesh-adjusted odd ratio (AOR):2.1; confidence interval (CI):1.2, 3.6, Nepal-AOR:6.2; CI:1.9, 19.9]., (© 2023. The Author(s).)

Purpose: To determine the prevalence and severity of diabetic retinopathy (DR) at first presentation among diabetic patients attending national vitreoretinal (VR) services in Bhutan STUDY DESIGN: Retrospective cross-sectional study METHODS: We included all diabetic patients in Bhutan who presented for retinal evaluation for the first time over a 3-year period (2013-2016). Data including demography, clinical details, diagnostic tests, and clinical staging of DR were analyzed., Results: A total of 843 diabetic patients, aged 57.2 ± 12.0 (range 18-86) years, were enrolled. The majority were male (452, 53.6%; cumulative frequency [cf] 391, 46.4%; P = .14) and from urban settings (570, 67.6%; cf 273; 32.4%) and did not have modern schooling (555, 65.8%). Hypertension was the most common systemic comorbidity (501, 59.4%). The prevalence of DR was 42.7%, with mild nonproliferative DR (NPDR) being the most common type (187, 51.9%), followed by moderate NPDR (88, 24.4%) and proliferative DR (45, 12.5%). In addition, 120 patients had clinically significant macular edema (CSME), with a prevalence of 14.2%. Best-corrected visual acuity (BCVA) of 6/60 or worse occurred in 231 eyes (13.7%), and 41 patients (4.86%) had BCVA of 6/60 or worse bilaterally due to DR/CSME. A logistic regression model indicated that the major determinant of DR was the duration of diabetes, the odds rising by 1.27× with each year of disease (P < .0001)., Conclusion: The prevalence of DR, including CSME, was high. Although a national DR screening program is established in Bhutan, there is a need to accelerate health education, community screening, and referral systems to reduce the prevalence of DR and CSME., (© 2023. Japanese Ophthalmological Society.)

Underdiagnosis and underreporting of scrub typhus has increasingly affected public health in Bhutan since its initial detection in 2008. Identifying scrub typhus risk factors would support early diagnosis and treatment for this nonspecific febrile disease, reducing the incidence of potentially fatal complications. We conducted a hospital-based, case‒control study during October‒December 2015 in 11 scrub typhus‒prone districts. We identified harvesting cardamom as the major risk factor (odds ratio 1,519; p<0.001); other factors were traditional housing, largely caused by an outside toilet location, as well as owning a goat and frequently sitting on grass. Harvesting vegetables, herding cattle in the forest, and female sex were protective. Age had a nonlinear effect; children and the elderly were more likely to seek treatment for clinical scrub typhus. This study has informed public health policies and awareness programs for healthcare workers through development of National Guidelines for Prevention, Treatment and Control of Scrub Typhus in Bhutan.

Epilepsy is an important cause of morbidity and mortality especially in low- and middle-income countries. People with epilepsy (PWE) face difficulties in access to healthcare, appropriate diagnostic tests and anti-seizure medications (ASM). Bhutan is one such country in the Himalayas that has reported doubling of the prevalence of epilepsy from 155.7 per 100,000 population in 2017 to 312.4 in 2021. The country has one centre for electroencephalography and magnetic resonance imaging for a population of 0.7 million and does not have any neurologists as of 2023. There are 16 ASMs registered in the country but only selected medications are available at the primary level hospitals (phenobarbital, phenytoin and diazepam). There are challenges in the availability of these medicines all time round the year in all levels of hospitals. Neurosurgical treatment options are limited by the lack of adequate pre-surgical evaluation facilities and lack of trained human resources. The majority of PWE have reported facing societal stigma with significant impact on the overall quality of life. It is important to screen for psychiatric comorbidities and provide psychological support wherever possible. There is a need for a comprehensive national guideline that will cater to the needs of PWE and their caregivers within the resources available in the country. A special focus on the institutional and human resource capacity development for the study and care of epilepsy is recommended., Competing Interests: Conflicts of interest The authors declare no conflicts of interests., (Copyright © 2023. Published by Elsevier B.V.)

Non-pharmacological measures, such as hand hygiene and face mask use, continue to play an important role in the fight against the COVID-19 pandemic. However, there is a paucity of studies on the adherence to these measures among students in Bhutan. Therefore, we aimed to investigate hand hygiene and face mask-wearing behaviours, as well as their associated factors, among the students of Mongar Higher Secondary School, Bhutan. We conducted a cross-sectional study amongst the students of Mongar Higher Secondary School in Bhutan. The students self-answered the questionnaire on web-based Google Forms. Multivariable logistic regression for good hand washing and face mask use was conducted in order to identify statistically significant socio-demographic covariates. The correlation between hand hygiene and mask use was investigated using Pearson’s correlation coefficient. A total of 533 students completed the survey questionnaire, 52.9% (282) of whom were female students. Facebook (44.3%, 236) and TV (35.5%, 189) were the two most popular sources of information on COVID-19 prevention and control. Good (scores of ≥80% of total scores) hand hygiene and face mask use were reported in 33.6% (179) and 22.1% (118) of students. In multivariable logistic regression, male students presented 79% (adjusted odds ratio [AOR] = 1.79, 95% confidence interval [CI] = 1.23−2.613) odds of engaging in good hand hygiene, compared to female students. Compared to grade 9, those in grade 10 were 60% (AOR = 0.4, 95% CI 0.158−0.998) less likely to engage in good hand hygiene. Boarding students presented 68% (AOR = 1.68, 95% CI 1.001, 2.813) higher odds of wearing a face mask compared to day students. There was a significant positive correlation between good hand hygiene and face mask use (r = 0.3671, p-value < 0.001). Good hand hygiene and face mask use were reported in less than one-third of the study participants. It is recommended to continue educating students on good hand hygiene and face mask use through popular information sources., Competing Interests: The authors declare no conflict of interest.

During the recent COVID-19 pandemic, risk communication and community engagement (RCCE) were instrumental in inducing behavior change in tandem with the evolving evidence and phases of the pandemic. Infodemic management also became one of the areas where much emphasis was laid in Bhutan's response to the COVID-19 pandemic along with other critical response strategies such as surveillance, contact tracing, quarantine, isolation, and testing. Over the past 3 years of the pandemic, much has been learnt about the significance and impact of RCCE. In this article, the authors will highlight some of the methods and practices that were implemented to manage public information and also share experiences with regard to RCCE over the course of Bhutan's response to the pandemic. Furthermore, it will also outline some of the media and risk communication mechanisms that were in place before Bhutan's response to the COVID-19 pandemic.

The digital divide proved a critical barrier to accessing information and healthcare during the COVID-19 pandemic and negatively impacted the Bhutanese refugee community. Moving beyond a technological model of the digital divide that highlights a lack of access to computers and the internet, we engaged the community to co-produce a dynamic approach that identifies the impact of socio-cultural and socio-environmental factors as well. Our paper reports on our community-academic research partnership and explores how the digital divide exacerbates health disparities in a midwestern Bhutanese refugee community. Combining the efforts of the community, anthropologists and social workers, this paper reports on the health disparities that confront the community as well as interventions designed to mitigate social inequities.

Background: Assessment of occupational exposures is an integral component of population-based studies investigating the epidemiology of occupational diseases. However, all the available methods for exposure assessment have been developed, tested and used in high-income countries. Except for a few studies examining pesticide exposures, there is limited research on whether these methods are appropriate for assessing exposure in LMICs. The aim of this study is to compare a task-specific algorithm-based method (OccIDEAS) to a job-specific matrix method (OAsJEM) in the assessment of asthmagen exposures among healthcare workers in a high-income country and a low- and middle- income country (LMIC) to determine an appropriate assessment method for use in LMICs for future research., Methods: Data were obtained from a national cross-sectional survey of occupational asthmagens exposure in Australia and a cross-sectional survey of occupational chemical exposure among Bhutanese healthcare workers. Exposure was assessed using OccIDEAS and the OAsJEM. Prevalence of exposure to asthmagens and inter-rater agreement were calculated., Results: In Australia, the prevalence was higher for a majority of agents when assessed by OccIDEAS than by the OAsJEM (13 versus 3). OccIDEAS identified exposures to a greater number of agents (16 versus 7). The agreement as indicated by κ (Cohen's Kappa coefficient) for six of the seven agents assessed was poor to fair (0.02 to 0.37). In Bhutan, the prevalence of exposure assessed by OccIDEAS was higher for four of the seven agents and κ was poor for all the four agents assessed (-0.06 to 0.13). The OAsJEM overestimated exposures to high-level disinfectants by assigning exposures to all participants from 10 (Bhutan) and 12 (Australia) ISCO-88 codes; whereas OccIDEAS assigned exposures to varying proportions of participants from these ISCO-codes., Conclusion: There was poor to fair agreement in the assessment of asthmagen exposure in healthcare workers between the two methods. The OAsJEM overestimated the prevalence of certain exposures. As compared to the OAsJEM, OccIDEAS appeared to be more appropriate for evaluating cross-country exposures to asthmagens in healthcare workers due to its inherent quality of assessing task-based determinants and its versatility in being adaptable for use in different countries with different exposure circumstances., (© 2022. The Author(s).)

Objectives: Older displaced persons often receive limited attention from aid organizations, policy-makers and service providers in countries of resettlement. The objective of this study is to identify the relationship between experiencing traumatic events and stressors prior to resettlement, current resettlement stressors, social support, and mental health of older Bhutanese with a refugee life experience., Method: Study participants were 190 older Bhutanese with a refugee life experience living in a metropolitan area in New England (US) and Ontario (Canada). We used structural equation modeling to determine the association between traumatic and stressful events in Bhutan and Nepal, current resettlement stressors, and symptoms of anxiety and depression, as measured by the GAD-7 and PHQ-9. We assessed the role of social support as an effect modifier in the relationship between these variables., Results: Surviving torture was associated with anxiety ( p =.006), and experiencing threats to physical wellbeing in Nepal was associated with both anxiety ( p =.003) and depression ( p =.002). The relationship between physical threats in Nepal and current mental health were partially mediated by resettlement stressors. Social support moderated the relationship between trauma, stress, and mental health., Conclusion: Both past traumas and current resettlement stressors contribute to the current psychosocial functioning of older Bhutanese with a refugee life experience. Based on our findings, social support is critical in promoting mental health in this population.

Cardiovascular disease is a leading cause of death in the Kingdom of Bhutan, and early detection of hypertension is critical for preventing cardiovascular disease. However, health-seeking behavior, including blood pressure measurement, is infrequently investigated in Bhutan. Therefore, this study investigated factors related to blood pressure measurement in Bhutan. We performed a secondary data analysis of a target population of 1,962 individuals using data from the "2014 Bhutan STEPS survey data"as a cross-sectional study. Approximately 26% of those with hypertension who were detected during the STEPS survey had never had their blood pressure measured. Previous blood pressure measurement was significantly associated with age and working status in men (self-employed [odds ratio (OR): 0.219, 95% CI: 0.133-0.361], non-working [OR: 0.114, 95% CI: 0.050-0.263], employee [OR: 1.000]). Previous blood pressure measurement was significantly associated with higher income in women (Quartile-2 [OR: 1.984, 95% CI: 1.209-3.255], Quartile-1 [OR: 2.161, 95% CI: 1.415-3.299], Quartile-4 [OR: 1.000]). A family history of hypertension (OR: 2.019, 95% CI: 1.549-2.243) increased the likelihood of having experienced a blood pressure measurement in both men and women. Multivariate logistic regression showed that people with unhealthy lifestyles (high salt intake [adjusted odds ratio (AOR): 0.247, 95% confidence interval (CI): 0.068-0.893], tobacco use [AOR: 0.538, 95% CI: 0.380-0.761]) had a decreased likelihood of previous blood pressure measurement. To promote the early detection of hypertension in Bhutan, we suggest that more attention be paid to low-income women, non-working, self-employed, and low-income men, and a reduction of barriers to blood pressure measurement. Before the STEPS survey, a substantial number of hypertensive people had never had their blood pressure measured or were unconcerned about their health. As a result, we propose that early blood pressure monitoring and treatment for people with hypertension or at higher risk of hypertension be given increased emphasis., Competing Interests: The authors have declared that no competing interests exist. The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The common cold is a leading cause of morbidity and contributes significantly to the health costs in Bhutan. The study utilized multivariate Zero-inflated Poisson regression in a Bayesian framework to identify climatic variability and spatial and temporal patterns of the common cold in Bhutan. There were 2,480,509 notifications of common cold between 2010 and 2018. Children aged < 15 years were twice (95% credible interval [CrI] 2.2, 2.5) as likely to get common cold than adults, and males were 12.4% (95 CrI 5.5%, 18.7%) less likely to get common cold than females. A 10 mm increase in rainfall lagged one month, and each 1 °C increase of maximum temperature was associated with a 5.1% (95% CrI 4.2%, 6.1%) and 2.6% (95% CrI 2.3%, 2.8%) increase in the risk of cold respectively. An increase in elevation of 100 m and 1% increase in relative humidity lagged three months were associated with a decrease in risk of common cold by 0.1% (95% CrI 0.1%, 0.2%) and 0.3% (95% CrI 0.2%, 0.3%) respectively. Seasonality and spatial heterogeneity can partly be explained by the association of common cold to climatic variables. There was statistically significant residual clustering after accounting for covariates. The finding highlights the influence of climatic variables on common cold and suggests that prioritizing control strategies for acute respiratory infection program to subdistricts and times of the year when climatic variables are associated with common cold may be an effective strategy., (© 2022. The Author(s).)

Background: Medical services are still developing in Bhutan. There is no published national report on age-related macular degeneration (AMD). We therefore aim to determine the demographic characteristics and severity of AMD at first presentation among Bhutanese patients attending their recently inaugurated vitreoretinal (VR) clinics over a 3-year national survey, and to inform national health policy to develop suitable health program to prevent AMD-related blindness and visual impairment., Methods: A retrospective cross-sectional consecutive case series study was conducted on all new AMD cases in Bhutan. If a patient presented with asymmetrical AMD, the eye with more severe AMD was considered. If both the eyes had the same severity one eye was chosen randomly. Collection of demographic data and clinical details including diagnostic testing (fundus photography, OCT and fluorescent angiography) and clinical staging were performed., Results: Of 521 new AMD patients aged 71.9 ± 11.3 years, 306/521 (58.7%) were males (p = 0.005). At their first presentation, 234/521 patients (44.9%) already had late-stage AMD. Importantly, 69/234 patients (29.5%), that is half of total neovascular AMD (nAMD) patients, had disciform scars (DS) which were beyond treatment, and 7/234 patients (3.0%) had geographic atrophy (GA). Seven patients had retinal pigment epithelium tear at presentation. Fourteen of nineteen polypoidal choroidal vasculopathy (PCV) patients were younger than 50 years., Conclusions: Half of nAMD cases presented as DS not amenable to the treatment. Many potentially treatable nAMD patients had already lost central vision and were legally blind. Young people with PCV losing vision early in life with longer morbidity-affected life and socio-economic burden was concerning. GA and DS cases need visual rehabilitation to improve their QoL. Incorporating a screening program for AMD with effective health education, and maintaining a national AMD Registry, would potentially lower AMD-related blindness and visual impairment., (© 2022. The Author(s).)

Introduction: The transmission trend of SARS-CoV-2 is continuously evolving. Understanding the dynamics in different settings is crucial for any effective containment measures. We aimed to study the characteristics of household transmission of SARS-CoV-2 in Bhutanese households by determining the transmissibility within household contacts of confirmed COVID-19 index cases and their factors of infectivity., Methods: We conducted a retrospective observational study on household transmission in 306 household contacts of 93 COVID-19 positive index cases diagnosed from April 16, 2021, to June 30, 2021. A pro forma was used to collect data on the epidemiological, demographic, and clinical profile of all recruited individuals. Secondary attack rates (SAR) were calculated, and risk factors for transmission were estimated., Results: 180 of 306 household contacts developed secondary household transmission (SAR 58.8%; 95% CI: 53.2-64.2). The median age of household contacts was 22 years. The median household size was 4 (mean 4.3 ± 2.199) members. Contacts exposed to adult index cases (aPR 1; 95% CI 1, 1.02, p = 0.01) and vaccinated index cases (uPR 0.41, 95% CI 0.25, 0.66, p < 0.001) had a higher SAR and prevalence of secondary infections., Conclusions: Our findings suggest substantial evidence of secondary infections among household contacts, especially in the context of public health mandated lockdowns. Aggressive early contact tracing and case identification with subsequent case isolation from other household members remains a crucial step in preventing secondary transmission., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Jimba Jatsho et al.)

Febrile illness is a common cause of hospital admission in developing countries, including Bhutan. Prolonged fever admission can add considerable strain on healthcare service delivery. Therefore, identifying the underlying cause of prolonged hospital stays can improve the quality of patient care by providing appropriate empirical treatment. Thus, the study’s aims were to evaluate the aetiologies and factors of prolonged fever admission in Samtse Hospital, Bhutan. Fever admission data from 1 January to 31 December 2020 were retrieved from the Samtse Hospital database. Prolonged hospital stay was defined as those with >5 days of hospital admission. Univariable and multivariable logistic regression was used to identify risk factors for a prolonged hospital stay. Of 290 records, 135 (46.6%) were children (≤12 years), 167 (57.6%) were males, and 237 (81.7%) patients were from rural areas. The common aetiologies for fever admissions were respiratory tract infection (85, 29.3%) and acute undifferentiated febrile illness (48, 16.6%). The prolonged stay was reported in 87 (30.0%) patients. Patients from rural areas (adjusted odds ratio [AOR] = 4.02, 95% CI = 1.58−10.24) and those with respiratory tract infections (AOR = 5.30, 95% CI = 1.11−25.39) and urinary tract infections and kidney disease (AOR = 8.16, 95% CI = 1.33−49.96) had higher odds of prolonged hospital stay. This epidemiological knowledge on prolonged hospital stay can be used by the physician for the management of fever admission in Samtse Hospital.

Introduction: All Coronavirus disease 2019 (COVID-19) positive cases in Samtse District, Bhutan were isolated in the isolation facilities managed by the government hospitals. This study aimed to identify the socio-demographic risk factors for developing COVID-19 symptoms amongst these patients., Methods and Materials: A secondary data of the COVID-19 positive cases from isolation facilities of Samtse District from 5 May to 7 September 2021 was used for this study. Survival analysis was carried out to estimate the cumulative probability of symptom onset time by each risk factor. Kaplan-Meier curves were used to estimate the probabilities for the onset of symptoms at different time points and a log-rank test was employed to assess the differences between covariates., Results: A total of 449 patients were included, of which 55.2% were males and 73.3% (328) were aged >18 years. The mean age was 42 years with a range of 3 months to 83 years. Forty-seven percent (213) reported at least one symptom. Common symptoms were fever (32.3%, 145), headache (31.6%, 142), and cough (30.1%, 135), respectively. Males were 64% less likely to be symptomatic than females [adjusted hazard ratio (aHR) = 0.36, 95% confidence interval (CI) 0.183-0.917]. Farmers (aHR = 3.17, 95% CI 1.119-8.953), and drivers and loaders (aHR = 3.18, 95% CI 1.029-9.834) were 3 times more likely to be symptomatic compared to housewives. Residents of Samtse sub-districts were 5 times more likely to be symptomatic than those living in other sub-districts (aHR = 5.16, 95% CI 2.362-11.254)., Conclusion: The risk of developing COVID-19 symptoms was being fe male, farmers, drivers and loaders, and residents of the Samtse sub-district. These high-risk groups should be provided additional care when in isolation facilities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lhendup, Tsheten, Rinzin and Wangdi.)

The study aimed to estimate the prevalence, distribution, and correlates of ideal cardiovascular health (CVH) among individuals (20-69 years) across three cross-sectional surveys in 2007, 2014 and 2019 in Bhutan. Cross-sectional data were analysed from 9712 individuals (20-69 years, mean age = 37.6 years) who participated in the 2007, 2014 or 2019 Bhutan STEPS surveys, had complete measurement of CVH metrics, and had no history of a cardiovascular disease in 2014 and 2019. Ideal CVH measures included non-smoking, healthy diet, physical activity, body mass index (< 23 kg/m 2 ), blood pressure < 120/ < 80 mmHg, total cholesterol < 200 mg/dL, and fasting blood glucose < 100 mg/dL). The prevalence of five to seven ideal CVH metrics increased from 11.6% in 2007 to 37.9% in 2019. Trend analyses showed that ideal physical activity, ideal total cholesterol, ideal blood pressure, and ideal fasting glucose increased from 2007 to 2019, while ideal fruit and vegetable intake, ideal smoking, and ideal body mass index decreased from 2007 to 2019. Five to seven ideal CVH metrics, 0-7 ideal CVH metrics, and 0-14 poor, intermediate, and ideal CVH metrics increased from 2007 to 2019. In the adjusted logistic regression analysis, older age decreased the odds of having 5-7 ideal CVH metrics in all three study years. Male sex increased the odds, and employment decreased the odds of 5-7 ideal CVH metrics in 2007, and urban residence increased the odds of 5-7 ideal CVH metrics in 2014 and decreased the odds in 2019. The proportion of meeting 5-7 ideal CVH metrics increased in Bhutan. Primary and secondary prevention programmes must be strengthened to improve CVH in Bhutan, considering identified associated factors., (© 2022. The Author(s).)

Background: The COVID-19 pandemic has reaffirmed an all-knowing truth-that health is central in the 2030 Sustainable Development Agenda. To fully control the infection in a community, accurate testing of suspected cases along with effective tracing and appropriate treatment (3Ts) is still crucial to slowing transmission of COVID-19 virus This study explored factors that influenced COVID-19 testing in Bhutan. The lessons learned from this study could serve as a roadmap to strengthen the current respond to COVID-19 and for future outbreaks, particularly in low- and middle-income countries., Methods: The study employed an exploratory qualitative design. Data collection methods included interviews with key informants with a purposively selected sample of 20 participants. The interview findings were augmented by reviewing both published literature and unpublished documents.For the analysis of qualitative interviews, a hybrid approach of inductive and deductive coding and theme development was conducted to analyze findings. A tailored version of the WHO Health System Framework incorporating the Essential Public Health Function was used to guide data interpretation., Results: Political will through the influence and leadership of the King of Bhutan played a crucial role in raising attention to the problem, and provision of adequate financial and technical relief to ensure that all people irrespective of their socioeconomic status do not pay to get tested of COVID-19. A compassionate leadership, Whole of Society approach is backed by the scientific community, functional health systems and community-based approaches, use of information technology for awareness creation and improved surveillance system, and fast-tracked COVID-19 testing service delivery., Conclusion: Bhutan's success relied greatly on multi-sectoral and systematic approach during policy design, implementation and monitoring, and active collaborative efforts involving consultation and engagements with a broad range of local (community members), national and global actors for accelerated COVID-19 testing. These efforts were made possible through improved health governance and leadership at all levels of the society., (© 2022. The Author(s).)

There is no international reporting of SARS-CoV-2 infections in health care workers (HCWs). Estimates suggest that a HCW dies every thirty minutes from COVID-19. This worsened the shortages and burnout of HCWs worldwide. Twenty months into the pandemic, Bhutan recorded over 2600 COVID-19 positive cases and three deaths. About 906 HCWs were directly involved in managing these laboratory confirmed cases but no infections occured amongst this group. This zero infection was possible through the clustered management of positive cases in four national COVID-19 centers, strategic deployment of HCWs, the uninterrupted provision of quality personal protective equipment (PPE) and repeated training on the correct use of PPE. This is an exemplary achievement for a small country with limited expertise and resources.

We analyzed the Population and Health Census of Bhutan (PHCB) 2017 to assess the prevalence and pattern of self-reported disability among people aged ≥15 years and the associated factors. The PHCB 2017 used the Washington Group Short Set on Functioning questionnaire to assess the disability ("lot of difficulty" or "cannot do at all") in seeing, hearing, mobility, cognition, self-care, and communication. Of the 536 443 persons included in the analysis, 384 101(71.6%) were aged <45 years, 283 453(52.8%) were men, and 206 103(38.4%) were from the rural area. The prevalence of any self-reported disability was 2.8%, among whom 34.2% reported multiple disabilities. The disability prevalence (any) was significantly higher among people aged ≥65 years, illiterate, economically inactive, permanent residents, residing in a rural area, and from central and eastern regions of the country compared with their respective counterparts. Further research on access to rehabilitation and linking with social protection schemes for the disabled is required in this country.

The unprecedented experience of national lockdowns and uncertainty of academic career due to the COVID-19 pandemic has multifaceted impacts on mental health among university students worldwide. This study determined its impact on depression and anxiety level, and associated risk factors among engineering students studying at College of Science and Technology (CST), Phuentsholing, Bhutan during the first lockdown in the country. Self-reported depression and anxiety levels were assessed using Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) respectively. Data was collected using an e-questionnaire link generated in Google form and the link was shared with students via the student's official email group. A total of 278 students (response rate, 26.9%) completed the questionnaire. The majority of respondents were male (69.8%) and were aged from 18 to 30 (Mean: 21.7 ±SD 2.07) years. The prevalence of self-reported moderate to severe depression and anxiety were 44.2% (95% CI, 38.5-49.6) and 27.3% (95% CI, 22.3-32.4) respectively. Participants having their family members as frontline workers reported a significantly higher level of anxiety (χ2 = 4.85, p = 0.028). In multivariable logistic regression analysis, students who were academically lagging showed a higher risk of depression (AOR = 5.36, 95% CI = 2.86-10.04) and anxiety (AOR = 3.83, 95%CI = 1.86-7.88) as compared to students who were not academically behind. A high percentage of depression and anxiety was reported by students of CST during the COVID-19 pandemic. Findings from the study highlight the importance of adopting appropriate online-based teaching and learning methods to ensure timely academic and professional achievements. Moreover, the relevant stakeholders should put health system strategies in place to provide psychological support to university students during the COVID-19 pandemic., Competing Interests: The authors have declared that no competing interests exist.

Protecting the citizens who are living abroad has been a challenge for many countries during the current COVID-19 pandemic. In Bhutan, since the start of the pandemic, it has repatriated its citizens living and working abroad and putting them into a 21-day state-sponsored quarantine. They were also tested for COVID-19 on reverse transcription polymerase chain reaction (RT-PCR) that was funded by the government. While this measure is a blessing for its people, for the government it is a huge economic challenge.

It is important for malaria-endemic countries to address malaria control across international borders, and in particular to prioritize appropriate rapid diagnosis, treatment and surveillance. Bhutan and India aim to achieve malaria elimination by 2023 and 2030 respectively. Malaria elimination along the Indo-Bhutan border is of common concern. We delineated malaria epidemiology along the border to provide a blueprint for focusing malaria control efforts in key foci within this region. Epidemiological data from 2015 to 2019 were analyzed, as the most drastic reductions in malaria burden across most parts of India were witnessed in this time frame. Several areas of concern include low surveillance in most border districts, favorable climatic conditions for perennial malaria transmission, and movement of potential parasite carriers because of the porous borders. India and Bhutan need to control the importation/exportation of malaria cases. We highlight the foci of concern for which implementing tailor-made malaria control strategies may benefit both countries.

COVID-19 is a disease that is caused by a highly transmissible and pathogenic novel coronavirus: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). All of the COVID-19 positive cases in Bhutanese travellers returning via the Phuentsholing point of entry, the local population, and Indian nationals were isolated in the Phuentsholing COVID-19 isolation ward, Bhutan. This study aimed to identify the risk factors for developing symptoms among COVID-19 positive patients in this ward. A retrospective cohort study was conducted using the data regarding COVID-19 positive cases in the Phuentsholing COVID-19 isolation ward from 28 May 2020 to 31 May 2021. The Cox proportional hazards regression model was used to identify the risk factors of developing COVID-19 symptoms. There were 521 patients in the study; 368 (70.6%) were males and 153 (29.4%) were females. The mean age was 32 years (with a range of 1-78 years), and 290 (56.0%) reported at least one symptom. The median length of isolation was eight days (with a range of 3-48 days). The common symptoms were: cough (162, 31.0%), fever (135, 26.0%), and headache (101, 19.0%). In the multivariable Cox regression, vaccinated patients were 77.0% ( p = 0.047) less likely to develop symptoms compared to those who were not vaccinated. The front line workers and the mini-dry port (MDP) workers were 15 ( p = 0.031) and 41 ( p < 0.001) times more likely to be symptomatic compared to returning travellers. The young and economically active population group was most commonly affected by COVID-19. The presence of risk factors, such as being front line workers, MDP workers, or not being vaccinated against COVID-19, meant that patients had a higher probability of developing symptoms of COVID-19.

Pneumonia is one of the top 10 diseases by morbidity in Bhutan. This study aimed to investigate the spatial and temporal trends and risk factors of childhood pneumonia in Bhutan. A multivariable Zero-inflated Poisson regression model using a Bayesian Markov chain Monte Carlo simulation was undertaken to quantify associations of age, sex, altitude, rainfall, maximum temperature and relative humidity with monthly pneumonia incidence and to identify the underlying spatial structure of the data. Overall childhood pneumonia incidence was 143.57 and 10.01 per 1000 persons over 108 months of observation in children aged < 5 years and 5-14 years, respectively. Children < 5 years or male sex were more likely to develop pneumonia than those 5-14 years and females. Each 1 °C increase in maximum temperature was associated with a 1.3% (95% (credible interval [CrI] 1.27%, 1.4%) increase in pneumonia cases. Each 10% increase in relative humidity was associated with a 1.2% (95% CrI 1.1%, 1.4%) reduction in the incidence of pneumonia. Pneumonia decreased by 0.3% (CrI 0.26%, 0.34%) every month. There was no statistical spatial clustering after accounting for the covariates. Seasonality and spatial heterogeneity can partly be explained by the association of pneumonia risk to climatic factors including maximum temperature and relative humidity., (© 2021. The Author(s).)

Objectives: Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan., Methods: The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated., Results: Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior., Conclusion: Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Knowing the number of persons at risk for sexually transmitted diseases (STDs) and their risk behaviors are needed to allocate limited resources, set targets for prevention and care activities, gauge the reach of programs, and assess their impact. Female sex workers (FSWs) are a population at high risk for STD worldwide; little is known about FSW in Bhutan., Methods: We conducted a community-based survey and population size exercise of FSW in Bhutan. The survey used a hybrid venue-based/peer-referral sampling method. Population size estimation methods were key informant mapping, census and enumeration, unique object multiplier, and capture-recapture., Results: Of 517 women surveyed, 67.5% provided sex for money in the last year. Compared with FSWs at venues, FSWs referred by peers were more likely to have sex with alcohol (80.1% vs. 51.5%, P < 0.001) and more paying partners (mean, 3.5 vs. 2.0; P = 0.001), and less likely to have tested for an STD (28.3% vs. 51.0%, P < 0.001) or have outreach worker contact (27.6% vs. 41.5%, P = 0.007). The estimated number of FSWs in the 9 districts was 353 (95% confidence interval, 345-362). Extrapolation to the whole country projected 597 (417-777) FSWs nationally., Conclusions: Our estimate of the number of FSW in Bhutan corresponds to 0.71% of adult urban women, a figure in line with other countries in South and Southeast Asia. Our data highlight the need for outreach beyond venues where women are employed to reach FSW at higher risk for STD but who have less access to interventions., Competing Interests: Conflict of Interest and Sources of Funding: This study was funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria; Save the Children Bhutan; and the Australian Federation of AIDS Organization. The authors declare they have no conflict of interests., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The highly contagious nature of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) places physicians in South Asia at high risk of contracting the infection. Accordingly, we conducted this study to provide an updated account of physician deaths in South Asia during the COVID-19 pandemic and to analyze and compare the different characteristics associated with physician mortality amongst the countries of the region., Methods: We performed a cross-sectional study by using published news reports on the websites of news agencies from 9 selected countries in South Asia. Our study included only those physicians and doctors who died after contracting COVID-19 from their respective workplaces. All available data about the country of origin, type of, sex, age, medical or surgical specialty, and date of death were included., Results: The total number of physician deaths reported due to COVID-19 in our study was 170, with half (87/170, 51%) of the deaths reported from Iran. Male physician deaths were reported to be 145 (145/170 = 85%). Internal Medicine (58.43%) was the most severely affected sub-specialty. The highest physician mortality rate in the general population recorded in Afghanistan (27/1000 deaths). General physicians from India [OR = 11.00(95% CI = 1.06-114.08), p = 0.045] and public sector medical practitioners from Pakistan [aOR = 4.52 (95% CI = 1.18-17.33), p = 0.028] were showing significant mortality when compared with other regions in multivariate logistic regression., Conclusion: An increased number of physician deaths, owing to COVID-19, has been shown in South Asia. This could be due to decreased personal protective equipment and the poor health care management systems of the countries in the region to combat the pandemic. Future studies should provide detailed information of characteristics associated with physician mortalities along with the main complications arising due to the virus., (© 2021. The Author(s).)

Background: Bhutan is facing an epidemic of noncommunicable diseases; they are responsible for 53% of all deaths. Four main modifiable risk factors, including tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet, are the causes of most noncommunicable diseases (NCDs). This study aimed to assess 1) the prevalence of NCDs modifiable risk factors in Bhutan's adult population and 2) associations between the sociodemographic factors and the NCDs modifiable risk factors with overweight or obesity, hypertension, and diabetes., Methods: We used the 2014 Bhutan WHO Stepwise Approach to NCD Risk Factor Surveillance (STEPS) Survey dataset in this study. Data were analyzed using multiple logistic regressions, constructed with overweight or obesity, hypertension, and diabetes as outcome variables and modifiable risk factors as independent variables., Results: The prevalence of tobacco use, harmful use of alcohol, unhealthy diet (low fruits and vegetables intake) and physically inactive was 24.8% (95% CI: 21.5, 28.5), 42.4% (95% CI: 39.4, 45.5), 66.9% (95% CI: 61.5, 71.8), and 6.2% (95% CI: 4.9, 7.8), respectively. The prevalence of overweight or obesity, hypertension and diabetes was 32.9% (95%CI: 30.0, 36.0), 35.7% (95% CI: 32.8, 38.7) and 6.4% (95% CI: 5.1, 7.9), respectively. Multiple logistic regression showed that older age groups were more likely to be overweight or obese, hypertensive, and diabetic. Our analysis also found that tobacco users were less likely to be overweight or obese (aOR 0.71, 95% CI 0.52, 0.96), and to be hypertensive (aOR 0.74, 95% CI 0.56, 0.97); but they were more likely to be diabetic (aOR 1.64, 95% CI 1.05, 2.56). Alcohol users were more likely to be hypertensive aOR 1.41 (95% CI 1.15, 1.74). Furthermore, vigorous physical activity could protect people from being overweight or obese, aOR 0.47 (95% CI 0.31, 0.70), and those consuming more than five serves of fruits and vegetables per day were more likely to be overweight or obese, aOR 1.46 (95% CI 1.17, 1.82)., Conclusion: The prevalence of NCDs modifiable risk factors and overweight or obesity and hypertension was high in Bhutan. We found strong associations between tobacco use and diabetes, alcohol use, hypertension, physically inactive, and overweight or obesity. The results suggest that the government should prioritize NCDs prevention and control programs, focusing on reducing modifiable risk factors. The health sector alone cannot address the NCDs epidemic in Bhutan, and we recommend the whole of government approach to tackle NCDs through the Bhutan Gross National Happiness framework., Competing Interests: The authors have declared that no competing interests exist.

Background: Nutritional deficiencies are common worldwide and is most notable in low and middle income countries. In the early weeks of September 2018, oral sores mostly affecting the tongue were reported in three central schools under Tsirang district, Bhutan. A total of 204 students were affected in the three central schools. All the affected students have been assessed on the outbreak and nutritional survey was conducted in the three schools., Methods: A total of 204 students who complained of different oral lesions in the affected three schools were screened by the dental surgeon for clinical assessment and administered questionnaire for nutritional assessment by the nutritionist. Twenty-one students randomly selected were sent for blood tests for micronutrient assays and complete blood count. 41 students were tested for Exfoliative cell cytology to test for fungal elements. The collected data was double entered and validated using Epi-Data version 3.1 and analysed using Stata 15 IC. The characteristics of the participants are presented as frequencies, percentages, mean and standard deviation (SD)., Results: Almost all the affected students in all the three schools had complaints of Burning Sensation (n = 158) followed by Pain (n = 153), Impaired Taste Sensation (n = 100) and Intolerance to Spicy Food (n = 95). Nutritional assessment analysis suggested schools not meeting the Recommended Dietary Allowance (RDA) for all components of Vitamin B complexes and Iron., Conclusion: Clinical assessments and nutritional survey analysis found inadequate vitamin rich dietary intakes among all the three schools. Implementation of a strict school feeding program with a balanced diet has been suggested accordingly., (© 2021. The Author(s).)

Objective: The purpose of the study is to identify the risk factors such as age, the stage of patients based on the International Federation of Gynecology and Obstetrics system (FIGO stage) and treatment type, and their effect on the survival of cervical cancer patients receiving treatments at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Bhutan between January 2014 and December 2019., Methods: In this retrospective study, all 357 women diagnosed with cervical cancer were included. Kaplan-Meier model was applied to estimate survival, and the log-rank test was performed to compare survival distributions between subgroups stratified by each of the risk factors. Baseline demographics, cervical cancer stages, and treatment options were analyzed as factors and predictors of survival by Cox proportional hazards model., Results: The overall estimated 1- to 5-year survival rates are 82.1% (95% CI: 77.8-86.7), 75.6% (70.4-81.1), 65.2% (58.2-73.0), 62.3% (54.7-70.9) and 55.4% (44.9-68.3). The results reveal that age group, FIGO stage, treatment, and frequency of hospital visits are significant factors affecting the survival of cervical cancer patients in Bhutan. Patients aged >45 years increases the risk of dying (HR: 2.1, 95% CI: 1.2-3.9) compared to the young age group (≤45 years). Treatment types other than surgery only are significantly associated with an increased risk of mortality in patients with cervical cancers. The more frequency of hospital visits also reduces the risk of dying (HR: 0.1, 95% CI: 0-0.3). FIGO stage IV is the most significant risk factor for mortality with a hazard ratio of 6 (95% CI: 2.1-17.6)., Conclusion: The five-year survival rate of cervical cancer patients in this study was low. Late diagnosis of cervical cancer appears to be mainly associated with a higher risk of dying. The results provide valuable information for further research and policymaking in the prevention and management of cervical cancer. , .

Depression is highly prevalent among people living with human immunodeficiency virus across the globe. Data regarding prevalence and factors associated with depression among HIV-infected individuals in Bhutan remained unknown. Therefore, a cross-sectional study was undertaken among 103 adult (≥18 years) HIV patients attending anti-retroviral therapy clinics located at four different hospitals in Western Bhutan. Depression was assessed using the translated and validated Bhutanese version of centre for epidemiologic studies depression scale-revised. The overall response rate of our participants was 73.6%. Age of our participants ranged from 23 to 79 (mean = 40.29, standard deviation ± 11.22) years. The overall prevalence of depression among our participants was 27.2% (95% confidence interval [CI]: 19.4-35.9). Multivariate binary logistic regression analysis showed that females (adjusted odds ratio (AOR) = 3.96, 95% CI: 1.37-11.41) and the poor perceived family support (AOR = 3.31, 95% CI: 1.20-9.10) were significantly associated with depression. Divorced, low income, drinking alcohol and CD 4 <200 cells/mm 3 had no associations with depression. We recommend mental health interventions to be integrated into routine HIV care in Bhutan for proper management of depression.

Introduction: CD4 count is an important predictor of disease progression, opportunities infection, deaths, and to understand the time interval between initial HIV infection to the first diagnosis. However, baseline CD4 count and the time period between initial infection and the diagnosis amongst PLHIV in Bhutan never been evaluated., Methods: This is a retrospective study of the diagnosed PLHIV from the existing data system from January 10 to 30, 2021. Out of 512 reported HIV cases, 488 of those who were more than or equal to 18 years old and had their CD4 count testing within 6 months before initiating ART were considered for analysis. Descriptive statistical analysis was used to analyze the characteristics of the study population and relationship were established using the χ 2 Test. We have sought ethics approval and waiver for informed consent as it is the retrospective study of the client's record. The client's confidentiality was ensured by removing all the identifiers., Results: The mean CD4 was 345 cells/ml for males and females. Twenty-five percent of the clients had CD4 counts below 200, 30%, between 200 and 349, 25% between 350 and 499, and 20% above 500 cells/ml. A larger number of males showed a CD4 count below 200 cells/ml while more females showed a CD4 count more than 500 cells/ml. The mean time interval between initial infection to the first diagnosis was 4 years in males and females. However, about one-fourth were found to have been infected between 5 and 8 years before diagnosis and less than 10% were diagnosed within less than 1 year of infection., Conclusions: The study revealed a late diagnosis of HIV infection in Bhutan thereby risking the transmission to the community and risk of severe disease and mortality. The upscaling of voluntary counseling and testing, medical screening, and alternative methods like community-based testing including HIV Self Testing for early detection needs to be implemented in the country., (© 2021 The Authors. Immunity, Inflammation and Disease published by John Wiley & Sons Ltd.)

Cardiovascular disease is the leading cause of death in the Kingdom of Bhutan. Thus, the early detection and prevention of hypertension is critical for reducing cardiovascular disease. However, the influence of sociocultural factors on vulnerability to hypertension needs further investigation. This study performed secondary data analysis on 1,909 individuals in a cross-sectional study (the National survey for noncommunicable disease risk factors and mental health using World Health Organization (WHO) STEPS approach in Bhutan- 2014). Multivariate logistic regression demonstrated a significant association between gender with marital status and hypertension. Women had a higher odds ratio than men (Ref) when married (AOR: 1.27, 95% confidence intervals (CI): 1.23-1.31), and when separated, divorced, or widowed (AOR: 1.18, 95% CI: 1.12-1.26). People who speak the Tshanglakha language scored the highest odds (AOR: 1.24, 95% CI: 1.20-1.27), followed by Lhotshamkha (AOR: 1.09, 95% CI: 1.06-1.12) and Dzongkha (Ref) after adjusting for various social and biomedical factors. Additionally, tobacco use displayed decreased odds for hypertension. To promote the early detection and prevention of hypertension, these cultural factors should be considered even within small geographic areas, such as Bhutan. It is necessary to strengthen hypertension preventive strategies for people who speak Tshanglakha and Lhotshamkha. Furthermore, careful consideration should be given to preventing hypertension among adults aged 40 years or more, women who are married, separated, divorced, or widowed, and men who never married in Bhutan., Competing Interests: The authors declare no potential financial conflict of interest related to the manuscript. The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Foodborne diseases (FBDs) are a public health threat that can result in loss of lives and are a hurdle to socioeconomic development. The Foodborne Disease Burden Epidemiology Reference Group estimated that the annual burden of FBDs in the South-East Asia Region was more than 150 million illnesses, causing about 175,000 deaths. This review paper aims to compile evidence from the published articles and gray literatures on food-related disease outbreaks in Bhutan. Information was generated from the annual health bulletin published by the Ministry of Health and data from the National Early Warning Alert Response Surveillance and Information System hosted by Royal Centre for Disease Control. The laboratory confirmation rate of FBD investigation outbreaks increased from 25.5% (2012-2018) to 91.7% in 2020, as per the National Food Safety Indicator (FSI). At least 0.15% of the total population had suffered FBD from 2015 to 2020, and the baseline report shows that most of the FBD events occurred during hot and wet seasons (June and August). The common pathogen causing FBD was Salmonella species accounting for 42.9% of cases, followed by Shigella species (21.4%). Most of the FBD events were reported in schools (46.5%). The frequency of the reported FBD outbreaks had increased from 8 events in 2015 to 15 events in 2017 and 10 events in 2018. The study confirms the improved surveillance for FBDs in Bhutan and highlights the need to raise public awareness on food safety., Competing Interests: None

Objective: To investigate the factors associated with cesarean section (CS) in Bhutan., Methods: This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan., Results: The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS., Conclusion: In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph., (© 2020 International Federation of Gynecology and Obstetrics.)

Malaria in Bhutan has fallen significantly over the last decade. As Bhutan attempts to eliminate malaria in 2022, this study aimed to characterize the space-time clustering of malaria from 2010 to 2019. Malaria data were obtained from the Bhutan Vector-Borne Disease Control Program data repository. Spatial and space-time cluster analyses of Plasmodium falciparum and Plasmodium vivax cases were conducted at the sub-district level from 2010 to 2019 using Kulldorff's space-time scan statistic. A total of 768 confirmed malaria cases, including 454 (59%) P. vivax cases, were reported in Bhutan during the study period. Significant temporal clusters of cases caused by both species were identified between April and September. The most likely spatial clusters were detected in the central part of Bhutan throughout the study period. The most likely space-time cluster was in Sarpang District and neighboring districts between January 2010 to June 2012 for cases of infection with both species. The most likely cluster for P. falciparum infection had a radius of 50.4 km and included 26 sub-districts with a relative risk (RR) of 32.7. The most likely cluster for P. vivax infection had a radius of 33.6 km with 11 sub-districts and RR of 27.7. Three secondary space-time clusters were detected in other parts of Bhutan. Spatial and space-time cluster analysis identified high-risk areas and periods for both P. vivax and P. falciparum malaria. Both malaria types showed significant spatial and spatiotemporal variations. Operational research to understand the drivers of residual transmission in hotspot sub-districts will help to overcome the final challenges of malaria elimination in Bhutan.