How can mobile phones be used to improve nutrition service delivery in rural Bangladesh?

BACKGROUND: Nutrition has been integrated within the health services in Bangladesh as it is an important issue for health and development. High penetration of mobile phones in the community and favourable policy and political commitment of the Government of Bangladesh has created possibilities of using Information Communication Technology such as mobile phones for nutrition programs. In this paper the implementation of nutrition services with a specific focus on infant and young child feeding was explored and the potential for using mobile phones to improve the quality and coverage of nutrition services was assessed. METHODS: A qualitative study was conducted in Mirzapur and Chakaria sub-districts, Bangladesh from February-April 2014. We conducted 24 in-depth interviews (mothers of young children), 8 focus group discussions (fathers and grandmothers); and 13 key informant interviews (community health workers or CHWs). We also observed 4 facilities and followed 2 CHWs during their work day. The data was analyzed manually using pre-existing themes. RESULTS: In this community, mothers demonstrated gaps in knowledge about IYCF. They depended on their social network and media for IYCF information. Although CHWs were trusted in the community, mothers and their family members did not consider them a good source of nutrition information as they did not talk about nutrition. In terms of ICTs, mobile phones were the most available and used by both CHWs and mothers. CHWs showed willingness to incorporate nutrition counselling through mobile phone as this can enhance their productivity, reduce travel time and improve service quality. Mothers were willing to receive voice calls from CHWs as long as the decision makers in the households were informed. CONCLUSIONS: Our study indicated that there are gaps in IYCF related service delivery and there is a potential for using mobile phones to both strengthen the quality of service delivery as well as reaching out to the mothers in the community. It is important however, to consider the community readiness to accept the technology during the design and delivery of the intervention.

Cholera outbreaks in the classical biotype era.

In the Indian subcontinent description of a disease resembling cholera has been mentioned in Sushruta Samita, estimated to have been written between ~400 and 500 BC. It is however not clear whether the disease known today as cholera caused by Vibrio cholerae Vibrio cholerae O1 is the evolutionary progression of the ancient disease. The modern history of cholera began in 1817 when an explosive epidemic broke out in the Ganges River Delta region of Bengal. This was the first of the seven recorded cholera pandemics cholera pandemics that affected nearly the entire world and caused hundreds of thousands of deaths. The bacterium responsible for this human disease was first recognised during the fifth pandemic and was named V. cholerae which was grouped as O1, and was further differentiated into Classical and El Tor biotypes. It is now known that the fifth and the sixth pandemics were caused by the V. cholerae O1 of the Classical biotype Classical biotype and the seventh by the El Tor biotype El Tor biotype . The El Tor biotype of V. cholerae, which originated in Indonesia Indonesia and shortly thereafter began to spread in the early 1960s. Within the span of 50 years the El Tor biotype had invaded nearly the entire world, completely displacing the Classical biotype from all the countries except Bangladesh. What prompted the earlier pandemics to begin is not clearly understood, nor do we know how and why they ended. The success of the seventh pandemic clone over the pre-existing sixth pandemic strain remains largely an unsolved mystery. Why classical biotype eventually disappeared from the world remains to be explained. For nearly three decades (1963-1991) during the Seventh cholera pandemic seventh pandemic, cholera in Bangladesh has recorded a unique history of co-existence of Classical and El Tor biotypes of V. cholerae O1 as epidemic and endemic strain. This long co-existence has provided us with great opportunity to improve our understanding of the disease itself and answer some important questions.

Epidemiology of rotavirus and cholera in children aged less than five years in rural Bangladesh.

Despite the known presence of rotavirus-associated diarrhoea in Bangladesh, its prevalence, including records of hospitalization in rural health facilities, is largely unknown. In a systematic surveillance undertaken in two government-run rural health facilities, 457 children, aged less than five years, having acute watery diarrhoea, were studied between August 2005 and July 2007 to determine the prevalence of rotavirus. Due to limited financial support, the surveillance of rotavirus was included as an addendum to an ongoing study for cholera in the same area. Rotavirus infection was detected in 114 (25%) and Vibrio cholerae in 63 (14%) children. Neither rotavirus nor V cholerae was detected in 280 (61%) samples; these were termed 'non-rotavirus and non-cholera' diarrhoea. Both rotavirus and cholera were detected in all groups of patients (<5 years). The highest proportion (41%; 47/114) of rotavirus was in the age-group of 6-11 months. In children aged less than 18 months, the proportion (67%; 76/114) of rotavirus was significantly (p < 0.001) higher than that of cholera (16%; 10/63). By contrast, the proportion (84%; 53/63) of cholera was significantly (p < 0.001) higher than that of rotavirus (33%; 38/114) in the age-group of 18-59 months. During the study period, 528 children were hospitalized for various illnesses. Thirty-eight percent (202/528) of the hospitalizations were due to acute watery diarrhoea, and 62% were due to non-diarrhoeal illnesses. Rotavirus accounted for 34% of hospitalizations due to diarrhoea. Severe dehydration was detected in 16% (74/457) of the children. The proportion (51%; 32/63) of severe dehydration among V cholerae-infected children was significantly higher (p < 0.001) compared to the proportion (16%; 18/114) of rotavirus-infected children. The study revealed that 12-14% of the hospitalizations in rural Bangladesh in this age-group were due to rotavirus infection, which has not been previously documented.

El Tor cholera with severe disease: a new threat to Asia and beyond.

During epidemics of cholera in two rural sites (Bakerganj and Mathbaria), a much higher proportion of patients came for treatment with severe dehydration than was seen in previous years. V. cholerae O1 isolated from these patients was found to be El Tor in its phenotype, but its cholera toxin (CT) was determined to be that of classical biotype. Whether the observed higher proportion of severe dehydration produced by the El Tor biotype was due to a shift from El Tor to classical CT or due to other factors is not clear. However, if cholera due to strains with increased severity spread to other areas where treatment facilities are limited, there are likely to be many more cholera deaths.

Causes for hospitalizations at upazila health complexes in Bangladesh.

Morbidity and mortality data are important for planning and implementing healthcare strategies of a country. To understand the major causes for hospitalizations in rural Bangladesh, demographic and clinical data were collected from the hospital-records of five government-run rural health facilities (upazila health complexes) situated at different geographical regions of the country from January 1997 to December 2001. During this period, 75,598 hospital admissions in total were recorded, of which 54% were for male, and 46% were for female. Of all the admissions, diarrhoeal disease was the leading cause for hospitalization (25.1%), followed by injuries (17.7%), respiratory tract diseases (12.6%), diseases of the gastrointestinal tract (10.5%), obstetric and gynaecological causes (8.5%), and febrile illnesses (6.7%). A considerable proportion (8.3%) of the hospitalized patients remained undiagnosed. Despite the limitations of hospital-based data, this paper gives a reasonable insight of the important causes for hospitalizations in upazila health complexes that may guide the policy-makers in strengthening and prioritizing the healthcare needs at the upazila level in Bangladesh.

Serogroup, virulence, and genetic traits of Vibrio parahaemolyticus in the estuarine ecosystem of Bangladesh.

Forty-two strains of Vibrio parahaemolyticus were isolated from Bay of Bengal estuaries and, with two clinical strains, analyzed for virulence, phenotypic, and molecular traits. Serological analysis indicated O8, O3, O1, and K21 to be the major O and K serogroups, respectively, and O8:K21, O1:KUT, and O3:KUT to be predominant. The K antigen(s) was untypeable, and pandemic serogroup O3:K6 was not detected. The presence of genes toxR and tlh were confirmed by PCR in all but two strains, which also lacked toxR. A total of 18 (41%) strains possessed the virulence gene encoding thermostable direct hemolysin (TDH), and one had the TDH-related hemolysin (trh) gene, but not tdh. Ten (23%) strains exhibited Kanagawa phenomenon that surrogates virulence, of which six, including the two clinical strains, possessed tdh. Of the 18 tdh-positive strains, 17 (94%), including the two clinical strains, had the seromarker O8:K21, one was O9:KUT, and the single trh-positive strain was O1:KUT. None had the group-specific or ORF8 pandemic marker gene. DNA fingerprinting employing pulsed-field gel electrophoresis (PFGE) of SfiI-digested DNA and cluster analysis showed divergence among the strains. Dendrograms constructed using PFGE (SfiI) images from a soft database, including those of pandemic and nonpandemic strains of diverse geographic origin, however, showed that local strains formed a cluster, i.e., "clonal cluster," as did pandemic strains of diverse origin. The demonstrated prevalence of tdh-positive and diarrheagenic serogroup O8:K21 strains in coastal villages of Bangladesh indicates a significant human health risk for inhabitants.

Acute otitis media during the first two years of life in a rural community in Bangladesh: a prospective cohort study.

The study investigated the burden of acute otitis media (AOM) during the first two years of life in a cohort of 252 newborns in rural Bangladesh using data collected on occurrences of AOM. Trained community health workers (CHWs) conducted household surveillance and picked up cases of AOM using the study algorithm. The incidence rate was 0.9 episodes per child-year observed. Forty-six percent (n=115) of the 252 subjects developed AOM: 36% (n=91) during the first year of life and 10% (n=24) during the second year of life (p<0.001). The age-specific incidence rates of AOM varied; peaks occurred in the 6-12-month age-group and the lowest in the first three months of life. In total, 20% (n=49) of the study subjects had single, 26% (n=66) recurrent, and 54% (n=137) no episode of AOM. Perforation with discharge developed in 85% (n=322) of 375 episodes. The duration of discharge from the ears was < or =6 weeks in 95% of the episodes, but in 5% of the episodes, discharge from the ears continued for >6 weeks. The incidence of AOM was higher in the monsoon season compared to the summer season (p<0.003). The study documented AOM as an important cause of morbidity among rural children up to two years of age in Bangladesh and should be addressed with strategies to overcome the burden of disease.

Childhood mortality due to drowning in rural Matlab of Bangladesh: magnitude of the problem and proposed solutions.

Drowning is an important cause of mortality among children in rural Bangladesh. Children aged 1-4 year(s) are at a high risk of death from drowning. Although deaths of children due to drowning in Bangladesh are acknowledged as an important cause of death, little effort has been made to address the issue of preventing deaths from this cause. This study has attempted to describe the problem and suggests possible prevention strategies, which may contribute to reducing childhood mortality from drowning. Data presented in this study were collected from Matlab where ICDDR,B has been maintaining a demographic surveillance since 1966. During the study period from 1985 to 2000, 989 deaths from drowning were reported, of which 796 (80.5%) were children in the age-group of 1-4 year(s), 48 (4.8%) were in the age-group of less than one year, and 145 (14.7%) in the age-group of 5-19 years. During 1985-2000, death rate per 1,000 children due to all causes among children of 1-4-year age-group decreased appreciably from 20.7% to 5.2%, while drowning-related deaths did not. Forty-five percent (n = 359) of drowning-related deaths occurred in ponds, 16.8% (n = 134) in ditches, 8.1% (n = 64) in canals, and 4.4% (n = 35) in rivers. The sites of more than 25% of drowning-associated deaths were not recorded. Analysis of seasonal variation revealed that most deaths due to drowning occurred during April-October, i.e. mostly during the monsoon months. It was also observed that the majority (67%) of mothers of victims had no formal education. Deaths due to drowning were mostly associated with children aged 1-4 year(s) and were 20% more common among boys than among girls (odds ratio = 1.2, 95% confidence interval 1.04-1.38, p < 0.012). The paper recommends some interventions to reduce the number of deaths due to drowning in rural Bangladesh, which include: (a) increasing awareness among mothers and close family members about the risk of drowning, (b) door-fencing, and (c) filling of unused ditches and water holes around households.

Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin.

Antimicrobial resistance of Shigella isolates in Bangladesh, during 2001-2002, was studied and compared with that of 1991-1992 to identify the changes in resistance patterns and trends. A significant increase in resistance to trimethoprim-sulphamethoxazole (from 52% to 72%, p < 0.01) and nalidixic acid (from 19% to 51%, p < 0.01) was detected. High, but unchanged, resistance to tetracycline, ampicillin, and chloramphenicol, low resistance to mecillinam (resistance 3%, intermediate 3%), and to emergence of resistance to azithromycin (resistance 16%, intermediate 62%) and ceftriaxone/cefixime (2%) were detected in 2001-2002. Of 266 recent isolates, 63% were resistant to > or =3 anti-Shigella drugs (multidrug-resistant [MDR]) compared to 52% of 369 strains (p < 0.007) in 1991-1992. Of 154 isolates tested by E-test in 2001-2002, 71% were nalidixic acid-resistant (minimum inhibitory concentration [MIC] > or =32 microg/mL) and had 10-fold higher MIC90 (0.25 microg/mL) to ciprofloxacin than that of nalidixic acid-susceptible strains exhibiting decreased ciprofloxacin susceptibility, which were detected as ciprofloxacin-susceptible and nalidixic acid-resistant by the disc-diffusion method. These strains were frequently associated with MDR traits. High modal MICs were observed to azithromycin (MIC 6 microg/mL) and nalidixic acid (MIC 128 micdrog/mL) and low to ceftriaxone (MIC 0.023 microg/mL). Conjugative R-plasmids-encoded extended-spectrum beta-lactamase was responsible for resistance to ceftriaxone/cefixime. The growing antimicrobial resistance of Shigella is worrying and mandates monitoring of resistance. Pivmecillinam or ciprofloxacin might be considered for treating shigellosis with caution.

What is cholera? A preliminary study on caretakers' knowledge in Bangladesh.

BACKGROUND: Cholera has afflicted the Indian sub-continent for centuries, predominantly in West Bengal and modern-day Bangladesh. This preliminary study aims to understand the current level of knowledge of cholera in female Bangladeshi caretakers, which is important in the outcome of the disease and its spread. A pilot study was conducted among 85 women in Bangladesh using qualitative questionnaires to explore the ability of female caretakers in identifying cholera and its transmission. FINDINGS: The survey revealed that though all the female caretakers were aware of the term "cholera," nearly a third of the respondents did not associate diarrhea with cholera or mentioned symptoms that could not be caused by cholera (29 %). Approximately half of the respondents associated water with the cause of cholera (56 %) and only 8 % associated cholera with sanitation or hygiene. Shame and stigma (54 %) were more commonly described than death (47 %) as negative effects of cholera. CONCLUSIONS: The results from this study are suggestive of a need for reformulation of cholera and diarrhea communication. Messaging should be based on signs of dehydration, foregoing the use of medical terminology.

Salt Intake and Health Risk in Climate Change Vulnerable Coastal Bangladesh: What Role Do Beliefs and Practices Play?

BACKGROUND: High salt consumption is an important risk factor of elevated blood pressure. In Bangladesh about 20 million people are at high risk of hypertension due to climate change induced saline intrusion in water. The objective of this study is to assess beliefs, perceptions, and practices associated with salt consumption in coastal Bangladesh. METHODS: The study was conducted in Chakaria, Bangladesh between April-June 2011. It was a cross sectional mixed method study. For the qualitative study 6 focus group discussions, 8 key informant interviews, 60 free listing exercises, 20 ranking exercises and 10 observations were conducted. 400 adults were randomly selected for quantitative survey. For analysis we used SPSS for quantitative data, and Anthropac and Nvivo for qualitative data. RESULTS: Salt was described as an essential component of food with strong cultural and religious roots. People described both health benefits and risks related to salt intake. The overall risk perception regarding excessive salt consumption was low and respondents believed that the cooking process can render the salt harmless. Respondents were aware that salt is added in many foods even if they do not taste salty but did not recognize that salt can occur naturally in both foods and water. CONCLUSIONS: In the study community people had low awareness of the risks associated with excess salt consumption and salt reduction strategies were not high in their agenda. The easy access to and low cost of salt as well as unrecognised presence of salt in drinking water has created an environment conducive to excess salt consumption. It is important to design general messages related to salt reduction and test tailored strategies especially for those at high risk of hypertension.

Cholera.

Intestinal infection with Vibrio cholerae results in the loss of large volumes of watery stool, leading to severe and rapidly progressing dehydration and shock. Without adequate and appropriate rehydration therapy, severe cholera kills about half of affected individuals. Cholera toxin, a potent stimulator of adenylate cyclase, causes the intestine to secrete watery fluid rich in sodium, bicarbonate, and potassium, in volumes far exceeding the intestinal absorptive capacity. Cholera has spread from the Indian subcontinent where it is endemic to involve nearly the whole world seven times during the past 185 years. V cholerae serogroup O1, biotype El Tor, has moved from Asia to cause pandemic disease in Africa and South America during the past 35 years. A new serogroup, O139, appeared in south Asia in 1992, has become endemic there, and threatens to start the next pandemic. Research on case management of cholera led to the development of rehydration therapy for dehydrating diarrhoea in general, including the proper use of intravenous and oral rehydration solutions. Appropriate case management has reduced deaths from diarrhoeal disease by an estimated 3 million per year compared with 20 years ago. Vaccination was thought to have no role for cholera, but new oral vaccines are showing great promise.

Cell-mediated immune deficiency and malnutrition are independent risk factors for persistent diarrhea in Bangladeshi children.

A community-based longitudinal study was carried out at Matlab, Bangladesh, to investigate the magnitude of the problem of persistent diarrhea; 705 children aged < 5 y were followed, yielding 7300 child-months of observation in 1 y. Morbidity data were collected every fourth day by home visit, anthropometric status was determined monthly, and cell-mediated immune status was assessed every 3 mo. The incidence of persistent diarrhea was 34 episodes per 100 child-years; rates were highest in infancy and declined through the remainder of childhood. In a logistic-regression model, weight-for-height status and immune status were significant predictors of persistent diarrhea. Compared with those at zero Z score, children with weight-for-height at -2 would have a 3.5 times increased risk of persistent diarrhea. Compared with immunocompetent children, immunodeficient children had about twice the risk of developing persistent diarrhea. Thus, nutritional status and cell-mediated immune status were important independent risk factors for persistent diarrhea.

Cardiac failure in pregnant Northern Nigerian women.

Thirty-nine gravidae with congestive cardiac failure and ten pregnant patients with acute pulmonary edema treated at the Ahmadu Bello University Teaching Hospital in Kaduna, Nigeria, over a five-year period are presented. Congestive cardiac failure occurred more frequently in the postnatal period, and parity and socioeconomic class were not significantly related to cardiac failure. Maternal mortality was low in spite of all patients being in functional grades III and IV. Idiopathic cardiomegaly and chronic rheumatic heart disease were the most common underlying causes of heart failure in pregnancy. The dominant valvular lesions in the patients with rheumatic heart disease was mitral incompetence.

Epidemiological and clinical characteristics of acute and persistent diarrhoea in rural Bangladeshi children.

A community-based longitudinal study of acute and persistent diarrhoea in 705 children less than five years old was carried out for a year in a rural area of Bangladesh. Diarrhoea morbidity data were collected from each study child every fourth day by home visit. Clinical features of diarrhoeal episodes and diarrhoeal management information were documented. The overall diarrhoeal incidence rate in the study children was 4.6 episodes per child per year. The incidence of persistent diarrhoea was 34/100 child-years. Persistent diarrhoea was positively associated with young age and more severe illness, characterized by the presence of clinical dehydration or blood in the stool in the first week. Use of ORT in the first week was positively associated and use of an antibiotic was negatively associated with the occurrence of persistent diarrhoea. Reduced breast-feeding and consumption of cow's milk at some time during the episode were also positively associated with persistence. This would suggest that appropriate fluid and dietary management for all episodes should be the goal. Children with more severe initial illness characterized by the presence of blood in the stool or clinical dehydration should have more careful follow-up to identify persistent episodes and adverse nutritional effects. Breastfeeding should be continued during acute diarrhoea, but the role of ORT, antibiotics and cow's milk deserves further investigation.