Impact of COVID-19 on mental health in Bhutan: a way forward for action

The coronavirus disease 2019 (COVID-19) pandemic continues to impact mental health and wellbeing globally. There is a lack of scientific documentation highlighting the mental health impact of COVID-19 in Bhutan. We present the mental health burdens and control measures taken, and suggest ways to further strengthen mental health services in Bhutan. During the pandemic, a rise in depression and anxiety had been reported in Bhutan. Depression rose from an average prevalence of 9 per 10,000 between 2011 and 2019 to 16 per 10,000 in 2020 and 32 per 10,000 in 2021. Similarly, anxiety rose from an average prevalence of 18 per 10,000, to 29 per 10,000 in 2020, and 55 per 10,000 in 2021. Psychological impacts related to isolation due to lockdowns, economic losses, and poor coping abilities were associated with negative outcomes. Stigma and discrimination towards mental health disorders discouraged mentally distressed people from seeking care. In response to increased demand, Bhutan’s government initiated a range of interventions including home delivery of medicines and tele-counselling to people in need of urgent mental health care. Mental health care in Bhutan can be further improved through investment in services and human resources, and decentralization of services to the community.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Cervical cancer screening program in Thimphu, Bhutan: population coverage and characteristics associated with screening attendance

BACKGROUND

Bhutan has been engaged in good-quality cytology-based cervical screening since 2000 and has vaccinated >90% girls against human papillomavirus (HPV) since 2010. We explored the characteristics associated with lack of previous screening and screening coverage in women age ≥25 years.

METHODS

Women were invited at home or during their attendance at 2 outpatient clinics, in the capital, Thimphu, and nearby Lungthenphu. Age-adjusted odds ratios for lack of previous screening by selected characteristics were computed among 1,620 participating women. In Thimphu an invitation registry allowed to estimate screening history not only among participating women but also among additional 500 women who did not accept to join our study.

RESULTS

Among women who had a Pap smear, lack of previous screening was associated with age <35 or ≥45 years. It was also associated with some occupations; being single, or widowed/separated; and presence of HPV infection. Multiparity and use of contraceptive methods were associated with having been screened. In women invited at home in Thimphu screening history substantially differed by participation. Past screening attendance was 59% among women recruited in the 2 clinics, 53% in women who were invited from home and accepted the invitation, but only 25% in those who refused it. Based on all women recruited from home the estimate of population-based coverage in Thimphu is 34% (95% CI: 31-37).

CONCLUSIONS

Transition from an opportunistic screening to an all-reaching population-based screening is yet to be achieved in Bhutan, even in the capital. Better ways to target never-screened women are needed.

Human papillomavirus infection in Bhutan at the moment of implementation of a national HPV vaccination programme

BACKGROUND

Cervical cancer is the most common female cancer in Bhutan, the first low/middle-income country to implement a national human papillomavirus (HPV) vaccination programme.

METHODS

To provide a robust baseline for future evaluations of vaccine effectiveness, cervical cell specimens were obtained from 2,505 women aged 18-69 years from the general population, and biopsies from 211 cervical intraepithelial neoplasia grade 3 (CIN3) and 112 invasive cervical cancer (ICC) cases. Samples were tested for HPV using GP5+/6+ PCR.

RESULTS

Among the general population, HPV prevalence was 26%, being highest (33%) in women ≤24 years, but remaining above 15% in all age-groups. Determinants of HPV included age, marital status, and number of sexual partners. Among the eight percent with cytological abnormalities, 24 CIN3 and 4 ICC were histologically confirmed. Even after additional testing with a sensitive E7 PCR, no infections with vaccine-targeted HPV types were detected in the few vaccinated women (n = 34) compared to 6% prevalence in unvaccinated women of similar age (p = 0 · 215).

CONCLUSION

Based upon type-specific prevalence among biopsies, at least 70% of ICC in Bhutan are theoretically preventable by HPV16/18 vaccination, but screening programmes should be expanded among older women, who have an important underlying burden of CIN3 and ICC.

International health and the limits of its global influence: bhutan and the worldwide smallpox eradication programme

Histories of the global smallpox eradication programme have tended to concentrate on the larger national formations in Africa and Asia. This focus is generally justified by chroniclers by the fact that these locations contributed a major share of the world’s annual tally of variola, which meant that international agencies paid a lot of attention to working with officials in national and local government on anti-smallpox campaigns in these territories. Such historiographical trends have led to the marginalisation of the histories of smallpox eradication programmes in smaller nations, which are presented either in heroic, institutional tropes as peripheral or as being largely shorn of sustained campaigns against the disease. Using a case study of Bhutan, a small Himalayan kingdom sandwiched between India and China, an effort is made to reclaim the historical experiences in small national entities in the worldwide smallpox eradication programme. Bhutan’s experience in the 1960s and 1970s allows much more in addition. It provides us with a better understanding of the limited powers of international agencies in areas considered politically sensitive by the governments of powerful nations such as India. The resulting methodological suggestions are of wider historical and historiographical relevance.

Antimicrobial susceptibility and genetic characteristics of Neisseria gonorrhoeae isolates from India, Pakistan and Bhutan in 2007-2011

BACKGROUND

Knowledge on antimicrobial drug resistance and genetic characteristics of Neisseria gonorrhoeae isolates circulating in India, Pakistan, and Bhutan is sorely lacking. In this paper, we describe the prevalence of antimicrobial resistance and molecular characteristics of N. gonorrhoeae isolates from India, Pakistan, and Bhutan in 2007-2011.

METHODS

Antimicrobial susceptibility and β-lactamase production were tested for 65 N. gonorrhoeae isolates from India (n=40), Pakistan (n=18) and Bhutan (n=7) using Etest methodology (eight antimicrobials) and nitrocefin solution, respectively. Resistance determinants, i.e. penA, mtrR, porB1b, gyrA, and parC, were sequenced. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was performed for molecular epidemiology.

RESULTS

The highest resistance level was observed for ciprofloxacin (94%), followed by penicillin G (68%), erythromycin (62%), tetracycline (55%), and azithromycin (7.7%). All the isolates were susceptible to ceftriaxone, cefixime, and spectinomycin. Thirty-four (52%) of the isolates were producing β-lactamase. No penA mosaic alleles or A501-altered alleles of penicillin-binding protein 2 were identified. Forty-nine NG-MAST STs were identified, of which 42 STs have not been previously described worldwide.

CONCLUSIONS

Based on this study, ceftriaxone, cefixime, and spectinomycin can be used as an empirical first-line therapy for gonorrhoea in India, Pakistan, and Bhutan, whereas ciprofloxacin, penicillin G, tetracycline, erythromycin, and azithromycin should not be. It is imperative to strengthen the laboratory infrastructure in this region, as well as to expand the phenotypic and genetic surveillance of antimicrobial resistance, emergence of new resistance, particularly, to extended-spectrum cephalosporins, and molecular epidemiology.

Sex-trafficking, violence, negotiating skill, and HIV infection in brothel-based sex workers of eastern India, adjoining Nepal, Bhutan, and Bangladesh

A community-based cross-sectional study was conducted among brothel-based sex workers of West Bengal, eastern India, to understand sex-trafficking, violence, negotiating skills, and HIV infection in them. In total, 580 sex workers from brothels of four districts participated in the study. A pretested questionnaire was introduced to study their sociodemography, sex-trafficking, violence, and negotiating skills. Blood sample of 4-5 mL was collected from each sex worker using an unlinked anonymous method to study their HIV status. Data were edited and entered into a computer using the Epi Info software (6.04d version). Both univariate and multivariate analyses were done to find out any association between HIV and relevant risk factors. Results of the study revealed that a sizeable number of the participants were from Nepal (9%) and Bangladesh (7%). The seroprevalence of HIV was strikingly higher among Nepalese (43%) than among Bangladeshis (7%) and Indians (9%). Almost one in every four sex workers (24%) had joined the profession by being trafficked. Violence at the beginning of this profession was more among the trafficked victims, including those sold by their family members (57%) compared to those who joined the profession voluntarily (15%). The overall condom negotiation rate with most recent two clients was 38%. By multivariate analysis, HIV was significantly associated with sexual violence (odds ratio=2.3; 95% confidence interval 1.2-4.5). The study has documented that the trafficked victims faced violence, including sexual violence, to a greater magnitude, and sexual violence was associated with acquiring HIV in them. There is a need for an in-depth study to understand the problem of trafficking and its consequences.