Explore the vast range of titles available.

We conducted serosurveillance for Crimean-Congo hemorrhagic fever virus (CCHFV) among goats in southern Bhutan. Testing serum samples from 472 goats for CCHFV-specific IgG using an indirect fluorescent antibody test and ELISA, we found CCHFV antibody-positive goats along the analyzed border region with India, indicating widespread distribution of CCHFV in this area.

Background The national malaria control programmes in Cambodia, Nepal, and Bhutan aim to achieve malaria elimination by 2025–2030. While the vivax malaria burden remains challenging, the consistent decline in falciparum malaria in these countries over the last five years suggests that the goal is achievable. However, unexpected cases in previously falciparum malaria-free districts continue to occur. A virtual meeting was convened in May 2024, followed by smaller meetings, to discuss and share experiences among regional partners, focusing on falciparum malaria elimination. Main text The discussion among regional partners from these three countries was prompted by an isolated outbreak of falciparum malaria in April 2022 in a previously malaria-free district in Pursat province, Cambodia. The National Center for Parasitology, Entomology and Malaria Control (CNM) worked with stakeholders to contain the outbreak, which was likely to have originated in forest goers. Community-based village malaria workers (VMWs) were augmented with the additional resources required to test and treat malaria among forest goers under the supervision of health centres and district hospitals. This response rapidly reduced malaria cases in the subsequent months. Regional partners from Nepal and Bhutan, who are also engaged in the final phase of malaria elimination, reported that isolated malaria outbreaks in their countries were not unusual and were mostly imported from a neighbouring country, India. Importation of cases was facilitated by unsupervised transborder travel including the movement of migrant workers. The imported cases were only established during the case investigation such as when responding to the isolated outbreaks. In contrast, in Cambodia, spread of malaria was known to be facilitated by mobile and migrant workers, and forest goers within the country. The specific differences between Nepal and Bhutan (South Asia), and Cambodia (Greater Mekong Subregion) offered insights into strategies for malaria elimination. A relevant component for countries embarking on malaria elimination included strengthening of local malaria surveillance and response in collaboration with the community health workers, and community members targeting the ‘at risk’ population. Conclusion In countries approaching malaria elimination, resourcing community-based health workers could play a critical role in enhancing malaria surveillance, early case detection and treatment, including interventions targeting migrant populations such as forest goers and seasonal migrant workers.

Antimicrobial resistance is a major issue in the Shigellae, particularly as a specific multidrug-resistant (MDR) lineage of Shigella sonnei (lineage III) is becoming globally dominant. Ciprofloxacin is a recommended treatment for Shigella infections. However, ciprofloxacin-resistant S. sonnei are being increasingly isolated in Asia and sporadically reported on other continents. We hypothesized that Asia is a primary hub for the recent international spread of ciprofloxacin-resistant S. sonnei. We performed whole-genome sequencing on a collection of 60 contemporaneous ciprofloxacin-resistant S. sonnei isolated in four countries within Asia (Vietnam, n = 11; Bhutan, n = 12; Thailand, n = 1; Cambodia, n = 1) and two outside of Asia (Australia, n = 19; Ireland, n = 16). We reconstructed the recent evolutionary history of these organisms and combined these data with their geographical location of isolation. Placing these sequences into a global phylogeny, we found that all ciprofloxacin-resistant S. sonnei formed a single clade within a Central Asian expansion of lineage III. Furthermore, our data show that resistance to ciprofloxacin within S. sonnei may be globally attributed to a single clonal emergence event, encompassing sequential gyrA-S83L, parC-S80I, and gyrA-D87G mutations. Geographical data predict that South Asia is the likely primary source of these organisms, which are being regularly exported across Asia and intercontinentally into Australia, the United States and Europe. Our analysis was limited by the number of S. sonnei sequences available from diverse geographical areas and time periods, and we cannot discount the potential existence of other unsampled reservoir populations of antimicrobial-resistant S. sonnei. This study suggests that a single clone, which is widespread in South Asia, is likely driving the current intercontinental surge of ciprofloxacin-resistant S. sonnei and is capable of establishing endemic transmission in new locations. Despite being limited in geographical scope, our work has major implications for understanding the international transfer of antimicrobial-resistant pathogens, with S. sonnei acting as a tractable model for studying how antimicrobial-resistant Gram-negative bacteria spread globally.

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.

Cystic echinococcosis (CE), caused by Echinococcus granulosus s.l. is a neglected zoonosis posing a significant public health challenge. Little is known about human CE in Bhutan. This study was conducted to gain an understanding of the burden, distribution, and potential risk factors of CE in Bhutan. From January 2015 to December 2019 data from Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and 6 other district-level hospitals were reviewed. Descriptive statistics were used to summarize the data. DALYs and Poisson regression models were used to estimate the burden and explore the relationship between cases and possible risk factors. A total of 159 cases were recorded. Most cases (145) were admitted to the surgical ward and 14 cases were referred to India. The average annual incidence was 4.4 cases per 100 000 population. The burden of disease was estimated to be approximately 39 DALYs per year for treatment-seeking cases, or possibly 80 DALYs per year including non-treatment seeking cases. This translates to approximately to 5.2 DALYs and 10.2 per 100 000 per year respectively. The commonest sites of infection were the liver (78%) and lungs (13%). Most cases were treated with surgery (>82%), and more than 47% were admitted to the hospital for >4 days. Policy interventions targeting community engagement, awareness, education, high risk occupational groups, females, and those living in the endemic districts of the central and western regions may yield larger gains. More studies and the institution of a surveillance system can help better guide policy interventions.

We performed molecular characterization of Orientia tsutsugamushi on DNA sequences from 5 patients from Bhutan with scrub typhus. In the 56 kDa gene, all isolates aligned with those from other Asia countries, including Nepal, India, Thailand, and Taiwan. High serum IgM titers correlated with PCR positivity in acutely ill patients.

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.

Introduction Globally, colorectal cancer is the third most common cancer and the third leading cause of cancer-related deaths. This study describes the clinical and epidemiological profile of patients with colorectal cancer diagnosed at the Jigme Dorji Wangchuck National Referral Hospital, the only hospital with onco-surgery services in Bhutan. Methods This was a cross-sectional study based on the review of records of patients diagnosed with colorectal cancer between 2018 and 2024 at the National Referral Hospital, Thimphu. Results There were 182 patients diagnosed with colorectal cancers in the six-year period. The highest proportions were observed in the Trashigang (28, 15.4%), Pema Gatshel (15, 8.2%), Mongar (14, 7.7%), Samtse (14, 7.7%) and Sarpang (14, 7.7%) districts. The mean age at diagnosis was 61.5 ± 15.6 years; almost half were males (95, 52.2%) and 82 (45.1%) were ≥ 65 years. The common presenting symptoms were abdominal pain (48, 26.4%), altered bowel habits (35, 19.2%), and per rectal bleeding (33, 18.1%). The predominant location of the tumour was in the middle/lower rectum (43, 23.6%) and the right colon (40, 22.0%). The majority of the patients were diagnosed with Stage III (59, 32.4%) and Stage IV (16, 8.8%) diseases. The dominant histology pattern was adenocarcinoma (38, 20.9%). The common form of treatment offered was surgery with chemotherapy (74, 40.7%). Conclusion Higher proportion of colorectal cancers were reported among older adults and with Stage III or IV disease. This study reports the baseline description of patients with colorectal cancer in Bhutan.

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].

In 2023, Bhutan detected an outbreak of acute hemorrhagic conjunctivitis (AHC) in southern and central regions, coinciding with similar outbreaks reported in South and Southeast Asia. Laboratory results from clinical specimens were initially inconclusive in identifying the etiological agent. To address this, 18 clinical samples, comprising conjunctival swabs and throat/nasal swabs from nine patients were collected and sent to WRAIR-AFRIMS for further analysis. Specimens were tested using multiplex real-time RT-PCR (Fast-track respiratory 21 kit, FTD21) and hybrid-capture-based next-generation sequencing (NGS) with the Illumina Viral Surveillance Panel. FTD21 testing identified human adenovirus, human bocavirus, influenza A, enterovirus, and/or human rhinovirus in 10/18 specimens (56%). A higher detection rate was observed in conjunctival specimens (78%, 7/9) compared to throat/nasal specimens (33%, 3/9) from the same patients, highlighting the increased sensitivity of conjunctival samples in identifying causative agents of conjunctivitis. Further assessment by NGS detected only coxsackievirus A24 variant (CVA24v) genotype IV in 9/17 specimens (53%), with detection primarily from conjunctival samples. Phylogenetic analyses of CVA24v VP1 sequences revealed genetic distinctions in the 2023 isolates compared to prior outbreaks from 2002–2017, suggesting re-emergence driven by novel genetic mutations. These findings suggest that conjunctival samples are more reliable for detecting the etiological agent in AHC outbreaks compared to throat/nasal swabs. Additionally, the identification of a novel strain of CVA24v genotype IV underscores the importance of genomics.