Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh.

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh.

BACKGROUND: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh. METHODS: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs. RESULTS: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers. CONCLUSION: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh.

BACKGROUND: In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment. METHODS: In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions. RESULTS: The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs. CONCLUSION: CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities. TRIAL REGISTRATION: clinicaltrials.gov NCT03933423 , January 05, 2019.

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh.

BACKGROUND: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels. METHODS: The current analysis selected 4 indicators from the WASH Benefits trial- presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline. RESULTS: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (- 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, - 25% (- 35, - 15) Q2: - 34% (- 44, - 23%)] than the wealthiest household [Q5 DID: - 1% (- 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%). CONCLUSION: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. TRIAL REGISTRATION: WASH Benefits Bangladesh: ClinicalTrials.gov , identifier: NCT01590095 . Date of registration: April 30, 2012 'Retrospectively registered'.

Fecal Indicator Bacteria along Multiple Environmental Transmission Pathways (Water, Hands, Food, Soil, Flies) and Subsequent Child Diarrhea in Rural Bangladesh.

Enteric pathogens can be transmitted through multiple environmental pathways, yet little is known about the relative contribution of each pathway to diarrhea risk among children. We aimed to identify fecal transmission pathways in the household environment associated with prospectively measured child diarrhea in rural Bangladesh. We measured the presence and levels of Escherichia coli in tube wells, stored drinking water, pond water, child hand rinses, courtyard soil, flies, and food in 1843 households. Gastrointestinal symptoms among children ages 0-60 months were recorded concurrently at the time of environmental sample collection and again a median of 6 days later. Incident diarrhea (3 or more loose stools in a 24-h period) was positively associated with the concentration of E. coli on child hands measured on the first visit (incidence rate ratio [IRR] = 1.23, 95% CI 1.06, 1.43 for a log10 increase), while other pathways were not associated. In cross-sectional analysis, there were no associations between concurrently measured environmental contamination and diarrhea. Our findings suggest higher levels of E. coli on child hands are strongly associated with subsequent diarrheal illness rates among children in rural Bangladesh.

Do Sanitation Improvements Reduce Fecal Contamination of Water, Hands, Food, Soil, and Flies? Evidence from a Cluster-Randomized Controlled Trial in Rural Bangladesh.

Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). Following approximately 4 months of intervention, we enrolled households in the trial's control, sanitation and combined WSH arms to assess whether sanitation improvements, alone and coupled with water treatment and handwashing, reduce fecal contamination in the domestic environment. We quantified fecal indicator bacteria in samples of drinking and ambient waters, child hands, food given to young children, courtyard soil and flies. In the WSH arm, Escherichia coli prevalence in stored drinking water was reduced by 62% (prevalence ratio = 0.38 (0.32, 0.44)) and E. coli concentration by 1-log (Δlog10 = -0.88 (-1.01, -0.75)). The interventions did not reduce E. coli along other sampled pathways. Ambient contamination remained high among intervention households. Potential reasons include noncommunity-level sanitation coverage, child open defecation, animal fecal sources, or naturalized E. coli in the environment. Future studies should explore potential threshold effects of different levels of community sanitation coverage on environmental contamination.

Effects of Single and Combined Water, Sanitation and Handwashing Interventions on Fecal Contamination in the Domestic Environment: A Cluster-Randomized Controlled Trial in Rural Bangladesh.

Water, sanitation, and hygiene interventions have varying effectiveness in reducing fecal contamination in the domestic environment; delivering them in combination could yield synergies. We conducted environmental assessments within a randomized controlled trial in Bangladesh that implemented single and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). After one and two years of intervention, we quantified fecal indicator bacteria in samples of drinking water (from source or storage), child hands, children's food and sentinel objects. In households receiving single water treatment interventions, Escherichia coli prevalence in stored drinking water was reduced by 50% and concentration by 1-log. E. coli prevalence in food was reduced by 30% and concentration by 0.5-log in households receiving single water treatment and handwashing interventions. Combined WSH did not reduce fecal contamination more effectively than its components. Interventions did not reduce E. coli in groundwater, on child hands and on objects. These findings suggest that WSH improvements reduced contamination along the direct transmission pathways of stored water and food but not along indirect upstream pathways. Our findings support implementing water treatment and handwashing to reduce fecal exposure through water and food but provide no evidence that combining interventions further reduces exposure.

Prevalence of elevated blood lead levels among pregnant women and sources of lead exposure in rural Bangladesh: A case control study.

Prenatal and early childhood lead exposures impair cognitive development. We aimed to evaluate the prevalence of elevated blood lead levels (BLLs) among pregnant women in rural Bangladesh and to identify sources of lead exposure. We analyzed the BLLs of 430 pregnant women randomly selected from rural communities in central Bangladesh. Fifty-seven cases were selected with the highest BLLs, ≥ 7 µg/dL, and 59 controls were selected with the lowest BLLs, < 2 µg/dL. An exposure questionnaire was administered and soil, rice, turmeric, water, traditional medicine, agrochemical, and can samples were analyzed for lead contamination. Of all 430 women, 132 (31%) had BLLs > 5 µg/dL. Most women with elevated BLLs were spatially clustered. Cases were 2.6 times more likely than controls to consume food from a can (95% CI 1.0-6.3, p = 0.04); 3.6 times more likely to use Basudin, a specific brand of pesticide (95% CI 1.6-7.9, p = 0.002); 3.6 times more likely to use Rifit, a specific brand of herbicide (95% CI 1.7-7.9, p = 0.001); 2.9 times more likely to report using any herbicides (95% CI 1.2-7.3, p = 0.02); and 3.3 times more likely to grind rice (95% CI 1.3-8.4, p = 0.01). Five out of 28 food storage cans were lead-soldered. However, there was minimal physical evidence of lead contamination from 382 agrochemical samples and 129 ground and unground rice samples. Among 17 turmeric samples, one contained excessive lead (265 µg/g) and chromium (49 µg/g). Overall, we found evidence of elevated BLLs and multiple possible sources of lead exposure in rural Bangladesh. Further research should explicate and develop interventions to interrupt these pathways.

Escherichia coli contamination of child complementary foods and association with domestic hygiene in rural Bangladesh.

OBJECTIVE: To determine the frequency and concentration of Escherichia coli in child complementary food and its association with domestic hygiene practices in rural Bangladesh. METHOD: A total of 608 households with children <2 years were enrolled. We collected stored complementary food samples, performed spot checks on domestic hygiene and measured ambient temperature in the food storage area. Food samples were analysed using the IDEXX most probable number (MPN) method with Colilert-18 media to enumerate E. coli. We calculated adjusted prevalence ratios (APR) to assess the relationship between E. coli and domestic hygiene practices using modified Poisson regression, adjusting for clustering and confounders. RESULT: Fifty-eight percentage of stored complementary food was contaminated with E. coli, and high levels of contamination (≥100 MPN/dry g food) were found in 12% of samples. High levels of food contamination were more prevalent in compounds where the food was stored uncovered (APR: 2.0, 95% CI: 1.2-3.2), transferred from the storage pot to the serving dish using hands (APR: 2.0, 95% CI: 1.3-3.2) or stored for >4 h (APR: 2.5, 95% CI: 1.5, 4.2), in compounds where water was unavailable in the food preparation area (APR: 2.6, 95% CI: 1.6, 4.2), where ≥1 fly was captured in the food preparation area (APR: 1.6, 95% CI: 1.0, 2.6), or where the ambient temperature was high (>25-40 °C) in the food storage area (APR: 2.7, 95% CI: 1.5, 4.4). CONCLUSION: Interventions to keep stored food covered and ensure water availability in the food preparation area would be expected to reduce faecal contamination of complementary foods.

Animal Feces Contribute to Domestic Fecal Contamination: Evidence from E. coli Measured in Water, Hands, Food, Flies, and Soil in Bangladesh.

Fecal-oral pathogens are transmitted through complex, environmentally mediated pathways. Sanitation interventions that isolate human feces from the environment may reduce transmission but have shown limited impact on environmental contamination. We conducted a study in rural Bangladesh to (1) quantify domestic fecal contamination in settings with high on-site sanitation coverage; (2) determine how domestic animals affect fecal contamination; and (3) assess how each environmental pathway affects others. We collected water, hand rinse, food, soil, and fly samples from 608 households. We analyzed samples with IDEXX Quantitray for the most probable number (MPN) of E. coli. We detected E. coli in source water (25%), stored water (77%), child hands (43%), food (58%), flies (50%), ponds (97%), and soil (95%). Soil had >120 000 mean MPN E. coli per gram. In compounds with vs without animals, E. coli was higher by 0.54 log10 in soil, 0.40 log10 in stored water and 0.61 log10 in food (p < 0.05). E. coli in stored water and food increased with increasing E. coli in soil, ponds, source water and hands. We provide empirical evidence of fecal transmission in the domestic environment despite on-site sanitation. Animal feces contribute to fecal contamination, and fecal indicator bacteria do not strictly indicate human fecal contamination when animals are present.

Effectiveness of soil remediation intervention in abandoned used lead acid battery (ULAB) recycling sites to reduce lead exposure among the children.

Lead (Pb) is a neurotoxin, and children are vulnerable due to their evolving physiology and high-risk behaviours. Soil remediation interventions have proven effective in reducing Pb exposure. The primary objective is to measure the effectiveness of soil remediation at abandoned used lead acid battery (ULAB) recycling sites, nearby household cleaning, and community awareness in reducing blood lead levels (BLLs) in children. Additionally, this study aims to examine associations of Pb exposure with hematological, cardiovascular, renal, immunological, and endocrinological parameters in children aged 0-12 years. This study employs a quasi-experimental design, with abandoned ULAB sites as intervention sites and two control sites in Bangladesh. The intervention includes soil remediation coupled with community education. Data will be collected prior to the intervention and at a 12-month follow-up, including a comprehensive Pb exposure survey and collect environmental, turmeric samples, and blood from the child. Pb concentrations in environmental samples and turmeric samples will be determined using XRF analyser. Child BLL will be measured using Graphite Furnace Atomic Absorption Spectrometry (GF-AAS) and proposed biochemical parameters will be analysed using routine laboratory methods. This study could provide valuable insights for designing targeted interventions in similar settings and mitigating exposure to Pb.

Hormonal, liver, and renal function associated with electronic waste (e-waste) exposure in Dhaka, Bangladesh.

Electronic waste (e-waste) contains numerous metals and organic pollutants that have detrimental impacts on human health. We studied 199 e-waste recycling workers and 104 non-exposed workers; analyzed blood, urine, and hair samples to measure heavy metals, hormonal, liver, and renal function. We used quantile regression models to evaluate the impact of Pb, Cd, and Hg on hormonal, liver and renal function, and the role of DNA oxidative damage in mediating the relationship between exposures and outcomes. Exposed workers had higher blood lead (Pb) (median 11.89 vs 3.63 µg/dL), similar blood cadmium (Cd) (1.04 vs 0.99 µg/L) and lower total mercury (Hg) in hair (0.38 vs 0.57 ppm) than non-exposed group. Exposed workers also had elevated median concentrations of total triiodothyronine (TT3), aspartate aminotransferase (AST), alanine aminotransferase (ALT), urinary albumin, albumin creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) were significantly higher than non-exposed group (p≤0.05). Sex hormones including luteinizing hormone, follicle stimulating hormone, estrogen, progesterone and testosterone concentrations were not significantly different between exposed and non-exposed (all p≥0.05). The median concentration of ALT was 4.00 (95% CI: 0.23, 7.77), urinary albumin was 0.09 (95% CI: 0.06, 0.12) and ACR was 1.31 (95% CI: 0.57, 2.05) units higher in the exposed group compared to non-exposed group. Pb was associated with a 3.67 unit increase in the ALP (95% CI: 1.53, 5.80), 0.01 unit increase in urinary albumin (95% CI: 0.002, 0.01), and 0.07 unit increase in ACR (95% CI: 0.01, 0.13). However, no hormonal, renal, and hepatic parameters were associated with Cd or Hg. Oxidative DNA damage did not mediate exposure-outcome relationships (p≥0.05). Our data indicate e-waste exposure impairs liver and renal functions secondary to elevated Pb levels. Continuous monitoring, longitudinal studies to evaluate the dose-response relationship and effective control measure are required to protect workers from e-waste exposure.

WASH interventions and child diarrhea at the interface of climate and socioeconomic position in Bangladesh.

Many diarrhea-causing pathogens are climate-sensitive, and populations with the lowest socioeconomic position (SEP) are often most vulnerable to climate-related transmission. Household Water, Sanitation, and Handwashing (WASH) interventions constitute one potential effective strategy to reduce child diarrhea, especially among low-income households. Capitalizing on a cluster randomized trial population (360 clusters, 4941 children with 8440 measurements) in rural Bangladesh, one of the world's most climate-sensitive regions, we show that improved WASH substantially reduces diarrhea risk with largest benefits among children with lowest SEP and during the monsoon season. We extrapolated trial results to rural Bangladesh regions using high-resolution geospatial layers to identify areas most likely to benefit. Scaling up a similar intervention could prevent an estimated 734 (95% CI 385, 1085) cases per 1000 children per month during the seasonal monsoon, with marked regional heterogeneities. Here, we show how to extend large-scale trials to inform WASH strategies among climate-sensitive and low-income populations.

Blood lead, cadmium and hair mercury concentrations and association with soil, dust and occupational factors in e-waste recycling workers in Bangladesh.

BACKGROUND: Electronic waste (e-waste) recycling activities release toxic metals, which pose substantial hazard to the environment and human health. We evaluated metal concentrations in biological and environmental samples, and examined the associations between biological lead (Pb), cadmium (Cd), and mercury (Hg) with soil and dust metals, and other possible determinants, among populations exposed and non-exposed to e-waste in Bangladesh. METHODS: A total of 199 e-waste workers and 104 non-exposed individuals were recruited. We measured blood Pb (BPb) and Cd (BCd) concentrations and total Hg (THg) from hair samples. Data were collected on occupational, and behavioral factors. We fitted an elastic net regression (ENET) to model the relationship between a set of influencing factors and metals as outcome variables while controlling for potential covariates. RESULTS: The median concentrations of BPb (11.89 µg/dL) and BCd (1.04 µg/L) among exposed workers were higher than those of non-exposed workers (BPb: 3.63 µg/dL and BCd: 0.83 µg/L respectively). A 100 ppm increment in soil Pb level was associated with an increase in ln-Pb (transformed) in blood (ß = 0.002; 95% CI = 0.00, 0.02). Similarly, ln-BCd level increased (ß = 0.02; 95% CI = 0.001, 0.07) with every ppm increase in dust Cd level. The number of years worked in e-waste activities was associated with elevated ln-BPb (ß = 0.01; 95% CI = 0.01, 0.02) and ln-BCd levels (ß = 0.003; 95% CI = 0.00, 0.05). Smoking significantly contributed to elevated levels of ln-BCd (ß = 0.46; 95% CI = 0.43, 0.73). An increment of 100 kg of e-waste handling per week led to an increase in ln-BPb levels (ß = 0.002; 95% CI = 0.00, 0.01), while respondents knowledge about adverse impact on e-waste reduced the ln-BPb level (ß = -0.14; 95% CI = -0.31, -0.03). Fish consumption frequency had a positive association with THg in hair. CONCLUSIONS: Our data show the need for workplace controls to reduce exposure to Pb and Cd with a broader view of exposure source taken.

The Effects of Yogurt Supplementation and Nutritional Education on Malnourished Infants: A Pilot RCT in Dhaka's Slums.

Our objective was to quantify the effects of yogurt supplementation and nutrition education over three months on the linear growth of infants at risk of stunting. We conducted a three-arm pilot randomized controlled trial: (1) nutrition education for mothers; (2) nutrition education plus a daily yogurt supplement (50 g) for the index child; and (3) usual care (control). Dyads of children aged 4-6 months and at risk of stunting [length-for-age z-score (LAZ) ≤ -1 SD and >-2 SD] and their mothers with ≤10 years of education were eligible for the study. Participants were recruited from five slum areas in Dhaka, Bangladesh. Intention-to-treat (N = 162) and complete-case analyses (N = 127) showed no between-group statistically significant differences in LAZ or weight-for-age (WAZ). However, the yogurt group showed greater change in linear growth compared to the control (LAZ: mean difference 0.20, 95% CI: -0.06, 0.47, p-value 0.13), which was also slightly greater than the education-only group. Children in the yogurt plus group were five times (95% CI: 0.80, 31.80, p-value 0.09) more likely to meet the minimum dietary diversity (MDD) score compared to the control. A 3-month follow-up of this pilot study did not demonstrate that yogurt was beneficial to linear growth. However, there were encouraging trends that merit replication of the intervention with larger samples and longer follow-ups.

Cigarette smoking and associated factors among men in five South Asian countries: A pooled analysis of nationally representative surveys.

Smoking is one of the leading causes of premature deaths worldwide. The cigarette is the commonest form of tobacco smoking. This study investigated the factors associated with cigarette smoking among men in five South Asian countries. We analyzed nationally representative cross-sectional study (Demographic and Health Survey) data conducted in Afghanistan, India, Maldives, Nepal, and Pakistan from 2015-2018. Our study population was men aged between 15 and 49 years. The outcome variable was the prevalence of cigarette smoking. We performed both pooled and country-specific analyses using multivariable logistic regression. The prevalence of cigarette smoking among men is the highest (41.2%) in the Maldives and the lowest (20.1%) in Pakistan. Our pooled analysis found that higher age, lower education, lower wealth status, and involvement in any occupations were strongly associated with cigarette smoking (p-value <0.001). However, we did not find a significant association between age and wealth status in Afghanistan, occupations in Nepal and Pakistan, and education in Pakistan with cigarette smoking when country-specific analyses were performed. In this study, socioeconomic position, age, and urban area are strongly associated with cigarette smoking in South Asian countries. The country-specific circumstances should be considered in planning and designing national smoking control strategies and interventions. However, improving access to smoking cessation services could be an effective intervention for all studied countries, Afghanistan, India, Maldives, Nepal, and Pakistan.

Ecological Burden of e-Waste in Bangladesh-an Assessment to Measure the Exposure to e-Waste and Associated Health Outcomes: Protocol for a Cross-sectional Study.

BACKGROUND: e-Waste is a rapidly growing waste stream worldwide, and Bangladesh is a hub of e-waste handling. Informal e-waste recycling operations involve crude methods for dismantling, repairing, sorting, and recycling electronic goods with bare hands and without personal health protections. Direct inhalation or dermal exposure to toxicants during informal recycling is common. Evidence suggests that e-waste-derived toxicants pollute the terrestrial ecosystem and have been linked with adverse health effects. However, e-waste recycling-related occupational health hazards have not been adequately explored in the context of Bangladesh. OBJECTIVE: Our study aims to expand the current understanding of exposure to e-waste. This study will measure the metal concentrations in biological and environmental samples and evaluate the relationship between heavy metals and the biochemical systems of the e-waste workers. METHODS: The study uses a cross-sectional study design consisting of an exposed site and a nonexposed control site. The trained team collected information on individual exposures, detailed work and medical history, and biological samples (blood, urine, and hair) from each subject. This study will measure heavy metal levels (lead, cadmium, and mercury) and biochemical parameters (hematological, hormonal, renal, and others) from the biological samples with reported physical function as outcomes of interest. In addition, we also collected soil and dust samples from both exposed and nonexposed control sites to measure the health risk. All the environmental samples will be analyzed using inductively coupled plasma mass spectrometer to determine metal concentrations. We will also conduct a qualitative investigation for a deeper understanding of the e-waste management system in Bangladesh. RESULTS: The protocol has been approved by the Institutional Review Boards of the International Centre for Diarrheal Disease Research, Bangladesh, and The University of Queensland's Human Behavioral Ethics Committee. Informed written consent was obtained from all participants. We recruited 199 workers from the e-waste sites with at least 5 years of exposure and 104 control subjects with no industrial or e-waste exposure. Sample analysis is estimated to be completed in 2022. CONCLUSIONS: Although many studies have identified potential adverse health outcomes from exposure to e-waste, there is a lack of published epidemiological research in Bangladesh. Research in this field is particularly pressing in the context of the current e-waste trend and the need to deepen the understanding of exposures and outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/38201.

Effect of sanitation improvements on soil-transmitted helminth eggs in courtyard soil from rural Bangladesh: Evidence from a cluster-randomized controlled trial.

Improved sanitation has been hypothesized to reduce soil-transmitted helminth (STH) infections by reducing the prevalence and concentration of STH eggs/larvae in soil. We evaluated the effect of a randomized sanitation program (providing households with an improved dual-pit latrine, tools for child/animal feces management, and behavioral messaging) on reducing the prevalence and concentration of STH eggs in soil from household courtyards. We collected soil samples from 1405 households enrolled in the sanitation intervention (n = 419) and control (n = 914) groups of a cluster-randomized controlled trial (WASH Benefits) in rural Bangladesh approximately 2 years after the initiation of the interventions. We analyzed samples for Ascaris lumbricoides, Trichuris trichiura, and hookworm eggs by microscopy. We estimated prevalence ratios (PR) and egg count ratio (ECR) to compare the prevalence of STH eggs and arithmetic and geometric mean egg counts for STH eggs per gram of soil in the sanitation and control arms. Among intervention households, latrines achieved high and sustained user uptake by adults while child open defecation remained common and most households did not dispose of child feces hygienically. In courtyard soil from control households, the prevalence of any STH eggs was 75.7% and the prevalence of any larvated STH eggs was 67.3%. A. lumbricoides was detected in 63.0% of control samples and T. trichiura in 55.7% of control samples; hookworm was not detected in any sample. In the control arm, the arithmetic mean egg count for any STH was 3.96 eggs/dry gram, while the geometric mean was 1.58 eggs/dry gram. There was no difference between the intervention and control groups in the prevalence of any STH eggs (PR = 0.98 (95% CI: 0.91, 1.05)) or mean egg counts (ECR = 0.08 (95% CI: -0.10, 0.26) for geometric mean and 0.07 (95% CI: -0.22, 0.37) for arithmetic mean). Adjusted models gave similar results. A compound-level sanitation intervention that provided improved latrines and tools for disposal of child and animal feces did not have an impact on STH eggs in soil. In order to effectively reduce the prevalence and concentration of STH eggs in the environment, sustained, widespread use of sanitation strategies to isolate and hygienically dispose of child and animal feces may need to complement traditional strategies for containment of adult human feces. Trial Registration: NCT01590095.

Effective Treatment Strategies for the Removal of Antibiotic-Resistant Bacteria, Antibiotic-Resistance Genes, and Antibiotic Residues in the Effluent From Wastewater Treatment Plants Receiving Municipal, Hospital, and Domestic Wastewater: Protocol for a Systematic Review.

BACKGROUND: The widespread and unrestricted use of antibiotics has led to the emergence and spread of antibiotic-resistant bacteria (ARB), antibiotic-resistance genes (ARGs), and antibiotic residues in the environment. Conventional wastewater treatment plants (WWTPs) are not designed for effective and adequate removal of ARB, ARGs, and antibiotic residues, and therefore, they play an important role in the dissemination of antimicrobial resistance (AMR) in the natural environment. OBJECTIVE: We will conduct a systematic review to determine the most effective treatment strategies for the removal of ARB, ARGs, and antibiotic residues from the treated effluent disposed into the environment from WWTPs that receive municipal, hospital, and domestic discharge. METHODS: We will search the MEDLINE, EMBASE, Web of Science, World Health Organization Global Index Medicus, and ProQuest Environmental Science Collection databases for full-text peer-reviewed journal articles published between January 2001 and December 2020. We will select only articles published in the English language. We will include studies that measured (1) the presence, concentration, and removal rate of ARB/ARGs going from WWTP influent to effluent, (2) the presence, concentration, and types of antibiotics in the effluent, and (3) the possible selection of ARB in the effluent after undergoing treatment processes in WWTPs. At least two independent reviewers will extract data and perform risk of bias assessment. An acceptable or narrative synthesis method will be followed to synthesize the data and present descriptive characteristics of the included studies in a tabular form. The study has been approved by the Ethics Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh (protocol number: PR-20113). RESULTS: This protocol outlines our proposed methodology for conducting a systematic review. Our results will provide an update to the existing literature by searching additional databases. CONCLUSIONS: Findings from our systematic review will inform the planning of proper treatment methods that can effectively reduce the levels of ARB, ARGs, and residual antibiotics in effluent, thus lowering the risk of the environmental spread of AMR and its further transmission to humans and animals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/33365.

Contamination of Fresh Produce with Antibiotic-Resistant Bacteria and Associated Risks to Human Health: A Scoping Review.

Fresh produce, when consumed raw, can be a source of exposure to antimicrobial residues, antimicrobial-resistant bacteria (ARB) and antimicrobial resistance genes (ARGs) of clinical importance. This review aims to determine: (1) the presence and abundance of antimicrobial residues, ARB and ARGs in fresh agricultural products sold in retail markets and consumed raw; (2) associated health risks in humans; and (3) pathways through which fresh produce becomes contaminated with ARB/ARGs. We searched the Ovid Medline, Web of Science and Hinari databases as well as grey literature, and identified 40 articles for inclusion. All studies investigated the occurrence of multidrug-resistant bacteria, and ten studies focused on ARGs in fresh produce, while none investigated antimicrobial residues. The most commonly observed ARB were E. coli (42.5%) followed by Klebsiella spp. (22.5%), and Salmonella spp. (20%), mainly detected on lettuce. Twenty-five articles mentioned health risks from consuming fresh produce but none quantified the risk. About half of the articles stated produce contamination occurred during pre- and post-harvest processes. Our review indicates that good agricultural and manufacturing practices, behavioural change communication and awareness-raising programs are required for all stakeholders along the food production and consumption supply chain to prevent ARB/ARG exposure through produce.