A Naturalistic Evaluation of Group Integrative Adapt Therapy (IAT-G) with Rohingya Refugees During the Emergency Phase of a Mass Humanitarian Crisis in Cox's Bazar, Bangladesh.

Background: Studies of scalable psychological interventions in humanitarian setting are usually carried out when the acute emergency has stabilized. We report the first evaluation of an evidence-based group psychological intervention, Group Integrative Adapt Therapy (IAT-G), during the emergency phase of a mass humanitarian crisis amongst Rohingya refugees in Cox's Bazar, Bangladesh. Methods: We did a pragmatic naturalistic evaluation (2018-2020) of a seven-session group intervention with adult Rohingya refugees with elevated symptoms of depression (≥10 on the Patient Health Questionnaire) and/or posttraumatic stress disorder, PTSD, (≥3 on the Posttraumatic Stress Disorder-8), and functional impairment (≥17 on WHO Disability Assessment Schedule or WHODAS-brief). Screening was done across the most densely populated campsites. Blind assessments were completed at baseline, posttreatment, and at 3-month follow-up using culturally adapted measures of depression, anxiety, posttraumatic stress symptoms, complicated bereavement, adaptive stress associated with disrupted psychosocial support systems, functional impairment, and resilience. Findings: 383 persons were screened and of the 144 persons who met inclusion criteria all participated in the group intervention. Compared to baseline scores, IAT-G participants recorded significantly lower mean scores on key outcome indices (mental health symptoms, adaptive stress, and functional impairment) at posttreatment and 3-month follow-up (all pairwise tests significant Ps<.05). From baseline to 3-month follow-up, score changes were greatest for functional impairment (d = 2.24), anxiety (d = 2.15) and depression (d = 1.9), followed by PTSD symptoms (d = 1.17). Interpretation: A group-based intervention designed specifically to reflect the refugee experience and adapted to the language and culture, showed positive outcomes in the context of a pragmatic, naturalistic trial implemented in a mass humanitarian emergency. Funding: United Nations High Commissioner for Refugees; National Health and Medical Research Council Australia.

The culture, mental health and psychosocial wellbeing of Rohingya refugees: a systematic review.

AIMS: Despite the magnitude and protracted nature of the Rohingya refugee situation, there is limited information on the culture, mental health and psychosocial wellbeing of this group. This paper, drawing on a report commissioned by the United Nations High Commissioner for Refugees (UNHCR), aims to provide a comprehensive synthesis of the literature on mental health and psychosocial wellbeing of Rohingya refugees, including an examination of associated cultural factors. The ultimate objective is to assist humanitarian actors and agencies in providing culturally relevant Mental Health and Psychosocial Support (MHPSS) for Rohingya refugees displaced to Bangladesh and other neighbouring countries. METHODS: We conducted a systematic search across multiple sources of information with reference to the contextual, social, economic, cultural, mental health and health-related factors amongst Rohingya refugees living in the Asia-Pacific and other regions. The search covered online databases of diverse disciplines (e.g. medicine, psychology, anthropology), grey literature, as well as unpublished reports from non-profit organisations and United Nations agencies published until 2018. RESULTS: The legacy of prolonged exposure to conflict and persecution compounded by protracted conditions of deprivations and displacement is likely to increase the refugees' vulnerability to wide array of mental health problems including posttraumatic stress disorder, anxiety, depression and suicidal ideation. High rates of sexual and gender-based violence, lack of privacy and safe spaces and limited access to integrated psychosocial and mental health support remain issues of concern within the emergency operation in Bangladesh. Another challenge is the limited understanding amongst the MHPSS personnel in Bangladesh and elsewhere of the language, culture and help-seeking behaviour of Rohingya refugees. While the Rohingya language has a considerable vocabulary for emotional and behavioural problems, there is limited correspondence between these Rohingya terms and western concepts of mental disorders. This hampers the provision of culturally sensitive and contextually relevant MHPSS services to these refugees. CONCLUSIONS: The knowledge about the culture, context, migration history, idioms of distress, help-seeking behaviour and traditional healing methods, obtained from diverse sources can be applied in the design and delivery of culturally appropriate interventions. Attention to past exposure to traumatic events and losses need to be paired with attention for ongoing stressors and issues related to worries about the future. It is important to design MHPSS interventions in ways that mobilise the individual and collective strengths of Rohingya refugees and build on their resilience.

Comparison of clinical features and pathologic findings in fatal cases of typhoid fever during the initial and later stages of the disease.

This study was undertaken to correlate the clinical features and pathologic changes noted during the initial and later stages of fatal typhoid illness. Five cases who died during the initial stage of the illness (< 2 weeks from onset) had altered mental status, tachypnea, and tachycardia. Three had shock and elevation of serum creatinine values. Autopsies of all five revealed hyperplastic Peyer's patches, features of adult respiratory distress syndrome, and megakaryocytosis. Five other cases died during the later stage of the illness (> or = 2 weeks after onset). They had a left shift in peripheral blood leukocyte count. Autopsies revealed deep ileal ulcerations with or without perforation and peritonitis and intercurrent pneumonia. Three of them had disseminated intravascular coagulation. Further studies are warranted to understand the mediators of shock and tissue injuries during the initial period of the illness.

Training activities at the Centre.

PIP: This article describes the international training workshops conducted by the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B). During May 4-15, 1997, an international training course was conducted on the Laboratory Diagnosis of Common Diarrheal Disease Agents. The aim was to update the knowledge and skills of health professionals. 11 participants learned procedures for isolation and identification of pathogens, preparation of culture media, and laboratory safety. It is expected that those trained will spread their knowledge to others upon return to their home countries. A 4-week introductory course was conducted on Epidemiology and Biostatistics. The aim was to train persons from national institutions and nongovernmental organizations (NGOs) how to plan, design, analyze, and undertake epidemiological studies. A 2-week course was held on Emergency Response to Cholera and Shigella Epidemics. 12 participants from international NGOs that respond to disaster situations gained skills in managing epidemics and learning how to identify and apply measures to reduce morbidity and mortality from acute diarrhea in emergency and disaster situations. Participants learned how to recognize and manage patients with cholera and shigellosis and how to prepare an action plan for treatment and control purposes. This course consisted of theoretical lectures, hands-on training, and practical training. The Center's success in intervening in the Rwandan cholera epidemic justifies continued training for next year as well. 13 participants attended a 2-week course on Clinical Management of Diarrheal Diseases.^ieng

Erythromycin and trimethoprim-sulphamethoxazole in the treatment of cholera in children.

To evaluate the efficacy of erythromycin and trimethoprim-sulphamethoxazole (TMP-SMX) in the treatment of cholera in children aged 1-8 years, a randomised clinical trial was conducted at a diarrhoea treatment centre in Bangladesh from December 1991 to June 1992. Fifteen children received erythromycin, 50 mg/kg per day, in four equally divided doses, 18 children received 10 mg/kg per day of trimethoprim and 50 mg/kg per day of sulphamethoxazole in two equally divided doses (12 hourly) for five days, and 15 children received no antibiotic; children in all three groups received intravenous cholera saline for severe dehydration and for mild to moderate dehydration, a rice-based oral rehydration solution. The mean stool volumes in mL/kg body weight in the two treatment groups were less than that of the control group, and there were no significant differences in stool volume among the two treatment groups. However, 67% of the children in the erythromycin group and 82% in the TMP-SMX group recovered within 72 hours compared to 33% in the control group (p < 0.01). Similarly, the bacteriological cures were 80% in the erythromycin group and 83% in the TMP-SMX group compared to only 27% in the control group (p < 0.001). These results confirm that both erythromycin and trimethoprim-sulphamethoxazole are effective antimicrobials in the treatment of cholera. These drugs are of value specially in younger children in whom tetracycline is contraindicated or when the infecting Vibrio cholerae are resistant to tetracycline.

Effect of antimicrobial (nalidixic acid) therapy in shigellosis and predictive values of outcome variables in patients susceptible or resistant to it.

We observed the clinical features and results of simple laboratory tests on stools of 33 children with bacteriologically proven shigellosis to identify features that could be used to assess the effectiveness of antimicrobial therapy. Persistence of fever (rectal temperature > 37.8 degrees C), abdominal pain/tenderness and anorexia on days 3 and 5 were significantly more common (P < 0.001) among children who received an antimicrobial to which the infecting Shigella was resistant. Similarly, a significantly higher number of children treated with an ineffective antimicrobial had faecal leucocytes of > 50/high power microscopic field (HPF), erythrocytes of > 50/HPF and macrophages of > 5/HPF on study day 5. The best predictors of ineffective antimicrobial therapy on days 3 and 5 of treatment were fever, presence of blood by naked eye examination of stool, and minimum change in stool frequencies. These observations suggest that by careful follow-up of clinical features and simple laboratory tests, such as stool microscopic examinations, it is possible to identify patients unlikely to respond to initial therapy by 72 hours permitting the start of alternative antimicrobial treatment. This may be of great help where stool culture and sensitivity facilities for Shigella spp. are not available.

Development and evaluation of co-agglutination test to detect rotavirus antigens in stools of patients with diarrhoea.

Rotavirus is the most common cause of acute diarrhoea in infants and children in both the developed and developing countries including Bangladesh. Information about rotavirus diarrhoea in Bangladesh is insufficient primarily due to the lack of diagnostic facilities due to the high cost of reagents and equipment and lack of skilled personnel. A simple, suitable and less costly technique of co-agglutination test using protein-A secreting staphylococci was developed and evaluated against a commercially available ELISA kit to detect rotavirus antigen in stools of patients with diarrhoea. Staphylococcus cowan strain 1 was grown and coated with rabbit antisera raised against RV5 and SA11 rotavirus strains. The antibody-coated staphylococci were agglutinated specifically by rotavirus present in faecal samples within one or two minutes. A total of 1332 stool specimens were tested by co-agglutination and ELISA, of which 210 (15.77%) were positive by ELISA and 276 (20.72%) by co-agglutination test. Compared to ELISA, sensitivity of co-agglutination test was 76.19%, specificity 89.66% and predictive values of a positive and a negative test were 57.97% and 95.26% respectively. The results indicate that the co-agglutination test is a simple and suitable technique for rapid screening of rotavirus infection which could be adopted in clinical practice.

Moraxella septicemia in children with diarrheal disease.

We report 10 cases of Moraxella septicemia associated with diarrheal disease. Their clinical presentations and outcomes are discussed. Recognition of the pathogenicity of these microorganisms in appropriate clinical setting should result in prompt and specific therapy.

Double-blind comparison of oral gentamicin and nalidixic acid in the treatment of acute shigellosis in children.

To compare the efficacy of oral gentamicin with nalidixic acid in the treatment of acute shigellosis, we studied, in a double blind-trial, 79 comparable children with bloody diarrhoea of less than 72 h duration. Of them Shigella spp. were isolated in 71 patients. Patients were randomly assigned to receive either gentamicin 30 mg/kg/day or nalidixic acid 60 mg/kg/day, both given orally in four equal doses for 5 days. Stool frequency differed significantly between the groups from day two until completion of the study. Treatment failure was observed in 14 (42 per cent) patients receiving oral gentamicin compared to none of those with nalidixic acid-sensitive strains of Shigella spp. (P = 0.0002). Although all the shigella isolates were sensitive to gentamicin in vitro, 19 (58 per cent) patients on gentamicin therapy failed to eliminate shigella organisms from stool, compared to none in the nalidixic acid treated group infected with nalidixic acid-sensitive Shigella spp. (P < 0.001). One patient in each group had a bacteriological relapse. We conclude that gentamicin given orally was therapeutically ineffective in the treatment of acute shigellosis.

Enteric protein loss and intestinal permeability changes in children during acute shigellosis and after recovery: effect of zinc supplementation.

The effect of zinc supplementation on intestinal permeability changes and protein loss was studied in 32 children aged between 1 and 12 years during bouts of acute shigellosis and after recovery. An intestinal permeability test and then a 48 hour balance study were performed on all patients. They were then blindly assigned to receive vitamin B syrup either with or without zinc acetate (15 mg/kg per day) for a month. All patients received a five day course of nalidixic acid. The balance study was repeated during convalescence and follow up, but a permeability test was done only at follow up after one month. Intestinal permeability, expressed as a urinary lactulose:mannitol excretion ratio, improved significantly (p = 0.001) along with a significant increase (p = 0.005) in mannitol excretion in the zinc supplemented children, suggesting a resolution of small bowel mucosal damage. The latter was associated with a higher coefficient of nitrogen absorption (p = 0.03), suggesting a possible role of zinc in the treatment of shigellosis. Enteric protein loss, as assessed by faecal alpha 1 antitrypsin clearance, was not influenced by zinc supplementation.

Comparison of pivmecillinam and nalidixic acid in the treatment of acute shigellosis in children.

The efficacy of oral pivmecillinam was compared with nalidixic acid in the treatment of acute shigellosis in children 1-8 years of age. In a double-blind trial we studied 80 comparable children with bloody diarrhoea of less than 3 days' duration. Shigella spp. was isolated in 71 children. Patients were randomly assigned to receive either pivmecillinam, 50 mg/kg.day, or nalidixic acid, 60 mg/kg.day, both given orally for 5 days. The stool frequency decreased progressively in both treatment groups. Nalidixic acid failed to eradicate Shigella species in 10 patients, compared with three in the pivmecillinam group (p = 0.04). Similarly, clinical failure was observed in 11 of 37 patients receiving nalidixic acid and in 2 of 26 patients infected with nalidixic acid-susceptible strains as against none in the group receiving pivmecillinam. The results suggest that pivmecillinam given orally was, in fact, more effective than nalidixic acid in the treatment of acute shigellosis in children, particularly when the resistant strains are taken into account.

Management of acute diarrhoea in diabetic patients using oral rehydration solutions containing glucose, rice, or glycine.

OBJECTIVE: To assess the risk of hyperglycaemia with two standard oral rehydration solutions that contain carbohydrate compared with a carbohydrate free solution during rehydration of diabetic patients with acute diarrhoea. DESIGN: Prospective randomised allocation to one of three oral rehydration solutions (World Health Organisation (glucose), rice, or glycine) groups after admission to hospital with acute diarrhoea. SETTING: Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh. SUBJECTS: 45 diabetic patients aged between 15 and 60 who had had diarrhoea for fewer than three days on admission. MAIN OUTCOME MEASURES: Fluctuation of blood glucose concentrations measured three times a day, daily stool output, and time taken for recovery from diarrhoea. RESULTS: There were no significant differences in blood glucose concentrations, stool output, and duration of recovery from diarrhoea among the three groups. CONCLUSIONS: Oral rehydration solutions containing glucose, rice powder, or glycine can be safely administered to diabetic patients with acute diarrhoea and some dehydration.

Bacteraemia and meningitis among hospital patients with diarrhoea.

To characterize bacteraemia and meningitis in diarrhoeal patients, the records of 3395 blood cultures and 120 cerebrospinal fluid (CSF) cultures from 6132 patients admitted with diarrhoea to the Clinical Research Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh during 1989 were analysed. Microorganisms were isolated from 12% (417 of 3395) of blood cultures and 9% (11 of 120) of CSF cultures. Children below 5 years of age represented 80% of all patients who had blood cultures and 82% of those who had CSF cultures made. The nutritional status was significantly lower in patients who had positive blood cultures than in those who had negative cultures. 23% (97 of 417) of patients with positive blood cultures and 45% (5 of 11) with positive CSF cultures died. Deaths occurred twice as often among patients who had organisms isolated than among those who had no organisms isolated from blood cultures. The organisms isolated from blood cultures which predicted most deaths were Pseudomonas aeruginosa, Neisseria meningitidis, Escherichia coli and Klebsiella sp., and they were multiresistant. We conclude that bacteraemia and meningitis remain serious complications associated with diarrhoea, especially in malnourished children; the therapeutic problem is further complicated by multiple drug resistance of the isolates.

Characterisation of Plesiomonas shigelloides strains that share type-specific antigen with Shigella flexneri 6 and common group 1 antigen with Shigella flexneri spp. and Shigella dysenteriae 1.

Three strains of Plesiomonas shigelloides isolated from patients with diarrhoea were agglutinated with Shigella flexneri 6 antiserum in slide and tube tests. All the strains were also agglutinated with a monoclonal antibody to the common group 1 antigen shared between S. flexneri serotypes and S. dysenteriae type 1. Further studies with one strain also showed sharing of antigenicity in an enzyme-linked immunosorbent assay. The results suggest that the strains share type-specific antigen with S. flexneri 6 and the common group 1 antigen with S. flexneri serotypes and S. dysenteriae 1. The sharing of antigens may have implications for cross-protection. One strain adhered to HEp-2 cell monolayers. None of the strains contained high mol. wt plasmids and there was no sequence homology with the invasiveness plasmid of Shigella spp. in DNA probe hybridisation. They were susceptible to the commonly used antibiotics. However, they possessed four other virulence-associated properties of Shigella spp. that included Congo-red binding, hydrophobicity, toxicity to HeLa cells and HEp-2 cell invasiveness (although they gave negative results in the Sereny test for invasiveness). These data suggest that the three unique strains might be considered pathogenic. Studies in animal models and human volunteers would be necessary to establish their pathogenic potential.

Maternal nutritional status as a determinant of child health.

To determine the relationship between the nutritional status of the mother and that of the child, 339 children aged 3-36 months and their mothers in two urban hospitals and a community out-patient clinic, were studied. The weight and height of both children and their mothers were measured, and body mass indices (BMI) of the mothers were calculated. Socio-economic status, maternal educational level, and dietary information were recorded in a predesigned questionnaire. The child's nutritional status, as indicated by weight for age (as a percentage of NCHS median), was associated with the body mass index of the mother (P < 0.001), socio-economic status of the family (P < 0.001), and breastfeeding status of the child (P < 0.005) in a multivariate analysis after adjusting for several prognostic factors. The results indicate that maternal nutritional status is a proximate determinant of a child's nutritional status and should be considered in programmes aiming at improving child health.

Persistent diarrhoea: factors affecting absorption and clinical prognosis during management with a rice-based diet.

Twenty-six persistent diarrhoea patients aged 4 to 18 months were treated with a diet prepared with rice powder, soya oil, glucose, egg white and water. Absorption of macronutrients was estimated in a 72 h balance study and clinical response was examined during one week of dietary treatment. Nutrient absorption was compared with that of 25 healthy age-matched controls treated with the same diet. Twenty-one patients (81%) recovered from diarrhoea within seven days. Absorption of nutrients was significantly reduced among the persistent diarrhoea patients. More malnourished patients had a significantly reduced absorption of nutrients except carbohydrate and an increased severity and longer duration of diarrhoea. Total gut transit time had significant association with nutrient absorption in the persistent diarrhoea patients. The period of recovery negatively correlated with coefficient of absorption and positively with initial stool weight. Failure to recover was associated with severity of diarrhoea and systemic infection. The study indicates that nutrient absorption is significantly reduced in patients with persistent diarrhoea and nutritional status, and that initial purging rate and intestinal hurry are significantly related to the prognosis and nutrient absorption.

Campylobacter jejuni bacteraemia in children with diarrhoea in Bangladesh: report of six cases.

Campylobacter jejuni was isolated from blood cultures from 6 of 6,275 diarrhoeal children seeking treatment at the Clinical Research Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) between April 1989 and December 1990. The clinical records of these 6 children were reviewed. All children were male; 5 were less than 1-year old and were severely malnourished. Five patients presented with watery diarrhoea and one with bloody diarrhoea. Two children died in the hospital. All strains of Campylobacter isolated from the 6 children were negative for cell invasive properties as tested by the Sereny test. Of the two strains tested for serum bactericidal activity, one strain was serum sensitive (growth inhibition), and the other resistant. The ability of C. jejuni to cause bacteraemia suggests that the organisms may be responsible for diarrhoeal diseases especially in young and malnourished children. An early attempt to detect Campylobacter and start effective antimicrobial therapy is indicated.

Lack of therapeutic efficacy of vitamin A for non-cholera, watery diarrhoea in Bangladeshi children.

Vitamin A deficiency has been postulated to increase childhood mortality, possibly through increasing the severity and case-fatality of infectious diseases like diarrhoea. A clinical trial was conducted to measure the effect of vitamin A therapy on the severity and duration of acute episodes of non-cholera, watery diarrhoea; 83 children with less than 48 h of illness were randomized to receive vitamin A (200,000 IU of retinyl palmitate) orally or placebo during hospitalization at the International Centre for Diarrhoeal Disease Research in Bangladesh. The patients were similar initially with regard to age, nutritional status and severity of diarrhoea prior to admission. No adverse effects of vitamin A were detected. During hospitalization there were no differences between groups in duration of illness or stool output. Thus, vitamin A can be given safely during diarrhoeal illness to augment hepatic reserves and possibly provide a beneficial effect in regard to subsequent episodes of diarrhoea and other infections, but this supplementation should not be expected to have a therapeutic effect on a current episode.