Mapping the travel patterns of people with malaria in Bangladesh.

BACKGROUND: Spread of malaria and antimalarial resistance through human movement present major threats to current goals to eliminate the disease. Bordering the Greater Mekong Subregion, southeast Bangladesh is a potentially important route of spread to India and beyond, but information on travel patterns in this area are lacking. METHODS: Using a standardised short survey tool, 2090 patients with malaria were interviewed at 57 study sites in 2015-2016 about their demographics and travel patterns in the preceding 2 months. RESULTS: Most travel was in the south of the study region between Cox's Bazar district (coastal region) to forested areas in Bandarban (31% by days and 45% by nights), forming a source-sink route. Less than 1% of travel reported was between the north and south forested areas of the study area. Farmers (21%) and students (19%) were the top two occupations recorded, with 67 and 47% reporting travel to the forest respectively. Males aged 25-49 years accounted for 43% of cases visiting forests but only 24% of the study population. Children did not travel. Women, forest dwellers and farmers did not travel beyond union boundaries. Military personnel travelled the furthest especially to remote forested areas. CONCLUSIONS: The approach demonstrated here provides a framework for identifying key traveller groups and their origins and destinations of travel in combination with knowledge of local epidemiology to inform malaria control and elimination efforts. Working with the NMEP, the findings were used to derive a set of policy recommendations to guide targeting of interventions for elimination.

Arsenicosis and stigmatisation.

Arsenicosis is believed to have debilitating effects on social relations, but with arsenic poisoning previously associated directly with economic and cognitive impacts, the degree to which stigmatisation is influenced by socio-economic or health status has not been established in the literature. Based on face-to-face interviews with 100 arsenic outpatients from specialist arsenic clinics in rural Bangladesh, this study represents an early quantitative analysis of factors predicting social impacts of arsenicosis. Physical health status, average years of schooling, family size and the presence of non-government organisation (NGO) and government-run arsenic-awareness campaigns significantly predicted social impacts. We found that the presence of awareness-raising activities was by far the most significant predictor of social impacts after other key variables, including gender and income, thus underscoring the importance of public health interventions in mitigating the impact of stigmatised diseases. The study confirms previous qualitative findings that ostracism is a pervasive problem for arsenicosis patients, and that public health interventions can be a valuable counter to such social problems.

Spread of artemisinin resistance in Plasmodium falciparum malaria.

BACKGROUND: Artemisinin resistance in Plasmodium falciparum has emerged in Southeast Asia and now poses a threat to the control and elimination of malaria. Mapping the geographic extent of resistance is essential for planning containment and elimination strategies. METHODS: Between May 2011 and April 2013, we enrolled 1241 adults and children with acute, uncomplicated falciparum malaria in an open-label trial at 15 sites in 10 countries (7 in Asia and 3 in Africa). Patients received artesunate, administered orally at a daily dose of either 2 mg per kilogram of body weight per day or 4 mg per kilogram, for 3 days, followed by a standard 3-day course of artemisinin-based combination therapy. Parasite counts in peripheral-blood samples were measured every 6 hours, and the parasite clearance half-lives were determined. RESULTS: The median parasite clearance half-lives ranged from 1.9 hours in the Democratic Republic of Congo to 7.0 hours at the Thailand-Cambodia border. Slowly clearing infections (parasite clearance half-life >5 hours), strongly associated with single point mutations in the "propeller" region of the P. falciparum kelch protein gene on chromosome 13 (kelch13), were detected throughout mainland Southeast Asia from southern Vietnam to central Myanmar. The incidence of pretreatment and post-treatment gametocytemia was higher among patients with slow parasite clearance, suggesting greater potential for transmission. In western Cambodia, where artemisinin-based combination therapies are failing, the 6-day course of antimalarial therapy was associated with a cure rate of 97.7% (95% confidence interval, 90.9 to 99.4) at 42 days. CONCLUSIONS: Artemisinin resistance to P. falciparum, which is now prevalent across mainland Southeast Asia, is associated with mutations in kelch13. Prolonged courses of artemisinin-based combination therapies are currently efficacious in areas where standard 3-day treatments are failing. (Funded by the U.K. Department of International Development and others; ClinicalTrials.gov number, NCT01350856.).

Water consumption patterns and factors contributing to water consumption in arsenic affected population of rural West Bengal, India.

A direct water intake study was conducted for one year, involving 423 individuals from three arsenic (As) affected villages of West Bengal, India. Average direct water intake per person and per unit body weight was found to be 3.12±1.17 L/day and 78.07±47.08 mL/kg/day (± SD), respectively. Average direct water intakes for adult males, adult females and children (age <15 years) were 3.95, 3.03 and 2.14 L/day, respectively. Significant sex differentials were observed between ages 16-55 years. For all participants, a sharp increase in water intake up to 15 years of age was observed followed by a plateau at a higher intake level. Significant monthly, seasonal, regional, and occupational variability was also observed. Another study involving 413 subjects determined the amount of indirect water intake. Average indirect water intake per person was 1.80±0.64 L/day; for adult males, adult females and children, intake was 2.15, 1.81, and 1.10 L/day, respectively. Average total (direct + indirect) water intake was 4.92 L/person/day; for adult males, adult females and children, total intake was 6.10, 4.84, and 3.24 L/person/day, respectively. The overall contribution of indirect water intake to total water consumption was 36.6% for all participants. This study additionally elucidated several factors that contribute to variable water intake, which can lead to better risk characterization of subpopulations and water contaminant ingestion. The study reveals that the water intake rates in the three studied populations in West Bengal are greater than the assumed water intake rates utilized by the World Health Organization (WHO) in the establishment of drinking water quality guidelines; therefore, these assumed intake values may be inappropriate for the study population as well as similar ones.

Additional danger of arsenic exposure through inhalation from burning of cow dung cakes laced with arsenic as a fuel in arsenic affected villages in Ganga-Meghna-Brahmaputra plain.

In arsenic contaminated areas of the Ganga-Meghna-Brahmaputra (GMB) plain (area 569,749 sq. km; population over 500 million) where traditionally cow dung cake is used as a fuel in unventilated ovens for cooking purposes, people are simply exposed to 1859.2 ng arsenic per day through direct inhalation, of which 464.8 ng could be absorbed in respiratory tract.

An eight-year study report on arsenic contamination in groundwater and health effects in Eruani village, Bangladesh and an approach for its mitigation.

Based on several surveys during 1997-2005 and visits of a medical team to Eruani village, Laksham upazila, Comilla district, Bangladesh, the arsenic contamination situation and consequent clinical manifestations of arsenicosis among the villagers, including dermatology, neuropathy, and obstetric outcome, are reported here. Analysis of biological samples from patients and non-patients showed high body burden of arsenic. Even after eight years of known exposure, village children were still drinking arsenic-contaminated water, and many of them had arsenical skin lesions. There were social problems due to the symptoms of arsenicosis. The last survey established that there is a lack of proper awareness among villagers about different aspects of arsenic toxicity. The viability of different options of safe water, such as dugwells, deep tubewells, rainwater harvesting, and surface water with watershed management in the village, was studied. Finally, based on 19 years of field experience, it was felt that, for any successful mitigation programme, emphasis should be given to creating awareness among villagers about the arsenic problem, role of arsenic-free water, better nutrition from local fruits and vegetables, and, above all, active participation of women along with others in the struggle against the arsenic menace.

Arsenic contamination in groundwater: a global perspective with emphasis on the Asian scenario.

The incidence of high concentrations of arsenic in drinking-water has emerged as a major public-health problem. With newer-affected sites discovered during the last decade, a significant change has been observed in the global scenario of arsenic contamination, especially in Asian countries. This communication presents an overview of the current scenario of arsenic contamination in countries across the globe with an emphasis on Asia. Along with the present situation in severely-affected countries in Asia, such as Bangladesh, India, and China, recent instances from Pakistan, Myanmar, Afghanistan, Cambodia, etc. are presented.

Status of groundwater arsenic contamination and human suffering in a Gram Panchayet (cluster of villages) in Murshidabad, one of the nine arsenic affected districts in West Bengal, India.

A detailed study was carried out in a cluster of villages known as Sagarpara Gram Panchayet (GP), covering an area of 20 km2 and population of 24,419 to determine the status of groundwater arsenic contamination and related health effects. The arsenic analysis of all hand tubewells (n = 565) in working condition showed, 86.2% and 58.8% of them had arsenic above 10, and 50 microgl(-1), respectively. The groundwater samples from all 21 villages in Sagarpara GP contained arsenic above 50 microgl(-1). In our preliminary clinical survey across the 21 villages, 3,302 villagers were examined and 679 among them (20.6%) were registered with arsenical skin lesions. A total of 850 biological samples (hair, nail and urine) were analysed from the affected villages and, on average, 85% of them contained arsenic above the normal level. Thus, many people of Sagarpara might be sub-clinically affected. Our data was compared with the international one to estimate population in Sagarpara GP at risk from arsenical skin lesions and cancer. Proper watershed management and economical utilization of available surface water resources along with the villagers' participation is urgently required to combat the present arsenic crisis.

Ineffectiveness and poor reliability of arsenic removal plants in West Bengal, India.

In the recent past, arsenic contamination in groundwater has emerged as an epidemic in different Asian countries, such as Bangladesh, India, and China. Arsenic removal plants (ARP) are one possible option to provide arsenic-safe drinking water. This paper evaluates the efficiency of ARP projects in removing arsenic and iron from raw groundwater, on the basis of our 2-year-long study covering 18 ARPs from 11 manufacturers, both from home and abroad, installed in an arsenic affected area of West Bengal, India, known as the Technology Park Project (TP project). Immediately after installation of ARPs on August 29, 2001, the villagers began using filtered water for drinking and cooking, even though our first analysis on September 13, 2001 found that 10 of 13 ARPs failed to remove arsenic below the WHO provisional guideline value (10 microg/L), while six plants could not achieve the Indian Standard value (50 microg/L). The highest concentration of arsenic in filtered water was observed to be 364 microg/L. Our 2-year study showed that none of the ARPs could maintain arsenic in filtered water below the WHO provisional guideline value and only two could meet the Indian standard value (50 microg/L) throughout. Standard statistical techniques showed that ARPs from the same manufacturers were not equally efficient. Efficiency of the ARPs was evaluated on the basis of point and interval estimates of the proportion of failure. During the study period almost all the ARPs have undergone minor or major modifications to improve their performance, and after our study, 15 (78%) out of 18 ARPs were no longer in use. In this study, we also analyzed urine samples from villagers in the TP project area and found that 82% of the samples contained arsenic above the normal limit.

Murshidabad--one of the nine groundwater arsenic-affected districts of West Bengal, India. Part I: magnitude of contamination and population at risk.

INTRODUCTION: To understand the severity of the arsenic crisis in West Bengal, India, a detailed, 3-year study was undertaken in Murshidabad, one of the nine arsenic-affected districts in West Bengal. The district covers an area of 5324 km2 with a population of 5.3 million. METHODS: Hand tubewell water samples and biologic samples were collected from Murshidabad and analyzed for arsenic by FI-HG-AAS method. Inter laboratory analysis and analyses of standards were undertaken for quality assurance. RESULTS: During our survey we analyzed 29,612 hand tubewell water samples for arsenic from both contaminated and non-contaminated areas, and 26% of the tubewells were found to have arsenic above 50 microg/L while 53.8% had arsenic above 10 microg/L. Of the 26 blocks in Murshidabad, 24 were found to have arsenic above 50 microg/L. Based on our generated data we estimated that approximately 0.2 million hand tubewells are installed in all 26 blocks of Murshidabad and 1.8 million in nine arsenic-affected districts of West Bengal. It was estimated on the basis of our data that about 2.5 million and 1.2 million people were drinking arsenic-contaminated water with concentrations above 10 and 50 microg/L levels respectively in this district. The analysis of total 3800 biologic (nail, urine, and hair) samples from arsenic-affected villages revealed that 95% of the nail and 94% of the urine samples contained arsenic above the normal levels and 75% of the hair samples were found to have arsenic above the toxic level. Thus, many villagers in the affected areas of Murshidabad might be subclinically affected. DISCUSSION AND CONCLUSION: Comparing our extrapolated data with international dose response results, we estimated how many people may suffer from arsenical skin lesions and cancer. Finally, if the exposed population is provided safe water, better nutrition, and proper awareness about the arsenic problem, lives can be saved and countless suffering of the affected population can be avoided.

Murshidabad--one of the nine groundwater arsenic-affected districts of West Bengal, India. Part II: dermatological, neurological, and obstetric findings.

INTRODUCTION: To understand the severity of related health effects of chronic arsenic exposure in West Bengal, a detailed 3-year study was carried out in Murshidabad, one of the nine arsenic-affected districts in West Bengal. METHODS: We screened 25,274 people from 139 arsenic-affected villages in Murshidabad to identify patients suffering from chronic arsenic toxicity for evidence of multisystemic features and collected biological samples such as head hair, nail, and spot urine from the patients along with the tubewell water they were consuming. RESULTS: Out of 25,274 people screened, 4813 (19%) were registered with arsenical skin lesions. A case series involving arsenical skin lesions resulting in cancer and gangrene were noted during this study. Representative histopathological pictures of skin biopsy of different types of lesions were also presented. Out of 2595 children we examined for arsenical skin lesions, 122 (4%) were registered with arsenical skin lesions, melanosis with or without keratosis. Different clinical and electrophysiological neurological features were noticed among the arsenic-affected villagers. Both the arsenic content in the drinking water and duration of exposure may be responsible in increasing the susceptibility of pregnant women to spontaneous abortions, stillbirths, preterm births, low birth weights, and neonatal deaths. Some additional multisystemic features such as weakness and lethargy, chronic respiratory problems, gastrointestinal symptoms, and anemia were also recorded in the affected population. DISCUSSION: The findings from this survey on different health effects of arsenic exposure were compared to those from previous studies carried out on arsenic-affected populations in India and Bangladesh as well as other affected countries. CONCLUSION: Multisystemic disorders, including dermal effects, neurological complications, and adverse obstetric outcomes, were observed to be associated with chronic arsenic exposure in the study population in Murshidabad, West Bengal. The magnitude of severity was related to the concentration of arsenic in water as well as duration of the exposure.

Failure of national guidelines to diagnose uncomplicated malaria in Bangladesh.

During the mid 1990s, national guidelines were established in accordance with World Health Organization recommendations for the diagnosis of uncomplicated malaria in Bangladesh. Based on simple clinical and epidemiologic criteria these guidelines were designed to be applied outside of tertiary care centers where microscopy was not feasible. We evaluated the positive predictive value (PPV) of these criteria using microscopic slide examinations as the gold standard in 684 subjects diagnosed and treated for malaria, sampling from eight subdistrict centers. The PPV for malaria was 32% with 19% for falciparum and 14% for Plasmodium vivax. Medical officers assigned to the study also gave their own clinical impression of whether cases could have been malaria. With the additional criteria of a medical officers' diagnosis, the PPV increased negligibly to 37% with 23% and 14% for falciparum and vivax, respectively. Since the PPV of diagnosis is low and cannot be improved on clinical grounds alone, we recommend the incorporation of laboratory diagnosis. This is especially important as we detect resistance to the first-line therapy chloroquine and require more expensive, potentially more toxic, regimens.