Changing Water-Sanitation Determinants of Cholera over Two Decades in Bangladesh.

Cholera is a leading global public health threat, especially in developing countries. This study aimed to determine the changing determinants of cholera related to water-sanitation practices between 1994-1998 and 2014-2018 in Dhaka, Bangladesh. Data of all cause diarrhea cases were extracted from the Diarrheal Disease Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, and analysis was performed among three groups: Vibrio cholerae detected as sole pathogen, V. cholerae detected as mixed infection, and detection of no common enteropathogen in stool specimens (reference). Using sanitary toilet, drinking tap water, drinking boiled water, family size greater than five, and slum dwelling were the main exposures. Overall, 3,380 (20.30%) and 1,290 (9.69%) patients were positive for V. cholerae during 1994-1998 and 2014-2018, respectively. In 1994-1998, use of sanitary toilet (adjusted odds ratio [aOR]: 0.86, 95% CI: 0.76-0.97) and drinking tap water (aOR: 0.81, 95% CI: 0.72-0.92) were found to be negatively associated and in 2014-2018, drinking tap water (aOR: 1.47, 95% CI: 1.21-1.78) and slum dwelling (aOR: 1.43, 95% CI: 1.10-1.86) were found to be positively associated with V. cholerae infection after adjusting for age, sex, monthly income, and seasonality. Because the determinants of cholera such as drinking tap water can change over time in developing cities, ameliorating the water, sanitation, and hygiene (WASH) situation is of paramount importance. In addition, in settings such as urban slums, where long-term WASH monitoring might be difficult to achieve, mass vaccination with oral cholera vaccine should be introduced to control cholera.

Trend and risk factors of fatal pregnancy termination: A long-term nationwide population-based cross-section survey in Bangladesh.

BACKGROUND: Pregnant women often experience the fatal outcome of their pregnancy both in developed and impoverished countries. Due to strong health systems and services, factual and historical data are available from developed countries. However, the prevalence trend and risk factors of a fatal termination of pregnancy in developing countries like Bangladesh are still lacking. OBJECTIVE: The objective of the current study was to determine the 20 years trend of prevalence and risk factors of fatal pregnancy termination from 1997 to 2018 in Bangladesh. METHOD: This study utilised the publicly available seven consecutive cross-data on Bangladesh Demographic and Health Surveys data since 1997 following identical methods among women of reproductive age. Respondent was asked if they had had a fatal pregnancy termination ever. A Generalised Linear model with a log-Poisson link was used to estimate the relative risk of different predictors for four survey time points (1998, 2004, 2011, 2018). RESULTS: The proportions of fatal pregnancy termination in urban and rural areas were 24% vs. 19% and 24% vs. 22% in 1997 and 2018, respectively. In multivariable analysis, maternal age 30 years and above and obesity were strongly associated in all survey time points. The richest wealth index had a weak association in 1997 but was strongly associated in 2011 and 2018. A significant modest association with secondary complete education level was only observed in 2018. CONCLUSION: The overall proportions of fatal pregnancy termination in Bangladesh remain nearly static; however, its risk factors differed across different survey time points.

Toxoplasma gondii Infection Is Associated with Low Birth Weight: Findings from an Observational Study among Rural Bangladeshi Women.

Gestational Toxoplasma gondii (T. gondii) infection may cause substantial adverse effects on developing fetuses, newborns and also mothers. This study aims to estimate the seroprevalence of T. gondii among rural Bangladeshi pregnant women and determine the risk of a low birth weight (LBW). We followed a longitudinal design where 208 pregnant women were followed until the birth of their infants. Levels of IgG and IgM of T. gondii were assessed using chemiluminescent immunoassay. Modified Poisson regression was used to estimate crude and adjusted associations and multiple regression analysis was performed to understand the confounding and modifying effects of the variables. Thirty-nine (19%) children were born with LBW, among whom 15 (39%) mothers were positive for T. gondii IgG during pregnancy. After adjusting for several confounders and modifiers, pregnant women with T. gondii IgG or IgM seropositivity were significantly associated with LBW of infants (aRR: 2.00, 95% CI: 1.17-3.42). The strength of this association increased after adjusting for maternal education (aRR: 4.88, 95% CI: 1.74-13.69). The final model had an AROC of 0.84 with a sensitivity of 36% and specificity of 97%. Although causality is yet to be established, the study observed an association between T. gondii infection during pregnancy among rural Bangladeshi women and LBW of newborns.

Trend of maternal education in Bangladesh from 2004-2018: Analysis of demographic surveillance data.

BACKGROUND: Maternal education is universally recognised as a major factor in positive societal indicators (health, wellbeing, overall education, etc.) and a country's growth and economic sustainability, yet the underlying factors contributing to maternal education have not been widely investigated, especially in developing countries. OBJECTIVE: This study investigated the 15-year trend of maternal education in Bangladesh (2004-2018) to identify the factors contributing to maternal education. METHOD: This study used publicly available cross-data from five consecutive Bangladesh Demographic and Health Surveys (2004, 2007, 2011, 2014 and 2018). Level of maternal education was grouped as 'no education', 'incomplete primary', 'complete primary', 'incomplete secondary', 'complete secondary' and 'higher education' (reference group). The differences in factors/exposure variables suspected to contribute to maternal education were measured for these groups for 2004-2018, and a survey multinomial logistic regression was performed to estimate the explanatory value of these factors. RESULTS: From 2004-2018, there was a 62% gross reduction of the no education group and a 61% gross increase in the higher education group. A gross increase was also observed for complete secondary (49%), incomplete secondary (39%) and complete primary education (14%). In multivariate analysis, in rural areas, in 2018, the probability of a woman being in the complete primary, incomplete primary or no education groups was increased (adjusted relative risk ratio: 1.21, 1.40 and 1.59), compared to 2004 (0.73, 1.09, 1.12), respectively. From 2004-2018, the factor of no television watching reduced the probability of maternal education levels. Having a husband/partner who had no education increased the probability of a woman's education level. The probability of all maternal education levels decreased across all wealth index groups. CONCLUSION: The data suggest that average maternal education level in Bangladesh increased from 2004-2018. However, an integrated effort is required to improve factors associated with maternal education to both increase maternal education and Bangladesh's long-term sustainability.

Neonatal death is a major concern for Indigenous women with asthma during pregnancy and could be prevented with better models of care.

Asthma is the most common respiratory illness in Aboriginal and Torres Strait Islander Australians. From the Mater Mothers routinely collected perinatal data in Brisbane we have identified that 24% of Indigenous and 17% of non-Indigenous women have pregnancies complicated by asthma. Indigenous women with asthma are more likely to have poorer birth outcomes when compared to non-Indigenous women with asthma, with neonatal death being doubled in asthmatic Indigenous women. These data indicate that asthma management during pregnancy is an unmet need for Indigenous women and essential if we are to avoid these devastating outcomes for Indigenous families.

Maternal asthma during pregnancy and extremes of body mass index increase the risk of perinatal mortality: a retrospective cohort study.

OBJECTIVE: Asthma during pregnancy and extremes of body mass index (BMI) are independently associated with adverse pregnancy outcomes but the impact of the two conditions combined are currently unknown. The aim of this study was to determine the contribution of maternal BMI to adverse birth outcomes in pregnancies complicated by asthma. METHODS: The study utilized the routinely collected perinatal data on births at the Mater Mother's Hospital Brisbane, Australia, from January 2008 to December 2019. BMI was grouped as underweight (<18.5), normal weight (18.5-<24.99), overweight (25-29.99), and obese (≥30) and the population split by the presence and absence of maternal asthma. The comparison group was normal BMI, non-asthmatic pregnant women. A modified Poisson regression with robust variance was used to estimate the relative risk. RESULTS: In a retrospective cohort study of 110,057 pregnant women, 17.08% of women had asthma. Asthma and BMI were associated with an increased risk of poor fetal and neonatal outcomes. Asthma significantly increased the risk of stillbirth in underweight [adjusted RR: 2.22 (95% CI: 1.25-3.94] and obese [1.74 (1.11-2.71)]; neonatal death in underweight [3.41 (1.89-6.16)] and obese [2.22 (1.37-3.59)] and perinatal death in underweight [2.34 (1.50-3.66)] and obese [1.92 (1.38-2.67)] women. Admission to the neonatal intensive care unit was increased in neonates of underweight [1.65 (1.44-1.89)] and obese [1.26 (1.14-1.40)] asthmatic women. CONCLUSIONS: Extremes of BMI, specifically underweight and obesity, increased the risk of adverse perinatal outcomes among asthmatic women highlighting the importance of accounting for BMI during pre-conception and pregnancy related management of asthmatic women.

Characteristics of Rotavirus, ETEC, and Vibrio Cholerae Among Under 2-year Children Attending an Urban Diarrheal Disease Hospital in Bangladesh.

BACKGROUND: Information on comparative clinical and host characteristics of under-2 children with watery diarrhea caused by rotavirus, Enterotoxigenic Escherichia coli (ETEC), and Vibrio cholerae as single pathogens is lacking. We sought to investigate the sociodemographic, clinical, and host characteristics of under-2 children hospitalized due to these pathogens. METHODOLOGY: We conducted a hospital-based case-control study using the icddr,b Diarrheal Diseases Surveillance System. Children of either sex, <2 years with diarrhea, who attended the hospital during 2014 to 2018, constituted the study population. Stool specimens having a single pathogen like rotavirus, ETEC, or Vibrio cholerae constituted the cases and stool specimens having no detectable common enteropathogens comprised the controls. Multinomial logistic regression analysis was done where control was the reference group. RESULTS: A total of 14 889 patients were enrolled, 6939 of whom were under-2 children, and 5245 (76%) constituted our study population. Among them 48% (n = 2532), 3% (n = 148) and 1% (n = 49) had rotavirus, ETEC, and Vibrio cholera, respectively. A control group (diarrhea without these 3 or Shigella, Salmonella, Aeromonas) accounted for 48% (n = 2516). In multinomial regression model, children with rotavirus (adjusted odds ratio [aOR], 1.36; 95% confidence interval [95% CI], 1.19-1.55) less often presented with dehydrating diarrhea compared to those with ETEC (aOR, 1.54; 95% CI, 1.05-2.26) and cholera (aOR, 2.25; 95% CI, 1.11-4.57). Rotavirus diarrhea was associated (aOR, 1.25; 95% CI, 1.07-1.46) with those who received antimicrobials prior to hospital admission and protectively associated with drinking tap water (aOR, 0.84; 95% CI, 0.73-0.95); however, ETEC diarrhea had protective association (aOR, 0.62; 95% CI, 0.43-0.92) with children who received antimicrobials prior to hospital admission and was associated with drinking tap water (aOR, 1.78; 95% CI, 1.19-2.66). Use of intravenous fluid was associated with cholera (aOR, 10.36; 95% CI, 4.85-22.16) and had protective association with rotavirus episodes (aOR, 0.64; 95% CI, 0.45-0.91). CONCLUSIONS: Clinical presentations and host characteristics of rotavirus, ETEC, and Vibrio cholerae diarrhea differed from each other and the information may be helpful for clinicians for better understanding and proper management of these children.

Renal insufficiency among urban populations in Bangladesh: A decade of laboratory-based observations.

OBJECTIVE: The objective of this study was to describe the age and sex-specific prevalence of renal insufficiency, and observe its trends over a decade at an urban Bangladesh setup. METHOD: This was a cross-sectional study, in which we observed the Estimated Glomerular Filtration Rate (eGFR) of 218,888 adults, aged ≥19 years, who had submitted their blood specimen to the Clinical Biochemistry Laboratory of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) during the years 2006-2015. We applied CKD-EPI definition in estimating eGFR using their age-and sex-specific serum creatinine concentrations. Based on the eGFR, we classified the population into five stages of renal insufficiency (stage-1 to stage-5), at age intervals of five-years. Data were analysed using the Linear Regression and Multinomial Logistic Regression models. RESULTS: Females constituted 43% (n = 94,931) of the study population; and 34% (n = 42,576) of the males and 31% (n = 29,830) of the females had their serum creatinine concentrations above the upper limit of the laboratory reference cut-off. The overall prevalence of stage-2 to stage-5 renal insufficiency were 24% (n = 52,126), 17% (n = 38,539), 8% (n = 16,504) and 6% (n = 12,665) respectively; the prevalence were 23% (n = 1,890), 19% (n = 1,579), 9% (n = 769) and 9% (n = 770) respectively in 2006, and 24% (n = 10,062), 17% (n = 6,903), 6% (n = 2,537) and 5% (n = 1,924) respectively in 2015. The prevalence was higher among the females. At least 2% of the adults, younger than <44 years, had stage-4 and stage-5 in 2015. The age-adjusted eGFR was significantly lower among the post-menopausal females (aged ≥46 y) compared to the same age group males (64.08±10.83 vs. 66.83±10.41 mL/min/1.73 m2; p<0.001). Compared to 2006, the number of individuals with renal insufficiency (stage 2 and above) had increased at least two times, irrespective of age, in 2015. A single year of increase in the age was significantly associated with 1.32 unit reductions in the eGFR; and the reductions were higher for females who also had higher odds of renal insufficiency stages-2 and beyond. CONCLUSION: This study observed high prevalence of stage-2 to stage-5 renal insufficiency in Bangladeshi populations, irrespective of age, and especially among the females.

The effect of a newly established urban diarrhea treatment facility in Bangladesh: Changing patient characteristics and etiologies.

BACKGROUND: Mirpur treatment centre (MTC), Dhaka of the International Centre for Diarrhoeal Disease Research, Bangladesh, was established as a consequence of an outbreak of diarrheal disease during the summer month of April 2007 in Mirpur area. OBJECTIVE: The present study aimed to evaluate the impact of this new facility on patient load, common etiology, and other characteristics of patient population who sought treatment at Dhaka Hospital. METHODS: As part of the Diarrheal Disease Surveillance System (DDSS), 10% patients (every 10th) seeking care irrespective of age, sex, sociodemographic background, and severity of disease were enrolled at MTC as opposed to 2% (every 50th) at Dhaka Hospital following identical methodology from 2010 to 2013. Moreover, enrolled DDSS patients from 2005 to 2009 at Dhaka Hospital were also included in analysis to further examine the impact of MTC on Dhaka Hospital. RESULTS: Patient load from Mirpur area attending the Dhaka Hospital reduced from 13% during epidemic in 2010 to 6% in 2013 (53% reduction), whereas attendance in MTC increased substantially by 33%. This changing trend was also observed among children <5 years old. A significant reduction of patients presenting with moderately severe disease from Mirpur area at Dhaka Hospital was observed (69% reduction); however, attendance at MTC increased by 26% during same period. CONCLUSION: The number of patients from Mirpur area in Dhaka Hospital reduced but increased at MTC explaining the need for establishment of a set up for early treatment and control of diarrheal disease when consistent increase in annual number of cases or at the time of upsurge of cases is observed.

Long-term impact of changing childhood malnutrition on rotavirus diarrhoea: Two decades of adjusted association with climate and socio-demographic factors from urban Bangladesh.

BACKGROUND: There is strong association between childhood rotavirus, diarrhoea, climate factors and malnutrition. Conversely, a significant nutritional transition (reduced under-nutrition) with a concurrent increasing trend of rotavirus infection in last decade was also observed among under 5 children, especially in developing countries including Bangladesh. Considering the pathophysiology of rotavirus, there might be an interaction of this nutrition transition which plays a pivotal role in increasing rotavirus infection in addition to climate and other man-made factors in urban areas such as Dhaka, Bangladesh. METHODS: Relevant monthly data from 1993-2012 were extracted from the archive of the Diarrhoeal Disease Surveillance System of icddr, b and linked with data collected from the Dhaka station of the Bangladesh Meteorological Department (mean temperature, rainfall, sea level pressure and humidity). Seasonal autoregressive integrated moving average time series models were deployed to determine the association between the monthly proportion of rotavirus infection and underweight, stunting and wasting adjusting for climate, socio-demographic and sanitation factors. FINDING: The proportion of rotavirus cases among all causes diarrhoea increased from 20% in 1993 to 43% in 2012 (Chi squared for trend p = 0.010). In contrast, underweight, stunting and wasting decreased from 59%-29% (p<0.001); 53%-21% (p<0.001) and 32%-22% (p<0.001) respectively over the same period. Mean ambient temperature increased from 25.76°C-26.62°C (p = 0.07); mean rainfall, sea level pressure and mean humidity decreased from 234.92-111.75 mm (p = 0.5), 1008.30-1006.61 mm of hg (p = 0.02) and 76.63%-70.26% (p<0.001), respectively. In the adjusted model, a decrease in monthly proportion of underweight [coef.: -0.189 (95% CI:-0.376, -0.003)] and wasting [-0.265 (-0.455, -0.075)] were significantly and inversely associated with rotavirus infection. However, an inverse but insignificant association was observed for stunting [-0.070 (-0.249, 0.109)]. INTERPRETATION: The reduction of acute childhood malnutrition is significantly associated with increasing rotavirus diarrhoea among under-5 children. Thus mass vaccination in addition to interventions directed at man-made modifiable predictors for prevention and control is warranted.

Factors Associated With Pneumonia Among Overweight and Obese Under-Five Children in an Urban Hospital of a Developing Country.

To our knowledge, there are no data on the role of overweight and obesity in childhood pneumonia. We sought to determine that impact of overweight and obesity in such children. In this retrospective chart analysis, we enrolled hospitalized children aged 6 to 59 months in the Dhaka Hospital of the icddr,b, Bangladesh (International Centre for Diarrhoeal Disease Research, Bangladesh), from January 2010 to June 2014. Children with pneumonia having overweight and obesity (body mass index Z score [BMIZ] >2.00) constituted cases (n = 25), and those who had pneumonia without overweight and obesity (BMIZ -2.00 to 2.00) constituted controls (n = 75). Controls were 3-fold of the cases and were randomly selected. Demographic, clinical, and laboratory data of the cases and the controls were compared. The cases more often had diarrhea and dehydration (36% vs 12%, P = .013), hypoxemia (SpO2 < 90% in room air; 28% vs 7%, P = .009) on admission, and required to change antibiotics (32% vs 11%, P = .023) during hospitalization compared to the controls. However, in logistic regression analysis the cases were independently associated with diarrhea (P < .001) and hypoxemia (P = .024) on admission. Our data suggest that overweight and obesity in children with pneumonia is prone to be associated with hypoxemia on admission, which may guide clinicians in promptly managing pneumonia in order to evade its ramification in such children. However, future research with larger samples is imperative to consolidate or refute our observation.

Nutritional status of children <5 years of age who have a working mother: an epidemiological perspective of diarrhoeal children in urban Bangladesh.

OBJECTIVE: The present analysis aimed to observe nutritional impacts among children <5 years of age by mother's engagement in paid employment. DESIGN: Between 1996 and 2012, 21 443 children <5 years of age with diarrhoea attended the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka Hospital. They were enrolled in the hospital-based Diarrhoeal Disease Surveillance System and their relevant information was extracted from the electronic database. SETTING: The icddr,b, Bangladesh. SUBJECTS: The analytic sample was 19 597 children aged <5 years who had a mother aged ≤35 years with or without engagement in paid employment. RESULTS: Eleven per cent of the mothers (n 2051) were currently engaged in paid employment on behalf of the family. Univariate analysis showed that children with mothers engaged in paid employment had a 1·14 times higher risk of being undernourished, a 1·20 times of higher risk of being stunted, a 1·21 times higher risk of being wasted and a 1·31 times higher risk of being underweight (risk ratios) than were children with mothers not likewise engaged. Multivariate analysis showed that such associations remained significant for stunting (1·08; 95 % CI 1·00, 1·16), wasting (1·15; 95 % CI 1·06, 1·25) and underweight (1·09; 95 % CI 1·02, 1·17) after controlling for covariates. CONCLUSIONS: Mothers' engagement in income-generating employment was associated with undernutrition in children <5 years of age in urban Bangladesh.

Diarrhoea and smoking: an analysis of decades of observational data from Bangladesh.

BACKGROUND: Although cigarette smoking affects all biological systems of the human body including the gastrointestinal tract, there is a lack of evidence regarding its effect on the severity of diarrhoeal disease and whether a dose-response relationship exists. We therefore tested for the presence of specific causative pathogens for infectious diarrhoea, assessed the independent effect of smoking on its severity and tested whether any dose-response relationship existed while controlling for subjects' age, sociodemographic characteristics and presence of causative pathogens in an urban setting in Bangladesh. METHODS: A total of 20,757 patients aged 15 years and above with diarrhoea were enrolled into the Diarrhoeal Disease Surveillance System, managed by the International Centre for Diarrhoeal Disease Research, Bangladesh, from 1993 to 2012. We collected data on individuals' current daily consumption of cigarettes and bidis (traditional hand-rolled cigarettes) and conducted an ordered logistic regression to determine the effect of smoking on diarrhoeal disease severity and whether a dose-response relationship exists. RESULTS: We identified 19 % of patients with diarrhoea as smokers, of whom 52 % smoked 1-9 cigarettes per day. While 97 % of smokers were male, 41 % were aged 15-30 years of age. Smokers were found to have a significantly lower severity of diarrhoeal disease (OR: 0.92, 95 % CI: 0.85-0.99, p = 0.025) after adjusting for age, wealth quintile, illiteracy and the presence of specific causative pathogens (Vibrio cholerae and Shigella). We observed no dose-response relationship between the number of cigarettes smoked per day and disease severity when adjusting for the same covariates. Smokers were more frequently infected with Shigella (7 vs. 6 %, p < 0.001) and less often with Vibrio cholerae (22 vs. 26 %, p < 0.001) than their non-smoking counterparts. CONCLUSIONS: The aetiology and severity of diarrhoeal disease differed between smokers and non-smokers in our sample. However, we found no dose-response relationship between disease severity and the number of cigarettes smoked per day.

Changing childhood malnutrition in Bangladesh: trends over the last two decades in urban-rural differentials (1993-2012).

OBJECTIVE: The present study determined trends in malnutrition among under-5 children in urban and rural areas of Bangladesh. DESIGN: Surveillance. SETTING: The study was conducted in the urban Dhaka and the rural Matlab hospitals of the International Centre for Diarrhoeal Disease Research, Bangladesh, where every fiftieth patient and all patients coming from the Health and Demographic Surveillance System were enrolled. SUBJECTS: A total of 28,816 under-5 children were enrolled at Dhaka from 1993 to 2012 and 11,533 at Matlab between 2000 and 2012. RESULTS: In Dhaka, 46% of the children were underweight, 39% were stunted and 28% were wasted. In Matlab, the corresponding figures were 39%, 31% and 26%, respectively. At Dhaka, 0.5% of the children were overweight and obese when assessed by weight-for-age Z-score >+2.00, 1.4% by BMI-for-age Z-score >+2.00 and 1.4% by weight-for-height Z-score >+2.00; in Matlab the corresponding figures were 0.5%, 1.4% and 1.4%, respectively. In Dhaka, the proportion of underweight, stunting and wasting decreased from 59% to 28% (a 53% reduction), from 54% to 22% (59% reduction) and from 33 % to 21% (36% reduction), respectively, between 1993 and 2012. In Matlab, these indicators decreased from 51% to 27% (a 47% reduction), from 36% to 25% (31% reduction) and from 34% to 14% (59% reduction), respectively, from 2000 to 2012. On the other hand, the proportion of overweight (as assessed by BMI-for-age Z-score) increased significantly over the study period in both Dhaka (from 0.6% to 2.6%) and Matlab (from 0.8% to 2.2%). CONCLUSIONS: The proportion of malnourished under-5 children has decreased gradually in both urban and rural Bangladesh; however, the reduction rates are not in line with meeting Millennium Development Goal 1. Trends for increasing childhood obesity have been noted during the study period as well.

Changing characteristics of rotavirus diarrhea in children younger than five years in urban Bangladesh.

BACKGROUND: Childhood rotavirus diarrhea is still one of the major public health challenges. The present study aimed to determine changing characteristics of rotavirus diarrhea in under-5 children at two periods of time. METHODS: We enrolled 5,357 under-5 children with rotavirus positive in two different time periods; i) 1993-1997 (n = 2,493), and ii) 2008-2012 (n = 2,864) considering beginning and ending of two decades. These children were enrolled in the urban Dhaka Hospital of icddr,b. RESULTS: Overall, proportion of rotavirus was about 25% in 1993-97, which was 42% in 2008-12 (68% rise; p<0.001). Significant higher proportion of children were stunted [38% vs. 22%; aOR-1.33 (95% CI-1.09-1.62)], had vomiting [87% vs. 74%; aOR-2.58 (95% CI-2.02-3.28)], fever [10% vs. 8%; aOR-1.31 (95% CI-0.96-1.78)], family members >5 [38% vs. 35%; aOR-1.32 (95% CI-1.10-1.58)] required more intravenous fluid [9% vs. 3%; aOR-4.93 (95% CI-3.19-7.63)], had higher co-infection with Shigella [3% vs. 1%; aOR-3.36 (95% CI-1.61-7.03)], Vibrio cholerae [4% vs. 1%; aOR-3.70 (95% CI-2.12-6.46)]; and ETEC [13% vs. 7%; aOR-2.21 (95% CI-1.65-2.97)]; however, significantly lower proportion of them used sanitary toilets [54% vs. 78%; aOR-0.66 (95% CI-0.54-0.80)], boiled drinking water [16% vs. 38%; aOR-0.60 (95% CI-0.48-0.74)], used antimicrobial at home [63% vs. 82%; aOR-0.56 (95% CI-0.46-0.69)] and had some or severe dehydration [18% vs. 34%; aOR-0.15 (95% CI-0.12-0.20)] in 1st observation period compared to that of 2nd. CONCLUSION: Proportion of episodes of under-5 rotavirus diarrhea increased over the period. Concomitant changes in host, socio-demographic and clinical characteristics, and co-infections were also observed. Thus, vaccination campaign which is prevailing in private sector should also be introduced in public sector.

Gastroenteritis due to typhoidal Salmonella: a decade of observation at an urban and a rural diarrheal disease hospital in Bangladesh.

BACKGROUND: The study aimed to compare the socio-demographic, host and clinical characteristics, seasonality and antimicrobial susceptibility of Typhoidal Salmonella (Salmonella enterica serovar Typhi and Paratyphi) (TS) with diarrhea between urban and rural Bangladesh. METHODS: Relevant information of 77/25,767 (0.30%) and 290/17,622 (1.65%) patients positive with TS (in stool) were extracted from the data archive of Diarrheal Disease Surveillance System of icddr,b (urban Dhaka and rural Matlab Hospitals respectively) during 2000-2012. Comparison group (diarrhea patients negative for TS) was randomly selected from the database (1:3 ratio). Two poisson regression models were investigated for modelling seasonal effects on the number of cases. RESULTS: Salmonella Typhi was more frequently isolated in Dhaka than Matlab (57% vs. 5%, p < 0.001); while Salmonella Paratyphi was more frequent in Matlab than Dhaka (96% vs. 43%; p < 0.001). Fever [adj. OR-5.86 (95% CI: 2.16, 15.94)], antimicrobial use at home [5.08 (2.60, 9.90)], and fecal red blood cells [2.53 (1.38, 4.64)] were significantly associated with detection of TS in stool of patient from Dhaka. For Matlab, the correlates were, vomiting [1.88 (1.35, 2.64)], fecal macrophage [1.89 (1.29, 2.74)] in addition to fever and duration of diarrhea and antimicrobial use. At Dhaka, all Salmonella Typhi isolates were susceptible to ceftriaxone; while in Dhaka and Matlab however, for ciprofloxacin it was 45% and 91%, respectively. Susceptibility to chloramphenicol, ampicillin, trimethoprim-sulphamethoxazole and nalidixic acid ranged from 12%-58%. Salmonella Paratyphi were susceptible to ceftriaxone (99%). A significant seasonal trend and year difference (before and after 2007) for Matlab was observed (p < 0.001 for all effects). Dhaka does not show significant year or seasonal effects (p = 0.07 for years and p = 0.81 and p = 0.18 for the cos and sin components, respectively). While not significant, two seasonal peaks were observed in Dhaka (January-February and September-November); while a single peak (August-November) was observed in Matlab. CONCLUSIONS: Proportion of serovar distribution of TS and their clinical characteristics, antimicrobial susceptibility and seasonal pattern were different among diarrhea patients in urban Dhaka and rural Matlab of Bangladesh.

Diarrhoea in slum children: observation from a large diarrhoeal disease hospital in Dhaka, Bangladesh.

OBJECTIVES: To determine and compare socio-demographic, nutritional and clinical characteristics of children under five with diarrhoea living in slums with those of children who do not live in slums of Dhaka, Bangladesh. METHODS: From 1993 to 2012, a total of 28 948 under fives children with diarrhoea attended the Dhaka Hospital of icddr,b. Data were extracted from the hospital-based Diarrhoea Disease Surveillance System, which comprised 17 548 under fives children from slum and non-slum areas of the city. RESULTS: Maternal illiteracy [aOR = 1.57; 95% confidence interval (1.36, 1.81), P-value <0.001], paternal illiteracy [1.37 (1.21, 1.56) <0.001], mother's employment [1.59 (1.37, 1.85) <0.001], consumption of untreated water [2.73 (2.26, 3.30) <0.001], use of non-sanitary toilets [3.48 (3.09, 3.93) <0.001], 1st wealth quintile background [3.32 (2.88, 3.84) <0.001], presence of fever [1.14 (1.00, 1.29) 0.047], some or severe dehydration [1.21 (1.06, 1.40) 0.007], stunting [1.14 (1.01, 1.29) 0.030] and infection with Vibrio cholerae [1.21 (1.01, 1.45) 0.039] were significantly associated with slum-dwelling children after controlling for co-variates. Measles immunisation [0.52 (0.47, 0.59) P < 0.001] and vitamin A supplementation rates [0.36 (0.31, 0.41) P < 0.001] amongst children 12-59 months were lower for slum dwellers than other children in univarate analysis only. CONCLUSIONS: Slum-dwelling children are more malnourished, have lower immunisation rates (measles vaccination and vitamin A supplementation) and higher rates of measles, are more susceptible to diarrhoeal illness due to V. cholerae and suffer from severe dehydration more often than children from non-slum areas. Improved health and nutrition strategies should give priority to children living in urban slums.

Mothers' perception and healthcare seeking behavior of pneumonia children in rural bangladesh.

We describe mothers' perception about signs and symptoms, causes of the illness, and healthcare seeking behaviors related to pneumonia and express the major modifiable barriers to seeking timely treatment when their under-5 children had pneumonia in rural Bangladesh. Using focus group discussion, we understood mothers' perception and healthcare seeking behavior of childhood pneumonia. Although mothers described pneumonia as a serious life threatening disease in young children but most of the mothers (n = 24) could not diagnose whether their child had pneumonia or not. Environmental factors such as dust particles, spread from coughing mother, and drinking cold water or playing with water were perceived as the causes for pneumonia. Three common barriers noted were as follows: illness was not perceived as serious enough or distance from healthcare facility or lack of money at household for seeking treatment outside. Most of the rural mothers did not have knowledge about severity of childhood pneumonia.

Characteristics of Multidrug Resistant Shigella and Vibrio cholerae O1 Infections in Patients Treated at an Urban and a Rural Hospital in Bangladesh.

We determined the frequency of multidrug resistant (MDR) infections with Shigella spp. and Vibrio cholerae O1 at an urban (Dhaka) and rural (Matlab) hospital in Bangladesh. We also compared sociodemographic and clinical features of patients with MDR infections to those with antibiotic-susceptible infections at both sites. Analyses were conducted using surveillance data from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the years 2000-2012. Compared to patients with antibiotic-susceptible for Shigella infections, those in Dhaka with MDR shigellosis were more likely to experience diarrhea for >24 hours, while, in Matlab, they were more likely to stay inhospital >24 hours. For MDR shigellosis, Dhaka patients were more likely than those in Matlab to have dehydration, stool frequency >10/day, and diarrheal duration >24 hours. Patients with MDR Vibrio cholerae O1 infections in Dhaka were more likely than those in Matlab to experience dehydration and stool frequency >10/day. Thus, patients with MDR shigellosis and Vibrio cholerae O1 infection exhibited features suggesting more severe illness than those with antibiotic-susceptible infections. Moreover, Dhaka patients with MDR shigellosis and Vibrio cholerae O1 infections exhibited features indicating more severe illness than patients in Matlab.