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Nepal Anil Pandit, Amit Arjyal, Jeremy Farrar and Buddha Basnyat Practical Neurology 2006;6;129-133 doi:10.1136/jnnp.2006.089060

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Pandit, Arjyal, Farrar, et al 129

NEUROLOGICAL LETTER FROM…

Practical Neurology 2006; 6: 129-133

Nepal Anil Pandit, Amit Arjyal, Jeremy Farrar, Buddha Basnyat

A Pandit, A Arjyal, B Basnyat Department of Clinical Neuroscience, Umeå University, Umeå, Sweden

J Farrar Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam

B Basnyat Medical Director, Nepal International Clinic, Lal Durbar, Kathmandu, Nepal Correspondence to: Dr A Pandit, GPO 252, Kathmandu, Patan Hospital, Lalitpur, Nepal; [email protected]

Satellite image of Nepal. Jeff Schmaltz, MODIS Rapid Response Team, NASA/GSFC

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130 Practical Neurology

epal is a tiny Himalayan kingdom situated between China and India with a population of 21 million people of diverse ethnicities and religions. The country has snow clad mountains on the northern side bordering China and plains on the southern side bordering India. It is one of the poorest countries in the world, with a gross national product of only $200 per person. Almost 90% of the population live in rural areas, and 40% live below the poverty line. About 50% of children are undernourished. Infant mortality and maternal mortality are the worst in the region. The doctor:population ratio is 1:5000 people. Nepal was once a peaceful country but has been turned into a conflict zone after the Communist Party of Nepal-Maoist declared civil war against the state in 1996. So far more than 11000 Nepalese have lost their lives as a direct result of the conflict, which has affected both rural and urban healthcare facilities. However, the rural population has suffered more. People staffing rural health posts have deserted because of fear of being targeted. On 2 April 2005, the Maoist called for an 11 day total strike to block the transportation route to the capital Kathmandu. This blockade lead to a number of major healthcare problems, with referrals from outside Kathmandu not being able to get access to the city’s hospitals, including women in obstructed labour. There have also been attacks on health posts and ambushes on ambulances carrying patients. However, no teaching hospitals and institutions, medical personnel, or paramedical staff have been threatened or abducted by the warring parties. Medical education started in Nepal in 1978 when the Institute of Medicine was established with the vision of producing community oriented doctors. The first batch of doctors graduated in 1984. Until 1996, there were only two medical schools; now there are 10 producing a total of 1065 doctors per year. Of the 10, seven have established a postgraduate medical training programme but none teach or train neurology as a specialty. In 2005 there were seven specialist neurologists registered with the Nepal Medical Council (one for 3 million people), and about seven CT scanners available in the whole country. All these clinicians (and all the scanners) are exclusively in Kathmandu, and essentially only in the private sector, clearly emphasising the

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need for more neurologists in Nepal. The healthcare delivery system is two tiered. People in urban areas have better although still very limited access to doctors, hospitals, and other medical facilities than those living in rural areas. In a rural area, patients might have to be carried in a basket through the mountains for a 3–4 day trek to reach the nearest Primary Health Care centre which may itself be devoid of trained medical personnel. It is often more convenient to reach traditional healers who are very influential; they are the point of first contact for patients irrespective of the disease they are suffering from. This is important in a variety of neurological problems like epilepsy and stroke, because the rural population often ascribe these conditions to the wrath of God. Nepal has a variety of neurological problems ranging from the classical disorders of stroke, epilepsy, neonatal encephalopathy, and head injury, to acute mountain sickness, high altitude cerebral oedema, typhoid encephalopathy, Japanese encephalitis, and tuberculous meningitis.

STROKE An exact estimate of the burden of stroke in Nepal is not available. The Jaya Stroke Foundation, established by Nepalese doctors and family members of stroke patients, estimates that each year approximately 50,000 people have a stroke and 15,000 people die from stroke. A retrospective review1 from the Tribhuvan University Teaching hospital showed that the total number of stroke patients admitted in four years was 683, out of which 434 (63%) were ischaemic and 249 (27%) haemorrhagic. Among the risk factors hypertension was present in 42%; smoking in 28%; alcohol in 18%; and diabetes mellitus in 11%. Overall the case fatality was 17%, the worst outcome being in patients with subarchnoid haemorrhage (50%). The prevalence of diabetes is estimated in rural and urban areas to be 3% and 15% respectively,2 the difference perhaps because the urban populations are now leading a sedentary lifestyle and consuming a more westernised diet. Soon, with a rise in the incidence of diabetes, vascular as well as neurological complications will increase in Nepal as in many other developing countries. It is imperative that public health measures are directed towards better blood pressure and diabetic control.



EPILEPSY Epilepsy in Nepal remains a huge challenge with a prevalence of seven per 1000 population.3 A hospital based study3 in 2000 showed neurocysticercosis was the most common cause in adults, with obvious potential for prevention. The big treatment gap (between those who need and those who receive anti-epileptic drugs), the widespread use of traditional healers for treatment, and poor understanding of epilepsy among patients and the general public demands better focus on health education as well as awareness programmes. A survey4 from the Kaski District showed there were 113 patients with epilepsy in a population of 105,000, with a mean duration of 6.5 years before diagnosis. Based on a prevalence of seven per 1000 population, the treatment gap was more than 80%. Nepal et al reported in their survey that among 34 patients with epilepsy, three (9%) were treated by traditional healers and another 10 (29%) had previously been treated by traditional healers.5 Thus, the patients were just as likely to seek treatment from traditional healers as modern medicine. Another survey done in a village health post in Kaski district reported that it was more convenient to visit a traditional healer (Jhankri) than to come to the village health post.6 In addition, the traditional healer often made “house calls”. The largely rural population and the low number of doctors probably contributed to the frequent use of traditional healers’ services.

deaths in Kathmandu steadily increased during 1981–2003; the annual increase was 3.9%.8 A retrospective review from the Western Regional Hospital reported that head injury constituted 17% of all surgical admissions, out of which 84% were mild, 9% moderate, and 7% severe.9 Nepal has only one National Neurosurgical Referral Centre at Bir Hospital, Kathmandu. One can easily imagine the burden and plight of the neurosurgeons working in that single centre for a population of 21 million. Head injury patients outside the capital are either referred to Kathmandu or treated by general surgeons locally who also face major practical problems of travel time: the time a patient spends in an ambulance during transport averages more than six hours from any centre outside the capital.10 Even if a patient is evacuated by air, the time lapse from the primary hospital to ambulance and to airport and finally to the neurosurgery centre will again be in the order of 3–4 hours. This makes critically ill patients who need expert neurosurgical care very vulnerable. There is a pressing need to train general surgeons in basic neurosurgical skills.

Figure 1 MRI scan of the brain obtained with fluid attenuation inversion recovery (FLAIR) shows extensive increased signal intensity, especially in the splenium of the corpus callosum in high altitude cerebral oedema. Reproduced with permission from Wilderness and Environmental Medicine.

NEONATAL ENCEPHALOPATHY The frequency of neonatal encephalopathy is 6.1 per 1000 live births of which 63% are infants with moderate or severe encephalopathy.7 There was evidence of intrapartum hypoxia in 60% of the encephalopathic infants. This study further noted that newborn encephalopathy was associated with maternal hypothyroidism and severe anaemia. Intrapartum hypoxia, maternal hypothyroidism, and severe anaemia are all potentially preventable conditions with proper antenatal as well as intrapartum care.

HEAD INJURY AND ROAD TRAFFIC ACCIDENTS The true burden of head injury and its complications is not available for Nepal. An indirect way of estimating this is to look at road traffic accident trends. Traffic related www.practical-neurology.com


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Early morning sunrise on Mt Annapurna © Dr Basnyat

HIGH ALTITUDE ILLNESS High altitude illness is the collective term for the syndromes that can affect unacclimatised travellers shortly after ascent to high altitude. It encompasses the mainly cerebral syndromes of acute mountain sickness and high altitude cerebral oedema (fig 1), and the pulmonary syndrome of high altitude pulmonary oedema. High altitude cerebral oedema and high altitude pulmonary oedema occur much less frequently than acute mountain sickness, but are potentially fatal. In the Mount Everest region of Nepal, about 50% of trekkers who walk to altitudes higher than 4000 metres over five or more days develop acute mountain sickness and 84% of people who fly directly to 3860 metres are affected.11 There are also other well documented neurological conditions at high altitude that fall outside the usual definition of high altitude sickness: transient ischaemic attacks, intracranial venous thrombosis, seizures, syncope, double vision, and scotomas.

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SEVERE TYHPOID AND TYPHOID ENCEPHALOPATHY Severe typhoid is defined as delirium, obtundation, stupor, coma, or shock. In the typhoid capitals of the world, such as Kathmandu and New Delhi,12 there are still many cases every year.13 High dose steroids seem to be beneficial according to a randomised, double blind trial involving just 38 patients with culture proven specifically defined severe typhoid fever.14 However, there are no other studies supporting this result and it is surely prudent to determine the reproducibility of this effect before advocating high dose steroids in severe typhoid fever.

JAPANESE ENCEPHALITIS Japanese encephalitis is a serious mosquito borne viral zoonotic disease which is endemic in Nepal. It was first recognised in Japan in 1924 and in Nepal in the Rupandehi district (which lies in the central plains) in 1978.15 Since then it has become a major public health problem in all



southern districts of Nepal with the population growth and mass migration of people into the Kathmandu valley (often to escape the uprising in rural Nepal). This has led to unplanned and uncontrolled urbanisation, which in turn has led to deterioration of housing and of water, sewage, and waste management systems. The crowded human population living in intimate contact with increasingly higher densities of mosquito populations creates ideal conditions for increased mosquito borne diseases like Japanese encephalitis. Children aged 5–15 years are the main victims. The disease occurs mainly in the autumn with high case fatality (43%) and morbidity. About 50% of the survivors are left with neurological problems. There were 1687 cases with 353 deaths (21%) in 1996 and 1740 cases with 126 (7%) deaths in 1997.16 About 200,000 travellers visit Nepal annually and although no case of Japanese encephalitis has yet been diagnosed in a traveller in Kathmandu, the risk can no longer be said to be negligible.

TUBERCULOUS MENINGITIS About 45% of the Nepalese population are infected with TB. Every year, 44,000 develop active TB, of whom 20,000 have infectious pulmonary disease. Around 6000–7000 people continue to die every year.17 Many people still develop tuberculous meningitis, the severest form of infection with mycobacterium tuberculosis, causing death or severe neurological deficits in more than half of those affected in spite of antituberculosis chemotherapy.18, 19

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CONCLUSIONS Nepal has a variety of important neurological problems ranging from stroke to unique problems like high altitude illness and typhoid encephalopathy. In a resource poor setting like Nepal, increasing emphasis should be given to preventive measures for neurological problems. However, the need for tertiary level specialist care cannot be underestimated.

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Oli KK, Agarwal JP. Critical review of stroke. J Inst Med 2001;23:63–6. Singh DL, Bhattarai MD. High prevalence of diabetes

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and impaired fasting glycaemia in urban Nepal letter. Diabet Med 2003;20:170–1. Rajbhandari KC. Epilepsy in Nepal. Neurol J Southeast Asia 2003;8:1–4 Finkenbine RD, Acland S, Finkenbine SS. Epilepsy at four Kaski Village health posts. International workshop on epilepsy conducted jointly by EPICADEC epilepsy care developing countries and Department of Psychiatry, IOM Institute of Medicine. April 15, 1996, Kathmandu, Nepal, 24–3. Nepal MK, Sharma VD, Shrestha PM. Epilepsy prevalence, a case study of Morang District. International workshop on epilepsy conducted jointly by EPICADEC epilepsy care developing countries and Department of Psychiatry, IOM Institute of Medicine. April 15, 1996, Kathmandu, Nepal, 17–23. Sharma VD. Prevalent opinion of traditional healers about clients who faint or are possessed. International workshop on epilepsy conducted jointly by EPICADEC epilepsy care developing countries and Department of Psychiatry, IOM Institute of Medicine. April 15, 1996, Kathmandu, Nepal, 39–46. Ellis M, Manandhar M, Manandhar DS, et al. Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched casecontrol study. BMJ 2000;320:1229–36. Tandukar KP, Nakahara S, Poudel KC, et al. Traffic fatalities in Nepal. JAMA 2004;291:2542. Ghimire P. Head injury management in the western regional hospital Pokhara, Nepal. VI International Surgical Conference 2002: 21–23 November, Society of Surgeons of Nepal. Timilsina DS. General Surgeons in the management of head injuries. JSSN 2005;8:3–10 Basnyat B, Murdoch DR. High altitude illnes. Lancet 2003;361:1967–7. Sinha A, Sazawal S, Kumar R, et al. Typhoid fever in children aged less than 5 years. Lancet 1999;354:734–7. Basnyat B. Typhoid fever. N Engl J Med 2002;348:1183. Hoffman SL, Punjabi NH, Kumala S, et al. Reduction of mortality in chloramphenicol - treated severe typhoid fever by high-dose dexamethasone. N Engl J Med 1984;310:82–8. Joshi DD, Bista PR, Joshi H. Japanese encephalitis: a public health problem in Nepal (Report from 1978– 1994). NZFHRC, 1995. Joshi DD. Epidemiological profile of Japanese encephalitis in Nepal 1996–1997. J Inst Med 2000;22:23–31. National Tuberculosis Program Nepal, SouvenirWorld TB Day-24 March 2002. National Tuberculosis Center, Thimi, Nepal. Girgis NI, Sultan Y, Farid Z, et al. Tuberculous meningitis, Abbassia Fever Hospital–Haval Medical Research Unit No 3–Cairo, Egypt, from 1976 to 1996. Am J Trop Med Hyg 1998;58:28–34. Hosoglu S, Geyik MF, Balik I, et al. Predictors of outcome in patients with tuberculous meningitis. Int J Tuberc Lung Dis 2002;6:64–70.

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