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Background: Malaria is still a priority public health problem of Nepal where about 84% of the population are at risk. The aim of this paper is to highlight the past and present malaria situation in this country and its challenges for long-term malaria elimination strategies.
Methods: Malariometric indicator data of Nepal recorded through routine surveillance of health facilities for the years between 1963 and 2012 were compiled. Trends and differences in malaria indicator data were analysed.
Results: The trend of confirmed malaria cases in Nepal between 1963 and 2012 shows fluctuation, with a peak in 1985 when the number exceeded 42,321, representing the highest malaria case-load ever recorded in Nepal. This was followed by a steep declining trend of malaria with some major outbreaks. Nepal has made significant progress in controlling malaria transmission over the past decade: total confirmed malaria cases declined by 84% (12,750 in 2002 vs 2,092 in 2012), and there was only one reported death in 2012. Based on the evaluation of the National Malaria Control Programme in 2010, Nepal recently adopted a long-term malaria elimination strategy for the years 2011–2026 with the ambitious vision of a malaria-free Nepal by 2026. However, there has been an increasing trend of Plasmodium falciparum and imported malaria proportions in the last decade. Furthermore, the analysis of malariometric indicators of 31 malaria-risk districts between 2004 and 2012 shows a statistically significant reduction in the incidence of confirmed malaria and of Plasmodium vivax, but not in the incidence of P. falciparum and clinically suspected malaria.
Conclusions: Based on the achievements the country has made over the last decade, Nepal is preparing to move towards malaria elimination by 2026. However, considerable challenges lie ahead. These include especially, the need to improve access to diagnostic facilities to confirm clinically suspected cases and their treatment, the development of resistance in parasites and vectors, climate change, and increasing numbers of imported cases from a porous border with India. Therefore, caution is needed before the country embarks towards malaria elimination.
Background: Rapidly increasing temperatures in the mountain region of Nepal and recent reports of dengue fever and lymphatic filariasis cases from mountainous areas of central Nepal prompted us to study the spatio-temporal distribution of the vectors of these two diseases along an altitudinal transect in central Nepal.
Methodology/Principal Findings: We conducted a longitudinal study in four distinct physiographical regions of central Nepal from September 2011 to February 2012. We used BG-Sentinel and CDC light traps to capture adult mosquitoes. We found the geographical distribution of the dengue virus vectors Aedes aegypti and Aedes albopictus along our study transect to extend up to 1,310 m altitude in the Middle Mountain region (Kathmandu). The distribution of the lymphatic filariasis vector Culex quinquefasciatus extended up to at least 2,100 m in the High Mountain region (Dhunche). Statistical analysis showed a significant effect of the physiographical region and month of collection on the abundance of A. aegypti and C. quinquefasciatus only. BG-Sentinel traps captured significantly higher numbers of A. aegypti than CDC light traps. The meteorological factors temperature, rainfall and relative humidity had significant effects on the mean number of A. aegypti per BG-Sentinel trap. Temperature and relative humidity were significant predictors of the number of C. quinquefasciatus per CDC light trap. Dengue fever and lymphatic filariasis cases had previously been reported from all vector positive areas except Dhunche which was free of known lymphatic filariasis cases.
Conclusions/Significance: We conclude that dengue virus vectors have already established stable populations up to the Middle Mountains of Nepal, supporting previous studies, and report for the first time the distribution of lymphatic filariasis vectors up to the High Mountain region of this country. The findings of our study should contribute to a better planning and scaling-up of mosquito-borne disease control programmes in the mountainous areas of Nepal.
Background: Dengue fever (DF) is the most rapidly spreading mosquito-borne viral disease in the world. In this decade it has expanded to new countries and from urban to rural areas. Nepal was regarded DF free until 2004. Since then dengue virus (DENV) has rapidly expanded its range even in mountain regions of Nepal, and major outbreaks occurred in 2006 and 2010. However, no data on the local knowledge, attitude and practice (KAP) of DF in Nepal exist although such information is required for prevention and control measures.
Methods: We conducted a community based cross-sectional survey in five districts of central Nepal between September 2011 and February 2012. We collected information on the socio-demographic characteristics of the participants and their knowledge, attitude and practice regarding DF using a structured questionnaire. We then statistically compared highland and lowland communities to identify possible causes of observed differences.
Principal findings: Out of 589 individuals interviewed, 77% had heard of DF. Only 12% of the sample had good knowledge of DF. Those living in the lowlands were five times more likely to possess good knowledge than highlanders (P<0.001). Despite low knowledge levels, 83% of the people had good attitude and 37% reported good practice. We found a significantly positive correlation among knowledge, attitude and practice (P<0.001). Among the socio-demographic variables, the education level of the participants was an independent predictor of practice level (P<0.05), and education level and interaction between the sex and age group of the participants were independent predictors of attitude level (P<0.05).
Conclusion: Despite the rapid expansion of DENV in Nepal, the knowledge of people about DF was very low. Therefore, massive awareness programmes are urgently required to protect the health of people from DF and to limit its further spread in this country.
Snake bite is one of the most neglected public health issues in poor rural communities living in the tropics. Because of serious misreporting, the true worldwide burden of snake bite is not known. South Asia is the world's most heavily affected region, due to its high population density, widespread agricultural activities, numerous venomous snake species and lack of functional snake bite control programs. Despite increasing knowledge of snake venoms' composition and mode of action, good understanding of clinical features of envenoming and sufficient production of antivenom by Indian manufacturers, snake bite management remains unsatisfactory in this region. Field diagnostic tests for snake species identification do not exist and treatment mainly relies on the administration of antivenoms that do not cover all of the important venomous snakes of the region. Care-givers need better training and supervision, and national guidelines should be fed by evidence-based data generated by well-designed research studies. Poorly informed rural populations often apply inappropriate first-aid measures and vital time is lost before the victim is transported to a treatment centre, where cost of treatment can constitute an additional hurdle. The deficiency of snake bite management in South Asia is multi-causal and requires joint collaborative efforts from researchers, antivenom manufacturers, policy makers, public health authorities and international funders.
Shaped by some of the most dramatic tectonic events of the Cenozoic, the parts of southern and eastern Asia that have become known as the Oriental faunal region comprise vast areas of great geological complexity and ecological diversity. One of the four major groups of terrestrial elapid snakes in this region is the genus Bungarus. These nocturnal and predominantly ophiophagous snakes are widely known as kraits and are an important cause of snakebite mortality throughout their wide range that extends from Afghanistan to Vietnam and eastern China, and south to the Indonesian islands of Java and Bali. Although present on Borneo, kraits have not been found on any island of the Philippines, nor on Lesser Sunda Islands east of Bali. Despite their medical significance and the great importance of Bungarus toxins as tools in neuropharmacology, krait systematics and taxonomy have remained largely unstudied. Twelve species of Bungarus were recognized at the beginning of the present study. Many of these are rare in collections, and most aspects of their biology are unknown. While some species are highly distinct, most kraits are conservative morphologically, rendering molecular methods invaluable for the study of their diversity and biogeography. This study is the first to address the relationships within Bungarus and the historical biogeography of kraits based on molecular evidence. I inferred phylogeographic relationships based on analyses of new nucleotide sequences of the entire mitochondrial cytochrome b gene of 51 kraits and partial NADH dehydrogenase subunit 4 sequences of 40 kraits which I analyzed together with a representative sample of 32 published elapid and non-elapid outgroup taxa using Bayesian, maximum-likelihood, maximum-parsimony and neighbor-joining methods. I then used the recovered phylogeny to investigate the evolution of selected morphological characters and, together with collections-based geographical distribution information, in dispersal-vicariance analyses with models of variable taxonomic and biogeographic complexity. The phylogenetic analyses demonstrate that the current taxonomy of kraits does not adequately represent either the relationships or the genetic diversity in this genus. In contrast, I identified monophyletic groups that are congruent with recognized biogeographic units as well as extensive ecomorph evolution and morphologically cryptic speciation. The following additional conclusions are collectively supported by the mitochondrial phylogeny and morphological as well as biochemical synapomorphies: (1) Kraits are monophyletic with respect to the remaining taxa of the Elapidae; (2) Bungarus flaviceps and Bungarus bungaroides form the monophyletic sister clade of a clade formed by B. fasciatus, black-and-white-banded, and uniformly black taxa; (3) the remaining taxa are divisible into two sister clades, the South Asian species (Bungarus sindanus (Bungarus caeruleus, Bungarus ceylonicus)) vs. Himalayan, Burmese, Southeast and East Asian taxa; (4) within the latter, Burmese taxa form the sister clade to Southeast and East Asian taxa; (5) the widespread and medically significant species Bungarus candidus and Bungarus multicinctus are paraphyletic. The results of this study highlight the importance of vicariant geological events and sea level fluctuations for the cladogenesis of kraits. Events of particular importance in the evolution of kraits include the uplift of the Indo-Burman ranges (Arakan-Naga Hills) which separated black-and-white banded kraits in India and Southeast Asia, and the uplift of mountain ranges in Yunnan, China (e.g., the Gaoligong Shan), which coincided with lineage separation in two distantly related clades of kraits. Alternating dispersal and vicariance events due to Pleistocene climatic and sea level changes have caused complex phylogeographic patterns in kraits in Southeast Asia. Zones of contact between closely related evolutionary lineages of the B. candidus complex are identified in Thailand, Vietnam, and southern China (Hainan). Within this complex, two main clades are revealed. One includes populations from the Southeast Asian mainland and is in contact with B. multicinctus in southern China. The other consists of populations from Thailand, southern Vietnam, Java, and Bali. The phylogeny as well as genetic distances suggest a scenario in which a Pleistocene southward dispersal of B. candidus to Sumatra, Java, and Bali during times of low sea levels was temporarily interrupted by vicariant events (rising sea levels, especially flooding of the Malacca Strait between Sumatra and the Malay Peninsula, and of the Bali Strait between Java and Bali). In this context, the close phylogenetic relationship between haplotypes from southern Vietnam and those from Java and Bali suggests that "southern" B. candidus dispersed directly via colonization of the widely receded South Chinese Sea, and not by taking a detour via the Malay Peninsula and Thailand, which were already inhabited by other populations of B. candidus. Using these phylogenetic estimates as the framework for a study on the diversity and evolution of krait venom components, I applied biochemical and molecular genetic approaches to identify and quantify polypeptide and protein toxins in krait venom, focusing on the distribution and molecular evolution of alpha-bungarotoxin, an irreversible competitive antagonist of nicotinic acetylcholine receptors with an exceptionally high applied significance as a receptor probe. I was specifically interested in the medically relevant question of intraspecific and interspecific variability in toxin diversity, and whether receptor-binding postsynaptic toxins evolve at rates different from those of presynaptic neurotoxins like beta-bungarotoxin, which act by destroying the nerve terminal and are believed to exhibit hypervariable functional diversification due to an accelerated mode of molecular evolution. In the context of this question, I isolated and purified the major lethal neurotoxins from B. candidus venoms by sequential steps of liquid chromatography for structural and functional characterization studies. Cloning and sequence analysis of toxin-coding genomic DNAs showed that the gene encoding the alpha-bungarotoxin alanine-31 variant, originally isolated from B. multicinctus venom, is widely present and highly conserved in multiple populations of B. candidus and is expressed as the principal postsynaptic neurotoxin at least in Javan B. candidus. In addition to the widespread presence of genomic DNAs encoding the alpha-bungarotoxin alanine-31 variant, the present study also revealed the partial genes of three novel alpha-bungarotoxin isoforms in addition to the previously known alanine-31 and valine-31 variants, all of which share an invariant exon 3 coding region. While alpha-bungarotoxin is the principal postsynaptic neurotoxin of Taiwanese B. multicinctus and Javan B. candidus, the main postsynaptic neurotoxin of Thai B. candidus both by quantity and lethality was a novel polypeptide of similar toxicity with a mass of 8030 Da and 73 amino acid residues, whose characterization at the genetic and protein levels revealed a novel subgroup of krait neurotoxins, here named alpha-delta-bungarotoxins and represented by four sequences from Bungarus caeruleus and B. candidus. alpha-delta-Bungarotoxins share high sequence homology with alpha-bungarotoxins but the purified, 8030 Da alpha-delta-bungarotoxin-1 exhibits only reversible, low affinity binding to nicotinic receptors and high site-selectivity for the acetylcholine binding site at the alpha-delta-subunit interface of the receptor. These properties render alpha-delta-bungarotoxin not only the first snake long-chain neurotoxin with reversible binding and binding-site selectivity, but also an exciting natural tool with which to address structure-function relationships at the subunit interfaces of the human receptor. The results of comparisons of the number of non-synonymous nucleotide substitutions per nonsynonymous site (dN) to the number of synonymous nucleotide substitutions per synonymous site (dS) strongly suggest that positive selection is acting on exon 2 of the alpha-bungarotoxin and probably also of the alpha-delta-bungarotoxin genes. In addition, the numbers of nucleotide substitutions per site of intron (dI) compared to the dS value of the toxin-coding exon regions provide strong evidence for accelerated molecular evolution in exon 2 of alpha-delta-bungarotoxins —whose value of dI is only one-eighth of the value of dS—whereas the hypothesis of accelerated evolution is rejected for 13 unique genomic DNAs encoding five alpha-bungarotoxin isoforms from B. candidus and B. multicinctus....