Background: The proportion of incident cases of HPV-attributable cancers is highest in the low-and middleincome countries (LMICs) but many are yet to initiate HPV vaccination programs. This meta-analysis was performed to assess the uptake of HPV vaccination in LMICs at the beginning of the global strategy to eliminate cervical cancer and describes the gaps and challenges. Methods: A systematic search was conducted in PubMed, EMBASE, Scopus, Web of Science, and CENTRAL databases for observational studies that reported the uptake of HPV vaccination until October 2020. The meta-analysis was done using a random-effects model to assess the pooled estimate of HPV uptake. CRD42021218429 Findings: During 2008À2020, an estimated 3.3 million females received at least one dose of HPV vaccine with 61.69% of the target population vaccinated. In countries with high uptake, the pooled estimate of uptake was higher in females than males (45.48% vs 8.45%) and showed significant decline in 2015À2020 compared to 2006À2014 (89.03% vs 41.48%). In countries with low uptake, the estimate of uptake was low in both males and females (5.31% vs 2.93%) and showed increase in uptake in 2015À2020 compared to 2006À2014 (0.76% vs 5.22%). In countries with high uptake, compared to routine programs, the estimate was higher when delivered through demonstration programs (89.94% vs 59.74%). Interpretation: The major concern was a significant drop in the uptake in countries that started with high uptake, challenges in the maintenance of vaccine uptake, sustainability of funding and the lack of standard monitoring and reporting.
The elimination of HPV is "embedded" in several cervical cancer prevention initiatives. Cervical cancer is a global public health concern and a leading cause of mortality among women with an estimated 570 000 cases and 311 000 deaths in 2018. 1 Low-and middle-income countries have a substantially higher burden of cervical cancers due to lack of organized screening and vaccination programs, and lack of access to adequate treatment facilities. 2 Cervical cancer is both preventable-via HPV vaccination (primary prevention) and screening (secondary prevention)-and also curable when detected early and treated adequately. 3,4 The World Health
Background The third Sustainable Development Goal for 2030 development agenda aims to reduce maternal and newborn deaths. Pregnant women’s understanding of danger signs is an important factor in seeking timely care during emergencies. We assessed knowledge of obstetric danger signs using both recall and understanding of appropriate action required during obstetric emergencies. Methods This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan’s largest hospital in Thimphu. Recall was assessed against seven obstetric danger signs outlined in the Mother and Child Health Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Knowledge was scored out of 20 points and reported as ‘good’ (≥80%), ‘satisfactory’ (60–79%) and ‘poor’ (< 60%). Correlation between participant characteristics and knowledge score as well as number of danger signs recalled was tested using Pearson’s correlation coefficient. Association between knowledge score and participant characteristics was tested using t-tests (and Kruskal-Wallis test) for numeric variables. Socio-demographic and clinical characteristics associated with the level of knowledge ('good’ versus ‘satisfactory’ and ‘poor’ combined) were assessed with odds ratios using a log-binomial regression model. All results with p < 0.05 were considered significant. Results Four hundred and twenty-two women responded to the survey (response rate = 96.0%). Mean (±SD) knowledge score was 12 (±2.5). Twenty women (4.7%) had ‘good’ knowledge, 245 (58.1%) had ‘satisfactory’ knowledge and 157 (37.2%) had ‘poor’ knowledge. The median number of danger signs recalled was 2 (IQR 1, 3) while 68 women (20.3%) could not recall any danger signs. Most women were knowledgeable about pre-labour rupture of membranes (96.0%) while very few women were knowledgeable about spotting during pregnancy (19.9%). Both knowledge score and number of danger signs recalled had significant correlation with the period of gestation. Women with previous surgery on the reproductive tract had higher odds of having ‘good’ level of knowledge. Conclusions Most pregnant women had ‘satisfactory’ knowledge score with poor explicit recall of danger signs. However, women recognized obstetric emergencies and identified the appropriate action warranted.
Bhutan—a landlocked country in South Asia—has reported 3381 COVID-19 cases per million population and three deaths until August 2021. The country implemented stringent public health measures to prevent widespread outbreak of COVID-19. This paper describes travel-related measures taken by Bhutan and discusses the way forward after COVID-19 vaccination.
Background Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. Methods This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015–2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital. Results For the period 2015–2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were ‘past caesarean section’ (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%). Conclusion Bhutan’s caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan’s efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.
Background: The carriage of loads on the back in children, >10% of one’s body weight (BW), induces postural change and morbidity related to spinal pain. We studied the weight of schoolbags and the prevalence of musculoskeletal pain related to carrying schoolbags among children in Thimphu, Bhutan. Methods: This was a cross-sectional study, with a multistage cluster sampling, conducted amongst grade 8 and 10 students. Data were collected using a standardized self-administered questionnaire and weights of students and schoolbags were measured. Descriptive statistics were used to present the findings. Means were compared using t test and risk factors were identified using logistic regression. Results: There were 131 students whose schoolbags weighed >10% body weight (BW). The mean weight of schoolbags was 4.6 ±1.5 kg for grade 8 students and 4.0 ±1.5 kg for grade 10 students. Musculoskeletal pain in at least one body region was reported by 411 students. Schoolbags weighing >10% BW and carrying the bags over only one shoulder were significant risk factors for reporting musculoskeletal pain. There were 197 students whose schoolbags did not have any safety feature; students did not use them consistently even if they were present. Conclusions: The weight of school bags that were more than the recommended ≤10% BW was a strong factor in reporting musculoskeletal pain. Parents and students may be educated on the use of schoolbags with safety features. Measures such as providing storage facilities in schools may reduce the weight of bags.
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