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Background: Bhutan is committed to eliminating hepatitis B and hepatitis C, though recent baseline estimates of disease burden in the general population are unknown. In 2017, we carried out a biomarker survey in the general population to estimate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) biomarkers to evaluate the impact of immunization and guide further efforts. Methods: In 2017, a cross-sectional, population-based, three-stage cluster survey was undertaken of the general population (1-17 and 20+ years of age). We visited households, collected blood specimens and administered a standard questionnaire. Specimens were collected for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We calculated prevalence of infection and selected characteristics, along with confidence intervals (CIs). Results: Of 1372 individuals approached, 1358 (99%) participated. Of those, 1321 (97%) had a specimen tested for HBsAg, and among 1173 enrolled individuals 5 years of age or older, 1150 (98%) individuals were tested for anti-HCV. The prevalence of HBsAg was 2.0% in 775 persons 20 years of age or older (95% CI: 1.0-4.0) and 0.5% in 546 persons 1-17 years of age (95% CI: 0.1-1.8). The prevalence of anti-HCV was 0.3% (95% CI: 0.1-0.8) among persons ≥5 years. Conclusions: Universal hepatitis B immunization of infants has resulted in a low prevalence of chronic HBV infection in persons 1-17 years of age and the prevalence of anti-HCV is low among persons aged ≥5 years. Efforts should continue to reach high coverage of the timely birth dose along with completion of the hepatitis B vaccine series. To reduce the chronic liver disease burden among adults, HBV and HCV testing and treatment as indicated might be restricted to pregnant women, blood donors, individuals with chronic liver diseases, and other groups with history of high-risk exposures.

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IntroductionEqual access to water, sanitation and hygiene (WASH) for all requires leadership that prioritises and drives inclusion. Inclusive WASH also presents opportunities to advance equality more widely, with WASH a pathway to meaningful participation and empowerment for diverse groups. The concept of gender-transformative leadership-which connects ideas of leadership to transformative models of gender equality in development theory that challenge prevailing power structures-is a relevant lens for exploring inclusive WASH. This article shares findings and reflections from a positive deviance study that aimed to investigate gender-transformative leadership in the WASH sector to explore (i) the factors shaping gender-transformative leadership and the characteristics of gender-transformative leaders; (ii) actions taken by gender-transformative leaders; (iii) the types of outcomes achieved; and (iv) ways to strengthen gender-transformative leadership.MethodsThe study was undertaken during the COVID-19 pandemic and consisted of interviews with 19 leaders in Bhutan, Lao People's Democratic Republic, and Nepal. We developed a conceptual framework which considers leaders' (i) personal values and traits; (ii) leadership styles; (iii) actions; and (iv) outcomes, influenced by a range of (v) enabling factors and barriers.ResultsLeaders' personal values and traits included a strong learning orientation, social justice values, humility, courage, and altruism. Leadership styles were primarily empathetic, with leaders guided by a mission to lead by example and pursue equality in their professional and personal lives. Exploration of actions and outcomes revealed a range of inclusion-oriented WASH activities responding to pandemic-related challenges, with associated potential outcomes in shifting norms. However, validation of outcomes was not possible due to the study timeframe and complexity of tracing complex social change in a positive deviance study reliant on self-reporting. Analysis of enablers and barriers to gender-transformative leadership respectively emphasized the importance of educational opportunities and the persistence of traditional gender norms.ConclusionFindings contribute to the body of knowledge on gender-transformative leadership, being the first study to connect this concept to WASH. Future research could build further evidence by applying the conceptual framework to analyze additional contexts or sectors, and by more fully articulating and validating outcomes in terms of their potential for gender-transformative leadership to drive equality both in and beyond WASH.