Chronic Kidney Disease Awareness Campaign and Mobile Health Education to Improve Knowledge, Quality of Life, and Motivation for a Healthy Lifestyle Among Patients With Chronic Kidney Disease in Bangladesh: Randomized Controlled Trial.

BACKGROUND: Chronic kidney disease (CKD) is linked to major health consequences and a poor quality of life. Despite the fact that CKD is becoming more prevalent, public knowledge of the disease remains low. OBJECTIVE: This study aimed to evaluate the outcome of a health education intervention designed to enhance knowledge, health-related quality of life (QOL), and motivation about healthy lifestyle among adults with CKD. METHODS: This study was a parallel-group (1:1), randomized controlled trial in the Mirzapur subdistrict of Bangladesh that compared 2 groups of patients with CKD. Adults with CKD (stages 1-3) were enrolled in November 2020 and randomly assigned the intervention or control group. The intervention group received health education through a CKD awareness campaign and mobile health technologies and was observed for 6 months, whereas the control group received standard treatment. The primary outcome was the evaluation of improved scores on the CKD knowledge questionnaire, and the secondary outcomes were improved QOL and changes in the levels of blood pressure (BP), BMI, serum creatinine, fasting blood sugar (FBS), hemoglobin, cholesterol, high-density lipoprotein cholesterol, triglyceride, serum uric acid, blood urea nitrogen (BUN), and albumin-to-creatinine ratio. RESULTS: The study enrolled 126 patients (control: n=63; intervention: n=63) and performed intention-to-treat analysis. The analyses included repeated measures ANOVA, and the results were observed to be significantly different from within groups (P<.001), between groups (P<.001), and the interaction of group × time factor (P<.001) for knowledge score. Diastolic BP and BMI showed significant differences arising from within groups (P<.001 and P=.01, respectively) and the interaction of group × time factor (P=.001 and P=.02, respectively); food salinity and hip circumferences showed significant differences arising from within groups (P=.001 and P=.03, respectively) and between groups (P=.001 and P=.02, respectively). Moreover, systolic BP and waist circumference showed significant differences from within groups (P<.001 and P=.003, respectively). However, no significant differences were found arising from within groups, between groups, and the interactions of group × time for QOL, urine salinity, and mid-upper arm circumference. Regarding the laboratory findings, from baseline to 6 months, the mean (SD) FBS decreased by 0.51 (3.77) mmol/L in the intervention group and 0.10 (1.44) mmol/L in the control group (P=.03); however, blood urea nitrogen increased by 3.64 (7.17) mg/dL in the intervention group and 1.68 (10.10) mg/dL in the control group (P=.01). CONCLUSIONS: The health education strategy, which included a campaign and mobile health, showed promise for enhancing CKD knowledge among patients with CKD. This strategy may also aid patients with CKD in controlling their FBS and BP. The combined health education initiatives give evidence for scaling them up in Bangladesh and possibly other low- and middle-income countries, particularly in rural and peri-urban settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT04094831; https://clinicaltrials.gov/ct2/show/NCT04094831. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/30191.

Changing trends in measles vaccination status between 2004 and 2014 among children aged 12-23 months in Bangladesh.

OBJECTIVE: To assess the current measles vaccination status in Bangladesh, explain changing differentials in measles vaccination, and determine contexts that may improve measles vaccination coverage. METHODS: Secondary data analysis of datasets (2004-2014) from the nationally representative Bangladesh Demographic and Health Surveys that followed stratified, multi-stage cluster sampling design conducted both in urban and rural contexts. RESULTS: 5468 children aged 12-23 months were surveyed, of whom 892 (16%) reported non-compliance to measles vaccine. After simultaneous adjusting for covariates in multivariate logistic regression, children who came from a poor socio-economic background, who had mothers with no formal schooling, who were underweight, of higher birth order (≥4), who had adolescent mothers, who had a history of home delivery and who had no exposure to media were observed to be significantly associated with lack of measles vaccination. Measles vaccination coverage among children of adolescent mothers was consistently low. Despite lack of media exposure, measles vaccination status gradually increased from 26% in 2004 to 33% in 2014. Lack of maternal education was no longer associated with measles vaccination status in 2007, 2011 and 2014. Stunted children continued to be associated with lack of measles immunisation in 2014. Children with higher birth order demonstrated 53% excess risk for not being immunised with measles vaccine. Mothers with no exposure to mass media were two times more likely to have children without measles immunisation as indicated by BDHS 2014 data. CONCLUSIONS: Our findings will help policy makers formulate strategies for expanding measles vaccination coverage in order to achieve further reduction in disease burden and mortality in Bangladesh.

OBJECTIF: Evaluer l'état actuel de la vaccination antirougeoleuse au Bangladesh, expliquer l'évolution des écarts de vaccination antirougeoleuse et déterminer les contextes susceptibles d'améliorer la couverture vaccinale antirougeoleuse. MÉTHODES: Analyse des données secondaires des ensembles de données (2004 à 2014) des enquêtes démographiques et sanitaires du Bangladesh représentatives au niveau national, qui ont suivi un plan d'échantillonnage stratifié en grappes à plusieurs niveaux, mené à la fois dans des contextes urbains et ruraux. RÉSULTATS: 5.468 enfants de 12 à 23 mois ont été interrogés, dont 892 (16%) ont déclaré une non-adhésion au vaccin contre la rougeole. Après ajustement simultané des covariables dans la régression logistique multivariée, les enfants issus d'un milieu socioéconomique pauvre, dont les mères n'avaient pas de scolarité formelle, qui étaient en insuffisance pondérale, de rang de naissance supérieur (≥4), qui avaient des mères adolescentes, qui avaient un les antécédents d'accouchement à domicile et qui n'avaient pas été exposés aux médias étaient significativement associés à l'absence de vaccination contre la rougeole. La couverture vaccinale contre la rougeole chez les enfants de mères adolescentes était constamment faible. Malgré le manque d'exposition aux médias, le statut de vaccination contre la rougeole a progressivement augmenté, passant de 26% en 2004 à 33% en 2014. Le manque d'éducation maternelle n'était plus associé au statut de vaccination contre la rougeole en 2007, 2011 et 2014. Les enfants souffrant d'un retard de croissance ont continué d'être associés au manque de la vaccination contre la rougeole en 2014. Les enfants dont le rang de naissance était plus élevé ont démontré un risque de 53% en excès de ne pas être vacciné contre la rougeole. Les mères sans exposition aux médias de masse étaient deux fois plus susceptibles d'avoir des enfants sans vaccination contre la rougeole, comme l'indiquent les données BDHS 2014. CONCLUSIONS: Nos résultats aideront les décideurs à formuler des stratégies pour étendre la couverture vaccinale contre la rougeole afin de réduire encore la charge de morbidité et la mortalité au Bangladesh.

Pathogen-specific risk of seizure in children with moderate-to-severe diarrhoea: Case control study with follow-up.

OBJECTIVE: To determine the pathogen-specific risk of seizure in under-five children hospitalised with moderate-to-severe diarrhoea (MSD) in rural settings. METHOD: This was a prospective case-control study with follow-up, conducted in a sentinel facility of Global Enteric Multicenter Study in Mirzapur, a rural community of Bangladesh between 2007 and 2010. Children aged 0-59 months who presented with MSD and seizure constituted the cases whereas those who did not have seizure comprised the controls. MSD was defined if the episodes were associated with dehydration or dysentery or required hospitalisation with diarrhoea or dysentery. All enrolled children were followed up at home within 50-90 days of enrolment. A total of 64 cases and 128 randomly selected controls formed the analysable dataset. RESULTS: The result of logistic regression analysis after adjusting for potential confounders revealed that shigellosis (Shigella species, OR = 5.34, 95% CI = 2.37-12.04) particularly S. flexneri (OR = 3.34, 95% CI = 1.48-7.57), S. flexneri 6 (OR = 23.24, 95% CI = 2.79-193.85), S. sonnei (OR = 6.90, 95% CI = 2.34-19.85); norovirus (OR = 6.77, 95% CI = 1.69-27.11), fever (OR = 16.75, 95% CI = 1.81-154.70) and loss of consciousness (OR = 35.25, 95% CI = 1.71-726.20) were the independent risk factors for seizure in MSD children. At enrolment, cases had lower WHZ (P = 0.006) compared to their peers, follow-up anthropometrics showed significant improvement in WHZ (P < 0.001) and WAZ (P < 0.05), whereas deterioration in HAZ (P < 0.001) in both cases and controls. CONCLUSION: Childhood MSD episodes particularly due to Shigella and norovirus are often associated with seizure. Prompt identification and appropriate management of children with shigellosis may reduce occurrence and adverse consequences of seizure linked with MSD.

OBJECTIF: Déterminer le risque spécifique de convulsions chez les enfants de moins de cinq ans hospitalisés pour une diarrhée modérée à sévère (DMS) en milieu rural. MÉTHODE: Il s'agissait d'une étude prospective cas-témoins avec suivi, menée dans un établissement sentinelle de l'Etude Globale Multicentrique Entérique à Mirzapur, une communauté rurale du Bangladesh entre 2007 et 2010. Les enfants âgés de 0 à 59 mois qui se sont présentés avec une DMS et des convulsions constituaient les cas, tandis que ceux qui n'avaient pas des convulsions constituaient les témoins. La DMS a été définie si les épisodes étaient associés à une déshydratation ou à une dysenterie ou nécessitaient une hospitalisation pour diarrhée ou dysenterie. Tous les enfants recrutés ont été suivis à domicile dans les 50 à 90 jours suivant le recrutement. Un total de 64 cas et 128 témoins sélectionnés au hasard ont constitué l'ensemble de données analysables. RÉSULTATS: Le résultat de l'analyse de régression logistique après ajustement des facteurs de confusion potentiels a révélé que la shigellose (espèce Shigella, OR = 5,34 ; IC95%: 2,37-12,04) en particulier S. flexneri (OR = 3,34 ; IC95%: 1,48-7,57), S. flexneri 6 (OR = 23,24 ; IC95%: 2.79-193,85), S. sonnei (OR = 6,90 ; IC95%: 2,34-19,85) ; les norovirus (OR = 6,77 ; IC95%: 1,69-27,11), la fièvre (OR = 16,75 ; IC95%: 1,81-154,70) et la perte de conscience (OR = 35,25 ; IC95%: 1,71-726,20) étaient les facteurs de risque indépendants de convulsions chez les enfants souffrant de DMS. Lors du recrutement, les cas avaient un score Z poids pour la taille (ZPT) plus faible (P = 0,006) que leurs pairs, les anthropométries de suivi ont montré une amélioration significative du ZPT (P < 0,001) et du score Z poids pour l'âge (P < 0,05); tandis que le score Z taille pour l'âge (p < 0,001) s'est détérioré chez cas et chez les témoins. CONCLUSION: Les épisodes de DMS de l'enfance, notamment due à Shigella et aux norovirus, sont souvent associés à des convulsions. L'identification rapide et la prise en charge appropriée des enfants atteints de shigellose peuvent réduire la survenue et les conséquences négatives des crises liées aux DMS.

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.

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007-2011: Case-Control Study.

BACKGROUND: Diarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child's risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age. METHODS/FINDINGS: The GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1-2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India. CONCLUSIONS: This study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children's Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.

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.

Effect of birth weight on adulthood renal function: A bias-adjusted meta-analytic approach.

While the association between low birth weight (LBW; <2500 g) and development of adult chronic renal disease (CKD) is inconsistently reported, less information is available regarding association of high birth weight (HBW; ≥4000 g) with CKD. We undertook a systematic review and meta-analysis on studies published before 30 September 2015 and report associations between birth weight and renal function. Blood (glomerular filtration rate (GFR)) and urine (microalbuminuria/albumin excreation rate (AER)/urinary albumin creatinine ratio (ACR)) parameters were used to define CKD. Three different effect size estimates were used (odds ratio, regression coefficient and mean difference). The odds of developing CKD in the life course among those born LBW was 1.77 (95% CI: 1.42, 2.20) times and 1.68 (1.27, 2.33) times, assessed by blood and urine parameters respectively. Higher risk was also observed among Asian and Australian populations (blood: OR 2.68; urine: OR 2.28), individuals aged ≤30 years (blood: OR 2.30; urine: OR 1.26), and ≥50 years (blood: OR 3.66; urine: OR 3.10), people with diabetes (blood: OR 2.51), and aborigines (urine: OR 2.32). There was no significant association between HBW and CKD. For every 1 kg increase in BW, the estimated GFR increased by 2.09 mL/min per 1.73 m(2) (1.33-2.85), and it was negatively associated with LogACR (ß -0.07, 95% CI: -0.14, 0.00). LBW inborn had lower mean GFR -4.62 (-7.10, -2.14) compared with normal BW. Findings of this study suggest that LBW increased the risk of developing CKD, and HBW did not show any significant impact.

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.

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.

Long-term comparison of antibiotic resistance in Vibrio cholerae O1 and Shigella species between urban and rural Bangladesh.

From 2000 to 2012, Vibrio cholerae O1 and Shigella species isolates from urban Dhaka and rural Matlab were tested for resistance to all clinically relevant antibiotics in Bangladesh. Resistances in urban and rural Bangladesh tended to rise and fall together, especially a few years after the introduction of new resistance.

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.

Urban-rural differentials in overweight and obese individuals with diarrhea in bangladesh.

OBJECTIVE: The study aimed to determine urban and rural differences in overweight and obesity (OO) with diarrhea regarding subjects' sociodemographic, clinical characteristics, etiology, and antimicrobial susceptibility. METHODS: Relevant information from 2000 to 2011 were extracted from the data archive of the Diarrheal Disease Surveillance System of urban Dhaka (1248, 4.5%) and rural Matlab (615, 3.4%) hospitals of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). RESULTS: The proportion of OO significantly increased in both urban (3-7%; chi-square for trend p < 0.001) and rural (1-6%; p < 0.001) areas over the study period. In multivariate modeling, monthly income more than US$100 (odds ratio [OR] = 54.44, 95% confidence interval [CI], 25.37-116.82, p < 0.001), high wealth quintile (OR = 18.23, 95% CI, 8.63-38.49, p < 0.001), access to sanitary toilet (OR = 3.07. 95% CI. 1.76-5.26. p < 0.001), boiled drinking water (OR = 2.77, 95% CI, 1.09-7.05, p = 0.032), antimicrobial use before hospitalization (OR = 4.99, 95% CI, 2.85-8.74, p < 0.001), fever (OR = 0.14, 95% CI, 0.37, 0.50, p < 0.001), watery stools (OR = 5.59, 95% CI, 2.11-14.80, p < 0.001), dehydrating diarrhea (OR = 5.17, 95% CI, 2.54-10.52, p < 0.001), intravenous saline infusion after hospitalization (OR = 2.65, 95% CI, 1.28-5.49, p = 0.009), and Salmonella infection (OR = 0.20, 95% CI, 0.50-0.83, p = 0.027) remained significantly associated with urban OO individuals. At least 88% of Shigella isolates were susceptible to ciprofloxacin in both urban and rural areas; for mecillinum it was 90%. Ciprofloxacin had the least detected resistance for Vibrio cholerae (0%) and trimethoprim-sulfamethoxazole (TMP-SMX) showed the greatest resistance (Dhaka 86%; Matlab 98%). Susceptibility for Salmonella showed ampicillin (95%), chloramphenecol (100%), ciprofloxacin (95%), ceftraxone (93%), TMP-SMX (95%) at both sites. CONCLUSION: Urban OO with diarrheal illnesses was significantly different from that in rural areas, including antimicrobial susceptibility.

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.

A novel norovirus recombinant strain GII.4/GII.21 in Bangladesh, 2011.

We identified a novel inter-genotype recombinant norovirus strain, Dhaka85/2011/BGD, collected from a stool specimen of a nine-month-old infant who was hospitalized with diarrhea. Molecular investigation and phylogenetic analysis classified its RNA polymerase gene as GII.4-like, which commonly circulates in humans. The capsid gene was classified as GII.21-like, most likely originated from water. The discovery of this novel strain is an illustration of the enormous diversity among the norovirus strains, especially in developing countries and has important implications for future vaccine strategies.

Changing profile of rotavirus genotypes in Bangladesh, 2006-2012.

BACKGROUND: Rotavirus is the leading cause of severe diarrhea in infants and young children worldwide including Bangladesh. Unlike what was seen in high-income countries, the licensed rotavirus vaccines did not show high efficacy in Bangladeshi trials. We assessed rotavirus prevalence and genotypes in Bangladesh over six-year period to provide baseline information on the rotavirus burden and changing profile in the country. METHODS: This study was conducted from June 2006 to May 2012 in Matlab, Bangladesh. Group A rotaviruses were detected in stools collected from diarrhea patients by ELISA and genotyped using multiplex reverse transcription PCR followed by nucleotide sequencing. RESULTS: Of the 9678 stool samples, 20.3% were positive for rotavirus. The most predominant genotype was G1P[8] (22.4%), followed by G9P[8] (20.8%), G2P[4] (16.9%) and G12P[8] (10.4%). Mixed infections were detected in 14.2% of the samples. Emergence of an unusual strain, G9P[4] was documented during 2011-12. Several amino acid mismatches in the antigenic epitopes of VP7 and VP4 between Bangladeshi and the vaccine strains were identified. CONCLUSIONS: Our study provides important information on rotavirus genotypes that should be considered for the selection and introduction of rotavirus vaccines in Bangladesh.

Pulmonary tuberculosis in severely-malnourished or HIV-infected children with pneumonia: a review.

Presentation of pulmonary tuberculosis (PTB) as acute pneumonia in severely-malnourished and HIV-positive children has received very little attention, although this is very important in the management of pneumonia in children living in communities where TB is highly endemic. Our aim was to identify confirmed TB in children with acute pneumonia and HIV infection and/or severe acute malnutrition (SAM) (weight-for-length/height or weight-for-age z score <-3 of the WHO median, or presence of nutritional oedema). We conducted a literature search, using PubMed and Web of Science in April 2013 for the period from January 1974 through April 2013. We included only those studies that reported confirmed TB identified by acid fast bacilli (AFB) through smear microscopy, or by culture-positive specimens from children with acute pneumonia and SAM and/or HIV infection. The specimens were collected either from induced sputum (IS), or gastric lavage (GL), or broncho-alveolar lavage (BAL), or percutaneous lung aspirates (LA). Pneumonia was defined as the radiological evidence of lobar or patchy consolidation and/or clinical evidence of severe/ very severe pneumonia according to the WHO criteria of acute respiratory infection. A total of 17 studies met our search criteria but 6 were relevant for our review. Eleven studies were excluded as those did not assess the HIV status of the children or specify the nutritional status of the children with acute pneumonia and TB. We identified only 747 under-five children from the six relevant studies that determined a tubercular aetiology of acute pneumonia in children with SAM and/or positive HIV status. Three studies were reported from South Africa and one each from the Gambia, Ethiopia, and Thailand where 610, 90, 35, and 12 children were enrolled and 64 (10%), 23 (26%), 5 (14%), and 1 (8%) children were identified with active TB respectively, with a total of 93 (12%) children with active TB. Among 610 HIV-infected children in three studies from South Africa and 137 SAM children from other studies, 64 (10%) and 29 (21%) isolates of M. tuberculosis were identified respectively. Children from South Africa were infected with HIV without specification of their nutritional status whereas children from other countries had SAM but without indication of their HIV status. Our review of the existing data suggests that pulmonary tuberculosis may be more common than it is generally suspected in children with acute pneumonia and SAM, or HIV infection. Because of the scarcity of data, there is an urgent need to investigate PTB as one of the potential aetiologies of acute pneumonia in these children in a carefully-conducted larger study, especially outside Africa.

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.

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.

Changing trend of persistent diarrhoea in young children over two decades: observations from a large diarrhoeal disease hospital in Bangladesh.

AIM: We studied the changing trend and factors associated with persistent diarrhoea (PD) in under-five children presenting to a large diarrhoeal disease hospital in urban Dhaka, Bangladesh, over the last two decades. METHODS: We used an unmatched case-control design, with a case (persistent diarrhoea; n=944) to control (acute diarrhoea; n=2832) ratio of 1:3 attending the Dhaka Hospital of icddr,b between 1991 and 2010. RESULTS: The proportion of children with PD decreased significantly from 8% in 1991 to 1% in 2010. The proportion of breastfeeding practices, measles vaccination coverage and vitamin A supplementation among 12-59 months old improved from 79% to 85%, 69% to 85% and 26% to 74%, respectively, which were significant. Although the isolation of rotavirus from stool in children with PD and acute diarrhoea increased, the isolation of Shigella spp., and Vibrio cholerae O1 decreased significantly. In a logistic regression analysis, wasting (OR=1.62), use of antibiotic before attending hospital (OR=5.94), absent clinical dehydration (OR=1.53) and bloody/mucoid stool (OR=3.33) were significantly associated with persistent diarrhoea. CONCLUSION: There, thus, is a need to integrate an appropriate and sustainable deterrent strategy to take the benefit of the significant reduction in prevalence as well as risks of PD in such population.