Perinatal colonization with extended-spectrum beta-lactamase-producing and carbapenem-resistant Gram-negative bacteria: a hospital-based cohort study.

BACKGROUND: Antimicrobial resistance (AMR) is a growing global health threat that contributes to substantial neonatal mortality. Bangladesh has reported some of the highest rates of AMR among bacteria causing neonatal sepsis. As AMR colonization among newborns can predispose to infection with these bacteria, we aimed to characterize the frequency of and risk factors for colonization of mothers and newborns during hospitalization for delivery. METHODS: We enrolled pregnant women presenting for delivery to a tertiary care hospital in Faridpur, Bangladesh. We collected vaginal and rectal swabs from mothers pre- and post-delivery, rectal swabs from newborns, and swabs from the hospital environment. Swabs were plated on agars selective for extended-spectrum-beta-lactamase producing bacteria (ESBL-PB) and carbapenem-resistant bacteria (CRB). We performed logistic regression to determine factors associated with ESBL-PB/CRB colonization. RESULTS: We enrolled 177 women and their newborns during February-October 2020. Prior to delivery, 77% of mothers were colonized with ESBL-PB and 15% with CRB. 79% of women underwent cesarean deliveries (C-section). 98% of women received antibiotics. Following delivery, 98% of mothers and 89% of newborns were colonized with ESBL-PB and 89% of mothers and 72% of newborns with CRB. Of 290 environmental samples, 77% were positive for ESBL-PB and 69% for CRB. Maternal pre-delivery colonization was associated with hospitalization during pregnancy (RR for ESBL-PB 1.24, 95% CI 1.10-1.40; CRB 2.46, 95% CI 1.39-4.37). Maternal post-delivery and newborn colonization were associated with C-section (RR for maternal CRB 1.31, 95% CI 1.08-1.59; newborn ESBL-PB 1.34, 95% CI 1.09-1.64; newborn CRB 1.73, 95% CI 1.20-2.47). CONCLUSIONS: In this study, we observed high rates of colonization with ESBL-PB/CRB among mothers and newborns, with pre-delivery colonization linked to prior healthcare exposure. Our results demonstrate this trend may be driven by intense use of antibiotics, frequent C-sections, and a contaminated hospital environment. These findings highlight that greater attention should be given to the use of perinatal antibiotics, improved surgical stewardship for C-sections, and infection prevention practices in healthcare settings to reduce the high prevalence of colonization with AMR organisms.

Multidrug-resistant Escherichia coli isolated from patients and surrounding hospital environments in Bangladesh: A molecular approach for the determination of pathogenicity and resistance.

Extended spectrum ß-lactamase producing Escherichia coli (ESBL E. coli) is a primary concern for hospital and community healthcare settings, often linked to an increased incidence of nosocomial infections. This study investigated the characteristics of ESBL E. coli isolated from hospital environments and clinical samples. In total, 117 ESBL E. coli isolates were obtained. The isolates were subjected to molecular analysis for the presence of resistance and virulence genes, antibiotic susceptibility testing, quantitative adherence assay, ERIC-PCR for phylogenetic analysis and whole genome sequencing of four highly drug resistant isolates. Out of the 117 isolates, 68.4% were positive for blaCTX-M, 39.3% for blaTEM, 30.8% for blaNDM-1, 13.7% for blaOXA and 1.7% for blaSHV gene. Upon screening for diarrheagenic genes, no isolates were found to harbour any of the tested genes. In the case of extraintestinal pathogenic E. coli (ExPEC) virulence factors, 7.6%, 11%, 5.9%, 4.3% and 21.2% of isolates harbored the focG, kpsMII, sfaS, afa and iutA genes, respectively. At a temperature of 25°C, 14.5% of isolates exhibited strong biofilm formation with 21.4% and 28.2% exhibiting moderate and weak biofilm formation respectively, whereas 35.9% were non-biofilm formers. On the other hand at 37°C, 2.6% of isolates showed strong biofilm formation with 3.4% and 31.6% showing moderate and weak biofilm formation respectively, whereas, 62.4% were non-biofilm formers. Regarding antibiotic susceptibility testing, all isolates were found to be multidrug-resistant (MDR), with 30 isolates being highly drug resistant. ERIC-PCR resulted in 12 clusters, with cluster E-10 containing the maximum number of isolates. Hierarchical clustering and correlation analysis revealed associations between environmental and clinical isolates, indicating likely transmission and dissemination from the hospital environment to the patients. The whole genome sequencing of four highly drug resistant ExPEC isolates showed the presence of various antimicrobial resistance genes, virulence factors and mobile genetic elements, with isolates harbouring the plasmid incompatibility group IncF (FII, FIB, FIA). The sequenced isolates were identified as human pathogens with a 93.3% average score. This study suggests that ESBL producing E. coli are prevalent in the healthcare settings of Bangladesh, acting as a potential reservoir for AMR bacteria. This information may have a profound effect on treatment, and improvements in public healthcare policies are a necessity to combat the increased incidences of hospital-acquired infections in the country.

Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: Findings from a health and demographic surveillance system.

Adolescent pregnancies, a risk factor for obstetric complications and perinatal mortality, are driven by child marriage in many regions of South Asia. We used data collected between 2017-2019 from 56,155 married adolescents and women in a health and demographic surveillance system to present a population-level description of historical trends in child marriage from 1990-2019 as well as epidemiologic associations between maternal age and pregnancy outcomes in Baliakandi, a rural sub-district of Bangladesh. For pregnancies identified between 2017-2019, we used Kaplan-Meier estimates to examine timing of first pregnancies after first marriage and multinomial logistic regression to estimate associations between maternal age and perinatal death. We described the frequency of self-reported obstetric complications at labor and delivery by maternal age. In 1990, 71% of all marriages were to female residents under 18 years of age. This decreased to 57% in 2010, with the largest reduction among females aged 10-12 years (22% to 3%), and to 53% in 2019. Half of all newly married females were pregnant within a year of marriage, including adolescent brides. Although we observed a decline in child marriages since 1990, over half of all marriages in 2019 were to child brides in Baliakandi. In this same population, adolescent pregnancies were more likely to result in obstetric complications (13-15 years: 36%, 16-17 years: 32%, 18-34 years: 23%; χ2 test, p<0.001) and perinatal deaths (13-15 years: stillbirth OR 2.23, 95% CI 1.01-2.42; 16-17 years: early neonatal death OR 1.57, 95% CI: 1.01-2.42) compared to adult pregnancies. Preventing child marriage can improve the health of girls and contribute to Bangladesh's commitment to reducing child mortality.

Effectiveness of home-based "egg-suji" diet in management of severe acute malnutrition of Rohingya refugee children.

BACKGROUND: Prevalence of severe acute malnutrition (SAM) among Rohingya children aged 6-59 months who took shelter in refugee camp in Cox's Bazar District, Bangladesh, was found to be 7.5%. OBJECTIVE: To measure the effectiveness of homemade diet in the management of severe acute malnutrition of Rohingya refugee children. METHODS: In total, 645 SAM children (MUAC < 11.5 cm) aged 6-59 months were selected and fed the homemade diet for 3 months by their caregivers and followed up for next 2 months. Nutrition counseling, demonstration of food preparation and the ingredients of food (rice powder, egg, sugar and oil) were provided to the families for 3 months to cook "egg-suji" diet to feed the children. RESULTS: The study children were assessed for nutritional status. After intervention, energy intake from diet increased from 455.29 ± 120.9 kcal/day to 609.61 ± 29.5 kcal/day (P = 0.001) in 3 months. Frequency of daily food intake improved from 4.89 ± 1.02 to 5.94 ± 0.26 (P = 0.001). The body weight of children increased from 6.3 ± 1.04 kg to 9.93 ± 1.35 kg (P = 0.001), height increased from 67.93 ± 6.18 cm to 73.86 ± 0.35 (P = 0.001) cm, and MUAC improved from 11.14 ± 1.35 cm to 12.89 ± 0.37 cm (P = 0.001). HAZ improved from - 3.64 ± 1.35 to - 2.82 ± 1.40 (P = 0.001), WHZ improved from - 2.45 ± 1.23 to 1.03 ± 1.17 (P = 0.001), WAZ improved from - 3.8 ± 0.61 to - 0.69 ± 0.78, and MUACZ improved from - 3.32 ± 0.49 to 1.8 ± 0.54 (P = 0.001) from the beginning to the end of observation. Morbidity was found in 5.12% children in the first month which reduced to 0.15% at the end of follow-up. CONCLUSIONS: Nutritional counseling and supply of food ingredients at refugee camps resulted in complete recovery from severe malnutrition for all children which was sustainable.

Antibiotic usage practices and its drivers in commercial chicken production in Bangladesh.

Irrational and inappropriate use of antibiotics in commercial chicken production can contribute to the development of antimicrobial resistance. We aimed to assess antibiotic usage in commercial chicken production in Bangladesh, and identify factors associated with this practice. We conducted a large-scale cross-sectional study to collect information on antibiotic usage in commercial chickens from January to May 2021. Structured interviews were conducted with 288 broiler, 288 layer and 192 Sonali (locally-produced cross-bred) farmers in 20 sub-districts across Bangladesh. The frequency of antibiotic usage, the types of antibiotics and purpose of usage were estimated for each production type. Adjusted odds ratios (aOR) were calculated to measure the association between antibiotic usage and factors related to the characteristics of the farms and farmers using multivariable logistic regression models. The proportion of farms, irrespective of their production type, reporting usage of antibiotics in the 24 hours preceding the interview was 41% (n = 314, 95% CI: 37-44%). Forty-five percent (n = 344, 41-48%) reported antibiotic usage in the last 72 hours, 86% (n = 658, 83-88%) in the last 14 days, and almost all farms, 98% (n = 753, 97-99%), had used antibiotics since the start of their production cycle. Use of antibiotics in the 24 hours preceding an interview was more frequently reported in broiler (OR 1.91, 95% CI: 1.36-2.69) and Sonali (OR 1.94, 95% CI: 1.33-2.33) than layer farms. Oxytetracycline (23-31%, depending on production type), doxycycline (18-25%), ciprofloxacin (16-26%) and amoxicillin (16-44%) were the most frequently used antibiotics. Antibiotics were reported to be used for both treatment and prophylactic purposes on most farms (57-67%). Usage of antibiotics in the 24h preceding an interview was significantly associated with the occurrence of any illnesses in chickens (aOR broiler: 41.22 [95% CI:13.63-124.62], layer: aOR 36.45[9.52-139.43], Sonali: aOR 28.47[4.97-162.97]). Antibiotic usage was mainly advised by veterinary practitioners (45-71%, depending on production type), followed by feed dealers (21-40%) and farmers (7-13%). Improvement of chicken health through good farming practices along with changes in key stakeholders (feed dealers and practitioners) attitudes towards antibiotic recommendations to farmers, may help to reduce the levels of antibiotic usage and thus contribute to mitigate antimicrobial resistance.

Antibiotics usage practices in aquaculture in Bangladesh and their associated factors.

Background: Irrational and inappropriate use of antibiotics in aquaculture can contribute to the development of antibiotic resistance. Objectives: In this study, we aimed to assess antibiotic usage in inland and coastal fish farms in Bangladesh and identify factors associated with this practice. Methods: We conducted a cross-sectional study to collect antibiotic usage information from 672 fish farmers in Bangladesh. The frequency of use, the types of antibiotics, the purpose of usage, and antibiotic prescribing practices were estimated. Adjusted odds ratios (aOR) were calculated to measure the association between antibiotic usage and factors related to the characteristics of the farms and farmers using multivariable logistic regression models. Results: Twenty-two farms reported using antibiotics in the last 24 h preceding the interview (3%, 95% CI: 2-5%); 36 farms (5%, 95% CI: 4-7%) in the last 72 h, 141 farms (21%, 95% CI: 18-24%) in the last 14 days, and 478 farms (71%, 68-75%) reported antibiotic usage at least once since the start of their production cycle. Antibiotics usage in the last 14 days preceding the interviews was higher in freshwater fish farms (98%) than in brackish water farms (2%). Oxytetracycline, ciprofloxacin, and amoxicillin were the most frequently used antibiotics. Most of the antibiotics were reported to be used for both therapeutic and prophylactic purposes (71%, 95% CI: 63-78%). Antibiotics used within the last 14 days were mainly advised by feed dealers or drug sellers (51%, 95% CI: 43-60%), followed by farmers themselves (31%, 95% CI: 23-38%) and local service providers (18%, 95% CI, 12-25%). Fish farms having history of antibiotic use within the last 14 days preceding interviews was significantly associated with illness in fish (aOR 1.98, 95% CI:1.21-3.29) compared to farms with healthy fish and fishes cultured in ponds (aOR 9.34, 95% CI: 3.69-23.62) compared to enclosure cultures. Conclusions: Improvement of fish health through better farming practices and changes in feed dealers' and farmers' attitudes towards self-prescription of antibiotic without veterinarian diagnostics may help to reduce the levels of antibiotic usage and thus contribute to mitigating antimicrobial resistance.

Healthcare Facilities as Potential Reservoirs of Antimicrobial Resistant Klebsiella pneumoniae: An Emerging Concern to Public Health in Bangladesh.

The emergence of virulent extended spectrum ß-lactamase producing Klebsiella pneumoniae (ESBL-KP) including carbapenem-resistant Klebsiella pneumoniae (CRKP) in hospital-acquired infections has resulted in significant morbidity and mortality worldwide. We investigated the antibiotic resistance and virulence factors associated with ESBL-KP and CRKP in tertiary care hospitals in Bangladesh and explored their ability to form biofilm. A total of 67 ESBL-KP were isolated from 285 Klebsiella pneumoniae isolates from environmental and patient samples from January 2019 to April 2019. For ESBL-KP isolates, molecular typing was carried out using enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC-PCR), antibiotic susceptibility testing, PCR for virulence and drug-resistant genes, and biofilm assays were also performed. All 67 isolates were multidrug-resistant (MDR) to different antibiotics at high levels and 42 isolates were also carbapenem-resistant. The most common ß-lactam resistance gene was blaCTX-M-1 (91%), followed by blaTEM (76.1%), blaSHV (68.7%), blaOXA-1 (29.9%), blaGES (14.9%), blaCTX-M-9 (11.9%), and blaCTX-M-2 (4.5%). The carbapenemase genes blaKPC (55.2%), blaIMP (28.4%), blaVIM (14.9%), blaNDM-1 (13.4%), and blaOXA-48 (10.4%) and virulence-associated genes such as fimH (71.6%), ugeF (58.2%), wabG (56.7%), ureA (47.8%) and kfuBC (28.4%) were also detected. About 96.2% of the environmental and 100% of the patient isolates were able to form biofilms. ERIC-PCR-based genotyping and hierarchical clustering of K. pneumoniae isolates revealed an association between environmental and patient samples, indicating clonal association with possible transmission of antimicrobial resistance genes. Our findings can help in improving patient care and infection control, and the development of public health policies related to hospital-acquired infections.

COVID-19 among staff and their family members of a healthcare research institution in Bangladesh between March 2020 and April 2021: a test-negative case-control study.

OBJECTIVE: To identify factors associated with COVID-19 positivity among staff and their family members of icddr,b, a health research institute located in Bangladesh. SETTING: Dhaka, Bangladesh. PARTICIPANTS: A total of 4295 symptomatic people were tested for SARS-CoV-2 by reverse-transcription PCR between 19 March 2020 and 15 April 2021. Multivariable logistic regression was done to identify the factors associated with COVID-19 positivity by contrasting test positives with test negatives. RESULT: Forty-three per cent of the participants were tested positive for SARS-CoV-2. The median age was high in positive cases (37 years vs 34 years). Among the positive cases, 97% were recovered, 2.1% had reinfections, 24 died and 41 were active cases as of 15 April 2021. Multivariable regression analysis showed that age more than 60 years (adjusted OR (aOR)=2.1, 95% CI 1.3 to 3.3; p<0.05), blood group AB (aOR=1.5, 95% CI 1.1 to 2; p<0.05), fever (aOR=3.1, 95% CI 2.6 to 3.7; p<0.05), cough (aOR=1.3, 95% CI 1.1 to 1.6; p<0.05) and anosmia (aOR=2.7, 95% CI 1.3 to 5.7; p<0.05) were significantly associated with higher odds of being COVID-19 positive when compared with participants who were tested negative. CONCLUSIONS: The study findings suggest that older age, fever, cough and anosmia were associated with COVID-19 among the study participants.

Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh.

For supporting antibiotic stewardship interventions, the World Health Organization (WHO) classified antibiotics through the AWaRe (Access, Watch, and Reserve) classification. Inappropriate use of antimicrobials among hospital-admitted patients exposes them to the vulnerability of developing resistant organisms which are difficult to treat. We aimed to describe the proportion of antibiotic use based on the WHO AWaRe classification in tertiary and secondary level hospitals in Bangladesh. A point prevalence survey (PPS) was conducted adapting the WHO PPS design in inpatients departments in 2021. Among the 1417 enrolled patients, 52% were female and 63% were from the 15-64 years age group. Nearly 78% of patients received at least one antibiotic during the survey period. Third-generation cephalosporins (44.6%), penicillins (12.3%), imidazoles (11.8%), aminoglycosides (7.2%), and macrolides (5.8%) were documented as highly used antibiotics. Overall, 64.0% of Watch, 35.6% of Access, and 0.1% of Reserve group antibiotics were used for treatment. The use of Watch group antibiotics was high in medicine wards (78.7%) and overall high use of Watch antibiotics was observed at secondary hospitals (71.5%) compared to tertiary hospitals (60.2%) (p-value of 0.000). Our PPS findings underscore the need for an urgent nationwide antibiotic stewardship program for physicians including the development and implementation of local guidelines and in-service training on antibiotic use.

High Prevalence of Cervical High-Grade Lesions and High-Risk Human Papillomavirus Infections in Women Living with HIV: A Case for Prioritizing Cervical Screening in This Vulnerable Group.

INTRODUCTION: Women living with HIV (WLHIV) are at an increased risk of developing cervical precancerous lesions and cervical human papillomavirus (HPV) infection. This study aimed at evaluating the prevalence of cervical lesions and high-risk HPV (HR-HPV) infection in WLHIV in comparison to the HIV-negative women undergoing opportunistic screening. In addition, these findings among WLHIV were correlated with the clinic-demographic factors. METHODS: A cross-sectional study was conducted among WLHIVs at a tertiary hospital and linked antiretroviral therapy (ART) center, while HIV-negative women were recruited from the health promotion clinic at our institute. With informed consent, a semi-structured questionnaire was filled on demographic and epidemiological parameters. Conventional cervical smears and samples for HPV DNA detection by HC2 high-risk HPV DNA test were collected in all participants. Cervical smears were reported using the Bethesda system 2014. Appropriate statistical analysis was performed for bivariate and multivariate logistic regression analysis for comparison between WLHIV and HIV-negative women and for correlation of abnormal cervical cytology and HR-HPV infection among WLHIVs. RESULTS: The clinic-demographic characteristics of WLHIVs and HIV-negative women were similar. On cytology, the prevalence of cervical cytological abnormalities were significantly higher (p < 0.001) among WLHIVs (14.1%) compared to HIV-negative women (3.1%). High-grade lesions were seen in 3.7% of WLHIVs, while no high-grade lesions were detected in HIV-negative women. Cervical HR-HPV infection was also significantly higher (p < 0.001) in WLHIVs (28.9%) than HIV-negative women (9.3%). Cervical precancerous lesions in WLHIVs showed positive association with current sexually transmitted infection (STI), multiple sexual partners, tobacco use, and CD4 count less than 200/µL, while cervical HPV was positively associated with current STI, tobacco use, CD4 count less than 200/µL and negatively with ART intake. On multivariate logistic regression, cervical cytological abnormalities showed a significant association with multiple sexual partners (p < 0.001), while cervical HR-HPV infection was positively associated with current STI (p = 0.01), nadir CD4 count <200/µL (p = 0.004), abnormal cervical cytology (p = 0.002) and negatively with ART intake (p = 0.03). CONCLUSION: Women living with HIV have a significantly higher prevalence of cervical precancerous lesions and HR-HPV infection compared to the general population. Considering the lack of an organized population-based cervical cancer screening program in many low-resource countries like ours, specific focus on screening this highly vulnerable population to reduce the morbidity and mortality due to cervical cancer is imperative.

Pattern of Antibiotic Dispensing at Pharmacies According to the WHO Access, Watch, Reserve (AWaRe) Classification in Bangladesh.

The WHO Essential Medicines List Access, Watch, and Reserve (AWaRe) classification could facilitate antibiotic stewardship and optimal use. In Bangladesh, data on antibiotic dispensing in pharmacies according to the AWaRe classification are scarce. We aimed to explore antibiotic dispensing pattern in pharmacies according to the WHO AWaRe classification to aid pharmacy-targeted national antibiotic stewardship program (ASP). From January to July 2021, we interviewed drug-sellers from randomly selected pharmacies and randomly selected customers attending the pharmacies. We collected data on demographics and medicines purchased. We classified the purchased antibiotics into the Access, Watch, and Reserve groups among 128 pharmacies surveyed, 98 (76.6%) were licensed; 61 (47.7%) drug-sellers had pharmacy training. Of 2686 customers interviewed; 580 (21.6%) purchased antibiotics. Among the 580 customers, 523 purchased one, 52 purchased two, and 5 purchased three courses of antibiotics (total 642 courses). Of the antibiotic courses, the Watch group accounted for the majority (344, 53.6%), followed by the Access (234, 36.4%) and Reserve (64, 10.0%) groups. Approximately half of the antibiotics (327/642, 50.9%) were purchased without a registered physician's prescription. Dispensing of non-prescribed antibiotics was higher in the Access group (139/234, 59.4%), followed by Watch (160/344, 46.5%) and Reserve (28/64, 43.8%) groups. These findings highlight the need to implement strict policies and enforce existing laws, and pharmacy-targeted ASP focusing on proper dispensing practices to mitigate antimicrobial resistance in Bangladesh.

Antibiotic Usage and Resistance in Food Animal Production: What Have We Learned from Bangladesh?

Irrational and inappropriate use of antibiotics in commercial chicken and aquaculture industries can accelerate the antibiotic resistance process in humans and animals. In Bangladesh, the growing commercial chicken and aquaculture industries are playing significantly important roles in the food value chain. It is necessary to know the antibiotic usage practices and antibiotic resistance in food animal production to design rational policies, guidelines, and interventions. We conducted a narrative review to understand the level of antibiotic usage and resistance in food animal production in Bangladesh. Information about antibiotic usage in different food animal production systems, including commercial chickens and aquaculture in Bangladesh is inadequate. Only a few small-scale studies reported that the majority (up to 100%) of the broiler and layer chicken farms used antibiotics for treating and preventing diseases. However, numerous studies reported antibiotic-resistant bacteria of public health importance in commercial chicken, fish, livestock, and animal origin food. The isolates from different pathogenic bacteria were found resistant against multiple antibiotics, including quinolones, the third or fourth generation of cephalosporins, and polymyxins. Veterinary practitioners empirically treat animals with antibiotics based on presumptive diagnosis due to inadequate microbial diagnostic facilities in Bangladesh. Intensive training is helpful to raise awareness among farmers, feed dealers, and drug sellers on good farming practices, standard biosecurity practices, personal hygiene, and the prudent use of antibiotics. Urgently, the Government of Bangladesh should develop and implement necessary guidelines to mitigate irrational use of antibiotics in food animals using a multi-sectoral One Health approach.

Antibiotics Use and Its Knowledge in the Community: A Mobile Phone Survey during the COVID-19 Pandemic in Bangladesh.

The general population has been excessively using antibiotics during the COVID-19 pandemic. Therefore, the use of antibiotics for any reported illnesses in the preceding four weeks and knowledge of antibiotics among the general population in the community were assessed for possible interventions. A mobile phone survey among a general population across eight administrative divisions of Bangladesh was conducted during January-March 2021. Reported illness episodes irrespective of COVID-19 in the preceding four weeks of the interview, use of antibiotics for the illnesses, and knowledge on antibiotics among the general population were recorded. Descriptive analyses were performed. We randomly interviewed 1854 participants, with a mean age of 28.5 years (range: 18-75 years); 60.6% were male. Among all participants, 86.3% (95% CI: 84.7-87.8) heard names of antibiotics, but only 12.1% reported unspecified harmful effects, and 3.5% reported antimicrobial resistance when antibiotics were taken without a physician's prescription. Among 257 (13.9%) participants, who consumed medicines for their recent illness episode, 32.7% (95% CI: 27.2-38.6) reported using antibiotics. Of those who could recall the names of antibiotics prescribed (n = 36), the most frequently used was azithromycin (22.2%) followed by cefixime (11.1%) and ciprofloxacin (5.6%). Our findings show an increased antibiotic use for illnesses reported in the preceding four weeks and an elevated knowledge at the community level during the COVID-19 pandemic compared with the pre-pandemic period.

Grant Report on mCARE: Mobile-Based Care for Children with Autism Spectrum Disorder (ASD) for Low- and Middle-Income Countries (LMICs).

In low- and middle-income countries, especially in Bangladesh, Autism Spectrum Disorder (ASD) may be considered an anathema, and social-cultural-financial constraints mean that there are few facilities available for treatment for ASD children. The revolution in the use of the mobile phone (~80%) by the majority of people in Bangladesh in recent years has created an opportunity to improve the overall scenario in the treatment or remote monitoring process for children with ASD. In this grant project, we planned and developed a mobile phone-based system to remotely monitor children with ASD and help their treatment process both at the caregiver and care practitioner ends. In developing mCARE, we utilized a Remote Experience Sampling Method to design, build, deploy, and study the impact of mobile based monitoring and treatment of children with ASD in Bangladesh. We developed a mobile application using the Experience Sampling Method (ESM). A caregiver routinely reported the behavioral and milestone parameters of their children with ASD. The care practitioners monitored the longitudinal data that helped them in decision-making in a particular patient's treatment process. The Value Sensitive Design (VSD) was used to make this mobile application more user friendly with consideration of the local economic, social, and cultural values in Bangladesh.

A Case Series Describing the Recurrence of COVID-19 in Patients Who Recovered from Initial Illness in Bangladesh.

To date, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has infected over 80 million people globally. We report a case series of five clinically and laboratory confirmed COVID-19 patients from Bangladesh who suffered a second episode of COVID-19 illness after 70 symptom-free days. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), is a leading public health research institution in South Asia. icddr, b staff were actively tested, treated and followed-up for COVID-19 by an experienced team of clinicians, epidemiologists, and virologists. From 21 March to 30 September 2020, 1370 icddr,b employees working at either the Dhaka (urban) or Matlab (rural) clinical sites were tested for COVID-19. In total, 522 (38%) were positive; 38% from urban Dhaka (483/1261) and 36% from the rural clinical site Matlab (39/109). Five patients (60% male with a mean age of 41 years) had real-time reverse transcription-polymerase chain reaction (rRT-PCR) diagnosed recurrence (reinfection) of SARS-CoV-2. All had mild symptoms except for one who was hospitalized. Though all cases reported fair risk perceptions towards COVID-19, all had potential exposure sources for reinfection. After a second course of treatment and home isolation, all patients fully recovered. Our findings suggest the need for COVID-19 vaccination and continuing other preventive measures to further mitigate the pandemic. An optimal post-recovery follow-up strategy to allow the safe return of COVID-19 patients to the workforce may be considered.

A comparison of MITS counseling and informed consent processes in Pakistan, India, Bangladesh, Kenya, and Ethiopia.

Globally, more than 5 million stillbirths and neonatal deaths occur annually. For many, the cause of death (CoD) is unknown. Minimally invasive tissue sampling (MITS) has been increasingly used in postmortem examinations for ascertaining the CoD in stillbirths and neonates. Our study compared the counseling and consent methods used in MITS projects in five countries in Africa and south Asia. Key informant interviews were conducted with researchers to describe the characteristics and backgrounds of counselors, the environment and timing of consent and perceived facilitators and barriers encountered during the consent process. Counselors at all sites had backgrounds in social science, psychology and counseling or clinical expertise in obstetrics/gynecology or pediatrics. All counsellors received training about techniques for building rapport and offering emotional support to families; training duration and methods differed across sites. Counselling environments varied significantly; some sites allocated a separate room, others counselled families at the bedside or nursing stations. All counsellors had a central role in explaining the MITS procedure to families in their local languages. Most sites did not use visual aids during the process, relying solely on verbal descriptions. In most sites, parents were approached within one hour of death. The time needed for decision making by families varied from a few minutes to 24 h. In most sites, extended family took part in the decision making. Because many parents wanted burial as soon as possible, counsellors ensured that MITS would be conducted promptly after receiving consent. Barriers to consent included decreased comprehension of information due to the emotional and psychological impact of grief. Moreover, having more family members engaged in decision-making increased the complexity of counselling and achieving consensus to consent for the procedure. While each site adapted their approach to fit the context, consistencies and similarities across sites were observed.

Effectiveness of a Behavior Change Intervention with Hand Sanitizer Use and Respiratory Hygiene in Reducing Laboratory-Confirmed Influenza among Schoolchildren in Bangladesh: A Cluster Randomized Controlled Trial.

Schoolchildren are commonly linked to influenza transmission. Handwashing with soap has been shown to decrease infections; however, improving handwashing practices using soap and water is difficult in low-resource settings. In these settings, alternative hygiene options, such as hand sanitizer, could improve handwashing promotion to reduce influenza virus infections. We conducted a cluster randomized control trial in 24 primary schools in Dhaka to assess the effectiveness of hand sanitizer and a respiratory hygiene education intervention in reducing influenza-like illness (ILI) and laboratory-confirmed influenza during June-September 2015. Twelve schools were randomly selected to receive hand sanitizer and respiratory hygiene education, and 12 schools received no intervention. Field staff actively followed children daily to monitor for new ILI episodes (cough with fever) through school visits and by phone if a child was absent. When an illness episode was identified, medical technologists collected nasal swabs to test for influenza viruses. During the 10-week follow-up period, the incidence of ILI per 1,000 student-weeks was 22 in the intervention group versus 27 in the control group (P-value = 0.4). The incidence of laboratory-confirmed influenza was 53% lower in the intervention schools (3/1,000 person-weeks) than in the control schools (6/1,000 person-weeks) (P-value = 0.01). Hand sanitizer and respiratory hygiene education can help to reduce the risk of influenza virus transmission in schools.

IL-33 mediated amplification of allergic response in human mast cells.

Context: IL-33 is a pro-inflammatory cytokine that is involved in the development of chronic inflammatory diseases and the initiation of allergic inflammation in response to pathogens and acts an alarmin.Objective: Present study aims to explore the IL-33 mediated effects of histamine induced allergic inflammation in human mast cells.Materials and methods: In this study, cord blood derived CD34+ mast cells and HMC-1 cells were primed with IL-33 followed by the stimulation with histamine. We investigated the functional activation of mast cell by intracellular calcium release using calcium mobilization assay, release of granular content using degranulation assay, profiling of various inflammatory and regulatory cytokines as well as chemokines by Luminex Bioplex assay and its signaling mechanisms involved using western blot analysis.Results: In our study, we found that the IL-33 acts as a mediator in the allergic inflammation induced by the histamine. IL-33 potentiates the release of intracellular calcium and degranulation content in human mast cells. Also, it enhances the production of Th2, Th1 cytokines and chemokines and down-regulates the production of regulatory cytokine. Furthermore, it enhanced the phosphorylation of the signaling molecules such as ERK, Akt, and NFκB in activated mast cells. Therefore, IL-33 acts as a potent activator of mast cells and it can elicit inflammatory response synergistically with histamine.Conclusions: Taken together, IL-33 acts as a potent mediator by inducing the inflammatory response in activated mast cells, hence increasing their responsiveness to antigens and amplifying the allergic response.

Barriers to and motivators of handwashing behavior among mothers of neonates in rural Bangladesh.

BACKGROUND: To design a maternal handwashing intervention for the newborn period, this qualitative study explored drivers of handwashing among mothers and other caregivers of neonates and infants in two rural areas of Bangladesh. METHODS: We conducted 40 semi-structured observation sessions to observe handwashing behaviors of primiparous and multiparous mothers of neonates, and to understand the contextual factors that facilitated or hampered those behaviors. We then conducted 64 interviews with mothers of neonates and mothers of infants and 6 group discussions with mothers of infants, other female caregivers and fathers to explore perceptions, beliefs, and practices related to handwashing in the neonatal period. Based on a conceptual model and the Theory of Reasoned Action/Theory of Planned Behavior, we developed a conceptual model a priori, we performed thematic analysis to explain determinants of maternal handwashing behaviors. RESULTS: We conducted 200 h of observation among mothers of neonates. The age range of participating mothers varied between 17 and 25 years and their maximum education was up to 10th grade of schooling. Mothers, other female caregivers and fathers perceived a need to wash hands with or without soap before eating or before feeding a child by hand to prevent diarrhea. Mothers expressed the importance of washing their hands before holding a baby but were rarely observed doing so. All respondents prioritized using soap for visible dirt or feces; otherwise, water alone was considered sufficient. Lack of family support, social norms of infrequent handwashing, perceptions of frequent contact with water as a health threat and mothers' restricted movement during first 40 days of neonate's life, and childcare and household responsibilities adversely impacted handwashing behavior. CONCLUSIONS: Addressing emotive drivers of handwashing within existing social norms by engaging family members, ensuring handwashing facilities and clarifying neonatal health threats may improve maternal handwashing behavior in the neonatal period.

Pilot Intervention Study of Household Ventilation and Fine Particulate Matter Concentrations in a Low-Income Urban Area, Dhaka, Bangladesh.

Fine particulate matter (PM2.5) is a risk factor for pneumonia; ventilation may be protective. We tested behavioral and structural ventilation interventions on indoor PM2.5 in Dhaka, Bangladesh. We recruited 59 good ventilation (window or door in ≥ 3 walls) and 29 poor ventilation (no window, one door) homes. We monitored baseline indoor and outdoor PM2.5 for 48 hours. We asked all participants to increase ventilation behavior, including opening windows and doors, and operating fans. Where permitted, we installed windows in nine poor ventilation homes, then repeated PM2.5 monitoring. We estimated effects using linear mixed-effects models and conducted qualitative interviews regarding motivators and barriers to ventilation. Compared with poor ventilation homes, good ventilation homes were larger, their residents wealthier and less likely to use biomass fuel. In multivariable linear mixed-effects models, ventilation structures and opening a door or window were inversely associated with the number of hours PM2.5 concentrations exceeded 100 and 250 µg/m3. Outdoor air pollution was positively associated with the number of hours PM2.5 concentrations exceeded 100 and 250 µg/m3. Few homes accepted window installation, due to landlord refusal and fear of theft. Motivators for ventilation behavior included cooling of the home and sunlight; barriers included rain, outdoor odors or noise, theft risk, mosquito entry, and, for fan use, perceptions of wasting electricity or unavailability of electricity. We concluded that ventilation may reduce indoor PM2.5 concentrations but, there are barriers to increasing ventilation and, in areas with high ambient PM2.5 concentrations, indoor concentrations may remain above recommended levels.