Management of Children Admitted to Hospitals across Bangladesh with Suspected or Confirmed COVID-19 and the Implications for the Future: A Nationwide Cross-Sectional Study.

There is an increasing focus on researching children admitted to hospital with new variants of COVID-19, combined with concerns with hyperinflammatory syndromes and the overuse of antimicrobials. Paediatric guidelines have been produced in Bangladesh to improve their care. Consequently, the objective is to document the management of children with COVID-19 among 24 hospitals in Bangladesh. Key outcome measures included the percentage prescribed different antimicrobials, adherence to paediatric guidelines and mortality rates using purposely developed report forms. The majority of 146 admitted children were aged 5 years or under (62.3%) and were boys (58.9%). Reasons for admission included fever, respiratory distress and coughing; 86.3% were prescribed antibiotics, typically parenterally, on the WHO 'Watch' list, and empirically (98.4%). There were no differences in antibiotic use whether hospitals followed paediatric guidance or not. There was no prescribing of antimalarials and limited prescribing of antivirals (5.5% of children) and antiparasitic medicines (0.7%). The majority of children (92.5%) made a full recovery. It was encouraging to see the low hospitalisation rates and limited use of antimalarials, antivirals and antiparasitic medicines. However, the high empiric use of antibiotics, alongside limited switching to oral formulations, is a concern that can be addressed by instigating the appropriate programmes.

Health services reform in Bangladesh: hearing the views of health workers and their professional bodies.

BACKGROUND: In Bangladesh, widespread dissatisfaction with government health services did not improve during the Health and Population Sector Programme (HPSP) reforms from 1998-2003. A 2003 national household survey documented public and health service users' views and experience. Attitudes and behaviour of health workers are central to quality of health services. To investigate whether the views of health workers influenced the reforms, we surveyed local health workers and held evidence-based discussions with local service managers and professional bodies. METHODS: Some 1866 government health workers in facilities serving the household survey clusters completed a questionnaire about their views, experience, and problems as workers. Field teams discussed the findings from the household and health workers' surveys with local health service managers in five upazilas (administrative sub-districts) and with the Bangladesh Medical Association (BMA) and Bangladesh Nurses Association (BNA). RESULTS: Nearly one half of the health workers (45%) reported difficulties fulfilling their duties, especially doctors, women, and younger workers. They cited inadequate supplies and infrastructure, bad behaviour of patients, and administrative problems. Many, especially doctors (74%), considered they were badly treated as employees. Nearly all said lack of medicines in government facilities was due to inadequate supply, not improved during the HPSP. Two thirds of doctors and nurses complained of bad behaviour of patients. A quarter of respondents thought quality of service had improved as a result of the HPSP.Local service managers and the BMA and BNA accepted patients had negative views and experiences, blaming inadequate resources, high patient loads, and patients' unrealistic expectations. They said doctors and nurses were demotivated by poor working conditions, unfair treatment, and lack of career progression; private and unqualified practitioners sought to please patients instead of giving medically appropriate care. The BMA considered it would be dangerous to attempt to train and register unqualified practitioners. CONCLUSIONS: The continuing dissatisfaction of health workers may have undermined the effectiveness of the HPSP. Presenting the views of the public and service users to health managers helped to focus discussions about quality of services. It is important to involve health workers in health services reforms.

What did the public think of health services reform in Bangladesh? Three national community-based surveys 1999-2003.

BACKGROUND: Supported by development partners, the Government of Bangladesh carried out a comprehensive reform of health services in Bangladesh between 1998 and 2003, intended to make services more responsive to public needs: the Health and Population Sector Programme (HPSP). They commissioned a series of surveys of the public, as part of evaluation of the HPSP. This article uses the survey findings to examine the changes in public opinions, use and experience of health services in the period of the HPSP. METHODS: We carried out three household surveys (1999, 2000 and 2003) of a stratified random sample of 217 rural sites and 30 urban sites. Each site comprised 100-120 contiguous households. Each survey included interviews with 25,000 household respondents and managers of health facilities serving the sites, and gender-stratified focus groups in each site. We measured: household ratings of government health services; reported use of services in the preceding month; unmet need for health care; user reports of waiting times, payments, explanations of condition, availability of prescribed medicines, and satisfaction with service providers. RESULTS: Public rating of government health services as "good" fell from 37% to 10% and the proportion using government treatment services fell from 13% to 10%. Unmet need increased from 3% to 9% of households. The proportion of visits to government facilities fell from 17% to 13%, while the proportion to unqualified practitioners rose from 52% to 60%. Satisfaction with service providers' behaviour dropped from 66% to 56%. Users were more satisfied when waiting time was shorter, prescribed medicines were available, and they received explanations of their condition. CONCLUSION: Services have retracted despite increased investment and the public now prefer unqualified practitioners over government services. Public opinion of government health services has deteriorated and the reforms have not specifically helped the poorest people. User satisfaction could be increased if government doctors improved their interaction with patients and if waiting times were reduced by better management of facilities.

Arsenic-contaminated water and extent of acute childhood malnutrition (wasting) in rural Bangladesh.

To investigate whether children's nutritional status, especially the extent of wasting [acute malnutrition as measured by weight-for-height Z (WHZ) score] is associated with arsenic contamination of drinking water, a survey was carried out in two discrete rural areas located less than 30 km southeast and northeast of Dhaka, the capital of Bangladesh. 761 children between 7 and 14 years of age were randomly selected, one child per household. The arsenic concentration in the tube well water used by each child and the prevalence and intensity of infection of three geo-helminths [Ascaris lumbricoides, Trichuris trichiura and hookworm (Ancylostoma duodenale or Necator americanus)] were determined. Each child had their height and weight measured and WHZ score determined using the World Health Organization (WHO) reference values. Basic socio-demographic data and knowledge of arsenic poisoning were collected using a questionnaire. 62.2% of the households studied were using well water with arsenic concentrations above the 0.01 mg/L WHO guideline (i.e. arsenic-contaminated households). The mean WHZ score of all the 761 children was -0.843 (sd 1.227) but children living in contaminated households were significantly more wasted than children living in noncontaminated households (mean difference = -0.361, p 0.001). When the effects of the differences in socio-economic status and prevalence of geo-helminths were also taken into account, the difference in means remained highly significant (-0.330, p = 0.006). This study suggests that arsenic contamination has a negative impact on children's acute nutritional status.

The burden of chronic disease.

The shift from acute infectious and deficiency diseases to chronic noncommunicable diseases is not a simple transition but a complex and dynamic epidemiological process, with some diseases disappearing and others appearing or reemerging. The unabated pandemic of childhood and adulthood obesity and concomitant comorbidities are affecting both rich and poor nations, while infectious diseases remain an important public health problem, particularly in developing countries. More attention should be given to the high burden of disease associated with soil-transmitted helminths and schistosomiasis, which until recently was not considered a priority even though regular drug treatment is obtainable at relatively little cost. In developing countries, the pressing requirement is to provide an accessible and good quality health-care system, whereas industrialized countries have a major need for greater public health education and the promotion of healthy life-styles.

Children at risk of developing dehydration from diarrhoea: a case-control study.

To identify the factors related to dehydration from diarrhoea, a hospital-based case-control study was carried out among under-2-year-old Bangladeshi children. The study compared 80 cases who had 'some' or severe dehydration with 160 age-matched controls who had 'no signs' of dehydration. All the cases and controls were examined and the mothers were interviewed in the hospital and followed at home on the 14th day of illness. Thirty-eight factors were studied for their probable influence on the development of dehydration. In bivariate analysis, 17 factors were found to be associated significantly with the development of dehydration and were treated with stepwise logistic regression analysis. A combination of vomiting, oral rehydration therapy at home, mother's dirty finger nails, and residing more than 3 km away from the hospital provided the maximum sensitivity (77.5 per cent) and specificity (91.2 per cent) for predicting development of dehydration. These prognostic factors would be helpful for community health workers to identify children at risk of developing diarrhoea-associated dehydration, and preventive strategies could be designed to alter the prognostic factors.

Environmental, health and economic conditions perceived by 50 rural communities in Bangladesh.

For randomly selected 50 villages in Bangladesh, an interview survey with a structured questionnaire was conducted to reveal their perception on the environmental, health and economic conditions at present and for the past 10-year change. The eight following items were analyzed in this paper: air pollution and water pollution, which represent environmental conditions with close relation to health conditions, soil degradation and deforestation, which represent environmental conditions with close relation to economic conditions, epidemic diseases and malnutrition, which represent health conditions, and poverty and jobless, which represent economic conditions. Among the 50 villages, deforestation was most frequently perceived serious at present and worsened in the past 10 years. Of the remaining seven items, those related to economic conditions were more seriously perceived than those related to health and environmental conditions. As revealed by the cluster analysis for the inter-item relations, epidemic diseases, which formed the same cluster with the environmental items, were recognized less serious whereas malnutrition, which formed the same cluster with the economic items, was recognized more serious. These findings are useful not only for rural development programs but also for mitigation programs toward health and environmental hazards in Bangladesh.