Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys.

Background: After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods: We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results: Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016. Conclusions: Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

Adult mortality trends in Matlab, Bangladesh: an analysis of cause-specific risks.

OBJECTIVE: With socioeconomic development, improvement in preventing and curing infectious diseases, and increased exposure to non-communicable diseases (NCDs) risk factors (eg, overweight/obesity, sedentary lifestyle), the majority of adult deaths in Bangladesh in recent years are due to NCDs. This study examines trends in cause-specific mortality risks using data from the Matlab Health and Demographic Surveillance System (HDSS). DESIGN, SETTINGS AND PARTICIPANTS: We conducted a follow-up study from 2003 to 2017 using data from Matlab HDSS, which covers a rural population of 0.24 million (in 2018) in Chandpur, Bangladesh. HDSS assessed the causes of all deaths using verbal autopsy and classified the causes using the 10th revision of the International Statistical Classification of Diseases. We examined 19 327 deaths involving 2 279 237 person-years. METHODS: We calculated annual cause-specific mortality rates and estimated adjusted proportional HRs using a Cox proportional hazards model. RESULTS: All-cause mortality risk declined over the study period among people aged 15 and older, but the risk from stroke increased, and from heart disease and cancers remained unchanged. These causes were more common among middle-aged and older people and thus bore the most burden. Mortality from causes other than NCDs-namely, infectious and respiratory diseases, injuries, endocrine disorders and others-declined yet still constituted over 30% of all deaths. Thus, the overall mortality decline was associated with the decline of causes other than NCDs. Mortality risk sharply increased with age. Men had higher mortality than women from heart disease, cancers and other causes, but not from stroke. Lower household wealth quintile people have higher mortality than higher household wealth quintile people, non-Muslims than Muslims. CONCLUSION: Deaths from stroke, heart disease and cancers were either on the rise or remained unchanged, but other causes declined continuously from 2003 to 2017. Immediate strengthening of the preventive and curative healthcare systems for NCDs management is a burning need.

Socioeconomic disparities in diabetes prevalence and management among the adult population in Bangladesh.

BACKGROUND: Diabetes, one of the major metabolic disorders, is rising in Bangladesh. Studies indicate there is inequality in prevalence and care-seeking behavior, which requires further exploration to understand the socioeconomic disparities in the pathophysiology of diabetes. This study examined the latest nationally representative estimates of diabetes prevalence, awareness, and management among adults aged 18 years and above in Bangladesh and its association with socioeconomic status in 2017-18. METHODS: We used the 2017-18 Bangladesh Demographic and Health Survey data. Diabetic status of 12,092 adults aged 18 years and above was measured in the survey using fasting plasma glucose levels. We applied multivariate logistic regressions to examine the role of socioeconomic status on diabetes prevalence, awareness, and management, after controlling for relevant covariates. RESULTS: Overall, 10% of adults had diabetes in Bangladesh in 2017-18, with the highest prevalence of 16% in the age group 55-64 years. Our analyses found statistically significant disparities by socioeconomic status in the prevalence of diabetes as well as the person's awareness of his/her diabetic condition. However, the effect of socioeconomic status on receiving anti-diabetic medication only approached significance (p = 0.07), and we found no significant association between socioeconomic status and control of diabetes. CONCLUSIONS: We expect to see an 'accumulation' of the number of people with diabetes to continue in the coming years. The rising prevalence of diabetes is only the tip of an iceberg; a large number of people with uncontrolled diabetes and a lack of awareness of their condition will lead to increased morbidity and mortality, and that could be the real threat. Immediate measures to increase screening coverage and exploration of poor control of diabetes are required to mitigate the situation.

Improving methods to measure comparable mortality cause (IMMCMC) gold standard verbal autopsy dataset.

OBJECTIVES: Gold standard cause of death data is critically important to improve verbal autopsy (VA) methods in diagnosing cause of death where civil and vital registration systems are inadequate or poor. As part of a three-country research study-Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study-data were collected on clinicopathological criteria-based gold standard cause of death from hospital record reviews with matched VAs. The purpose of this data note is to make accessible a de-identified format of these gold standard VAs for interested researchers to improve the diagnostic accuracy of VA methods. DATA DESCRIPTION: The study was conducted between 2011 and 2014 in the Philippines, Bangladesh, and Papua New Guinea. Gold standard diagnoses of underlying causes of death for deaths occurring in hospital were matched to VAs conducted using a standardized VA questionnaire developed by the Population Health Metrics Consortium. 3512 deaths were collected in total, comprised of 2491 adults (12 years and older), 320 children (28 days to 12 years), and 702 neonates (0-27 days).

Demographic, socioeconomic, and biological correlates of hypertension in an adult population: evidence from the Bangladesh demographic and health survey 2017-18.

BACKGROUND: Bangladesh is well advanced in the epidemiologic transition from communicable to noncommunicable diseases, which now account for two out of three deaths annually. This paper examines the latest nationally representative hypertension prevalence estimates, awareness, treatment, and control-to identify their association with potential correlates. METHODS: The analyses are based on the recent Bangladesh Demographic and Health Survey 2017-18 data. Univariate analyses and bivariate analyses between the outcome variables and individual covariates were carried out. Then chi-square tests were done to see the proportional differences between them. To examine the demographic, socioeconomic and biological factors affecting hypertension, awareness, treatment and control, we used multivariate logistic regression models. RESULTS: We found that prevalence of hypertension for females and males together aged 35 or more has risen by half between 2011 (25.7%) to 2017 (39.4%). With the broader age range used in 2017, the prevalence is now 27.5% in the population aged 18 years or more. The factors associated with hypertension included older age, being female, urban residence, higher wealth status, minimal education, higher body mass index and high blood glucose level. Following multivariate analyses, many of these characteristics were no longer significant, leaving only age, being female, nutritional status and elevated blood glucose level as important determinants. Over half (58%) of females and males who were found to be hypertensive were not aware they had the condition. Only one in eight (13%) had the condition under control. CONCLUSION: In the coming years, a rising trend in hypertension in Bangladeshi adults is expected due to demographic transition towards older age groups and increase in overweight and obesity among the population of Bangladesh. With more women being hypertensive than men, a targeted approach catering to high risk groups should be thoroughly implemented following the Multisectoral NCD Action Plan 2018-2025. Acting in close collaboration with other ministries/relevant sectors to bring an enabling environment for the citizens to adopt healthy lifestyle choices is a prerequisite for adequate prevention. While screening the adult population is essential, the public sector cannot possibly manage the ever-expanding numbers of hypertensives. The private sector and NGOs need to be drawn into the program to assist.

An Association between Rainy Days with Clinical Dengue Fever in Dhaka, Bangladesh: Findings from a Hospital Based Study.

BACKGROUND: Dengue, a febrile illness, is caused by a Flavivirus transmitted by Aedes aegypti and Aedes albopictus mosquitoes. Climate influences the ecology of the vectors. We aimed to identify the influence of climatic variability on the occurrence of clinical dengue requiring hospitalization in Zone-5, a high incidence area of Dhaka City Corporation (DCC), Bangladesh. METHODS AND FINDINGS: We retrospectively identified clinical dengue cases hospitalized from Zone-5 of DCC between 2005 and 2009. We extracted records of the four major catchment hospitals of the study area. The Bangladesh Meteorological Department (BMD) provided data on temperature, rainfall, and humidity of DCC for the study period. We used autoregressive integrated moving average (ARIMA) models for the number of monthly dengue hospitalizations. We also modeled all the climatic variables using Poisson regression. During our study period, dengue occurred throughout the year in Zone-5 of DCC. The median number of hospitalized dengue cases was 9 per month. Dengue incidence increased sharply from June, and reached its peak in August. One additional rainy day per month increased dengue cases in the succeeding month by 6% (RR = 1.06, 95% CI: 1.04-1.09). CONCLUSIONS: Dengue is transmitted throughout the year in Zone-5 of DCC, with seasonal variation in incidence. The number of rainy days per month is significantly associated with dengue incidence in the subsequent month. Our study suggests the initiation of campaigns in DCC for controlling dengue and other Aedes mosquito borne diseases, including Chikunguniya from the month of May each year. BMD rainfall data may be used to determine campaign timing.

HEV study protocol : design of a cluster-randomised, blinded trial to assess the safety, immunogenicity and effectiveness of the hepatitis E vaccine HEV 239 (Hecolin) in women of childbearing age in rural Bangladesh.

INTRODUCTION: Hepatitis E virus (HEV) is a leading cause of acute viral hepatitis in the developing world and is a public health problem, in particular among pregnant women, where it may lead to severe or fatal complications. A recombinant HEV vaccine, 239 (Hecolin; Xiamen Innovax Biotech, Xiamen, China), is licensed in China, but WHO calls for further studies to evaluate the safety and immunogenicity of this vaccine in vulnerable populations, and to evaluate protection in pregnancy. We are therefore conducting a phase IV trial to assess the effectiveness, safety and immunogenicity of the HEV 239 vaccine when given in women of childbearing age in rural Bangladesh, where HEV infection is endemic. METHODS AND ANALYSIS: Enrolment of a target of approximately 20 000 non-pregnant women, aged 16-39 years, started on 2 October 2017 in Matlab, Bangladesh. Sixty-seven villages were randomised by village at a 1:1 ratio to receive either the HEV vaccine or the control vaccine (hepatitis B vaccine). A 3-dose vaccination series at 0, 1 and 6 months is ongoing, and women are followed up for 24 months. The primary outcome is confirmed HEV disease among pregnant women. After vaccination, participants are requested to report information about clinical hepatitis symptoms. Participants who become pregnant are visited at their homes every 2 weeks to collect information about pregnancy outcome and to screen for clinical hepatitis. All suspected hepatitis cases undergo laboratory testing for diagnostic evaluation. The incidence of confirmed HEV disease among pregnant and non-pregnant women will be compared between the HEV vaccinated and control groups, safety and immunogenicity of the vaccine will also be evaluated. ETHICS AND DISSEMINATION: The protocol was reviewed and approved by the International Centre for Diarrhoeal Disease Research, Bangladesh Research Review Committee and Ethical Review Committee, and the Directorate General of Drug Administration in Bangladesh, and by the Regional Ethics Committee in Norway. This article is based on the protocol version 2.2 dated 29 June 2017. We will present the results through peer-reviewed publications and at international conferences. TRIAL REGISTRATION NUMBER: The trial is registered at clinicaltrials.gov with the registry name "Effectiveness Trial to Evaluate Protection of Pregnant Women by Hepatitis E Vaccine in Bangladesh" and the identifier NCT02759991.

Reducing Inequity in Urban Health: Have the Intra-urban Differentials in Reproductive Health Service Utilization and Child Nutritional Outcome Narrowed in Bangladesh?

Bangladesh is undergoing a rapid urbanization process. About one-third of the population of major cities in the country live in slums, which are areas that exhibit pronounced concentrations of factors that negatively affect health and nutrition. People living in slums face greater challenge to improve their health than other parts of the country, which fuels the growing intra-urban health inequities. Two rounds of the Bangladesh Urban Health Survey (UHS), conducted in 2013 and 2006, were designed to examine the reproductive health status and service utilization between slum and non-slum residents. We applied an adaptation of the difference-in-differences (DID) model to pooled data from the 2006 and 2013 UHS rounds to examine changes over time in intra-urban differences between slums and non-slums in key health outcomes and service utilization and to identify the factors associated with the reduction in intra-urban gaps. In terms of change in intra-urban differentials during 2006-2013, DID regression analysis estimated that the gap between slums and non-slums for skilled birth attendant (SBA) during delivery significantly decreased. DID regression analysis also estimated that the gap between slums and non-slums for use of modern contraceptives among currently married women also narrowed significantly, and the gap reversed in favor of slums. However, the DID estimates indicate a small but not statistically significant reduction in the gap between slums and non-slums for child nutritional status. Results from extended DID regression model indicate that availability of community health workers in urban areas appears to have played a significant role in reducing the gap in SBA. The urban population in Bangladesh is expected to grow rapidly in the coming decades. Wide disparities between urban slums and non-slums can potentially push country performance off track during the post-2015 era, unless the specific health needs of the expanding slum communities are addressed. To our knowledge, this is the first systematic explanation and quantification of the role of various factors for improving intra-urban health equity in Bangladesh using nationally representative data. The findings provide a strong rationale for continuing and expanding community-based reproductive health services in urban areas by the NGOs with a focus on slum populations.

Arsenic exposure and young adult's mortality risk: A 13-year follow-up study in Matlab, Bangladesh.

BACKGROUND: Widespread arsenic contamination in underground water is a well-documented public health concern that threatens millions of lives worldwide. We investigated the risk of young-adult mortality due to high chronic exposure to arsenic through years of drinking arsenic contaminated water. METHODS: A prospective cohort study of 58,406 individuals was enrolled who were 4-18 years at baseline. Since Matlab HDSS (Health and Demographic Surveillance System) has an active surveillance system, all individuals were included in the follow up. Each individual's arsenic exposure was calculated at (1) baseline As level as current exposure (2) time-weighted lifetime (average or lifetime average) and (3) cumulative arsenic exposure. Age, sex, educational attainment and SES were adjusted during the analysis. In this 13 years closed-cohort study (2003-2015), all young-adult deaths were captured through verbal autopsy (VA) using International Classification of Diseases (ICD-10) to define the causes. RESULTS: Although, girls had higher values of cumulative arsenic exposure via tube well water than boys (median: 1858.5 µg/year/L vs. 1798.8 µg/year/L) but higher mortality due to cancers and due to cerebro-vascular disease, cardio-vascular disease, and respiratory disease (7.0 vs. 5.7 per 100,000 person-years and 6.4 vs. 4.2 per 100,000 person-years respectively). Higher risk of deaths among young adults (Adjusted HR: 2.7, 1.3-5.8) due to all cancers among those who were exposed to As > 138.7 compared to As ≤ 1.1 µg/L. For cerebro-vascular disease, cardio-vascular disease, and respiratory disease deaths, average arsenic in well water (>223.1 µg/L vs. ≤90.9 µg/L) and cumulative arsenic in well water (>2711.0 µg/year/L vs. ≤1013.3 µg/year/L) had 4.8 (1.8-12.8) and 5.1 (1.7-15.1) times higher risks of mortality than to those lowest exposed. CONCLUSION: Higher concentration of, and chronic exposure to arsenic in drinking water, increases the mortality risk among the young adults, regardless of gender.

Comparing tariff and medical assistant assigned causes of death from verbal autopsy interviews in Matlab, Bangladesh: implications for a health and demographic surveillance system.

BACKGROUND: Deaths in developing countries often occur outside health facilities, making it extremely difficult to gather reliable cause of death (COD) information. Automated COD assignment using a verbal autopsy instrument (VAI) has been proposed as a reliable and cost-effective alternative to traditional physician-certified verbal autopsy, but its performance is still being evaluated. The purpose of this study was to compare the similarity of diagnosis by Medical Assistants (MA) in the Matlab Health and Demographic Surveillance System (HDSS) with the SmartVA Analyze 1.2 (Tariff 2.0) diagnosis. METHODS: This study took place between January 2011 and April 2014 in Matlab, Bangladesh. MA with 3 years of medical training assigned COD to Matlab residents by reviewing the information collected using the Population Health Metrics Research Consortium (PHMRC) long-form VAI. Smart VA Analyze 1.2 automatically assigned COD using the same questionnaire. COD agreement and cause-specific mortality fractions (CSMFs) were compared for MA and Tariff. RESULTS: Of the 4969 verbal autopsy cases reviewed, 4328 were adults, 296 were children, and 345 were neonates. Cohen's kappa was 0.38 (0.36, 0.40) for adults, 0.43 (0.38, 0.49) for children, and 0.27 (0.22, 0.33) for neonates. For adults, the top two COD for MA were stroke (29.6%) and ischemic heart diseases (IHD) (14.2%) and for Tariff these were stroke (32.0%) and IHD (14.0%). For children, the top two COD for MA were drowning (33.5%) and pneumonia (13.2%) and for Tariff these were also drowning (36.8%) and pneumonia (12.4%). For neonates, the top two COD for MA were birth asphyxia (41.2%) and meningitis/sepsis (22.3%) and for Tariff these were birth asphyxia (37.0%) and preterm delivery (30.9%). CONCLUSION: The CSMFs for Tariff and MA showed very close agreement across all age categories but some differences were observed for neonate preterm delivery and meningitis/sepsis. Given the known advantages of automated methods over physician certified verbal autopsy, the SmartVA software, incorporating the shortened VAI questionnaire and Tariff 2.0, could serve as a cost-effective alternative to Matlab MA to routinely collect and analyze verbal autopsy data in a HDSS to generate essential population level COD data for planning.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

BACKGROUND: Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. METHODS: The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data. RESULTS: The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%). CONCLUSION: Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

Implementing the PHMRC shortened questionnaire: Survey duration of open and closed questions in three sites.

BACKGROUND: More countries are using verbal autopsy as a part of routine mortality surveillance. The length of time required to complete a verbal autopsy interview is a key logistical consideration for planning large-scale surveillance. METHODS: We use the PHMRC shortened questionnaire to conduct verbal autopsy interviews at three sites and collect data on the length of time required to complete the interview. This instrument uses a novel checklist of keywords to capture relevant information from the open response. The open response section is timed separately from the section consisting of closed questions. RESULTS: We found the median time to complete the entire interview was approximately 25 minutes and did not vary substantially by age-specific module. The median time for the open response section was approximately 4 minutes and 60% of interviewees mentioned at least one keyword within the open response section. CONCLUSIONS: The length of time required to complete the interview was short enough for large-scale routine use. The open-response section did not add a substantial amount of time and provided useful information which can be used to increase the accuracy of the predictions of the cause of death. The novel checklist approach further reduces the burden of transcribing and translating a large amount of free text. This makes the PHMRC instrument ideal for national mortality surveillance.

Spatial and temporal dynamics of multidimensional well-being, livelihoods and ecosystem services in coastal Bangladesh.

Populations in resource dependent economies gain well-being from the natural environment, in highly spatially and temporally variable patterns. To collect information on this, we designed and implemented a 1586-household quantitative survey in the southwest coastal zone of Bangladesh. Data were collected on material, subjective and health dimensions of well-being in the context of natural resource use, particularly agriculture, aquaculture, mangroves and fisheries. The questionnaire included questions on factors that mediate poverty outcomes: mobility and remittances; loans and micro-credit; environmental perceptions; shocks; and women's empowerment. The data are stratified by social-ecological system to take into account spatial dynamics and the survey was repeated with the same respondents three times within a year to incorporate seasonal dynamics. The dataset includes blood pressure measurements and height and weight of men, women and children. In addition, the household listing includes basic data on livelihoods and income for approximately 10,000 households. The dataset facilitates interdisciplinary research on spatial and temporal dynamics of well-being in the context of natural resource dependence in low income countries.

The Evolving Demographic and Health Transition in Four Low- and Middle-Income Countries: Evidence from Four Sites in the INDEPTH Network of Longitudinal Health and Demographic Surveillance Systems.

This paper contributes evidence documenting the continued decline in all-cause mortality and changes in the cause of death distribution over time in four developing country populations in Africa and Asia. We present levels and trends in age-specific mortality (all-cause and cause-specific) from four demographic surveillance sites: Agincourt (South Africa), Navrongo (Ghana) in Africa; Filabavi (Vietnam), Matlab (Bangladesh) in Asia. We model mortality using discrete time event history analysis. This study illustrates how data from INDEPTH Network centers can provide a comparative, longitudinal examination of mortality patterns and the epidemiological transition. Health care systems need to be reconfigured to deal simultaneously with continuing challenges of communicable disease and increasing incidence of non-communicable diseases that require long-term care. In populations with endemic HIV, long-term care of HIV patients on ART will add to the chronic care needs of the community.

Using health and demographic surveillance for the early detection of cholera outbreaks: analysis of community- and hospital-based data from Matlab, Bangladesh.

BACKGROUND: Cholera outbreaks are a continuing problem in Bangladesh, and the timely detection of an outbreak is important for reducing morbidity and mortality. In Matlab, the ongoing Health and Demographic Surveillance System (HDSS) data records symptoms of diarrhea in children under the age of 5 years at the community level. Cholera surveillance in Matlab currently uses hospital-based data. OBJECTIVE: The objective of this study is to determine whether increases in cholera in Matlab can be detected earlier by using HDSS diarrhea symptom data in a syndromic surveillance analysis, when compared to hospital admissions for cholera. METHODS: HDSS diarrhea symptom data and hospital admissions for cholera in children under 5 years of age over a 2-year period were analyzed with the syndromic surveillance statistical program EARS (Early Aberration Reporting System). Dates when significant increases in either symptoms or cholera cases occurred were compared to one another. RESULTS: The analysis revealed that there were 43 days over 16 months when the cholera cases or diarrhea symptoms increased significantly. There were 8 months when both data sets detected days with significant increases. In 5 of the 8 months, increases in diarrheal symptoms occurred before increases of cholera cases. The increases in symptoms occurred between 1 and 15 days before the increases in cholera cases. CONCLUSIONS: The results suggest that the HDSS survey data may be able to detect an increase in cholera before an increase in hospital admissions is seen. However, there was no direct link between diarrheal symptom increases and cholera cases, and this, as well as other methodological weaknesses, should be taken into consideration.

Fifteen years of sector-wide approach (SWAp) in Bangladesh health sector: an assessment of progress.

The Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh embarked on a sector-wide approach (SWAp) modality for the health, nutrition and population (HNP) sector in 1998. This programmatic shift initiated a different set of planning disciplines and practices along with institutional changes in the MOHFW. Over the years, the SWAp modality has evolved in Bangladesh as the MOHFW has learnt from its implementation and refined the program design. This article explores the progress made, both in terms of achievement of health outcomes and systems strengthening results, since the implementation of the SWAp for Bangladesh's health sector. Secondary analyses of survey data from 1993 to 2011 as well as a literature review of published and grey literature on health SWAp in Bangladesh was conducted for this assessment. Results of the assessment indicate that the MOHFW made substantial progress in health outcomes and health systems strengthening. SWAps facilitated the alignment of funding and technical support around national priorities, and improved the government's role in program design as well as in implementation and development partner coordination. Notable systemic improvements have taken place in the country systems with regards to monitoring and evaluation, procurement and service provision, which have improved functionality of health facilities to provide essential care. Implementation of the SWAp has, therefore, contributed to an accelerated improvement in key health outcomes in Bangladesh over the last 15 years. The health SWAp in Bangladesh offers an example of a successful adaptation of such an approach in a complex administrative structure. Based on the lessons learned from SWAp implementation in Bangladesh, the MOHFW needs to play a stronger stewardship and regulatory role to reap the full benefits of a SWAp in its subsequent programming.

Prenatal arsenic exposure and drowning among children in Bangladesh.

There is increasing concern regarding adverse effects of prenatal arsenic exposure on the neurodevelopment of children. We analyzed mortality data for children, who were born to 11,414 pregnant women between 2002 and 2004, with an average age of 5 years of follow-up. Individual drinking-water arsenic exposure during pregnancy was calculated using tubewell water arsenic concentration between last menstrual period and date of birth. There were 84 drowning deaths registered, with cause of death ascertained using verbal autopsy (International Classification of Diseases, 10th revision, codes X65-X70). The prenatal water arsenic exposure distribution was tertiled, and the risk of drowning mortality was estimated by Cox proportional hazard models, adjusted for potential confounders. We observed a significant association between prenatal arsenic exposure and drowning in children aged 1-5 years in the highest exposure tertile (HR=1.74, 95% CI: 1.03-2.94). This study showed that in utero arsenic exposure might be associated with excess mortality among children aged 1-5 years due to drowning.

Causes of adult female deaths in Bangladesh: findings from two National Surveys.

BACKGROUND: Assessment of causes of death and changes in pattern of causes of death over time are needed for programmatic purposes. Limited national level data exist on the adult female causes of death in Bangladesh. METHOD: Using data from two nationally representation surveys, the 2001 and 2010 Bangladesh Maternal Mortality Surveys (BMMS), the paper examines the causes of adult female death, aged 15-49 years, and changes in the patterns of these deaths. In both surveys, all household deaths three years prior to the survey were identified. Adult female deaths were then followed by a verbal autopsy (VA) using the WHO structured questionnaire. Two physicians independently reviewed the VA forms to assign a cause of death using the ICD-10; in case of disagreement, a third physician made an independent review and assigned a cause of death. RESULTS: The overall mortality rates for women aged 15-49 in 2001 and 2010 were 182 per 100,000 and 120 per 100,000 respectively. There is a shift in the pattern of causes of death during the period covered by the two surveys. In the 2001 survey, the main causes of death were maternal (20 %), followed by diseases of the circulatory system (15 %), malignancy (14 %) and infectious diseases (13 %). However, in the 2010 survey, malignancies were the leading cause (21 %), followed by diseases of the circulatory system (16 %), maternal causes (14 %) and infectious diseases (8 %). While maternal deaths remained the number one cause of death among 20-34 years old in both surveys, unnatural deaths were the main cause for teenage deaths, and malignancies were the main cause of death for older women. Although there is an increasing trend in the proportion of women who died in hospitals, in both surveys most women died at home (74 % in 2001 and 62 % in 2010). CONCLUSION: The shift in the pattern of causes of adult female deaths is in agreement with the overall change in the disease pattern from communicable to non-communicable diseases in Bangladesh. Suicide and other violent deaths as the primary cause of deaths among teenage girls demands specific interventions to prevent such premature deaths. Prevention of deaths due to non-communicable diseases should also be a priority.

Agricultural livelihoods in coastal Bangladesh under climate and environmental change--a model framework.

Coastal Bangladesh experiences significant poverty and hazards today and is highly vulnerable to climate and environmental change over the coming decades. Coastal stakeholders are demanding information to assist in the decision making processes, including simulation models to explore how different interventions, under different plausible future socio-economic and environmental scenarios, could alleviate environmental risks and promote development. Many existing simulation models neglect the complex interdependencies between the socio-economic and environmental system of coastal Bangladesh. Here an integrated approach has been proposed to develop a simulation model to support agriculture and poverty-based analysis and decision-making in coastal Bangladesh. In particular, we show how a simulation model of farmer's livelihoods at the household level can be achieved. An extended version of the FAO's CROPWAT agriculture model has been integrated with a downscaled regional demography model to simulate net agriculture profit. This is used together with a household income-expenses balance and a loans logical tree to simulate the evolution of food security indicators and poverty levels. Modelling identifies salinity and temperature stress as limiting factors to crop productivity and fertilisation due to atmospheric carbon dioxide concentrations as a reinforcing factor. The crop simulation results compare well with expected outcomes but also reveal some unexpected behaviours. For example, under current model assumptions, temperature is more important than salinity for crop production. The agriculture-based livelihood and poverty simulations highlight the critical significance of debt through informal and formal loans set at such levels as to persistently undermine the well-being of agriculture-dependent households. Simulations also indicate that progressive approaches to agriculture (i.e. diversification) might not provide the clear economic benefit from the perspective of pricing due to greater susceptibility to climate vagaries. The livelihood and poverty results highlight the importance of the holistic consideration of the human-nature system and the careful selection of poverty indicators. Although the simulation model at this stage contains the minimum elements required to simulate the complexity of farmer livelihood interactions in coastal Bangladesh, the crop and socio-economic findings compare well with expected behaviours. The presented integrated model is the first step to develop a holistic, transferable analytic method and tool for coastal Bangladesh.