In a national analysis conducted in Israel—an area with unique climate conditions and high air pollution levels, we estimated the association between short-term PM2.5 exposure and ischemic stroke, intracerebral hemorrhage (ICH), or transient ischemic attacks (TIA). Using the Israeli National Stroke Registry, we obtained information on all stroke cases across Israel in 2014–2018. We obtained daily PM2.5 exposures from spatiotemporally resolved exposure models. We restricted the analytical data to days in which PM2.5 levels did not exceed the Israeli 24 h standard (37.5 µg/m3). We repeated the analysis with a stratification by sociodemographic characteristics and comorbidities. For all outcomes, the exposure–response curves were nonlinear. PM2.5 exposure was associated with a higher ischemic stroke risk, with larger effect estimates at higher exposure levels. Although nonsignificant, the exposure–response curve for TIA was similar. The associations with ICH were nonsignificant throughout the PM2.5 exposure distribution. The associations with ischemic stroke/TIA were larger among women, non-Jewish individuals, older adults, and individuals with diabetes, hypertension, and ischemic heart disease. In conclusion, short-term PM2.5 exposure is associated with a higher risk for ischemic stroke and possibly TIA, even when PM2.5 concentrations do not exceed the Israeli air quality guideline threshold. Vulnerability to the air pollution effects differed by age, sex, ethnicity, and comorbidities.Stroke is the second most common cause of death and disability in the world. Many studies have found fine particulate matter (PM Global response . Inhalinlar risk ,7.3 increase in chronic fine particulate matter (PM2.5) exposure was associated with an 11% increase in ischemic stroke risk [2.5 exposure and stroke.Ambient air pollution contributes to approximately 4.2 million deaths annually, and has been linked to atherosclerotic cardiovascular outcomes, and specifically stroke, in many studies ,8,9. Foroke risk . HoweverIn many studies, certain populations were found to be more susceptible to air-pollution-related health effects. Studies in Israel found larger air pollution effects on respiratory outcomes among the non-Jewish population ,13, poss2.5 exposure and stroke in a national population-based study in Israel. Israel is in Western Asia and is surrounded by the Sahara Desert [2.5 levels ranged from 21 to 25 µg/m3 in the last two decades. These levels are considerably higher compared to other developed countries. For example, the mean annual PM2.5 levels in the United States ranged from 7 to 10 µg/m3 in the last two decades [2.5 composition differs across Israel. In dense cities such as Tel Aviv, traffic is a major air pollution source. In Southern Israel, natural dust is a major source. Haifa has a higher concentration of pollutants originating from industrial sources, as well as from the combustion of fuel oil and the combustion of residual oils used by ships [2.5 exposure and ischemic stroke, ICH, or transient ischemic attacks (TIA), and identified populations more vulnerable to the PM2.5 effect.We analyzed the association between PMa Desert , Middle  decades . The PM2by ships ,20. We uIn this retrospective cohort study, we utilized the INSR to identify all stroke cases of individuals 18 years and older across Israel between the years 2014 and 2018. The INSR was formed in 2014 and includes data on all permanent residents in Israel admitted to a general hospital with a final International Classification of Disease, ninth edition (ICD-9) diagnosis of ischemic stroke , ICH (ICD-9: 431), or TIA (ICD-9: 435). Data are retrieved from electronic medical records of inpatient hospital visits quarterly and contains sociodemographic information  and clinical information . Information on sociodemographic variables was retrieved from the Ministry of Interior and linked to the INSR. Ethnicity was grouped into Jewish versus non-Jewish due to the small percentage of the non-Jewish population. The non-Jewish group includes Arab, Druze, or other ethnic groups. Sex was coded as male or female. Age was calculated in years using the year of birth. A universal coded ID was available for each participant and allowed us to link demographic and clinical data and track repeated events. We excluded 2036 repeated events within the study period (2.2%) to avoid bias due to a differential baseline risk. We additionally excluded 1289 individuals without a valid residential address (1.6%).2.5 and temperature estimates from satellite-based spatiotemporal models that apply a hybrid approach and estimate daily mean temperature and PM2.5 exposures at a fine resolution [2.5 or temperature estimations at a 1 × 1 km spatial resolution. The models were calibrated daily by applying a mixed-modeling approach using the MODIS-based multiangle implementation of atmospheric correction (MAIAC) aerosol optic depth (AOD) and various spatial and temporal predictors. This resulted in excellent performance with out-of-sample cross-validated R2 values of 0.82–0.92 for the PM2.5 model and 0.966–0.986 for the temperature model. Exposures were linked to each individual based on proximity to geocoded residential address.We obtained PMsolution ,22. Brie2.5 levels did not exceed the Israeli air quality standard of 37.5 µg/m3. We linked the PM2.5 and temperature exposures based on a participant’s residential address. Based on previous studies, we defined the window of exposure as exposure on the same day and additionally assessed the associations with exposures 1–2 days before the event.To portray the potential risks posed by air pollution exposure that occurred within the range of acceptable air quality levels, our study was restricted to days in which the average PM2.5 exposure and stroke using a conditional logistic regression in a case crossover approach [2.5 exposures at lag days 0, 1, or 2 with each of the outcomes, with adjustment for temperature exposure at the same exposure window as PM2.5. To allow for nonlinear associations, we repeated the models using a spline function for the PM2.5 exposure. As a sensitivity analysis, we further restricted the data to individuals with exact address information , to make sure our results were not biased due to exposure measurement error.We assessed the association between short-term PMapproach . This ap2.5 associations with ischemic stroke/TIA. Since we did not observe an association with ICH, and since the exposure–response curves of the associations with ischemic stroke and TIA were similar, we pooled these cases together for the purpose of this secondary analysis.As a secondary analysis, we created subcohorts of sociodemographic groups  and comorbidities  to identify populations that were more vulnerable to the PM2.5 concentrations did not exceed the 24 h Israeli standard (37.5 µg/m3) in 97% of the days during 2014–2018. During these days, the average daily mean PM2.5 concentration was 17.8 µg/m3, with an interquartile range (IQR) of 6.3 µg/m3. The average daily mean temperature was 21.3 °C, with an IQR of 9.8 degrees.We included 74,052 cases, of which 64.8% were ischemic stroke, 7.7% ICH, and 27.6% TIA. About 46% were women, the mean age was 71, and 80.9% were Jewish. Diabetes, hypertension, and hyperlipidemia were highly prevalent . PM2.5 c3) in PM2.5 exposure on the event day was associated with a 1.7% increase in the risk for ischemic stroke , a 2.7% increase in the risk for TIA , and a 4.4% decrease in the risk of ICH . We did not find associations between PM2.5 exposure in lag days 1–2 and either of the outcomes  and 13.18% , among Jewish vs. non-Jewish, 3.97%  and 7.92%  among younger vs. older adults, and 4.44%  and 7.80%  among men vs. women.For example, the percent increases in ischemic stroke/TIA risks (95% CI) associated with a 1 µg/m2.5 and ischemic stroke/TIA associations were also larger among individuals with diabetes, hypertension, and ischemic heart disease, compared to those without the disease  and 4.96%  increased risks among people with and without diabetes, 6.65%  and 3.81%  among people with and without hypertension, and 8.70%  and 4.74%  among people with and without IHD.The PM disease . For exa2.5 exposure models at a fine spatiotemporal resolution to assess the association between PM2.5 exposure and stroke. While restricting our analysis to only days where average PM2.5 concentrations fell within the Israeli air quality standard of 37.5 µg/m3, we found an increased risk of ischemic stroke associated with PM2.5 exposure. Furthermore, this association was modified by sociodemographic factors and comorbidities, with larger effects observed among women, non-Jewish individuals, older adults, and individuals with diabetes, hypertension, and ischemic heart disease.In this retrospective cohort study, we leveraged a population-based registry and PM2.5 exposure was associated with a hazard ratio of 1.53 among those exposed to levels higher than 78.2 µg/m3 compared to those exposed to lower levels [3 increase in PM2.5 in studies conducted in North America and Asia [Our findings corroborate the existing literature that found associations between long-term and short-term particulate matter exposure and ischemic stroke among other cardiovascular morbidities. For example, a prospective cohort study conducted in China found that long-term PMr levels . A meta-and Asia .2.5 and ozone exposure within the National Ambient Air Quality Standards (NAAQS) set by the U.S. EPA, Quin Di et al. found that air pollution was still associated with higher risks of mortality among older adults [2.5 exposure even within the air quality standards [2.5 levels below 15 µg/m3. The WHO guidelines are reflected in the Israeli Clean Air Act, and the interim target for daily PM2.5 levels is 15 µg/m3. The standard, however, is much higher (37.5 µg/m3). Our findings imply that current policies and standards attempting to safeguard populations from the harmful effects of air pollution exposure may not be enough to protect those at risk.More importantly, we added evidence of harmful air pollution effects of exposure levels lower than national standards ,26,27,28r adults . A few or adults ,30. Wolftandards . In 2021tandards . The cur2.5 and ICH was observed in some studies which they attributed to the differences in the pathology of ICH and ischemic stroke [Regarding ICH, we initially observed a protective effect while using a linear term. However, as supported by the nonlinear exposure–response curve, there was no association with ICH and the protective effect could be attributed to larger errors in this smaller groups. The lack of association with ICH can be due to the lower occurrence of this type of stroke, or due to a different pathology. Similar to our findings, a recent meta-analysis concluded that the majority of studies evaluated did not find a significant association between ICH and short-term air pollution exposure . A nonsic stroke ,9.An important finding of our study is the larger effects observed among women, older adults, non-Jewish individuals, and people with cardiometabolic chronic conditions. As with our findings, a few other studies found larger estimates among women ,34. HoweAs in our study, other studies have found larger susceptibility to air pollution health effects among the non-Jewish population ,13. A re2.5 pollution. It may also be related to population characteristics that might be different in Southern Israel compared to other regions. Finally, as often seen in studies evaluating air pollution health consequences [Similar to our findings, other studies have found larger air pollution effects on stroke among older individuals ,39,40. Hequences ,17,43, w2.5 exposure. Our study also has several limitations. First, like other air pollution studies, we might have had an exposure misclassification error. However, due to the use of our highly spatiotemporally resolved exposure mode, this error is expected to be minimal [The major strength of this study is the use of a national cohort with comprehensive health information which allowed us to gain a better understanding of the association at a population level, including a broad population representing both rural and urban locations in an area with a unique climate and high concentrations of PM minimal . Additio2.5 exposure with certain populations more vulnerable to PM2.5 exposure effects. This emphasizes the importance of not only behavioral health interventions in cardiovascular risk prevention, but population-level interventions to reduce exposure to air pollution. Even within the Israeli air quality standards, a higher risk of ischemic stroke is still present as exposure to PM2.5 increases. These findings support the importance of mitigating exposure to PM2.5 through policy and regulation. Policy and air quality standards must shift to integrate the growing evidence from research findings that bolster the associations between air pollution exposure and cardiovascular health in their continued decision-making.We found a higher risk of ischemic stroke associated with PM


Sepsis is a life-threatening dysfunction resulting from the dysregulated host response to infection. The mortality of sepsis in Jamaica remains high amid the proven efficacy of the Surviving Sepsis Guidelines implementation in some countries.To evaluate the inter-relationship of healthcare workers’ attitude towards, knowledge of and practice of sepsis management in Jamaica.A survey was done using an anonymous self-administered validated questionnaire to healthcare workers across Jamaica. Questions on knowledge, attitude, and practice of sepsis within private and public hospitals were answered.A total of 616 healthcare workers were eligible for analysis. Most respondents agree that healthcare workers need more training on sepsis (93.7%) and that formal sepsis training modules should be implemented at their hospitals or practice (93.2%). Several signs of sepsis as outlined by qSOFA were correctly identified as such by most respondents (60.6% to 76.4%), with the exception of a low PaCO2 (34.9%), which was correctly identified by a minority of respondents. While a majority (69.3%) were able to correctly define sepsis, only 8.8% of respondents knew the annual sepsis mortality rate. Postgraduate training (p<0.01) and formal sepsis training (p<0.05) were both predictive of high correct knowledge and practice scores. Specialization in Anaesthesia/ Critical Care Medicine (p<0.05) or Emergency Medicine (p<0.05) was predictive of high knowledge scores and Internal Medicine predictive of high practice scores (p<0.01).This study revealed that education for healthcare workers on sepsis and the implementation of SSC is needed in Jamaica. Sepsis is a global health problem, causing one in five deaths around the world. In 2017, an estimated 48.9 million incident cases of sepsis were reported worldwide with 11.0 million sepsis-related deaths .Preventive measures are key to reducing the burden of infection and these include good hand hygiene, vaccination, and proper sanitation. However, the management of infected persons necessitates prompt identification of the condition to facilitate timely intervention that will improve clinical outcomes. The presentation of sepsis may include a wide variety of signs and symptoms which can be hard to detect. The recognition of a septic patient and the start of appropriate antibiotics are critical decisions made by clinicians. These decision-making skills are often more practiced and nuanced by critical care clinicians, than other generalist physicians.Rapid diagnosis and management of sepsis is critical for good outcome , 5, 6, 7Studies which have been done to highlight the variability in healthcare workers’ knowledge of sepsis have utilized surveys and analyzed results according to their varied demographics and clinical training . For thiOur study was approved by the University Hospital of the West Indies/ University of the West Indies (UHWI/ UWI) Faculty of Medical Sciences Ethics Committee (Mona)  and ethics committee of Ministry of Health of Jamaica (2016/31).A 25-item questionnaire was developed by the researchers and adjustments were made after a pilot study. The first 9 questions were on demographics . All the other questions were in a multiple-choice format and assessed knowledge of, attitude towards and typical practice of sepsis management based on the 2016 International Sepsis Guidelines ) compared to female respondents .Across clinical groups, nurses scored the lowest in correct knowledge (2.6[2.1-3.1]) and correct practice (6.2[5.4-7.0]) scores and consultants, interns/SHO, residents and senior/chief residents all had significantly higher correct knowledge (p<0.01) and correct practice (p<0.01) scores. GPs also had significantly higher practice scores compared to nurses (p<0.05) but slightly lower than other groups. Conversely, senior/chief residents and junior residents were the lowest scoring groups in incorrect knowledge (2.6[2.2-3.0]) / 2.9[2.7-3.1], respectively) and practice scores , GPs (p<0.01) and nurses (p<0.01) all had significantly higher incorrect knowledge and practice scores.With respect to classification according to years of experience post-registration there was no significant difference in correct knowledge scores (range 3.6 to 4.1). However, respondents that had 6-11 years post registration experience scored the highest in correct practice scores (9.2[8.8-9.5]), which was significantly higher than those with 0-5 yrs experience (p<0.01), and ≥ 24yrs experience (p<0.01).Conversely, respondents with 6-11yrs experience had the lowest incorrect knowledge (2.9[2.7-3.1]) and incorrect practice (1.8[1.6-2.0]) and participants with 18-23 yrs experience (p<0.05) and ≥ 24yrs experience (p<0.01) had higher incorrect knowledge scores. All other experience groups had significantly higher incorrect practice scores.Both post-graduate training and sepsis training were indicators of higher correct knowledge scores  and correct practice scores  compared to those without this training (p<0.01/p<0.05). Conversely, respondents with post-graduate training (2.2[2.0-2.4]) and sepsis training (2.1[2.0-2.3]) had lower incorrect practice scores compared to those without this training (p<0.01), however there was no statistical difference with respect to incorrect knowledge scores among those with or without either of these types of training.Respondents who specialized in Anaesthesia/ Critical Care Medicine (4.8[4.1-5.6]) and Emergency medicine (5.0[4.4-5.5]) had the highest correct knowledge scores (p<0.05) compared to those in Paediatrics (3.1[2.53.6]) and Public Health (3.1[1.9-4.2]), who scored the lowest. These 2 groups of respondents, Anaesthesia/ Critical Care Medicine (2.2[1.2-3.3]) and Emergency medicine (2.2[1.5-2.9]) also had the lowest incorrect knowledge scores, while those in Obstetrics & Gynaecology , Public Health , Psychiatry  and Family medicine  had the highest incorrect knowledge scores.Respondents specializing in Internal Medicine (10.1[9.3-10.8)] scored highest in correct practice (p<0.01), compared to those in Psychiatry (6.6[4.88.5]), Family Medicine (7.5[5.8-9.2]), and other specialties (7.5[5.9-9.0]). Respondents specializing in Psychiatry had the highest incorrect practice scores (3.9(3.0-4.7]) compared to those in Anaesthesia/Critical Care Medicine, Emergency Medicine, Haematology/Pathology, Internal medicine, Paediatrics and Surgery who all had significantly lower incorrect practice scores (p<0.01).With respect to independent predictors of high and low values for each of the 4 quantitative scores after elimination of confounding factors: the clinical specialty, the clinical position, and the years of post-registration experience of the respondent were the most influential predictive factors .Anaesthesia/ Critical Care Medicine and Emergency Medicine specialties were independent predictors of high correct knowledge scores while unnamed specialties, Psychiatry, Public Health, Family Medicine, Paediatrics specialties and Nurse clinical position were independent predictors of low correct knowledge scores. This multivariate linear regression model accounted for 20% of the variability noted in the incorrect knowledge score in the cohort.The clinical positions of GP and Consultant and O&G and Paediatrics specialties were all independent predictors of high incorrect knowledge scores. This multivariate linear regression model accounted for 20% of the variability noted in the incorrect knowledge score in the cohort.Internal Medicine specialty was the only independent predictor of a high correct practice score. GP and Nurse clinical positions, Psychiatry, and those with 0-5 years post-registration experience were independent predictive factors for low correct practice scores. This multivariate linear regression model accounted for 21% of the variability noted in the correct practice score in the cohort.Psychiatry specialty, nurse clinical position, no sepsis training and post-registration experience of 0-5yrs, 12-17yrs and ≥ 24yrs were all independent predictors of high incorrect practice scores. This multivariate linear regression model accounted for 25% of the variability noted in the incorrect practice score in the cohort.This study is the first in the region, evaluating the knowledge, practice, and attitudes towards the management of sepsis by healthcare workers in Jamaica. The recent update to the Surviving Sepsis Guidelines for Management of Sepsis and Septic Shock (SSC Guidelines) provides best practice principles for the management of sepsis patients in a hospital setting . The assPrevious surveys about the knowledge of nurses and doctors about sepsis guidelines indicated that it was poor or inadequate , 22, 23.Other key factors that predict good sepsis knowledge and practice are the extent of training as well as specific training geared towards sepsis management and the seniority of positions.While persons 6 - 11 years post-registration had the highest sepsis practice scores, there was no significant difference in knowledge scores across groups of varying time post-registration.The fact that sepsis practice scores decrease after 11 years post-registration and that there was no difference in knowledge scores across the groups highlights the overall need for training in all groups of respondents with a focus on retraining to maintain correct sepsis management principles and practice even in physicians with specialty training.Both post-graduate and sepsis training were indicators of higher correct knowledge and correct practice scores in our study, which were in contrast to several previous studies ,18. A stMost of the persons 69.3%) could correctly define sepsis as a dysregulated host infection response, which is comparative to a smaller study in 2003 which found that 54% of training grade doctors could recognize the definition of the stage of sepsis . On the 9.3% coulOnly a small number of respondents (less than 10%) knew the correct worldwide annual sepsis mortality rate, which was significantly less compared to >40% reported in Puerto Rico . HoweverThere are some limitations of this study. The total number of nurses was disproportionately lower than physicians which was due to the low response rate among this group of workers. Therefore, our results are not generalizable to nurses in Jamaica. Also, we used a convenience sampling method to recruit participants which has its inherent selection bias. However, we sought to ensure that all categories of physicians from interns to consultants were represented. The strength of this study is that it includes a wide range of participants from the major hospitals and outpatient settings across the island of Jamaica. We used the 2016 International Guidelines for Management of Sepsis and Septic Shock which were current during the study period. Therefore, our study reflected the knowledge and practice of healthcare workers based on the then current international guidelines as a standard of practice. Those guidelines were subsequently updated in 2021 to call for the utilization of different sepsis screening tools and to clarify the need for immediate antimicrobial therapy. Interestingly, those changes did not significantly affect the correct responses to our questions.In a survey, it was observed physicians who were Anaesthetists or worked in Critical Care/Emergency medicine had the greatest knowledge of sepsis. Evidence is shown that more sepsis education is required for healthcare workers in Jamaica. The management of sepsis may benefit from implementation of SSC bundles in Jamaica.


Plasmodium transmission foci, in the malaria epidemic-prone zone of Kisii highland.The vulnerable population within the malaria epidemic zone remains at risk of increased burden and fatality. This is because of unpreparedness and overstretching of healthcare capacity in the event of a full-fledged epidemic. The purpose of this study was to determine the prevalence of microscopic and submicroscopic infections, as well as map specific Plasmodium species 18S rRNA gene was used to detect the presence of submicroscopic infections on DNA extracted from dry blood spots.Patients seeking malaria treatment at Eramba health facility in the epidemic-prone zone of Kisii highland were enrolled in the study. Malaria outpatient data for the entire month of May were also included in the analysis. Patients' finger prick blood smears were examined for microscopic infections, while a real-time polymerase chain reaction targeting the 2 = 75.05, df 2, p < 0.0001). Children under the age of five had the highest positivity rate , followed by children aged 5–15 years , and individuals aged 15 years and above . Out of the 102 patients recruited, the positivity rate by microscopy was 57.8% (59/102) and 72.5% (74/102) by RT-PCR. Most of the microscopic infections  were from Morara and Nyabikondo villages in Rioma and Kiomooncha sublocations, respectively. The submicroscopic prevalence was 14.7% (15/102) and was observed only in patients from high-infection villages in Rioma  and Kiomooncha  sublocations. Across gender and age groups, females  and patients aged 15 years and above  had high levels of submicroscopic infections. There were two mixed infections of P. falciparum/P. malariae and P. falciparum/P. ovale, both from patients residing in Kiomooncha sublocation.Based on outpatient data, the malaria positivity rate was 20.7% . The positivity rate varied significantly by age group (χPlasmodium falciparum infections remained relatively high in the Marani subcounty. Infections were concentrated in two villages, which could serve as a target for future public health intervention, particularly during a malaria epidemic. However, epidemic-prone areas, particularly the highlands bordering malaria-endemic areas, remain vulnerable . BecausePlasmodium falciparum infection within epidemic zones. The purpose of this study was to determine the prevalence of microscopic and submicroscopic P. falciparum infections in clinical patients from the epidemic-prone Kisii highland in western Kenya, with the goal of mapping existing malaria transmission pockets.Increased deaths have been reported in Rift Valley epidemics-prone counties such as Baringo, Marakwet, and West Pokot as a result of a strained healthcare system during the recent malaria outbreak . For exa22.1This was a health-based survey conducted at Kisii County's Eramba health facility. The research was conducted in May 2019, when the health facility received 1115 patients seeking malaria treatment. The health facility is located on a highland adjacent to the malaria-endemic Lake Victoria basin in the Marani subcounty, which is administratively divided into locations and sublocations . Partici2.2The blood samples from finger prick were spotted on coded Whatman™ Blood Stain Cards  and smears made on glass slides. Microscopists at the hospital prepared and read Giemsa-stained slides for the presence and density of asexual parasites. Microscopy reading, estimation of parasite density and quality control were done as previously described .2.3Plasmodium DNA was stored at −20 °C. To confirm samples with parasite DNA, a species-specific real-time polymerase chain reaction (RT-PCR) targeting 18 s rRNA was performed. Amplification was carried out on a QuantStudio 3 Real-Time PCR System  with species-specific primers and probes, as previously described (Parasite DNA was extracted from DBS using the modified Chelex resin (Chelex-100) saponin method . The extescribed . The PCR2.4P. falciparum infections across gender, age groups, and sublocations. The analyses were carried out using SPSS version 25 for Windows and GraphPad Prism v.8.0.1 software. Data were considered statistically significant at p < 0.05.Patient data were entered into Microsoft Excel v.2016, and summarized using descriptive statistics. The Pearson chi-square test was used to compare microscopic and submicroscopic 2.5Maseno University's Ethical Review Committee granted ethical approval for this study (Reference No. 00456). Participants in the study provided written consent for the retrieval of patient data and the storage of their blood samples at the hospital. Parents or guardians provided consent as children's legal representatives. To avoid ethical code violations, patients' identities were not recorded.33.1P. falciparum infections than females, the difference was not significant . When compared to adults and children aged 5–15 years, children under the age of five had a higher prevalence of P. falciparum infections .Generally, the health facility attracted 1115 patients who sought malaria treatment in the month of May 2019. Females who sought malaria treatment were 78.6% (876/1115) whereas males were 21.4% (239/1115). Across age groups, 42.9% (478/1115) were adults followed by children aged 5–15 years 31.9% (356/1115) and > 5 years 25.2% (281/1115). Based on outpatient data, 935 febrile patients were examined by microscopy and 180 by the CareStart™ malaria HRP2 (Pf) rapid diagnostic kit (mRDT). The hospital's overall positivity rate was 20.7% . The positivity rate by microscopy was 20.1% (188/935), while the rate by mRDT was 23.9% (43/180). Despite males having higher proportion of fections . The var3.2Of the 935 outpatients, 102 study participants were randomly recruited. These included participants who were diagnosed by microscopy and their blood spotted on filter paper for RT-PCR assay. Most 57 (55.9%) were from Rioma sublocation whereas the rest were from Kiomooncha 37 (36.2%), Rikenye 6 (5.9%), Engoto Goti 1 (1%) and Megogo 1 (1%) sublocations. Sixty-one (59.8%) were female whereas 41 (40.2%) were males. Children between age group 5–15 years were largest group 41 (40.2%) followed by adults 38 (37.3%) and those <5 years 23 (22.5%). Female dominance was evident across two age groups as follows, 16 (69.6%) and 27 (71.1%) among <5 years and adults (≥15 years) respectively. More than half of recruited participants within the school-going age group (5–15 years) were males 23 (56.1%).3.32 = 2.98, df 1, p = 0.084). Adults had the most submicroscopic infections 21.1% (8/38) of any age group. The difference across the age groups was however not significant . These infections were only confirmed in patients from Rioma and Kiomooncha sublocations . Rioma sublocation had the highest proportion of patients with total infections (microscopic and submicroscopic) (80.7%), followed by Kiomooncha (59.5%), and Rikenye (66.7%). Females had 68.9% more total infections than males  of screened blood smears tested positive for microscopic infections. The majority of patients with positive smears 62.7% (37/59) and 27.1% (16/59) were Rioma and Kiomooncha residents, respectively. In the two sublocations, two villages, Morara in Rioma and Nyabikondo in Kiomooncha each had 12 patients with microscopic infections and contributed to 40.8% (24/59) of the slide positive rate. There were 17.6% (15/102) of submicroscopic infections, with female patients infected more than males . These iocations . Two paran males . Both in4In May, the malaria positivity rate among clinically ill patients was high in the epidemic-prone Marani subcounty. Males and children under the age of five were the most affected groups in this epidemic-prone zone, according to the total number of reported malaria cases in the facility. The infections were zoned to two major sublocations, Rioma and Kiomooncha, with transmission foci traced to Morara and Nyabikondo villages, respectively. The levels of submicroscopic infections, on the other hand, were low and were only confirmed on patients from the two sublocations. Females bore a disproportionate share of the submicroscopic infections compared to males, with high prevalence of total infections and parasite densities still being recorded among children aged 5–15 years.As observed in endemic zones, more females in Kisii highland sought malaria treatment at health facility as compared to males . FurtherP. falciparum. Morara and Nyabikondo villages in Rioma and Kiomooncha, which have a high number of microscopic infected individuals, serve as a guide for possible focal parasite or vectorial intervention targets in the event of a future outbreak of P. falciparum infections in the Marani subcounty.The majority of the microscopic infections observed were focal and could be traced back to Rioma or Kiomooncha sublocations. The two sublocations also had the highest number of patients seeking malaria treatment and are adjacent to each other while bordering an endemic region, Homa Bay County. Their proximity to endemic areas may predispose residents to malaria infections , as wellSubmicroscopic infections were relatively low, with females and adult patients having the highest levels. The slightly higher prevalence of this type of infection in females and adults supports previous findings and has been linked partly to immunity . However5This study established high malaria positivity rates and low levels of submicroscopic infections in five sublocations in the epidemic-prone region of Kisii county. The transmission was focalized to two main sublocation of which two key villages were observed as sentinel sites with the potential targeted parasite or vectorial intervention in case of malaria epidemic.10.13039/100000002National Institutes of Health (U19 AI129326 and D43 TW001505).The work was supported by Grants from the Authors have no conflict of interest to disclose.


Vulpes vulpes) is the most widespread wild carnivore globally, occupying diverse habitats. The species is known for its adaptability to survive in dynamic anthropogenic landscapes. Despite being one of the most extensively studied carnivores, there is a dearth of information on red fox from the Trans-Himalayan region. We studied the home range sizes of red fox using the different estimation methods: minimum convex polygon (MCP), kernel density estimator (KDE), local convex hull (LoCoH) and Brownian-bridge movement model (BBMM). We analysed the daily movement and assessed the habitat selection with respect to topographic factors , environmental factor (distance to water) and anthropogenic factors (distance to road and human settlements). We captured and GPS-collared six red fox individuals  from Chiktan and one female from Hemis National Park, Ladakh, India. The collars were programmed to record GPS fixes every 15-min. The average BBMM home range estimate (95% contour) was 22.40 ± 12.12 SD km2 (range 3.81–32.93 km2) and the average core area (50% contour) was 1.87 ± 0.86 SD km2 (range 0.55–2.69 km2). The estimated average daily movement of red fox was 17.76 ± 8.45 SD km/d (range 10.91–34.22 km/d). Red fox significantly selected lower elevations with less rugged terrain and were positively associated with water. This is the first study in the Trans-Himalayan landscape which aims to understand the daily movement of red fox at a fine temporal scale. Studying the movement and home range sizes helps understand the daily energetics and nutritional requirements of red fox. Movement information of a species is important for the prioritisation of areas for conservation and can aid in understanding ecosystem functioning and landscape management.Red fox ( One of the basic fundamentals for understanding an animal’s ecology is its home range size, which is defined as an individual’s area where movement occurs for normal activities like gathering food, mating and raising the young . The cauVulpes vulpes) is the most widespread wild carnivore in the world , wolf (Canis lupus), Ladakh urial (Ovis vignei), blue sheep (Pseudois nayaur), ibex (Capra ibex), weasel , and stone marten (Martes foina) occur in this area.The study was conducted in Ladakh, which belongs to the northwestern Trans-Himalayan region of India . The are2 . Foxes w2 . Rumbuck2 . BesidesWe captured seven adult red foxes from October 2018 to January 2019 using five Victor soft catch #3 leg hold traps. Six individuals were captured in Chiktan and one in Hemis National Park. The animals were immediately collared with Sirtrack collars  and released within 20–30 min at the place of capture. Animal handling, capture and release were approved by the Department of Wildlife Protection, Jammu and Kashmir (CCFWL\Permission\2016\575-76). No drugs were administered to the animals, and the methodology was refined to ensure minimum stress, handling time, and injury to the captured individual, approved by Wildlife Institute of India, animal ethics committee. The foxes were weighed and sexed before release . Weight The data from seven red foxes included 31,261 GPS fixes and were filtered in ArcGIS 9.2.1 with the ArcMET filter tools . The fili.e., the sum of displacement in one day, with the help of trajectory details from the ArcMET path statistics tool in ArcGIS. We considered the daily movement as the sum of linear distances obtained from each consecutive GPS fix from the first location of midnight and the last location of the same day. For M3 and M4 individuals, we use only the 15-min data for estimating the daily movement. While estimating the daily movements, we found an abrupt change in trajectories in certain instances. On inspecting the spatial data further, we could identify irregular spikes in the speed of these trajectories. Hence to remove these high movements, we truncated data above 98%  for land cover data which consisted of nine classes  by relaxing the implicit assumption that these are independent  to those of randomly placed steps  within the movement path. The random steps are generated using distances sampled from a gamma distribution fitted to the empirical step length distribution and random turning angles by von Misses distribution. We generated both true and random steps for 15-min intervals for all the individuals. We produced 10 random steps per used step, based on the recommendations of For habitat selection in relation to topography , an environmental factor (distance to water) and anthropogenic disturbances (distance to road and to human settlements), we used integrated step-selection functions (iSSF) from the amt package in R . iSSF joependent . This me2 and the average core area (50% contour) was 1.87 ± 0.86 SD km2. The smallest home range was for individual F1 (3.81 km2) whilst M1, M2, and F3 utilised multiple core areas  than that of males . However, the difference between sexes was not statistically significant, probably due to the limited sample size and high variability among individuals. In our study, the average LoCoH and BBMM methods had a smaller estimated home ranges (LoCoH 17.33 ± 15.29 SD km2 and BBMM 22.40 ± 12.12 SD km2) than MCP method (MCP 43.24 ± 40.52 SD km2).The red foxes we observed showed high variation in the size of their home ranges and core areas . We alsore areas . The aven = 4) than those of females . Individual M3 showed the highest variation and average daily movement (34.22 ± 20.85km/d). The daily movement of our largest individual M2, was least  than other land-use categories, while F2 was mainly found in barren land (70.14%). M1 and M2 were present in agriculture and barren land. Similarly, M3 and M4 exploited agriculture and barren land, but also used areas with snow in higher proportions . F3 vixen in Hemis National Park used only barren land (62.32%) and alpine vegetation (37.67%), respectively .P < 0.001, P < 0.001), while F3, M2, M3 and M4 selected to be near human settlements (P < 0.01). Individuals F2 and M1 did not exhibit significant selection for or avoidance of human settlements. The red fox tended to select for water bodies. However, for M3 and M4 individuals, this trend was non-significant. Except for F2 and F1, all individuals avoided roads and slope (P < 0.001).For habitat selection, we found the red fox selected lower elevations and less rugged terrain (2 (95% MCP) to 8.97 km2 (95% LoCoH). We also found the largest home range for M1 (118.77 km2 95% MCP) while the largest core area was found for M2 (24.47 km2 50% MCP). The MCP method is adversely affected by extreme locations resulting in larger home range estimates. However, the core area of M2, the largest individual, overlapped with the core areas of all other individuals. The traditional methods MCP and kernels utilisation distribution allow comparisons between studies but may overpredict the actual home ranges because of exploratory behaviour. Since our study site consists of rugged terrain and we used short interval between GPS fixes, LoCoH and BBMM are likely to be better methods for home range estimation. The LoCoH method identifies steep slopes and inaccessible areas while BBMM incorporates space, time and animal-specific parameters or habitat  shrub. Additionally, due to the high anthropogenic food subsidy prevalent at the study site of Chiktan  in the Arctic or even more extensive which are determined majorly by the type of habitat  has been comparatively well studied and is reported to be 51.9 ± 11.7 km/d  as compared to other individuals, but its average daily movement was 11.10 ± 7.72 SD km/d. Daily distance travelled by individuals having a smaller home range may be similar to individuals having a larger home range, and the difference may only reflect the different foraging sites used by the individuals  are covered with snow all throughout the year. Agricultural land is scarce and present near the river valleys. We found that the larger foxes, category . On the category , Fig. 3.Red foxes are known for their highly adaptable behaviour and often show large variations in their habitat selection . In our Studies on the red fox population in the Trans-Himalayan region are limited and their current status remains unknown. However, a previous study has reported few retaliatory killings due to predation on poultry . This st10.7717/peerj.13967/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.13967/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.13967/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.13967/supp-4Supplemental Information 4Click here for additional data file.10.7717/peerj.13967/supp-5Supplemental Information 5Click here for additional data file.


BackgroundWhile immunization programs across the world have made considerable progress, children and communities continue to be beyond the reach of healthcare services. Globally, they are now referred to as zero-dose (ZD) children . Pre-COVID-19 pandemic analyses suggest that nearly 50% of vaccine-preventable deaths occur among ZD children. Two-thirds of these children live in extremely poor households suffering from multiple deprivations including lack of access to reproductive health services, water, and sanitation. Hence, ZD children have now been prioritized as a key cohort for identification and integration with the health systems as we build back from the pandemic.MethodologyExtracting data from the last two National Family Health Survey (NFHS) rounds , this study aims to ascertain the status of ZD children aged 12-23 months in India, the challenges, and the necessary action agenda going forward. Data were analyzed for equity determinants such as gender, place of residence, religion, birth order, caste, and mother’s schooling. Key determinants included the change in ZD prevalence at the national, state, and district levels; variations across equity parameters and states with maximum improvements; and disparity across these indicators. A correlation analysis was also conducted to understand the nature of the association between ZD prevalence and critical maternal and child health indicators.ResultsThe overall ZD prevalence between the two rounds was reduced by 4.1% (10.5-6.4%). A total of 26 states in the country reported a ZD prevalence of <10% in NFHS 5 compared to 18 in NFHS 4. In total, 324 districts reported a ZD prevalence of <5%, and 145 districts reported a prevalence of >10%. The equity parameters reflected a slow-footed reduction among ZD for girl children, across urban geographies, firstborn children, mothers with 12 or more years of schooling, and children in families with the highest wealth quintiles. A negative correlation accentuated between the two NFHS rounds was established between first-trimester registration, four or more antenatal visits, institutional deliveries, and ZD prevalence.ConclusionsThe findings point toward sustained improvement across key equity parameters, however, challenges do exist. Moreover, the impact of the pandemic on immunization programs across the globe and in India is bound to halt and reverse the progress and potentiate further inequities. It is thus imperative that continued and augmented efforts are continued to identify, integrate, and immunize ZD children, families, and communities. While immunization programs across the world have made considerable progress, children and communities continue to be beyond the reach of healthcare services. Globally, they are now referred to as zero-dose (ZD) children  . ZD chilHence, recent efforts recognize the need for reaching out to ZD children. The Immunization Agenda 2030 aims to half the number of ZD children by 2030 , and theIn line with the above efforts, the Government of India has prioritized efforts to reach out to ZD children, with the recent GAVI support to the country identifying 143 districts across 11 states for focused support . In addiThis article presents the findings of secondary analyses of data sourced from the National Family Health Survey (NFHS). NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India . It is uHaemophilus influenzae type b), oral polio vaccine, measles-containing vaccine (MCV), and rotavirus vaccine (RVV). In addition, data are available for key equity parameters including gender, place of residence, religion, birth order, caste, and mother’s schooling. While the NFHS factsheets provide data on key coverage indicators, the equity indicators are included as part of the state reports. The state reports also provide data on other program indicators, the impact of which can be assessed on the immunization program. Coverage of key immunization indicators for districts is available in the state reports.Data for immunization are available for the point of service (public and private) and the coverage estimates for individual antigens (BCG), hepatitis B birth dose, pentavalent . ZD proportions were measured using pentavalent 1 coverage as the indicator. The key determinants studied include the change in ZD prevalence at the national, state, and district levels; the proportion of change in equity determinants; the states with maximum improvements; the maximum disparity across these indicators; and the overall reduction in disparities. The data were interpreted in the form of tables and maps. The maps were created using choropleth maps on Datawrapper  and the A correlation analysis was conducted to understand the nature of the association between ZD prevalence and critical maternal and child health (MCH) indicators which include four or more antenatal care (ANC) visits, the timing of pregnancy registration, institutional delivery , children under five years old who are stunted (height-for-age), and children under five years old who are wasted (weight-for-height). For each of these indicators, data were collated for both the NFHS rounds (NFHS 5 and NFHS 4), and the Pearson correlation coefficient was obtained using the following formula: r=∑[(xi-x ¯)(yi-ȳ)] ⁄ √[∑(xi-x ¯)^2 ∑(yi-ȳ)^2]with the coefficient value r signifying the strength and direction of correlation between the two variables. The strength of association as per the correlation coefficient values was interpreted as follows: no association: 0, weak association: (±) 0.1 to less than 0.3, moderate association: (±) 0.3 to less than 0.5, strong association: (±) 0.5 to less than 1, and perfect association: (±) 1.The overall ZD prevalence between the two NFHS rounds has come down by 4.1% (10.5-6.4%), with an annual cohort of 26 million, which translates to 1.7 million ZD children in the country. Five states in the country, namely, Bihar, Madhya Pradesh, Maharashtra, Rajasthan, and Uttar Pradesh, which account for almost 55% of the birth cohort, account for about 63% of the ZD children.Data are available and comparable for 30 states in the country between the two rounds (NFHS 5 and NFHS 4). In NFHS 5, nine states reported a ZD prevalence of 0 to <5%, 17 states a prevalence of 5% to <10%, and two states each reported a prevalence of 10% to <15% and 15% and above. The corresponding figures for NFHS 4 were nine, nine, five, and seven, respectively. ZD prevalence in the country ranges from 17.8% in Meghalaya to 2% in Himachal Pradesh, as per NFHS 5, and this ranged from 31.9%  to 1.1% (Sikkim) as per NFHS 4. While three states  have shown the maximum reduction between the two NFHS rounds, Andhra Pradesh, Chhattisgarh, Jharkhand, Meghalaya, Sikkim, Punjab, and Telangana have reported an increase in ZD prevalence between NFHS 4 and NFHS 5. In addition, despite substantial reduction, northeastern states of the country continue to have the highest ZD prevalence across the country, and this reduction is attributable to the high baselines across these states in NFHS 4  and 4.9% (10.8% to 5.9%) in rural areas of the country. The reduction among Muslim children is 6.7% (16.0% to 9.3%) between the two rounds compared to 3.5% (9.3% to 5.8%) for Hindu children. Among children belonging to Scheduled Caste (SC) the prevalence has reduced from 9.8% to 6.1% (3.7%) between the two rounds, similarly the reduction has been from 13.6% to 7.1% (6.5%) for Scheduled Tribes (ST), 10.1% to 6.1% (4.0%) for Other Backward Class (OBC), and 10.3% to 6.7% (3.6%) among others. There has been a 2.4% reduction in ZD children among the first-born child (8.1% to 5.7%), 6.3% (15.9% to 9.6%) in birth orders four to five, and 9.4% (26.0% to 16.6%) in birth orders 6 and higher. Among mothers with no schooling, the ZD prevalence has reduced by 7.0% (17.1% to 10.1%) and mothers with 12 or more years of schooling by 1.2% (6.0% to 4.8%). The ZD prevalence has reduced from 7.1% to 5.5% among the highest wealth quintile, from 7.0% to 5.1% in the fourth highest quintile, from 8.8% to 5.4% in the middle quintile, 11.4% to 6.7% in the second lowest, and from 15.8% to 8.4% in the lowest wealth quintile. This translates to a reduction of 1.6%, 1.9%, 3.4%, 4.7%, and 7.4%, respectively, among the five groups  states reported a female ZD prevalence of 0 to <5%, 16 (55%) states a prevalence of 5% to <10%, two (7%) states, and three (10%) states a prevalence of 10 to <15% and 15% and above, and in NFHS 5, the corresponding figures for NFHS 4 being 28%, 28%, 24%, and 21%, respectively, for the four categories. The maximum reduction among female ZD proportions has been achieved in Arunachal Pradesh (19.2%), Tripura (16.9%), Nagaland (12.7%), Assam (11.6%), and Uttar Pradesh (8.7%). Eight states reported an increase in prevalence between the two rounds. These are Andhra Pradesh, Chhattisgarh, Jharkhand, Punjab, Sikkim, Telangana, Kerala, and Meghalaya.Male ZD prevalence of 0 to <5% was reported across nine (31%) states, 5 to <10% in 16 (55%) states, 10 to <15% in three (10%) states, and a prevalence of 15% and above in one (3%) states of the country. Overall, 28% of states reported a prevalence of 0 to <5% in NFHS 4, with 24% each being reported for the other three categories. The maximum improvement in male ZD prevalence was reported in Nagaland (19.3%), Arunachal Pradesh (17.4%), Mizoram (16.7%), Tripura (11.1%), and Rajasthan (9.4%). Six states reported an increase in prevalence between the two rounds. These are Andhra Pradesh, Chhattisgarh, Jharkhand, Punjab, Sikkim, and Telangana.Overall female ZD prevalence was less than male ZD across 10 (34%) states of the country as per NFHS 5, a dip of 4% compared to NFHS 4. The disparity between the two rounds was reduced more for male ZD compared to female ZD prevalence. While the prevalence for male ZD ranged from 32.4%  to 1.5% (Chhattisgarh) in NFHS 4, the same reduced to 17.9%  to 0.7%  in NFHS 5. Similarly, the prevalence of female ZD ranged from 32.8%  to 2.6% (Chhattisgarh) in NFHS 4 and from 18.5%  to 2.1% (Tamil Nadu) in NFHS 5. The maximum disparity between male and female ZD prevalence was reported by Nagaland (5.4%), Maharashtra (4.9%), and Bihar (3.4%) in NFHS 5.Mother’s Education and Zero-Dose StatusThe article provides a comparative analysis for ZD children wherein mothers who have had no schooling with respect to mothers who had 12 or more years of schooling. For mothers with no schooling, data were analyzed for 26 states for NFHS 5 and 25 states for NFHS 4. Data were analyzed for 29 and 28 states, respectively, for mothers with 12 or more years of schooling for NFHS 5 and NFHS 4, respectively.For mothers with no schooling, three (12%) states reported a prevalence of 0 to <5%, 15 (58%) a prevalence of 5 to <10%, five (19%) a prevalence of 10 to <15%, and three (12%) states a prevalence of 15% or more in NFHS-5, and the corresponding figures in NFHS 4 were three (12%), three (12%), six (24%), and 13 (52%) for the four cohorts. Twelve (41%) states reported a ZD prevalence of 0 to <5%, 15 (52%) a prevalence of 5% to <10%, and one (3%) state each a prevalence of 10% to <15% and 15% and above for mothers with 12 or more years of schooling in NFHS 5. Similarly, prevalence across the four cohorts in NFHS 4 was 14 (50%) states, 10 (36%) states, and two (7%) states for mothers with 12 or more years of schooling.ZD prevalence in mothers with no schooling has shown a substantial decline between the two rounds with Tripura (56.8%), Nagaland (41.9%), Mizoram (30%), Arunachal Pradesh (27.7%), and Manipur (22.8%) reporting the maximum improvement. In comparison, improvement in the other group was on the lower side. The maximum reductions were reported in Maharashtra (7.3%), Assam (5.2%), Odisha (4.6%), Tripura (4.5%), and Karnataka (4.4%). While the prevalence of ZD children in families where mothers have not received any schooling remains high, the disparities have reduced significantly between NFHS 4 and 5. While the range was 63.9% (Tripura) to 3.8% (Tamil Nadu) in NFHS 4, it has been reduced to between 25.8% (Mizoram) and 3.9% (Jammu & Kashmir and Karnataka) in NFHS 5. On the other hand, the disparities have increased in families with mothers having 12 or more years of schooling. This is reflected through a range of 18.1%  to 2.0% (Odisha) in NFHS 5 compared to 16.6% (Mizoram) and 0.9% (Andhra Pradesh) in NFHS 4. In addition, five states have reported an increase in ZD prevalence in mothers with no schooling group, and 14 states reported an increase in mothers with 12 or more years of schooling group.Birth Order and Zero-Dose StatusThe data for this parameter are fragmented across the two surveys. While data for birth order one has been analyzed for 29 states for NFHS 4 and 5, the analysis for birth order four to five is based on 23 states, and that for birth order six or more for 17 states in NFHS 4 and 11 states in NFHS 5.In NFHS 5, 13 (45%) states have reported a ZD prevalence of 0 to <5% for birth order one, 12 (41%) a prevalence of 5% to <10%, and 4 (14%) states a prevalence of 10% to <15%. The corresponding figures for NFHS 4 were 11 (38%), eight (28%), and six (21%). In addition, four (14%) states in NFHS 4 had reported a prevalence of 15% or higher. For birth order four to five in NFHS 5, two (9%) states reported a prevalence of 0 to <5%, 11 (48%) a prevalence of 5% to <10%, and four (17%) and six (26%) states a prevalence of 10% to <15% and 15% and higher, respectively. The figures in NFHS 4 for the four cohorts were one (4%), five (22%), five (22%), and 12 (52%). Similarly, for birth order six and above, a ZD prevalence of 5% to <10% was reported by one (9%) state in NFHS 5 and two (12%) states in NFHS 4. Three (27%) and two (12%) states reported a prevalence of 10% to <15%, and seven (64%) and 13 (76%) states, a prevalence of 15% and above.Disparities have significantly reduced for all the above three birth orders between the two rounds, with maximum reductions being observed for higher birth orders. This is evident from the reduction in the range observed for these cohorts, while for birth order six or more the highest prevalence was 59.6% in Arunachal Pradesh and the lowest 6.9% in Chhattisgarh (NFHS 4), the highest prevalence has reduced to 28.3% in Assam in NFHS-5. The lowest prevalence reported in NFHS-5 though has seen a rise with it being lowest in Rajasthan (8.9%). The range for birth order four to five has similarly reduced from 44.4%  to 1.6% (Chhattisgarh) in NFHS 4 to 27.6%  to 3.8% (Odisha) in NFHS 5. The corresponding figures for birth order one are 21.50%  to 0.50% (Chhattisgarh) and 13.70% (Mizoram) to 1.40%  for the two survey periods. The maximum reduction in ZD prevalence for birth order six and more is observed in Arunachal Pradesh (35.6%), Nagaland (28.0%), Rajasthan (26.5%), Uttar Pradesh (19.2%), and Haryana (10.2%) between NFHS 4 and NFHS 5 and in Arunachal Pradesh (29.6%), Rajasthan (14.8%), Assam (13.2%), Haryana (10.7%), and Nagaland and Uttar Pradesh each (10.5%) for birth order four to five. Tripura (13.8%), Maharashtra (9.4%), Nagaland (8.5%), Arunachal Pradesh (7.6%), and Rajasthan (6.2%) reported the maximum reduction between the two rounds for birth order one.The ZD prevalence has increased for birth order one in seven states, for four to five in three states, and for six and above across three states. The prevalence for all three cohorts has increased in Chhattisgarh. In addition, Manipur reports the maximum gap in ZD prevalence between birth order four to five (23.0%) and birth order one (4.1%), and Assam the maximum difference between birth order six and above (28.3%) and birth order one (8.6%) in NFHS-5.Religion and Zero-Dose StatusData for religion as an equity determinant is available for Buddhists, Christians, Hindus, Muslims, Sikhs, and others in NFHS rounds. However, due to the unavailability of data for multiple states, the current analysis has been undertaken for only Hindu and Muslim children. Data for Hindu children are available for 26 states under NFHS 5 and for 27 states under NFHS 4, and for Muslim children, it is available for 20 and 24 states, respectively.Nine (35%) states in the country reported a ZD prevalence of 0 to <5%, 16 (62%) a prevalence of 5% to <10%, and one (3%) state a prevalence of 10% to <15% for Hindu children in NFHS 5. The corresponding figures for NFHS 4 are nine (33%) each for the 0 to <5% and 5% to <10%, six (22%) a prevalence of 10% to <15%, and three (11%) states a prevalence of 15% and above. Five (25%) states reported a ZD prevalence of 0 to <5% in NFHS 5 for Muslim children, seven (35%) a prevalence of 5% to <10%, six (30%) a prevalence of 10% to <15%, and two (10%) states a prevalence of 15% and above. The figures for NFHS 4 for Muslim children were four (17%), seven (29%), three (13%), and 10 (42%), respectively.Tripura (15.2%), Arunachal Pradesh (9.7%), Rajasthan (7.5%), Gujarat (7.2%), and Karnataka and Maharashtra (both 5.9% each) were the states which have reported the maximum reduction in the proportion of ZD among Hindu children, while Haryana (18.4%), Assam (15.8%), Rajasthan (15.3%), Uttar Pradesh (12.2%), and Manipur (8.8%) reported the highest declines among Muslim children. Overall, 40% of the states in the country reported a lower ZD prevalence among Muslim children compared to Hindu children up from 29% in NFHS 4. While the prevalence of ZD among Hindu children increased across seven states between the two NFHS rounds, a rise among Muslim children was reported from three states of the country. The interstate disparity has reduced significantly among Muslim children, while the range was 62.3%  to 3.9% (Tamil Nadu) in NFHS 4, it has reduced to 16.3% (Maharashtra) to 1.8% (Tamil Nadu) in NFHS 5. The figures for Hindu children across the two rounds are 37.8%  and 1.9% (Chhattisgarh) in NFHS 4 and 11.1%  and 2.1% .Caste and Zero-Dose StatusData for social caste and ZD status has been analyzed for 25 states for OBC across both the NFHS rounds, for 25 states in NFHS-5 and 26 states in NFHS-4 for SC, and 22 and 23 states, respectively for ST in NFHS 5 and NFHS 4 and 26 states across both the rounds for others.Among OBCs, 10 (40%) and 15 (60%) states reported a ZD prevalence of 0 to <5% and 5% to <10% in NFHS 5, while eight (32%) states each reported similar prevalence in NFHS 4. Six (24%) and three (12%) states reported a prevalence of 10% to <15% and 15% and above in NFHS 4. Ten (40%), 13 (52%), and one (4%) state each reported a prevalence of 0 to <5%, 5% to <10%, 10% to <15%, and 15% and above among SC in NFHS 5, respectively, the corresponding figures in NFHS 4 being seven (27%), seven (27%), nine (35%) and three (12%) for the four cohorts. In the ST category, four (18%) states reported a prevalence of 0 to <5%, 14 (64%) states a prevalence of 5% to <10%, and two (9%) states each a prevalence of 10% to <15% and 15% and above in NFHS 5. The corresponding figures in NFHS 4 were four (17%), five (22%), three (13%), and 11 (49%) for the four cohorts, respectively. In the others category in NFHS 5, 10 (38%) states, 12 (46%) states, and two (8%) states each reported prevalence for the four cohorts with the corresponding figures being nine (35%), seven (27%), eight (31%), and two (8%) in NFHS 4.As with other equity determinants, the disparities for the OBC, SC, and ST groups have reduced between the two NFHS rounds. While for OBCs the range of disparity has reduced from 9.1% (Uttar Pradesh) to 2.8% (Tamil Nadu) and from 16.9% (Uttar Pradesh) to 1.4% (Jammu & Kashmir) between NFHS 4 and NFHS 5, this reduction for SC is from 61.50%  to 0.30% (Chhattisgarh) in NFHS 4 to 17.10%  to 1.30% (Odisha) in NFHS 5. Among the ST groups, the range has reduced from 38.6%  to 0.3%  in NFHS 4 to 18.0%  to 0.2%  in NFHS 5. The disparity for the other caste-based category has increased between the two rounds from 23.8% (Assam) to 0.3% (Punjab) to 26.8% (Tamil Nadu) to 1.6% .Residence and Zero-Dose StatusData for this equity determinant are available for 28 states for NFHS 5 and 29 states for NFHS 4 datasets. In the urban geographies of the country, seven (25%) states reported a ZD prevalence of 0 to <5%, 14 (50%) a prevalence of 5% to <10%, five (18%) a prevalence of 10% to <15%, and two (7%) states a prevalence of 15% and above in NFHS 5. The corresponding figures for NFHS 4 were eight (28%), 12 (41%), four (14%), and five (17%), respectively. In the rural geographies of the country, NFHS 5 reported a ZD prevalence of 0 to <5% across 10 (36%) states, while 14 (50%) states reported a prevalence of 5% to <10%, and two (7%) states each a prevalence of 10% to <15% and 15% and above. The prevalence reported in NFHS 4 was eight (28%), seven (24%), five (17%), and nine (31%) for the four categories starting from 0 to <5%.Arunachal Pradesh and Nagaland reported the maximum improvement in ZD prevalence across both urban and rural geographies. While the urban and rural ZD prevalence has reduced by 15.5% and 19.9% in Arunachal Pradesh, respectively, the reduction in Nagaland was 15.0% and 16.5%, respectively. Other states which reported appreciable declines in urban ZD proportions were Haryana (8.9%), Uttar Pradesh (7.8%), and Himachal Pradesh (7.2%). Rural ZD proportion declined significantly in the northeastern states of Tripura (16.9%), Mizoram (15.2%), and Assam (10.7%). Overall, 34% of states in NFHS 5 reported a lower urban ZD prevalence compared to rural ZD, a decline of 32% compared to NFHS 4. Urban ZD prevalence increased in nine states compared to four states which reported a rise in rural ZD prevalence between NFHS 4 and 5.The interstate disparities reflect a more pronounced decline for rural ZD compared to urban ZD between the two rounds. While the highest prevalence of rural ZD reduced from 34.7%  to 18.2% , the same reduced from 24.3%  to 22.8%  for urban ZD proportions.The states of Andhra Pradesh, Chhattisgarh, and Punjab reported an increase in the prevalence of ZD children in both urban and rural geographies over the two rounds. In the urban pockets, ZD proportions increased from 2.3% to 10.6% in Andhra Pradesh, 1.5% to 8.2% in Chhattisgarh, and 4.7% to 10.2% in Punjab. The corresponding increase in rural geographies was 3.9% to 5.4%, 2.2% to 3.9%, and 2.4% to 6.6% for the three states, respectively. Jharkhand is another state which has reported an increase in urban ZD proportions (3.4% to 12.8%) with the progress across rural geographies stagnating (6.8% to 6.5%) between the two rounds. Similarly, the proportion of ZD in Meghalaya increased by 16.7% in NFHS 5 compared to NFHS 4.Zero-Dose and Key Programmatic InterventionsTable As evident, there has been a reduction in ZD prevalence across the country and at state levels between the two NFHS rounds. While the overall rate of reduction is 4.1% between the two rounds, the number of states which reported a lower ZD prevalence of 5% to <10% has increased from nine to 17 and those reporting higher ZD prevalence of 10% and above reduced from 12 to four. The states that report a ZD prevalence of 0 to <5% remain constant with nine states each in NFHS 5 and NFHS 4. Similarly, there has been consistent progress across all the key equity parameters. Moreover, among these parameters, the maximum reduction has been for cohorts that have been traditionally vulnerable and marginalized. For instance, the rate of reduction is 4.9% in rural geographies, 6.7% among Muslim children, 6.5% among ST population groups, 9.4% among children with birth order six and above, 7.0% among mothers with no schooling, and 7.4% among populations in the lowest wealth quintile.This is reflective of the improved reach of the immunization program in India as evident through recent efforts. These include the Mission Indradhanush (MI) and Intensified Mission Indradhanush (IMI) rounds contributing to a sustained increase in coverage across underperforming districts of the country as is evident from an 18.5% increase in full immunization coverage (FIC) across 190 districts which conducted IMI rounds in 2017-2018 . SimilarHowever, what the data also reflect are the challenges and disparities that still surmount the immunization program in India. Five states of the country with high Pentavalent 1 coverage rates have reported an increase in ZD prevalence. This ranges from 0.5% in Odisha to 3.5% in Andhra Pradesh. Similarly, while states across the country have had a decline in ZD prevalence in line with earlier NFHS rounds, pockets in the country continue to report high proportions. Bihar, Madhya Pradesh, and Uttar Pradesh, which account for close to 40% of the national infant cohort in India, each report a prevalence of 6% or higher, with Uttar Pradesh reporting a high prevalence of 9.1%. Four of the northeastern states  continue to report a prevalence of more than 10%, with Assam, the largest northeastern state, reporting a prevalence of 9.3%. In line with earlier findings, the urbanized states of Andhra Pradesh, Gujarat, Maharashtra, and Telangana have a prevalence of 7.0% or more . Inter-dThe equity parameters also reflect a contrasting picture with a slow-footed reduction among ZD children for girl children, across urban geographies, first-born children, mothers with 12 or more years of schooling, and children in families with the highest wealth quintiles. This is expected as some of the abovementioned parameters have had lower baselines; however, the comparatively slow pace of reduction among girl children and urban geographies is particularly concerning.This article tries to analyze the impact of gender by examining the difference in ZD proportions among male and female children, the impact of maternal education, the birth order of the children, and touchpoints with health services as important predictors. Often gender is not identified as a major determinant for tracking immunization performance as the coverage rates among boys and girls remain almost the same ,16. HoweMaternal education has always been identified as an important positive predictor of immunization coverage with its impact more profound in low and low-middle-income countries (LMICs) ,19. WhilHowever, despite this reduction, the overall prevalence of ZD children among mothers with no schooling remains high. Moreover, 14 states of the country have reported an increase in ZD prevalence among mothers with 12 or more years of schooling, thus implying continued efforts in this direction. Most of the states included in this group are those where overall sociodemographic and public health indicators continue to remain weak, thus pointing toward early trends of changing equity dynamics. In line with other parameters studied, there has been a reduction in ZD prevalence among higher birth orders, thereby further potentiating better outcomes. However, the overall ZD prevalence remains very high for birth orders six, and this is aligned with evidence from other countries ,22. ThisAdding to the existing evidence base, the article aims to articulate the impact of access to health services by mothers as an important determinant of coverage ,24. A neOf all three indicators, the strongest correlation has been observed for institutional deliveries. A continued push toward improved maternal care services will have a definite impact on reducing ZD proportions. Moreover, efforts should be continued on ensuring that mothers with limited exposure to healthcare services be reached, a visit by the ASHA during the eighth or ninth month of pregnancy can be undertaken to promote institutional deliveries in pockets where ANC coverage continues to be low and home deliveries continue to be high. This has been demonstrated through programs advocating for community-based distribution of misoprostol for home deliveries which simultaneously had a positive impact on institutional deliveries . SimilarAlthough it is statistically not significant, the correlation between stunting and ZD children has been found to be positive and increasing, thereby articulating the long-term impact of ZD children missing out on other life course entitlements . While tReligion, caste, and socioeconomic status are the other equity parameters that have often been studied in relation to ZD proportions. While data availability across religions has limited comparisons to Hindu and Muslim children, data for wealth quintiles are only available at the national level. In line with other parameters, there has been improvement across states and population groups that have been traditionally disadvantaged. The improvement among Muslim children and SC and ST population groups has been on the higher side, again reiterating the improved reach of the program. A recent article in BMJ Global Health which studied the impact of ethnicity on ZD prevalence across 62 countries and used caste as a marker for ethnicity for India illustrates that differences among ethnic groups persisted after adjustment for wealth, maternal education, and area of residence . SimilarVariations in rural and urban ZD proportions are well established in this article. Not only has the overall reduction of ZD proportions in the urban areas been low compared to rural geographies in the country, the overall urban areas now account for a higher proportion of ZD prevalence in India. This mimics the trend for other immunization indicators in the country with the urban FIC now lower than the rural FIC (NFHS 5). In addition, the progress in urban geographies remains slow-footed compared to rural areas  ,32. ThisZD children and communities, as discussed above, remain functionally invisible to health systems and go without basic vaccines every year. These vaccination blindspots leave millions of children vulnerable to vaccine-preventable diseases. Reaching and integrating ZD children with the health systems remains an unfinished agenda, and it is not about numbers, but individuals, families, and communities who are often left out of the formal healthcare system. Evidence now tells us that focusing on ZD children is particularly important because those who are reached with the first vaccine are highly likely to also receive the remaining vaccines .Highly differentiated strategies are required to successfully reach ZD children and missed communities. Around 50% of ZD children reside in urban settings, remote rural settings, or conflict settings, while the rest of them are not reachable due to factors such as gender, poverty, ethnicity, and other sociocultural barriers. Building on the Identify-Reach-Monitor-Measure-Advocate framework developed by Gavi , we propIt is also important that the impact of the pandemic is factored in. Globally, it is estimated that the number of ZD children has increased from 13 million in the pre-pandemic period (2019) to 18 million in 2021 . India hWhile important insights are gleaned from the analysis, this article has its fair share of limitations. As the analysis has been sourced from NFHS reports and not raw data, the results need to be interpreted with caution. The early trends sourced from NFHS reports need to be complemented with detailed analysis from NFHS raw data to better identify and account for uncertainty estimates and rule out differences and reductions attributable to chance. The use of NFHS reports and the variability in the availability of data for certain equity determinants has also limited analysis to a certain extent, and the NFHS raw data should be further explored to better understand the interplay of the equity determinants at the national, state, and district levels. The high baselines for ZD prevalence across certain states in NFHS 4 also need to be factored in while reflecting on the reduction between the two rounds. Therefore, policy and programmatic decisions need to be accordingly aligned.Overall, despite the above limitations, the article provides valuable insights into the current scenario of ZD children in India. The data suggest that while there has been sustained progress at the national, state, and district levels and across key equity determinants for ZD children between 2015-2016 to 2019-2021, critical issues and challenges continue to exist. The pandemic is also bound to have a negative impact on the program. Hence, continued and augmented efforts are needed to further expand the reach of the immunization program. Adopting mechanisms to identify population cohorts beyond the reach of the program, a focus on vaccine demand interventions, and leveraging partnerships with other health programs and stakeholders beyond health is imperative and much needed. This will ensure that ZD population groups are identified and integrated with the health system and the impact of the pandemic is mitigated.


Fibromyalgia is a chronic disease with a high burden. We aim to be the first to investigate the prevalence of fibromyalgia (FM) in Syria and assess its risk factors.A self-reported questionnaire was distributed to the public to identify fibromyalgia patients using the American College of Rheumatology (ACR) 2010 modified criteria. Identified cases were matched using age with controls free from rheumatic disorders that were randomly sampled from the same population.Out of 2966 participants, 350 (11.8%) satisfied the diagnostic criteria. Of these, only 29 (8.2%) were previously diagnosed by a physician, 239 (68.3%) were females, and 69 (19.71%) were diagnosed with depression. Female sex (OR = 1.31), diagnosis of major depressive disorder (OR = 2.62), irritable bowel syndrome (OR = 1.8), and Restless legs syndrome (OR = 1.72) were associated with a higher likelihood of fibromyalgia.Our study revealed one of the highest prevalence rates of fibromyalgia ever reported in the general population. Efforts must be intensified to increase awareness about this disease in Syrian society as well as among healthcare providers.The online version contains supplementary material available at 10.1186/s41927-022-00294-8. Fibromyalgia (FM) is a complex disease characterized by chronic (longer than three months) widespread pain combined with tenderness in muscles and joints all over the body . Non-paiFM is considered a common disease to encounter in the clinic with a variation in prevalence in the general population in different countries. In Japan, the prevalence of FM was 2.1%, while in Canada, it was estimated at 3.3% (4.9% in women versus 1.6% in men) . Branco The lack of a gold standard and objective markers to diagnose FM led to the proposal of many diagnostic criteria that rely on clinical assessment and patient reports. In 1990, Wolfe et al. set the first American College of Rheumatology (ACR) criteria for FM diagnosis . It requThe war in Syria, which has lasted more than a decade, has had a profound impact on the population and has created many economic, social, and educational challenges. Damage to health care infrastructure and loss of medical staff have had a major impact on Syria's health care system. As a result, many have been injured, and approximately 511,000 have died . More thAs warfare is considered one of the most psychologically stressful events that anyone can experience , with caA two-stage population-based study was conducted, to determine the prevalence and the associated risk factors of fibromyalgia in the general population of Damascus, Syria.Using convenience and snowball sampling, a representative sample of Damascus habitants was questioned by a structured self-administered survey from April 1 to May 1, 2021.We distributed an electronic and paper-based survey in parallel. The electronic open survey was distributed as a Google Form® using social media platforms  on the authors' own accounts and many groups that concern health, youth, and residents of Damascus. No paid ads were used, and no incentives were offered to the participants.The paper-based survey was distributed by medical students who handed out the survey face-to-face to the patients, their companions, and workers in the outpatient clinics of Damascus Hospital and Ibn Al Nafees Hospital; two major public hospitals in Damascus, Syria. And then received it on site after the participants completed it.We included the participants who were surveyed from April 1 to May 1, 2021, and met the following conditions: (1) 18 years old or older, (2) living in Damascus at least for the last five years , financial status, employment status, educational level, health insurance, currently diagnosed by a physician with .Fibromyalgia questionnaire based on ACR 2010 modified criteria for fibromyalgia diagnosis were 18—29 years old, 1035 (34.9%) were 30—49 years old, and 211 7.1%) were ≥ 50 years. The majority were singles 1544 (52.1%), and 1422 (48%) were in a relationship. Unemployed individuals represented half of our sample [1502 (50.6%)]. The majority [2548 (85.9%)] did not have health insurance, and 2412 (81.3%) lived in a city. Regarding financial status, 1514 (51.1%), and 1452 (49%) were below average and had average financial status, respectively. When asked about previous medical history, 29 (0.9%) said that they were diagnosed with fibromyalgia, and 30 (1%), 163 (5.5%), 268 (15.3%), and 64 (3.7%) said they have systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), irritable bowel syndrome (IBS) and restless leg syndrome (RLS), respectively.  participants were found to meet the modified ACR 2010 criteria. Of these, 239 (68.3%) were females. The majority [250 (71.4%)] were 18—29 years old, single [199 (56.9%)], unemployed [237 (67.7%)], and did not have health insurance [266 (76%)]. Only 62 (17.7%) lived in rural areas. Regarding financial status, 127 (36.2%), and 223 (63.7%) were below average and had average financial status, respectively. When asked about previous medical history, only 29(8.2%) said that they were diagnosed with fibromyalgia, and 4 (1.1%), 41 (11.7%), 90 (25.8%), and 72 (20.5%) said they have systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), irritable bowel syndrome (IBS) and restless leg syndrome (RLS), respectively. On the other hand, an equal number of participants had the diagnosis of major depressive disorder [69 (19.8%)], and general anxiety disorder [69 (19.8%)], respectively ] stated that they had problems in 3 to 6 sites, and [305 (87.1%)] had problems in 7 or more sites.2(11) = 124.929, P-value < 0.001. The model explained 10.9% (Nagelkerke R2) of the variance in fibromyalgia and correctly classified 80.1% of the cases. Of the 10 variables, only 6 were statistically significant: gender, employment status, health insurance, currently diagnosed with major depressive disorder, irritable bowel syndrome, and restless legs syndrome. females had 1.31 higher odds to have fibromyalgia than males. Employment was associated with a reduction in the likelihood of having fibromyalgia. Having health insurance was associated with 1.96 higher odds of having fibromyalgia. Regarding associated diseases, diagnosis of major depressive disorder (OR = 2.62), Irritable bowel syndrome (OR = 1.8), and Restless legs syndrome (OR = 1.72) were associated with a higher likelihood of fibromyalgia.  have satisfied the ACR 2010 modified criteria of FM diagnosis, which represents one of the highest prevalence rates of FM in a general population. When considering that many studies showed a psychological predisposition to FM , our finUndiagnosed FM may result in inadequate treatment and relief of key symptoms like pain, fatigue, and unrefreshed sleep. This will mislead medical decisions to change or escalate the dosage of treatments of the underlying disease rather than addressing FM. In our study, only 29 (8.2%) of the 350 participants who satisfied the ACR 2010 modified criteria were diagnosed by a medical professional. A similar observation was made in a study conducted in Lebanon, as all FM cases were previously misdiagnosed and did not receive a diagnosis of FM . The diaOur study shows that females have greater odds to have FM (OR = 1.31), which goes in line with the literature , 11–13. In our study, 225 and 289 of our participants stated that they are diagnosed with major depressive disorder and/or generalized anxiety disorder. However, a recent national study conducted on the general population in Syria found that mental health disorders have reached high rates, with rates of depression and anxiety reaching 83.4% and 69.6%, respectively . This maFM is associated with a high burden of illness on patients and the healthcare system, which causes significant disability . We encoAs many of our participants were young in age, we think that The demographic distribution of our sample is relatively representative of Syrian society according to data from the Central Bureau of Statistics (CBS), Damascus, Syria. that documented in its last latest report that ~ 40% of the Syrian population were below 24 years old, 25.5% were 25–44 years old, 17.6% were 45–65 years old, and 5.3% were above 65 years old [FM appears to be a very common disease in Damascus, Syria. The lack of knowledge regarding the disease has resulted in many patients suffering due to the lack of recognition of the disease by patients and physicians alike.Additional file 1. Stage one database. Include the participants who met the inclusion criteria for stage one.Additional file 2. Stage two database. Include the cases and controls that were analyzed in stage two.


Dementia is a chronic and progressive syndrome due to disease of brain. Alzhemeir's disease is the most common cause of dementia. There are very few studies regarding prevalence of dementia in Nepal. The objective of this study is to find the prevalence of dementia in 50 years and older patients from the psychiatry out patient department of a tertiary care center.A descriptive cross-sectional study was done in patients attending to psychiatry outpatient department over one year from May 2020 to April 2021. Ethical approval was taken from the Institutional Review Committee (Reference number: 745/077-078). The data were assessed using Statistical Package for Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.Out of 1332 patients, 52 (3.9%)  patients had dementia in which 30 (57.7%) are male while 22 (42.3%) are female. Mean age of study population is 70.12±11.21 with age range of 50 years to 88 years. We found 29 (55.8%) moderate, 18 (34.6%) severe and 5 (9.6%) mild type of dementia. We had 34 (65.3%) Alzheimer's followed by 16 (30.8%) vascular and 2 (3.9%) others types of dementia.This study concludes that the prevalence of dementia in 50 years and older patients is similar in comparison to other studies done in similar settings. Dementia results from interactions of comorbidities, genes and the environment.7Dementia is a progressive disease with disturbance of multiple higher cortical functions.There is dearth of studies about different types, comorbidity and severity of dementia in the developing countries including Nepal. Moreover, study of dementia in 50 years and older is even less as most of the studies focus on elderly population.The objective of this study is to find the prevalence of dementia in 50 years and older patients from the psychiatry out patient department of a tertiary care center.This is a descriptive cross-sectional study done in patients attending to psychiatry outpatient and inpatient department in Nepalgunj Medical College, Kohalpur. Ethical clearance was taken from Institutional review committee (Ref.745/077-078). Out of total 1332  patients aged 50 years or more visited to psychiatry OPD from May 2020 to April 2021 in one year, suspected cases were first selected by using brief mental state examinations. Convenience sampling was done and those who gave written consent were included in the study. In patients who were unable to give written consent, consent was taken from immediate guardian and caretakers. Patients having history of alcohol use  were included. Patients who did not give consent, who were actively dependent on any psychoactive substance, had head injury, delirium, psychosis and younger than 50 years were excluded from the study. The sample size was calculated using the formula,2 × p × q / e2n = Z2 × 0.0129 × (1-0.0129) / (0.01)2  = 1.96  = 3.8416 × 0.0129 × 0.9871/0.0001  = 489Where,n = required sample sizeZ = 1.96 at 95% Confidence Interval7p = prevalence of dementia in 50 years and older in reference population 1.29%q = 1-pe = margin of error, 1%Adding 10% non-response rate we get 538. However, 1332 samples were taken. Following data collection tools were used, the ICD 10 classification of mental and behavioral disorders, diagnostic criteria for research, Semi-structured pro forma and MMSC check list . Data was collected in pro forma developed by the department of psychiatry. The data were analyzed using Statistical Package for Social Sciences version 20 and analyzed and presented in tables with frequencies and percentages.Out of 1332 patients, the prevalence of dementia in 50 years and above was found to be 52 (3.9%)  of which 516 (38.73%) were male 816 (61.26%) were female. Suspected cases were selected after initial brief mental state assessment and further interviewed. After a through screening using MMSE and ICD-10 diagnostic guidelines, 52 patients found to have dementia. Thus the prevalence rate of dementia in 50 years and above was 2 (3.9%).Out of 52 dementia patients 30 (57.7%) were male while 22 (42.3%) were female. Age ranges from 5088 years, 70.13 ± 11.21. Majority 36 (69.2%) were illiterate while 16(30.8%) were literate. Previous history of alcohol use was found in 20 (38.5%) of study population. Depression was present in 17 (32.7%) of patients while cerebro vascular accident (CVA) was present in 16 (30.8%).Similarly as per the MMSE score categorizations, most common cognitive dysfunction was moderate 29 (55.8%) followed by severe 18 (34.6%) while mild cognitive dysfunction was present in 5 (9.6%).Results are presented in the number and percentages in table that shows the gender, age, literacy status, history of alcohol use, comorbid depression, comorbid CVA and severity of dementia with MMSE scoring .In age range of dementia patients, most common rangewas 70-79 years that includes 22 (42.3%) followed by80 years or more 12 (23.1%), 50-59 years 10 (19.2%)with lowest being 60-69 years 8 (15.4%) .Regarding the types ofdementia,dementia due to Alzheimer's was 34 (65.3%) followed by vascular 16 (30.8%) with the least being other causes including HIV infection 2 (3.9%) ,4.7 However our finding is not consistent with another similar study from a referral hospital of eastern Nepal where the prevalence rate of Dementia for patients aged 60 years or more in hospital psychiatry OPD was 11.4%.8 This contrast may be due to inclusion of 50 years or more patients in our study in which dementia is not much remarkable. Also, it may be the fact that people in western Nepal have lack of awareness with regard to cognitive problems including dementia.The prevalence of dementia in patients 50 years or above in our study is 3.9%. This is comparable to study entitled annual period prevalence and risk factors of dementia among older Jordanian hospitalized patients in which the general annual period prevalence of dementia for people older than 50 years was 1.29%.Regarding the age groups, 22 (42.3%) were of age group 70-79 followed by 12 (23.1 %) in 80 and more; 10 (19.2%) in 50-59 years and 8 (15.4%) in 60-69 age brackets. Dementia progresses with age but this finding of more cases in age bracket of 70-79 may be due to lower life expectancy in Nepalese population with respect to developed and western countries. Also, more advance the age of a person, all the memory and behavioral problems are regarded normal for that age than considering a problem in our society and may not have been brought to hospital.Regarding the education level, literate are 16 (30.8%) while illiterate are 36 (69.2%). There is a history of alcohol use in 38.5% of study population while majority had no history of alcohol use.9 In another study in 183 person of age 60 or above from a rural community from West Bengal, 61% had mental illness and the majority of affected person had depression.10 In another study from eastern Nepal, depression was found in 36.7% of dementia patients.8Depression and CVA very common mental and physical comorbidity in patient with dementia and we have almost one third 32.7% and 30.8% patients respectively having comorbid depression and CVA during the time of check ups for dementia. Depression itself can cause pseudodementia which may further exacerbate the remaining cognitive resources in the individual suffering from dementia. Comorbidity of depression in dementia in our study is in line with another study in 40 dementia patients from India regarding behavioral and psychological symptom of dementia in which there were 37% of patients with affective disturbances.We found 29 (55.8%) moderate, 18 (34.6%) severe and 5 (9.6%) mild type of dementia as per the finding from MMSE.11 In another study regarding prevalence of dementia in urban Indian population, there were 65% had Alzheimer's dementia followed by vascular (22%) with increasing age being associated with higher prevalence of dementia.12As per our study finding, we have 34 (65.3%) Alzheimer's followed by 16 (30.8%) vascular and 2 (3.9%) others types of dementia. The type of dementia in our study is almost similar to one study from India in which there were 54% people having Alzheimer's dementia, followed by vascular (39%) and others (7%).13 Though age cannot be modified, control in consumption of alcohol can be directly or indirectly help in prevention or progression of dementia.Use of psychoactive substance including alcohol is said to be responsible for of cognitive disturbances. One review article regarding alcohol use and dementia concludes that reducing heavy alcohol use may be an effective dementia prevention strategy.The prevalence of dementia in 50 years and older age group was found to be similar to other studies. Hence, dementia is prevalent not only in elderly population but also in 50 years and older age group. Moderate dementia is more common in these age groups followed by severe and mild types.