ISBN 978-4-909675-21-7The Medical Education Project was conducted
as a technical cooperation project in two phases. In
the first phase (1980-1989), strengthening education,clinical practice, and the research infrastructure forbasic medicine and clinical medicine were mainly
implemented. In the second phase (1989-1996), a
technical cooperation project was implemented,
focusing mainly on improving medical education to haveTechnical Cooperation in Medical Education Project (1995)

international accreditation, enhancing the function ofbasic medicine, clinical medicine, and research, as wellas improving hospital management function. As a resultof the technical cooperation project over 16 years, thefoundation for a medical education system, hospitalmanagement, clinical medicine, research, and nursing
education was constructed at IOM.
2) After Completion of the Technical Cooperation
Project
The Medical Education Project was completed
in July 1996. Since then, IOM has greatly contributed tohealthcare in Nepal, gaining the trust of the people as

Symposium on Infection Control (2009)

the most important medical institution in Nepal. Human
resources trained by the technical cooperation project play leading roles not only in the capital Kathmandu
but throughout the nation, greatly contributing to the medical and healthcare field in Nepal. Aftercompletion of the project, based on the good relationship developed during the project, NCGM and IOM
have conducted small scale collaborative research activities on hepatitis, helicobacter infection, diarrhea,
multi-drug resistant bacteria in respiratory tract infections, etc. Due to continued unstable politicalconditions in Nepal, cooperative relations were temporarily suspended, but with the stabilizing of politicalconditions in recent years, the good relationship has been recovering.
In September 2009, a joint symposium on nosocomial infection control was held at IOM jointly
organized by NCGM and IOM, resulting in greater awareness of the importance of infection control andresearch collaboration. At the conference, successful technical cooperation in nosocomial infection control
IOM-NCGM Research Collaboration Office Annual Report 20137

in Vietnam was introduced. In 2013, the “Joint Conference on Infectious Diseases with Growing Concern in
Recent Years in Nepal” was held at IOM.
3. Conclusion of MOU and the Establishment of NCGM-IOM Research Collaboration Office
On January 18, 2013, NCGM concluded an agreement of cooperation with IOM in Nepal for researchand related human resource development, and IOM became the fifth overseas platform for NCGM. The
Memorandum of Understanding (MOU) was signed by the President of NCGM in Tokyo firstly, and then,was signed by the Dean of IOM at IOM in the capital Kathmandu on January 18, 2013. Based on this MOU,
unique activities of NCGM, such as collaborative research on infectious diseases, dual burden of infectious
diseases and non-communicable diseases, and development of human resources related to these researches
came to be actively promoted, seeking to improve healthcare in Nepal. Collaboration between NCGM and
IOM including related institutions (Kathmandu University School of Medicine, Clinics in Kathmandu, etc.)
mainly on research field will be continued hereafter. Conclusion of MOU is considered to be highly effective
for the smooth and efficient implementation of collaborations including related institutions.

Signing of MOU at NCGM (left) and IOM (right) (January 2013)

In September 2013, the IOM-NCGM Research Collaboration Office was established in the academic
building of IOM, and the necessary equipment (desk, chair, computer, projector and scanner) was installed.
One assistant was employed and given an orientation. Currently, although the office is being prepared,
activities utilizing grants from the International Health Cooperation Research (24-5, 25-5, 25-7), a grant from
the Ministry of Health, Labor and Welfare of Japan, are progressing utilizing the office as a platform. IOM’s
Department of Microbiology and NCGM’s Bureau of International Medical Cooperation manage the office
operation.
8

IOM-NCGM Research Collaboration Office Annual Report 2013

The persons in charge of divisions of basic andclinical medicines are the professors for the departmentof Microbiology and Internal Medicine, respectively. In
addition, there is a Research Department to manage
research, which serves as a counterpart.
4. Purpose of the Collaboration between NCGM and IOM
The purpose of this collaboration is to contributeto the healthcare in both countries by collaborative
research and related human resource development, and to

IOM-NCGM Research Collaboration Officestrengthen a reliable relationship.
5. Expected Outcomes
1. To strengthen research activities by the publication and presentation at academic conferences, etc. of
the collaborative research by IOM and NCGM.
2. To obtain research results effectively through collaboration with IOM that is the main medical care andmedical education institution in Nepal.
3. To provide benefits to younger staff members of NCGM by learning about the actual conditions of
medical care in developing countries and how international collaborations are conducted.
4. To promote a relationship by utilizing a good relationship built on the results of the technicalcooperation project.
5. To contribute to the quality improvement of medicalcare in Nepal by conducting researches focused onhigh-priority infectious diseases in Nepal and providing
related technical assistance. These results are also
beneficial for medical care in Japan.
6. To enable wider range of cooperation in the future,
because the inclusion of other medical institutions
other than IOM allows providing other possible
collaboration fields.
7. To contribute to expansion of the benefit of ODA
projects.

Visiting Kathmandu University
School of Medical Sciences to discussresearch collaboration on multi-drug resistant bacteria

IOM-NCGM Research Collaboration Office Annual Report 2013

9•

Recently in Nepal, although there has been increased awareness regarding nosocomial infection control,
implementation of control measures is still limited. In the Medical Education Project, technical guidance
was provided in almost all fields of medical care, but only control measures against nosocomial infection
were not included in the technical cooperation subjects. This was partly because of the poor awarenessfor nosocomial infection control even in developed countries including Japan at that time. Nosocomial
infection control is also an important research theme for NCGM-IOM collaborative research.
Effective nosocomial infection control is crucial in the healthcare facilities of developing countries,
but in actual fact, attention to it is still limited and control measures are not functioning well in many
countries. This study has been conducted with the purpose to investigate the actual conditions of
nosocomial infection control in Kathmandu City, Nepal as a basis for the possible contribution to its
improvement. (Research grants 25-7, 24-5)•

Collaborative researches are being conducted in Nepal utilizing the IOM-NCGM Research Collaboration
Office as a base (platform). Improvement of the base functions is essential to conduct researchsmoothly. We are trying to strengthen the function of the IOM-NCGM Research Collaboration Officeaiming at smooth implementation of researches and human resource development. 1n 2013 thefollowing activities were conducted. (Research grant 25-5)① Strengthening of management capacity of IOMNCGM Collaboration Office② Comparative study on outcomes of Medical 		
Education Project and current IOM/TUTH③ Preparation for enhancement of human resource
development④ Making the Annual Report 2013, NCGM-IOM 		
Research Collaboration Office
Collaboration with Nursing Director of TUTH
(right) to improve nosocomial infection control

2. Outline of each research
Table 1 shows overview of the collaborative researches between NCGM and IOM. Progress statusof each research (No. 1-6) is described on pages 13-22. We have already obtained some results, and these
IOM-NCGM Research Collaboration Office Annual Report 201311

results were published at medical conferences and on scientific papers as shown on pages 49-91 (related
papers in 2011 and 2012 are also included in addition to the papers in 2013). Among these researches it
is particularly outstanding that new strain of New Delhi metalo-β-lactactamase producer was identified
among the nosocomial infection cases and named NDM-8 (Cf. Pages 15-16, 71-73, 81-83)
Table 1		No.

Chief Researchers in Japan and Nepal
•

1

•

•
2

•

•
3

•

•
4
•

•
5

•

•
6

Collaborative researches in NCGM-IOM Collaboration Center, Nepal•

Affiliation in Nepal

Subject

Sourceof fund

Hiroshi Ohara (Bureau ofInternational Medical Cooperation, •NCGM)J e e va n B S h e rc h a n d ( D e p t . o f •Public Health, Insitutie of Meidicne,
Tribhuvan University)

Institute of Medicine,
Assessment of the interface between
Tribhuvan University
malaria control program and healthFaculty of Medicine,system strengthening
Kathandu University

24-5*

Te r u o K i r i k a e ( R e s e a r c hInstitute,NCGM)•
Bharat M. Pokhrel (Dept. ofMicrobiology, Institute of Medicine,
Tribhuvan University)

Institute of Medicine, Molecular epidemiology of nosocomial
Tribhuvan University
pathogens in developing countries

24-5*

Norio Ohmagari (Disease Control andPrevention Center, NCGM)•
Jatan Sherchan (School of Medicine,
Kathmandu University)

Evaluation of changing epidemiology
S c h o o l o f M e d i c i n e , of infectious diseases in a developing
Kathmandu University
countr y: The role of healthcare
associated opportunistic infections

24-5*

•
S h i n s a ku S a ku ra d a ( B u re a u o f
International Medical Cooperation,•
NCGM)
Jeevan B Sherchand (Tribhuvan•
University, Kathmandu)

Institute of Medicine,
Tribhuvan University,
Study on double burden tuberculosis
School of Medicine,(TB) and non-communicable diseases
Kathmandu Univeristy,(NCD) in Nepal
3 clinics in Kathmandu
City

24-5

Hiroshi Ohara (Bureau ofInternational Medical Cooperation,
NCGM)•
Bharat M. Pokhrel (Dept. ofMicrobiology, Institute of Medicine,
Tribhuvan University, Nepal)

Fact-finding survey of nosocomial
Institute of Medicine, infection control in major hospitals
Tribhuvan University
in Nepal and discussion on effective
improvement plans

24-5*
25-7*

Hiroshi Ohara (Bureau ofInternational, Medical Cooperation, •NCGM)
Bharat M. Pokhrel (Dept. of •Microbiology, Institute of Medicine,
Tribhuvan University)

Studies on enhancement of humanInstitute of Medicine, resource development utilizing the
Tribhuvan University,
IOM-NCGM Collaboration CenterS c h o o l o f M e i c i n e , - taking into consideration of the
Kathmandu University
dissemination of the benefits of ODA
project

25-5** grants from the International Health Cooperation Research, a grant from the Ministry of Health, Labor and Welfare of Japan

12

IOM-NCGM Research Collaboration Office Annual Report 2013

Research No.1
1.

Title(in English)

Assessment of the interface between malaria control program and health systemstrengthening

2.

Title(in Japanese)

マラリア対策とヘルスシステム強化に関する研究

3.

Main researcher

Hiroshi Ohara (Bureau of International Medical Cooperation, National Center for Global
Health and Medicine)4.

Co-Researcher(s)Jeevan B. Sherchand (Dept. of Public Health, Institute of Medicine, Tribhuvan University,
Nepal)
Jatan B. Sherchan (Dept. of Microbiology, Faculty of Medicine, Kathmandu University)

5.

Resource of fund

Grants of National Center for Global Health and Medicine (24-5)

6.

Affiliation(s) in Nepal

Department of Public Health, Institute of Medicine, Tribhuvan University,

7.

Period of the research

January 2012- March 20148.

Publications

Oral presentation
1. 53th Annual Meeting of the Japanese Society of Tropical Medicine, October 2012,
Obihiro, Japan
2. 54th Annual Meeting of the Japanese Society of Tropical Medicine, October 2013,
Ngasaki, Japan
Report (submitted to WHO)
1. Assessment of Health systems in relation to interface between malaria control
programs and health system strengthening: comparative study among Lao PDR,
Nepal and Viet Nam

9.

Summary:
Malaria has been a high priority issue in many tropical and sub-tropical countries. In order to implement malaria
control program effectively, it is crucial to utilize health system effectively. In this study, interactions between
malaria control program and health system strengthening was assessed.
The primary studies were conducted in Nepal and Vietnam with the methods of key informant interviews,
investigation in malaria endemic areas and document review. As retrospective study, encountered challenges inmalaria control and interventions for them were analyzed from the viewpoint of interactions between disease
specific program and general health system using the 6 Building Blocks of Health System Strengthening of WHO(Leadership and Governance, Service delivery, Workforce, Information system, Medical products and technologies,
and Financing). In addition, current challenges in malaria control were identified and possible interventions werediscussed.
In Nepal, malaria was showing high morbidity and mortality rate until the middle of 1990s, however thereafter
it decreased remarkably due to the effective control program. Leading factors contributed to the successful control
were identified as the best practices.
In Nepal, the general health system, which was fragile in the past, was strengthened and utilized in greater partin the malaria control program. During the period of political instability (1996-2006), health systems were affected,
but the influence on malaria control was minimal compared with other disease control programs due to the high13

governmental priority placed on malaria control and continuous support of the international community.
The followings were recognized as leading current challenges in malaria control in Nepal: 1) Increase of malaria
in some areas associated with population movement, 2) Shortage of health manpower in remote areas, 3) Poorly
developed reporting system from the private health sector, 4) Difficulty in treatment due to increasing resistanceof P. falciparum to anti- malaria drugs,    5) Low incentive for health workers, 6) existence of inequity of bednets
distribution.
We made a further study in 4 districts in Terai areas with the aim to examine variation in utilization of bednets
by socioecomomic groups and inequities in access to malaria control services. This study revealed the wider
disparity and pro-rich inequities in ownership of bednets. This implies that rich people were more likely to own anduse bednets than their poor counterparts. In area without bednet intervention, ownership was significantly higher
in the rich households. There was significant variation in bednet ownership across caste/ethnic groups. Disparity
in ownership between the poorest and richest group appeared to be smaller in area with bednet intervention andpeople equally use bednets irrespective of caste and ethnic background. Free mass distribution of bednets allowed
equitable ownership and reduce the inequality in usage of bednets across socioecomomic groups.
The results suggested that if provided freely, bednet distribution program will be an important opportunity to
reduce socioecomomic inequity in usage by allowing equitable ownership among the households of malaria risk
area.

14

IOM-NCGM Research Collaboration Office Annual Report 2013

Research No.2
1.

Title(in English)

Molecular epidemiology of nosocomial pathogens in developing countries

2.

Title(in Japanese)

開発途上国の医療機関で分離される多剤耐性菌の推移に関する研究

3.

Main researcher

Teruo Kirikae (Department of Infectious Diseases, Research Institute, National Center for
Global Health and Medicine)4.

Co-Researcher(s)Bharat M. Pokhrel (Dept. of Microbiology, Institute of Medicine, Tribhuvan University,
Nepal)

5.

Resource of fund

Grants of National Center for Global Health and Medicine (24-5)

6.

Affiliation(s) in Nepal

Department of Microbiology, Institute of Medicine, Tribhuban University,

7.

Period of the research

April 2012- March 20158.

Publications

1. Int J Antimicrob Agens. 2013, 42(4):372-374
2. Antimicrob Agents Chemother. 2013, 57(5):2394-2396
Oral presentation
1. 42th Annual Meeting of the Society for Bacterial Drug Resistance, October 2013,
Shizuoka, Japan

9.

Summary:
Emergenece of multidrug-resistant pathogens has become one of the most serious problems in medical settings
worldwide. There are serious concerns about dissemination of multidrug-resistant nosocomial pathogens in Nepal.
We started a study project of drug resistant pathogens isolated from inpatients hospitalized in Tribuvan
University Teaching Hospital, Kathomandu, Nepal, in collaboration between Department of Microbiology, Instituteof Medicine, Tribhuvan University and National Center for Global Health and Medicine from April 2012. Professor
Dr. Bharat M. Pokhrel and his colleagues obtained 308 Gram-negative isolates by November 2013, including
91 (29.5%) Acinetobactor baumannii, 80 (26.0%) Escherichia coli, 53 (17.2%) Klebsiella pneumoniae, 19 (6.2%)
Pseudomonas aeruginosa, and 9 (2.9%) Stenotrophomonas maltophilia isolates. Of 308 isolates, 194 isolates werehighly resistant to all aminoglycosides tested, including amikacin, arbekacin and gentamicin, with MICs of morethan 512 mg/L. These isolates had 16S rRNA methylase genes, including armA, rmtB, rmtC, rmtF.
Of the 80 E. coli isolates, we detected a novel NDM-type metallo-β-lactamase variant, NDM-8, in 5 isolates.
The amino acid sequence of NDM-8 has substitutions at positions 130 (Asp to Gly) and 154 (Met to Leu)compared with NDM-1. Expression of the blaNDM-8 and blaNDM-1 genes in E. coli DH5α conferred resistanceor reduced susceptibility to all cephalosporins, moxalactam, and carbapenems. The MICs of cefmetazole,cefoselis, cefpirome, doripenem, imipemen, panipenem, and moxalactam were one dilution higher for E. coli
expressing NDM-8 than NDM-1. In contrast, those of ceftriaxone and meropenem were one dilution lower
for NDM-8 than NDM-1. NDM-8 showed enzymatic activities against β-lactams similar to those of NDM-1.
We reported that multidrug-resistant Klebsiella pneumoniae clinical isolates with Various Combinations of
Carbapenemases (NDM-1 and OXA-72) and 16S rRNA Methylases (ArmA, RmtC and RmtF) were disseminating
in a medical setting in Nepal. Of 25 clinical isolates Klebsiella pneumonia obtained in 2012, 17 were resistant toimipenem and meropenem with MICs ≥4 mg/L, and 20 were highly resistant to arbekacin, amikacin and gentamicin
with MICs ≥512 mg/L.

IOM-NCGM Research Collaboration Office Annual Report 201315

The carbapenemase encoding genes blaNDM-1 and blaOXA-72 were observed in 17 and 9 isolates, respectively;
and the 16S rRNA methylase encoding genes armA, rmtC and rmtF were observed in 9, 5, and 9 isolates,
respectively. Fourteen isolates belonged to clonal complex (CC) 14 and 5 to CC11. Thirteen isolates belonged tomultilocus sequence type (MLST) ST15, 3 isolates to ST340, and 1 isolate each to types ST11, ST14, ST29, ST43,
ST378, ST395, ST437, ST1231 and ST1232. Pulsed-field gel electrophoresis (PFGE) pattern analysis showed 2clusters with more than 60% similarity, results mostly corresponding with those of MLST. These results suggestthat carbapenem- and aminoglycoside-resistant K. pneumoniae isolates producing various combinations ofcarbapenemase and 16S rRNA methylases are disseminated in medical settings in Nepal.
These data indicates that 16S rRNA methylase producing Gram-negative nosocomial pathogen are prevalent inmedical settings in Nepal. The project is currently in progress until March 2015.

16

IOM-NCGM Research Collaboration Office Annual Report 2013

Research No.3
1.

Title(in English)

Evaluation of changing epidemiology of infectious diseases in a developing country: The
role of healthcare associated opportunistic infections

2.

Title(in Japanese)

途上国における感染症の変貌と要因に関する研究 - 特に医療に関連した日和見感染に関する検討 -

3.

Main researcher

Norio Ohmagari (Disease Control and Prevention Center, National Center for Global
Health and Medicine)4.

Co-Researcher(s)Jatan Sherchan (Department of Medical Microbiology, Kathmandu University, School of
Medical Sciences, Nepal)
Kayoko Hayakawa (Disease Control and Prevention Center, National Center for Global
Health and Medicine)
Maki Nagamatsu (Disease Control and Prevention Center, National Center for Global
Health and Medicine)5.

Resource of fund

Grants of National Center for Global Health and Medicine (24-5)

6.

Affiliation(s) in Nepal

Department of Medical Microbiology, Kathmandu University, School of Medical Sciences

7.

Period of the research

September 2012- March 20148.

Publications

Molecular epidemiology and antibiotic susceptibility of IMP-type metallo-beta-lactamaseproducing Enterobacter cloacae isolated in a tertiary medical center in Japan.
T. Miyoshi-Akiyama, K. Hayakawa, M. Nagamatsu, K. Shimada, M. Kazuhisa, S. Kubota, E.
Kuroda, Y. Sugiki, M. Tojo, N. Takeshita, M. Ujiie, S. Kutsuna, Y. Hamada, N. Ohmagari, T.
Kirikae. Presented as poster at ID week, San Francisco, Oct, 2013.

9.

Summary:
The objective of this study is to evaluate the clinical epidemiology of opportunistic healthcare associatedinfections as well as infections due to drug-resistant pathogens in a developing country. The information would be
useful to seek for the effective preventing methods for healthcare associated infections and/or infections due todrug-resistant pathogens. Information pertaining to opportunistic healthcare associated infections in developing
countries are limited, and thus, this research would provide the valuable information. In addition, infections due
to drug-resistant pathogens pose serious public threat worldwide. The results from Nepal where there has beensparse information on clinical epidemiology of drug resistant pathogens would be beneficial in terms of providing
the epidemiology of global spread of resistant pathogens and their impact.
The study would include the analyses of the epidemiology of drug-resistant pathogens in Japan, and thecomparisons of epidemiological differences between two countries. These analyses would enable to identify the
key epidemiological factors associated specifically to opportunistic healthcare associated infections due to drugresistant pathogens in a developing country.

IOM-NCGM Research Collaboration Office Annual Report 201317

Research No.4
1.

Title(in English)

Study on double burden tuberculosis (TB) and non-communicable diseases (NCD) in
Nepal

2.

Title(in Japanese)

ネパールにおける結核と非感染性疾患の二重負荷に関する研究

3.

Main researcher

Shinsaku Sakurada (Bureau of International Medical Cooperation, NCGM)

4.

Co-Researcher(s)Takanori Hirayama (JATA/RIT), Yuko Tsuda (Health Bureau of Osaka City), Shyam K
Shrestha (FSB Clinic, Kathmandu), Jatan B Sherchan (Kathmandu University School of
Medicine, Dhulikhel), Kishor S Manandhar (CF Clinic, Kathmandu), Jeevan B Sherchand(Tribhuvan University, Kathmandu)

5.

Resource of fund

Grants of National Center for Global Health and Medicine (24-5)

6.

Affiliation(s) in Nepal

Department of Public Health, Institute of Medicine, Tribhuvan University, Kathmandu,
Nepal

7.

Period of the research

September, 2012-March, 20148.

Publications

Oral Presentation:
Joint Conference on Infectious Diseases with growing Concern in Recent Years in Nepal, inJanuary 2013.

9.

Summary:
NCD in developing countries has increased in recent decades and may affect control of communicable diseases inparticular TB. In Nepal incidence of TB has recently increased in elderly populations (>65 years old) but decreased
in young populations. This trend may inevitably lead Nepali people to double burden of TB and NCD. Our objective
is to survey the present status of TB and NCD in Kathmandu by epidemiological and sociological methods.
We conducted a clinic-epidemiological study at three clinics in Kathmandu city. One sampling site was a clinic ofrespirology expert, another two sampling sites were general clinics but one of those was located in the thickly
populated area with Tibetan refugees. We used use simple questionnaires with written informed consent to detectdouble burden cases. Then, we conducted focus group discussion (FGD) with heath officials, medical doctors,
public health nurses and DOTS providers in Kathmandu. We collected 414 TB samples and 649 NCD samples
from three sites. Preliminary analysis has shown high prevalence of TB among NCD patiernts in one general clinic
located in the commercial area of Kathmandu city. While the estimated prevalence of TB in Nepal, 2010 was 238
per 100,000 populations, but that in the general clinic was 2,800 per 100,000 populations (the number of newly
diagnosed patients was 8 in 282 NCD patients). There was ten-folds higher TB prevalence among NCD patients. In
FGD medical doctors agreed that the awareness of double burden is important in the both sides of patients andhealth care providers. They have a plan to distribute posters to clinics in Kathmandu to aware the double burden.
The results of this study might contribute to measures against TB control in a new era with double burden with
NCD.

18

IOM-NCGM Research Collaboration Office Annual Report 2013

Research No.5
1.

Title(in English)

Fact-finding survey of nosocomial infection control in major hospitals in Nepal andplanning of effective improvement

2.

Title(in Japanese)

ネパールの主要病院における院内感染対策の実情分析と効果的な改善策に関する検討

3.

Main researcher

Hiroshi Ohara (Bureau of International Medical Cooperation, National Center for Global
Health and Medicine)4.

Co-Researcher(s)Pokhrel BM, Shrestha RK, Dahal RK, Mishra SK, Kattel HP, Rijal BP (Dept. of Microbiology,
Institute of Medicine, Tribhuvan University, Nepal)
Jeevan B. Sherchand (Dept. of Public Health, Institute of Medicine, Tribhuvan University,
Nepal)
Shreshta DL (Dept. of Nursing Management, Tribhuvan University, Nepal)
Teruo Kirikae, Yumiko Haneishi (Bureau of International Medical Cooperation, National
Center for Global Health and Medicine)5.

Resource of fund

Grants of National Center for Global Health and Medicine (24-5, 25-7)

6.

Affiliation(s) in Nepal

Department of Microbiology, Institute of Medicine, Tribhuban University,

7.

Period of the research

September 2012- March 20168.

Publications

Oral presentation
1) 53th Annual Meeting of the Japanese Society of Tropical Medicine, October 2012,
Obihiro, Japan2) 54th Annual Meeting of the Japanese Society of Tropical Medicine, October 2013,
Ngasaki, Japan
Scientific Paper
1) Fact-finding survey of nosocomial infection control in hospitals in Kathmandu, Nepal- abasis for improvement, Trop Med Heatlh, 41(3): 113-119, 2013
2) Ventilator associated pneumonia in tertiary care hospital, Maharajgunj, Kathmandu,
Nepal, J Inst Med, 35(3) 21-28, 20139.

Summary:
In developing countries, where the incidence of infectious diseases is high and environmental conditions ofhealthcare facilities are poor, nosocomial infections may frequently occur. Effective nosocomial infection control
is crucial in the healthcare facilities of developing countries, but in actual fact, attention to it is still limited andcontrol measures are not functioning well in many countries. This study has been conducted with the purpose toinvestigate the actual conditions of nosocomial infection control in Kathmandu City, Nepal a basis for the possible
contribution to its improvement.
1. Fact-finding survey of nosocomial infection control in hospitals in Kathmandu, Nepal- a basis for improvement
The survey was conducted at 17 hospitals and the methods included a questionnaire, site visits and interviews.
Nine hospitals had manuals on nosocomial infection control, and seven had an infection control committee (ICC).
The number of hospitals that met the required amount of personal protective equipment preparation was asfollows: gowns (13), gloves (13), surgical masks (12).

IOM-NCGM Research Collaboration Office Annual Report 201319

Six hospitals had carried out in-service training over the past one year, but seven hospitals responded that nostaff had been trained. Eight hospitals were conducting surveillance based on the results of bacteriological testing.
The major problems included inadequate management of ICC, insufficient training opportunities for hospital
staff, and lack of essential equipment. Moreover, increasing bacterial resistance to antibiotics was recognized
as a growing issue. In comparison with the results conducted in 2003 targeting five governmental hospitals,
a steady improvement was observed, but further improvements are needed in terms of the provision of highquality medical care. Particularly, dissemination of appropriate manuals, enhancement of basic techniques, andstrengthening of the infection control system should be given priority.
2. Ventilator Associated Pneumonia in Tertiary Care Hospital, Maharajgunj, Kathmandu, Nepal
Ventilator Associate Pneumonia (VAP) is the most common nosocomial infection among ICU patients and lack ofmuch information in Nepal. This study was conducted to determine prevalence and bacteriological profile of VAP
with special reference to multi-drug resistant (MDR), Methicillin-resistant Staphylococcus aureus (MRSA), Metalloβ-Lactamase (MBL), Extended-Spectrum β-Lactamase (ESBL)- producing bacterial strains.  A total of 150 tracheal
specimens were studied as described by Americal Society for Microbiology. Combination disk method was done forthe detection of ESBL and MBL producing isolates.
Prevalence of BAP was found to be 34%. Acinetobacter calcoaceticus baumanii complex (44%) was thecommonest isolate, followed by Klebsiella pneumoniae (22%), Psudomonas aeruginosa (16%) and Staphylococus
aureus (12%).  Among MDR Gram negative bacteria, 39% were MBL and 33% were ESBL-producers. Prevalence of
MRSA was 75%, which were all sensitive to Vancomycin.
  High prevalene of VAP, MDR along with MRSA or ESBL or MBL producing straings was found in this study. Thus,
suitable control measures must be adopted to cope with this alarming situation with genetic characterization.

20

IOM-NCGM Research Collaboration Office Annual Report 2013

Research No.6
1.

Title(in English)

Studies on enhancement of human resource development utilizing the IOM-NCGM
Collaboration Center — taking into consideration of the dissemination of the benefits of
ODA project2.

Title(in Japanese)

ネパール拠点を活用した人材育成能力強化に関する研究 - ODA プロジェクトの成果拡大を視野に入れて3.

Main researcher

Hiroshi Ohara (Bureau of International Medical Cooperation, National Center for Global
Health and Medicine)4.

Co-Researcher(s)Bharat M. Pokhrel
Jeevan B. Sherchand (Dept. of Public Health, Institute of Medicine, Tribhuvan University,
Nepal)
Karbir N. Yogi (Dept. of Pulmonology, TUTH)
Mitsuhiro Kamimura (Dept. of Pulmonology, National Disaster Medical Center)
Pradeep Shrestha (Dept. of Internal Medicine, TUTH)

5.

Resource of fund

Grants of National Center for Global Health and Medicine (25-5)

6.

Affiliation(s) in Nepal

Department of Public Health, Institute of Medicine, Tribhuvan University,

7.

Period of the research

April 2013- March 20158.

Publications

9.

Summary:
Collaborative researches are being conducted in Nepal utilizing the IOM-NCGM Collaboration Office as a base.
Strengthening of the base functions is essential to conduct researches smoothly. This study was started tostrengthen the function of the IOM-NCGM Collaboration Office aiming at smooth implementation of researches
and human resource development.
In 2013 the following activities were conducted.
Strengthening of management capacity of IOM-NCGM Collaboration Office:Management system to conduct researches/activities was clarified and some instructions were conducted to
local staff. Equipment, which is crucial to conduct research and training activities such as desk, chair, computer,projector and scanner, was prepared at the office.
Comparative study on outcomes of Medical Education Project and current IOM/TUTH:
The overview of the Medical Education Project, which was implemented as Official Development Assistance by JICA
from 1980 to 1996, was summarized and the situations of IOM/TUTH at the end of the project and the present
time were compared.
Enhancement of human resource development:
The following activities were planned or already started.
1) Departments of Research and Microbiology: Hearing on the overall impact of JICA project and current problems
was conducted and it found that research methodology, especially, epidemiological methods and diagnostic
imaging methods were weak.
IOM-NCGM Research Collaboration Office Annual Report 2013212) Department of Pulmonology:
Regarding the upcoming research entitled “A case study of interstitial pneumonia at Tribhuvan University Teaching
Hospital”, NCGM started to give assistance on a creation of research plan as well as give advice on medical imaging
diagnosis method (chest X-ray and chest CT) to the department staff.
Making an Annual Report
The first Annual Report of the IOM-NCGM Collaboration Office was made.

22

IOM-NCGM Research Collaboration Office Annual Report 20134. Enhancement of Human Resource Development
After consulting with Research Department, Department of Microbiology, Department of Public
Health and Department of Internal Medicine, Department of Pulmonology the following activities were
initiated, focusing mainly on improving research ability (25-5, 24-5).
1. Research Department: Hearing on the overall impact of JICA project and current problems was
conducted and it found that research methods, especially, epidemiological methods and diagnostic
imaging methods were weak.
2. Department of Public Health:Regarding the collaborative research with the Department of Public Health entitled “Socio-medical
inequities in bed-net use in two different malaria endemicity of Nepal”, after conducting theepidemiological analysis and discussion with the department staff, we created the summary for
conference presentation. Research results were presented at the 54th Annual Meeting of the JapaneseSociety of Tropical Medicine (October 2013, Nagasaki City). The results of this study were summarized ina report and soon to be submitted to MOHP, Nepal.
3. Department of Microbiology:
Training for analysis of drug-resistant bacteria was conducted tothe staff members of Department of Microbiology as a part ofhuman resource development activities. In addition to technicalinstruction at IOM, NCGM invited two graduate students fromthe department to the Department of Infection Control at NCGM
and gave technical instructions from January to February in 2014(24-5). These 2 graduates will continue to do research based on

Technical guidance to the staff ofDepartmentof Microbiology, IOM

techniques learned, with the goal of obtaining PhD degrees.
4. Department of Internal Medicine, Department of Pulmonology:
Regarding the upcoming research entitled “A case study ofinterstitial pneumonia at Tribhuvan University Teaching Hospital”,
NCGM started to give assistance on a creation of research plan
as well as give advice on medical imaging diagnosis method (chest
X-ray and chest CT) to the department staff.

24

IOM-NCGM Research Collaboration Office Annual Report 2013

Collaboration in Internal Medicine

Fig. 1
Adult (15-45) HIV prevalenceFig. 2
Transition of the number of malaria cases and rateof falciparum malaria in Nepal

Report from the Ministry of Health and Population in Nepal (2011)

26

IOM-NCGM Research Collaboration Office Annual Report 2013

Medical Education project Phase 2 (1989-1996)•

Dispatch of Japanese Experts 		

86•

Invitation for Nepalese Trainees

28•

Equipment Provision

Local and International Seminar/ Symposium held by the Project•

HMG/Nepal-JICA Joint Symposium on Cholelithiasis			

6-8 January 1991•

Congress on Altitude Medicine and Physiology 				8 April 1992•

Nursing Research Conference 						2-4 November 1993•

International Symposium on Obstructive Jaundice 			

17-18 February 1994•

International Symposium on Diabetes Mellitus 				23-24 March 1995•

International Symposium on Infectious and Tropical Diseases 		

20-21 march, 1996

2. Grant-Aid:•

1981 Construction of outpatient building, etc.

•

1982 Construction of patients’ ward, etc.

•

1990 Construction of academic building, etc.

•

1991 Extension of patient’s ward, etc.

•

1992 Repair of operation theater, etc.
During the 16 year technical cooperation periodalmost all the basic and advanced techniques regarding
diagnosis, examination, treatment and clinical record,
which were indispensable to the daily medical care andmedical education in IOM/TUTH, were guided. IOM/
TUTH had grown to be a medical institution that carriedout a kernel function of Nepalese medical care, and had
gained extremely high reliance from Nepalese people.
IOM/TUTH developed to be an internationallyacknowledged medical institute; the MBBS (medicine
bachelor bachelor surgery) degree awarded by IOM,28

IOM-NCGM Research Collaboration Office Annual Report 2013

International Symposium on Infectious andTropical Diseases (1996)

Tribhuvan University was recognized by dental andmedical councils of Bangladesh and Pakistan, andmedical councils of India and Sri Lanka. Graduates of IOM
had already pursued post-graduates education in Japan,
Thailand, United Kingdom, U.S.A., and other countries.

Technical cooperation in hospital management

2. CURRENT IOM/TUTH (IN COMPARISON WITH THE PROJECT END OF TIME):
1. General information and activities
IOM was established as the first medical school in Nepal in 1980. Thereafter the number of medical
schools (faculty of medicine, medical university) increased and at the time of project termination in 1986
there were 4 medical schools in Nepal. As of January 2014, the number of medical schools in Nepal is 22,
in which 7 are affiliated with IOM. Post-graduate curriculums including diploma and degree programs havebeen improved so as to provide better medical personnel who can contribute efficiently to medical service.
Since its inception, IOM has produced more than 1,700 medical doctors (as of 1996 it was 307).
These doctors are working, not only in Kathmandu Valley, but also in rural and remote areas of Nepal,
and rendering valuable services. Beside, increasing number of doctors are studying or working in foreigncountries. It is noteworthy that not a few graduates of IOM are working in medical schools across thecountry as professors. Similarly, nursing and co-medical staff trained in IOM/TUTH are rendering medicalcare to the Nepalese people. IOM is carrying out quite important role in medical care as well as medical
education in Nepal. Table 4 shows comparison of hospital general information between 1985 and 2013.
2. Clinical Medicine
TUTH is a general hospital which has 750 beds (as of December 2013) under 20 Clinical
Departments. The equipment which was provided during the project period has been gradually replacedwith new ones, but not a few old equipment are still used. Advanced equipment such as CT scan, MRI,
hemodialyzers are also equipped purchased by Nepalese government. TUTH can provide advanced medicalcare as well as essential medical care and examinations. TUTH has been conferred duties and roles as themost important top referral medical institution in Nepal. Since 1990, Cardiovascular Center, Obstetrics &IOM-NCGM Research Collaboration Office Annual Report 201329

Gynecology Center and Emergency Center have been
constructed by Nepalese Government.
The number of out-patients, in-patients, andsurgical operation has been ever increasing since its
establishment, which means that the importance of
TUTH in Nepalese medical care has been increasing year
by year.
Tribuvan University Teaching Hospital (TUTH)

3. Basic Medicine
Basic Medicine consists of 8 departments, which are responsible for giving lectures and practicalstudies to MBBS students and a variety of post-graduate courses to MBBS graduates. These departments
are integrated in the academic building which was completed in 1992.
Research activities are another important role of the Basic Medicine departments in the university.
The efforts to establish the basis for conducting research were made during the project period, andcurrently active researches are being done (currently more than 200 researches are conducted in IOM/
TUTH). The results of research activities which were conducted in IOM/TUTH have been presented invarious domestic and international medical congresses and journals. The Journal of Institute of Medicine,which was founded by IOM in 1984 as the first medical journal in Nepal developed to be a high level journal
carrying a lot of valuable medical papers and it has become internationally acknowledged journal. Besides
the 8 basic medicine departments, Research department, Department of Information Technology andNational Center for Health Professional Education were set up after the project termination.
4. Prospects
As a result of the 16-year technical cooperation, IOM/TUTH has developed to be one of thebest medical institutions which receives the deep reliance of the nation and makes many contributions
to medical care in Nepal. In addition, the friendly relationship between Nepalese staff and Japanese
staff, and what is more, the Nepalese nation and the Japanese nation, has been firmly established. It isquite important to make the utmost effort to maintain these good results. It is true that the nationwide
expectation for IOM/TUTH as well as duties and roles has been increasing. However, IOM/TUTH has
problems such as small out-patient clinic space, obsolete equipment along with increasing number of non30

IOM-NCGM Research Collaboration Office Annual Report 2013

communicable diseases cases. Hereafter, more and more importance in the quality of medical care will be
attached. We expect IOM/TUTH will make every possible effort in order to live up to these expectations,addressing the existing challenges.

Table 4 		Situation and activities of IOM/TUTH : Comparison between 1985 and 2013)
1985

2013

1

Total No. of beds

401

738

2

No. of charity beds

40

63

3

No. of outpatients served (per year)

229,516

425,163

4

No. of in-patients served (per year)

11,973

19,978

5

Average length of hospitalization (days)

NA

7.27

6

No. of operations (per year)

5,237

11,227

7

Average bed occupancy rate (%)

NA

86.0

8

Number of Clinical Departments

13

20

9

Number of Basic Science Departments(including forensic medicine and public health)

8

8

10

No. of students (per school year grade)

40

75

11

Research department

-

01

12

Department of Information Technology

-

01

13

National Center for Health Professional Education-

01

IOM-NCGM Research Collaboration Office Annual Report 201331

3. Pulmonology Department: JICA project and thereafter
1. General discussion
During the JICA Project period, though each physician had his or her own subspecialty, department
of internal medicine was a single unit without subunit according to specific organs. The only one physician,Dr Rizyal, specialized pulmonology field but the number of the specialists in its field was extremely
unbalanced considering the huge burden of the lung diseases in Nepal. The backgrounds of limited
candidates for pulmonologists are as follows.
•

The results of the sputum examination included smear for tuberculosis bacilli were not reliable.

•

Almost all the cases of lung cancer were far-advanced stage and therapeutic intervention was notindicated, thus even making diagnosis of lung cancer was not rewarding process for the doctors. In
addition, CT was not available, which is essential for the proper diagnosis.

•

Spirometer was not available, which is necessary for diagnosing COPD and bronchial asthma
Nowadays, the quality of various examinations have been improved including sputum examinations,pulmonary function tests, and bronchofiberscope. Accordingly, the number of the doctors in pulmonology
department has been increased up to four.
2. Detailed discussion
˃˃ Diseases
The most common lung disease for admission is acute exacerbation of COPD. The lung cancer is also
common but once diagnosed then the patients will be transferred to Cancer center for the treatment.
Others include bronchial asthma, interstitial pneumonitis and so on. Tuberculosis seems to be common
in the ward, but without isolation. This structure remains almost the same as in the JICA Project period.
˃˃ Bronchoscopy
Before JICA Project, Dr. Prakasa Sayami, thoracic surgeon, was the only one who could practice theprocedure. The project intended to increase the number of the bronchoscopists. Nowadays two
pulmonologists, Prof. Yogi and Dr. Santa, do it, twice a week.

32

IOM-NCGM Research Collaboration Office Annual Report 2013˃˃ Pulmonary function tests
The spirometer, simple and portable one is now available and used for the diagnosis of obstructive lungdiseases.
˃˃ Clinical study
No clinical studies were conducted before the JICA Project. These days studies have been tried, by partthrough continuous activities by NCGM supports. Now the joint study is going on. By handling this study,
the problems which make conduction of clinical study difficult would be clarified, and the improvement
and correction of these problems will be done by first year of this study. One of these issues is the lackof efficient correspondence of the data between Nepal and Japanese institutes, NCGM or Disaster
Medical Center, thus internet connection has been established and improved and IT equipments has
been introduced. This would continuously facilitate the conductance of future joint study. The statisticalanalysis for collected data is supported by the Department of Community Medicine and its quality
control should also be taken into consideration.
3. Problems and future
DM course is not available in TUTH. The course
is established only in Dharan Hospital and Bir Hospital at
the moment. As the central medical institute in Nepal,
TUTH should also introduce one in the pulmonology
Department.
Practical study on respiratory rehabilitation at TUTH

Table 5		Weekly schedule at TUTH

Day

Morning

Afternoon

SundaySpirometry + Bronchoscopy + Ward RoundPulmonology Clinic

MondaySpirometry + Ward Round

DOTS consultation

Tuesday

General Medicine + Pulmonology (OPD)

Ward Round

Wednesday

Spirometry + Bronchoscopy + Ward Round

DOTS consultation

Thursday

General Medicine + Pulmonology (OPD)

Ward Round

FridaySpirometry + Ward RoundIOM-NCGM Research Collaboration Office Annual Report 201333

Attachment-1

11:25-11:45

A-3 : Intravascular catheter-related infections in tertiary care hospital		(Dr. Jatan B. Sherchan, Kathmandu Univ.)

11:45-12:05

A-4: Nursing care with special reference to infection prevention & control at Tribhuvan		University Teacing Hospital(Ns. Dharma L. Shrestha)

Session B:

Multi-drug resistant pathogens

		(Chair persons: Dr. Jatan B. Sherchan, Prof. Hiroshi Yoshikura)

13:00-13:20

B-1: Emergence of 16S rRNA methallo-beta-lactamase producing nosocomial pathogens in		a hospital in Nepal

		(Dr. Teruo Kirikae, NCGM)

13:20-13:40

B-2: Epidemiology on risk factors for isolation of CTX-M type extended- spectrum Betalactamase (ESBL) producing Escherichia coli in a large U.S. medical center		(Dr. Kayoko Hayakawa, NCGM)

Session C:

Vector borne diseases and other infectious diseases with growing concern		(Chair persons: Prof. Jeevan B. Sherchand, Dr. Shinsaku Skurada)

13:00-13:20

C-1: Assessment of the interface between malaria control program & general health systems

		in Nepal
		(Dr. Hiroshi Ohara, NCGM)

13:20-13:40

C-2: Socio-medical study and variation in utilization of bed-nets among different		socioeconomic groups of endemic and resurgence areas of Nepal		(Prof. Jeevan B. Sherchand, IOM)

13:40-14:00

C-3: Study on double burden of tuberculosis and non-communicable diseases in Nepal

		(Dr. Shinsaku Sakurada, NCGM)

14:00-14:20

C-4: Rotavirus gastroenteritis in children under five years of age in Nepal		(Prof. Jeevan B. Sherchand, Dr. Rushika Agrawal, IOM)

14:20-15:00

Discussion

		(Chair persons: Prof. Bharat M. Pokhrel, Prof. Hiroshi Yoshikura, Dr. Hiroshi Ohara )15:00 		Closing remarks: Prof. Prakash Sayami, Dean, IOM
IOM-NCGM Research Collaboration Office Annual Report 201335

Attachment-1(Key note speech)

Collaboration between IOM/TUTH and NCGM based on
the results of the JICA technical cooperation project
Hiroshi Ohara
Bureau of International Medical Cooperation
National Center for Global Health and Medicine, Tokyo, Japan
Tribhuvan University /Institute of Medicine (IOM)/ Teaching Hospital (TUTH) and National Center for Global
Health and Medicine (NCGM) have a long history of cooperation starting technical cooperation project
supported by JICA. During the project, particularly in the second phase, a lot of experts were dispatched from
NCGM and collaborated with TUTH/IOM staff aiming to improve medical and educational situation.
In view of the successful results on the project along with the intimate and reliable relationship, which havebeen created during the project period and subsequent period, IOM/TUTH and NCGM mutually recognized theimportance to continue and develop such precious relationship. After a series of discussion, IOM/TUTH and
NCGM agreed to enter into the Memorandum of Understanding (MOU) to promote collaboration between us
focusing on researches and related activities.
The overall subject of the collaboration is “Studies on the causative factors and trends of infectious diseases
with a growing concern in recent years in Nepal”. Under the above overall subject, sub-researches suchas malaria, multi-drug resistant bacteria, infectious diseases & dual burden, nosocomial infection control,
diarrheal diseases, hepatitis and so on are to be conducted. We are strongly convinced that such collaboration
will actively contribute to promotion of health along with medical science in both countries.
It is a great pleasure that “the Joint Conference on Infectious Diseases with a Growing Concern in Recent Years”
was realized in Kathmandu. This conference is jointly organized by IOM/TUTH and NCGM. A total of 12 papers
are presented in addition to the special lecture of Prof. H. Yoshikura. I hope this joint conference will be quite
successful, our friendly relationship will be tightened and our collaboration is much promoted.

36

IOM-NCGM Research Collaboration Office Annual Report 2013

Attachment-1(Special Lecture)

Geo-demographic consideration of measles elimination
Hiroshi Yoshikura
Adviser, Food Safety Division,
Ministry of Health Labour and Welfare
In 2005, World Health Assembly resolution WHA58.15 endorsed a global goal of measles mortality reduction(by 90% compared to the 2000 level) by 2010 or earlier. The reduction of mortality as expressed above could
be feasible. However, geo-demographical analysis on the progress of measles elimination in Japan and various
WHO regions indicated that attainment of the WHO’s numerical indicator of measles elimination by WHO, lessthan 1 per million population per year, would be very difficult in regions with high population size and density.
Geo-demographical consideration is necessary for programming of eradication/elimination of infectious
diseases. It may be also true for a small scale program like hospital infection.
References
Yoshikura, H. (2012): Relation between Measles Incidence and Population Size under the Advanced Vaccine
Program. Jpn. J. Infect. Dis., 65, 88-91, 2012
Yoshikura, H. (2012): On case-fatality rate: review and hypothesis. Jpn J Infect Dis. 65, 279-88.
Yoshikura, H. (2012): Geo-Demographic Factors Affecting Incidence of Measles. Jpn. J. Infect. Dis., 65, 354-358.
Yoshikura, H. (2012): Negative Impacts of Large Population Size and High Population Density on the Progress of
Measles Elimination. Jpn. J. Infect. Dis., 65, 450-454.
Yoshikura, H. (2012): Parameters That Characterize Different Food-Poisoning Outbreaks. Jpn. J. Infect. Dis., 65,
187-191.
Yanaka, Y, Tusaka, N, Yamamoto, K. (1999): More beds:more nosocomial infections. Jpn J Infect Dis 52, 180-181

IOM-NCGM Research Collaboration Office Annual Report 201337

Attachment-1(A-1)

Fact-finding survey of nosocomial infection control in hospitals
in Kathmandu, Nepal and trial to improvement
Bharat M Pokhrel2, Hiroshi Ohara1, Rajan K Dahal2, Shyam K Mishra2, Hari P Kattel2,
Dharma L Shrestha3, Yumiko Haneishi1, Jeevan B Sherchand2
1: Bureau of International Medical Cooperation, National Center for Global Healthand Medicine, Japan
2: Department of Microbiology, Institute of Medicine, Tribhuvan University, Nepal
3: Tribhuvan University Teaching Hospital, Institute of Medicine, Nepal
With the purpose to investigate the actual situation of nosocomial infection control in Kathmandu City,
Nepal and contribute to the improvement, a fact-finding survey was conducted targeting 17 hospitals in thecity. Survey methods included questionnaire, site visits and interviews. Study items consisted of the infection
control system, training situation, surveillance, preparation situation of the personal protective equipment(PPE), existing problems, etc.
Nine out of 17 hospitals had manuals on nosocomial infection control, 7 hospitals had nosocomial
infection control committee (ICC), but the meeting was held regularly in only 2 of them. Number of hospitals
which met the requited amount of PPE preparation were as follows: Gown (13), Gloves (13), Surgical mask
(12). In 6 hospitals in-service training was held during the past 1 year but 7 hospitals responded that no staff
had been trained. Surveillance based on the results of bacteriological testing was conducted in 8 hospitals.
According to the results in Tribhuvan University Teaching Hospital high frequency of bacterial resistance toantibiotics was shown. Major problems included improper management of ICC, few opportunities to get
training among hospital staff, lack of essential equipment. In comparison with the results conducted in 2003
targeting 5 governmental hospitals steady improvement was shown.
In view of the provision of high quality medical care nosocomial infection control in hospitals in
Kathmandu needs further improvement. Hereafter it is regarded that widespread of appropriate manual,enhancement of basic techniques, strengthening of the infection control system such as ICC and surveillance
are particularly important.
Key words:
38

Fact finding survey, Nosocomial infection control, Kathmandu, Nepal

IOM-NCGM Research Collaboration Office Annual Report 2013

Attachment-1(A-2)

Prevalence and Bacteriological Profile of Ventilator Associated Pneumonia
at Tribhuvan University Teaching Hospital (TUTH), a Tertiary Care Hospital,
Kathmandu, Nepal
Ram Krishna Shrestha1, Sangita Sharma1, Manoj Kumar Sah1, Hari Prasad Kattel1,
Rajan Kumar Dahal1, Shyam Kumar Mishra1, Keshab Parajuli1, Basista Prasad Rijal1,
Jeevan Bahadur Sherchand1, Hiroshi Ohara2, Bharat Mani Pokhrel1
1: Department of Microbiology, Institute of Medicine, Tribhuvan University, Nepal
2: Bureau of International Medical Cooperation, National Center for Global Health andMedicine, Japan
In a view to determine the preu, Nepal, from June 2011 to May 2012. One hundred and fifty tracheal
aspirates from mechanically ventilated patients were subjected for bacterial culture and their antibiotic
sensitivity test at bacteriology laboratory in the Department of Microbiology using standard protocol as
described by American Society for Microbiology (ASM). Out of 150 tracheal aspirates, significant bacterial
growth was observed in 64 specimens, among which 51 (34%) were associated with VAP. Acinevalenceand bacteriological profile of Ventilator Associated Pneumonia (VAP), a study was conducted at Tribhuvan
University Teaching Hospital (TUTH), Kathmandtobacter calcoaceticus baumannii complex (n=30, 43.47%),
was the most common isolate, followed by Klebsiella pneumoniae (n=15, 21.73%), Pseudomonas aeruginosa(n=11, 15.94%) and Staphylococcus aureus (n=8, 11.59%). Majority of these isolates were multi-drug resistant(MDR) (n=55, 79.7%). Among Gram negative bacteria, 24 (39.33%) isolates were Metallo-β-Lactamase (MBL)
producers and 20 (29.5%) isolates were Extended-Spectrum β-Lactamase (ESBL)-producers. Although 47.5%
of Gram negative isolates were resistant to Meropenem and Imipenem, however, none of the isolates wereresistant to Polymyxin B and Colistin sulphate. Among 8 isolates of S. aureus, 6 (75%) were Methicillin Resistant
Staphylococcus aureus (MRSA) which were all sensitive to Vancomycin. These results indicate that MDR alongwith MRSA or ESBL or MBL producing bacterial strains are prevalent in our Intensive Care Unit (ICU). Therefore,
suitable control measures must be adopted to cope up this alarming situation in the hospital.
Key words:

Ventilator Associated Pneumonia, MDR, MRSA, ESBL, MBL

IOM-NCGM Research Collaboration Office Annual Report 201339

Attachment-1(A-3)

Intravascular catheter-related infections in tertiary care hospital
Dr. Jatan B. Sherchan
Department of Microbiology,
Kathmandu University School of Medical Sciences, Dhulikhel
Introduction: This study had two objectives: 1) to determine the clinical and microbiological profiles of patientsdeveloping intravascular catheter-related local (localized catheter colonization and exit site) and systemic
infections and their predisposing factors; 2) to study the antibiotic sensitivity patterns of the organisms
isolated.
Methodology: This case-control study was conducted over 19 months involving 232 patients at a tertiary care
hospital. Non-tunneled central venous catheters and midline catheters were the two types studied. Catheter
tips were processed using Maki’s roll plate and endoluminal flush techniques. Blood cultures were drawn understrict aseptic precautions and processed by the BacT ALERT system. A “case” was any patient with provenlocalized catheter colonization, exit site infection or blood-stream infection and a “control” was any patientfrom whom the intravascular catheter yielded no organism in semi-quantitative cultures.
Results and Conclusions: The incidence of catheter-related blood-stream infections (CRBSI) in our institutewas 8.75 per 1,000 catheter days. The commonest organisms causing local infections were coagulase-negative
Staphylococci, and those causing CRBSI were Staphylococcus aureus. Multidrug-resistant organisms accounted
for 30.2% of the infections. Risk factors for development of catheter-related infections included an immune
compromised state, duration of the catheter in situ, femoral venous cannulation, and triple lumen catheters.
Choice of venous cannulation to minimize the risk of catheter-related infection in ascending order for riskof infection is the subclavian vein, jugular vein, basilic vein and then the femoral vein. There was no role for
empirical antibiotic therapy to prevent intravascular catheter-related local or systemic infections.
Key words:

40

central venous catheters; midline catheters; blood-stream infections; blood cultures

IOM-NCGM Research Collaboration Office Annual Report 2013

Attachment-1(A-4)

Nursing Care with Special Reference to Infection Prevention & Control
at Tribhuvan University Teaching Hospital
Dharma Laxmi Shrestha
Nursing Director,
Tribhuvan University Teaching Hospital, Kathmandu, Nepal
Tribhuvan University Teaching Hospital (TUTH) is a tertiary care health centre of Nepal which wasestablished in 1983 with the support of Japan International Cooperation Agency (JICA). Infection being the
major problem in almost all hospitals of Nepal, TUTH has it's own mechanism for prevention & control of
infection. This paper intends to share our procedures of infection control at TUTH. This hospital has it's own
infection control committee, infection control training curriculum and training program to impart for various
categories of heath care workers in the hospital. As a result we have been able to reduce morbidity andmortality rate of patients in the hospital. The author is expecting to have improved procedures for prevention& control of infection in other hospitals of Nepal as well.

IOM-NCGM Research Collaboration Office Annual Report 201341

Attachment-1(B-1)

Emergence of 16S rRNA methylase producing nosocomial pathogens
in a hospital in Nepal
Teruo Kirikae1, Tatsuya Tada1, Tohru Miyoshi-Akiyama1, Rajan K. Dahal3,
Manoj K. Sah3, Hiroshi Ohara2, Bharat M. Pokhrel3
1: Department of Infectious Diseases, Research Institute2: Department of International Medical-Cooporation,
National Center for Global Health and Medicine,
1-21-1 Toyama, Shinjuku, Tokyo 162-8655
3: Department of Microbiology, Institute of Medicine, Tribhuvan University,
Maharajgunj, Kathmandu, Nepal
We started a study project of drug resistant pathogens isolated from inpatients hospitalized in Tribuvan
University Teaching Hospital, Kathomandu, Nepal, in collaboration between Department of Microbiology,
Institute of Medicine, Tribhuvan University and National Center for Global Health and Medicine from April
2012. Professor Dr. Bharat M. Pokhrel and his colleagues obtained 71 Gram-negative isolates by September
2012, including 17 (24%) Acinetobactor baumannii, 16 (23%) Escherichia coli, 14 (20%) Klebsiella pneumonia, 6(8%) Providencia rettgeri, 4 (6%) Pseudomonas aeruginosa, and 3 (4%) Stenotrophomonas maltophilia isolates.
Of 71 isolates, 26 isolates were highly resistant to all aminoglycosides tested, including amikacin, arbekacin
and gentamicin, with MICs of more than 1024 mg/L. Of 26, 21 isolates had 16S rRNA methylase genes, thatis known to cause highly resistant to pan-aminogllycosides, i.e., 12 had armA, 2 had rmtB, 3 had rmtC, 4 had
isolates had rmtF. Remaining 5 isolates were negative for known 8 16S rRNA genes. These data indicates that
16S rRNA methylase producing Gram-negative nosocomial pathogen are prevalent in medical settings in Nepal.
The project is currently in progress until March 2015.

42

IOM-NCGM Research Collaboration Office Annual Report 2013

Attachment-1(B-2)

Epidemiology and risk factors for isolation of CTX-M type extended-spectrum
β-lactamase (ESBL)-producing Escherichia coli in a large U.S. medical center
Kayoko Hayakawa, MD, PhD1,2, Sureka Gattu, MS3, Dror Marchaim, MD2,
Jason M. Pogue, PharmD4, Karen Bush, PhD3, Keith. S. Kaye, MD, MPH2
1: Disease Control and Prevention Center, National Center for Global Healthand Medicine, Japan
2: Division of Infectious Diseases, Wayne State University, Detroit Medical
Center, Detroit, Michigan
3: Department of Biology, Indiana University, Bloomington, Indiana
4: Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan
Background: A case-case-control study was conducted to identify independent risk factors for recovery of CTXM-ESBL-producing E. coli (CME-E. coli) within a large medical center in Southeast Michigan.
Methods: Unique cases with isolation of ESBL-producing E. coli from 2/2010 –7/2011 were included andanalyzed by PCR for detection of CTX-M, TEM, SHV β-lactamase gene families. Patients with CME-E. coli werecompared to patients with non-CME-E. coli and uninfected controls.
Results: Of 575 patients with ESBL-producing E. coli, 491 (85.4%) tested positive for a CTX-M-ESBL. Threehundred and nineteen (84.6%) patients with CME-E. coli were compared to 58 (15.4%) patients with nonCME-E. coli; and the 319 patients with CME-E. coli were also compared to uninfected controls. Independent risk
factors for isolation of CME-E. coli compared to non-CME-E. coli included male gender, impaired consciousness,
H2 blocker use, immunosuppressive status, and exposure to penicillins and/or trimethoprim/sulfamethoxazole.
Compared to uninfected controls, independent risk factors for CME-E. coli isolation included the presence of aurinary catheter, history of urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional
status, non-home residence, and multiple comorbid conditions. Pathogens were recovered within 48 hoursof admission for 77.4% CME-E. coli cases and 75.9% non-CME-E coli cases. CME-E. coli were more resistant tomultiple classes of antibiotics than were non-CME-E. coli.
Conclusions: CTX-M-encoding genes represented the most common ESBL determinants recovered from ESBLproducing E. coli, and the majority of CME-E. coli were present upon admission. Regional infection control
efforts and judicious antibiotic use are needed to control the spread of ESBL-producing E. coli.
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Assessment of the interface between malaria control program andgeneral health system in Nepal
Hiroshi Ohara1, Jeevan B. Sherchand2, Jatan B. Sherchan3 and Takanori Hirayama1
1: Bureau of International Medical Cooperation, National Center for Global Health and Medicine
2: Public Health Laboratory, Institute of Medicine, Tribhuvan University
3: Department of Clinical Microbiology, Kathmandu University
Malaria has been a major public health problem in Nepal. Currently malaria control activities are
conducted in 65 out of 75 districts based on the National Malaria Control Program with the support of the
Global Fund. In order to implement malaria control effectively, strengthening of health system and integrationof the disease specific program into general health system is quite important.
In this study interface between general health system and malaria control program was assessed fromthe viewpoint of 6 building blocks of health system (Health policy & planning, Service delivery, Workforce,
Information system, Medicines & technologies, Financing) proposed by WHO. Based on the framework ofanalysis, past bottlenecks & good practices to have addressed, current bottlenecks, interactions between
general health system and malaria control program were assessed. Furthermore, the assessment results in
Nepal were compared with the results of Vietnam and Laos.
Followings were regarded as the leading current bottlenecks in Nepal: ①In some areas imported
malaria associated with migration of population and creation of new endemic areas associated with changing
environment have been noted. ②Collection of health data from private sector is not adequate. ③Budget for
the health programs is still insufficient and sustainability of the programs remains as a challenge. ④Shortageof health manpower is a significant issue at peripheral level. ⑤Long Lasting Insecticidal Nets (LLINs) are
not always distributed to the most needed or vulnerable populations. ⑥Quality assurance systems are
inadequate.
It is crucial to implement effective malaria control program addressing these bottlenecks towardelimination. Particularly, more efforts are requested to strengthen the health system in remote areas,
training of health staff at peripheral level, diagnosis based of accurate quality assurance, promotion of publicprivate relationship and addressing the issue of imported malaria. These tackling will directly lead to further
strengthening of the health system there and eventually effective implementation of various health programs.
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Socio-medical Study and variation in utilization of bed-nets among different
socioeconomic groups of malaria endemic and resurgence areas of Nepal*Jeevan B. Sherchand & **Hiroshi Ohara*Public Health Research Laboratory and Microbiology,
Tribhuvan University Institute of Medicine, Kathmandu, Nepal**National Center for Global Health and Medicine, Tokyo, JapanThe study examined the variation in utilization of bednets by socioeconomic groups and inequities in access tomalaria control services in Nepal. Village Development Committees (VDCs) from four districts were included
in which each district with LLIN intervention and two VDCs without intervention from each district were
purposively selected. A total of 1050 households from these VDCs were randomly selected and data collectedusing strutured interview through household survey and Focus Group Discussion. Analysed data reveals thewider disparity and pro-rich inequalities in ownership of bednets. In area without LLIN intervention, bednet
ownership was signficantly higher in the rich households where as with LLIN intervention, most of the villagers
reported that they did not have barriers to own and utilise bednets as they were getting bednet free of cost.
Lack of financial resource was major barrier to obtaining and using bednet in areas without LLIN intervention.
Due to the lack of community-based malaria control activities, villagers were less aware of malaria preventive
measures and could not link the health service of HP/SHPs with malaria control services. The results suggestthat most poor, excluded and illiterate people are likely to be less benefitted from free net distribution and freehealthcare services due to lack of awareness and some deficiencies in the existing programme and services.

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STUDY ON DOUBLE BURDEN OF TUBERCULOSIS AND
NON-COMMUNICABLE DISEASES IN NEPAL
Shinsaku Sakurada1, Takanori Hirayama2, Jatan B. Sherchan3, Shyam Shrestha4,
Kalyan Subedi5, Keshav Parajuli5, Jeevan B. Sherchand5, Hiroshi Ohara1
1: National Center for Global Health and Medicine, Tokyo, Japan
2: Research Institute of Tuberculosis, Japan anti-Tuberculosis Association, Tokyo, Japan
3: Kathmandu University, School of Medicne, Dulikhel, Nepal
4: Friends of Shanta Bhawan Clinic, Kathmandu, Nepal
5: Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
While globally the incidence of tuberculosis (TB) has declined gradually, the burden of noncommunicable diseases (NCD) has steadily increased in recent decades. There is an increasing trend indeveloping countries, where the demographic and socio-economic transition imposes more constraints on
dealing with the double burden of TB and NCDs in a poor setting. Importantly several NCDs including diabetes
mellitus (DM), chronic kidney diseases (CKDs) and alcohol use disorders as well as smoking-related conditions
are known to be responsible for a significant proportion of TB cases.
The age group most seriously affected by TB has shifted to elderly population in many developing andeven developed countries. There are obviously complications and constraints in finding and treating TB casesin the aged populations, since NCDs have high prevalence among these populations. There is, in particular, agrowing evidence that diabetes mellitus is an important risk factor for TB and might affect disease presentationand treatment response. However, the link between TB and other NCDs has not been fully studied yet.
In Nepal the incidence of TB has been declining year by year in recent 5 years, particularly among
young population. A slight shift of peak age to elder populations has been observed and it has increased inthese years among elder population over 65 years old. We, thus, hypothesize that the age shift may cause
complications of TB and NCDs in each individual and inevitably lead Nepali people to the double burden of TB
and NCDs.
To verify our hypothesis we have started a pilot study to describe the present stratus over thecomplication of TB among NCDs and those of NCDs among TB at two clinics in Kathmandu through reviewing
patients records, using simple questionnaires to selected patients and conducting focus group discussion ofhealth service staff.
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Rotavirus gastroenteritis in children under five years of age in Nepal
Jeevan B. Sherchand, Sarmila Tandukar, Rushika Agrawal,
Hiroshi Ohara, Bharat Mani Pokhrel
Tribhuvan University Institute of Medicine, Department of Medical Microbiology andPublic Health Research Laboratory; Maharajgunj, Kathmandu, Nepal
National Center for Global Health and Medicine, Tokyo, Japan
Background: Rotavirus as a causative agent of childhood diarrhea occurs worldwide causing serious illness
among children less than 5 years of age. Epidemiological profile, disease burden and diversity of G and P
genotypes of rotavirus in Nepal were studied.
Methods: Stool samples were tested for Rotavirus by Enzyme Immuno Assay; strains were genotyped by
Reverse-Transcription Polymerase Chain Reaction (RT-PCR).
Results: From January 2009 to December 2011, 2718 cases met the enrollment criteria. The annual enrollment
was 906 (33.3%) for 2009, 815 (30.0%) for 2010 and 997 (36.7%) for 2011. Rotavirus was more frequently
detected among inpatients (28.5%) than among outpatients (15.2%). Detection was slightly higher amongfemales (25.1%) than males (22.8%). In 2009, rotavirus was most frequently identified in stool specimens
collected from children 0 to 11 months of age (28.1%), whereas, in 2010 and 2011, rotavirus was morecommonly detected among children 12-23 months of age 35.5% and 26.7%, respectively. Group A rotaviruses
were detected by using both ELISA and RT-PCR. Over the three-year study period, 653 (24.4%) cases werepositive for rotavirus by ELISA. Genotyping by RT-PCR was completed on 638 samples. The most prevalent
genotype was G12P [6] (60.4%). Mixed infections were not uncommon (14% in 2009, 29% in 2010 an 7% in2011). Forty one samples were partially typed and 23 were completely untyped over the three years study
period.
Conclusions: Disease burden and diversity of rotavirus strains circulating in Nepal was studied which would
provide useful information to policy makers with regard to introduction of rotavirus vaccine.
Keywords:

Human rotavirus, prevalence, genotype, RT-PCR
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Assessment of health systems in relation to interface
between malaria control programs and health system strengthening:
Comparative study among Lao PDR, Nepal and Viet Nam
Hiroshi Ohara, Shinichiro Noda, Yasuyo Matsumoto, Takanori Hirayama,
Noriko Fujita, Yuriko Egami, Hitoshi Murakami, Hidechika Akashi and Tamotsu Nakasa
Bureau of International Medical Cooperation National Center for Global Health and Medicine (NCGM)
This report is available at http://ncgmimcj.ec-net.jp/HP/library/research doc/ncgm report oct2013.pdf
Executive summary
Global Health Initiatives (GHIs) such as the Global Fund against AIDS, Tuberculosis and Malaria (GFATM)
and the Global Alliance for Vaccines and Immunization (GAVI) have supported disease specific programs,
resulting in effective control measures in many developing countries. However, there is still some debate
regarding the interaction between these programs and the general health systems, as well as some bottlenecks
that hinder the smooth implementation of the programs.
This assessment was undertaken with malaria control programs in three countries (Lao PDR, Nepal
and Viet Nam) as entry points, in order to assess the interface between malaria control programs supported
by GFATM and health systems strengthening, with special reference to interaction between disease specificprograms and general health systems. Good practices and bottlenecks in the implementation of the control
programs were identified, and possible solutions for these bottlenecks along with synergic health systeminterventions to be incorporated into disease control programs were discussed.
Primary surveys in this report were conducted in Viet Nam (2009), Lao PDR (2011) and Nepal (2012).
In Viet Nam and Nepal the surveys were carried out with special emphasis on best practices and bottlenecks in
the implementation of malaria control programs, while in Lao PDR, surveys were carried out on the integrationof malaria control programs into the general health systems. In each country, the survey was conducted atvarious levels (from Ministry of Health to primary level) by document reviews, key informant interviews,
and observation of facilities. The results of the primary surveys were analyzed, summarized in reports andsubmitted to HSD/WPRO. Based on these reports, updating and supplementing more information, andcomparative analysis among these three countries, were performed.
In the three countries in this survey, malaria morbidity along with mortality rates were quite high inthe past and malaria was given the highest priority in the health policy by the administration. However, since
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the mid-1990s, malaria controls were actively implemented in these countries based on the National Malaria
Control Programs (NMCPs) and principles of Roll Back Malaria, which consists of strategic priorities including
vector control and personal protection, early diagnosis and prompt treatment (EDPT), malaria surveillanceand epidemic preparedness, behavioral change communication (BCC), and improving program management.
In particular, since early 2000s, GFATM has contributed a large budget to malaria control programs. Recently,
malaria in these countries has decreased remarkably; reaching pre-elimination levels (Viet Nam and Nepal) or
is no longer listed among from the top 10 diseases (Lao PDR).
In Viet Nam, the government has made great efforts to strengthen the existing health systems sincethe 1990s (both malaria specific and general health systems) and the international community also cooperated
with the policy implementation of Vietnam at various health system levels. Malaria control measures wereeffectively implemented under the strong leadership of the National Steering Committee, further strengthening
and utilizing the existing health system and mobilizing mass organizations.
In Nepal, the general health system, which was fragile in the past, was strengthened and utilized
in greater part in the malaria control program. During the period of political instability (1996-2006), healthsystems were affected, but the influence on malaria control was minimal compared with other disease control
programs due to the high governmental priority placed on malaria control and continuous support of theinternational community.
In Lao PDR, both general health systems (horizontal systems) and specific health systems for malaria
control (vertical systems) were weak. After the GFATM intervention, large funds were invested in verticalsystems and dissociation from horizontal systems became noticeable. Integration of a malaria control programin the general health system is still limited or partial, and budgetary dependence on GFATM is quite large (97%).
Generally, at upper levels, collaboration among disease specific programs is limited, and a health staff,
as well as an infrastructure, is dedicated to each program. However, there is greater integration at lower levelsof health care (in Vietnam and Nepal). By coordinating with the community and social organizations in thevillage, health workers carry out various tasks such as primary health care, implementation of national healthprograms, preventive medicine, IEC activities, etc. GFATM and other assistant partners provide support bystrengthening training and supplying essential medicine and equipment. Malaria control has gradually been
more integrated with the primary health care system.
As a result from the surveys in Viet Nam and Nepal, best practices were identified. Among them
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intensified education for residents focusing on disease prevention, strengthening of facilities at primary levelsuch as health posts along with training of health workers, utilization of health volunteers at the primary level,high priority attached to frontier areas, and setting up mobile teams, were noteworthy and recognized incommon in the two countries. In addition, effective implementation under the strong leadership of National
Steering Committee could be seen in Vietnam, utilizing the existing heath system was outstanding. The
management system of vertical health programs appeared to have a good impact on the general health system.
In Lao PDR, a survey was conducted focusing on the integration between the malaria control programand general health systems, and the results showed that the extent of integration was quite limited in many
elements of program implementation. Particularly, in health information, supply management (procurement,
storage, and distribution), and monitoring & evaluation, separate systems were set up between malaria control
program implementation and the general health systems. The national health management and information
system (HMIS) was considered to be weak, incomplete and unresponsive. Separate financing, governance andplanning functions for other disease specific programs, such as Tuberculosis and HIV, distinct from those of thegeneral health system, were also observed.
Bottlenecks/challenges in implementing malaria control were identified in two countries (Viet Nam,
Nepal), and points in common included malaria control in frontier areas (many hard-to-reach areas, shortage& low skill of manpower, etc.), low incentives for health workers, a poorly developed reporting system fromthe private health sector, inadequate quality assurance system for malaria testing (particularly in Nepal).
Most health workers are concentrated in large cities and towns, while many health facilities at the primarylevel (Health Centers; HCs, Primary Health Care Centers; PHCs, Health Posts; HPs, Sub-Health Posts; SHPs) andat some district hospitals the health personnel and/or medical supplies are insufficient. Weak coordination
between the local government and GFATM in the distribution of bed nets was pointed out in Nepal. In addition,
the current heavy dependence on GFATM undermines the assurance of sustainable malaria control.
Disease specific programs such as malaria control have had some synergic effects on the general healthsystem, particularly at the primary level. The management system of vertical health programs appeared to havea good impact on the general health system at various levels. However, it can be said that dissociation between
vertical malaria control program and horizontal general health system also exists. In addition, coordination
between malaria control programs and other disease specific programs is limited in many cases. It is true thatin implementing malaria control programs, carrying out a vertical health system is important, but scaling up
the malaria control program does not automatically lead to general health system strengthening. More effort isneeded to realize the maximum synergy between disease specific programs and the general health system, as
well as among different health programs.
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