The ability of non-physician health workers to identify chest indrawing to detect pneumonia in children below five years of age in low- and middle-income countries: A systematic review and meta-analysis.

Background: Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low- and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers' ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs. Methods: We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity. Results: We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97). Conclusions: We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children. New studies are needed to assess the new generation of health workers. Registration: PROSPERO (CRD42022306954).

Developing a video expert panel as a reference standard to evaluate respiratory rate counting in paediatric pneumonia diagnosis: protocol for a cross-sectional study.

INTRODUCTION: Manual counting of respiratory rate (RR) in children is challenging for health workers and can result in misdiagnosis of pneumonia. Some novel RR counting devices automate the counting of RR and classification of fast breathing. The absence of an appropriate reference standard to evaluate the performance of these devices is a challenge. If good quality videos could be captured, with RR interpretation from these videos systematically conducted by an expert panel, it could act as a reference standard. This study is designed to develop a video expert panel (VEP) as a reference standard to evaluate RR counting for identifying pneumonia in children. METHODS AND ANALYSIS: Using a cross-sectional design, we will enrol children aged 0-59 months presenting with suspected pneumonia at different levels of health facilities in Dhaka and Sylhet, Bangladesh. We will videorecord a physician/health worker counting RR manually and also using an automated RR counter (Children's Automated Respiration Monitor) from each child. We will establish a standard operating procedure for capturing quality videos, make a set of reference videos, and train and standardise the VEP members using the reference videos. After that, we will assess the performance of the VEP as a reference standard to evaluate RR counting. We will calculate the mean difference and proportions of agreement within±2 breaths per minute and create Bland-Altman plots with limits of agreement between VEP members. ETHICS AND DISSEMINATION: The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 39315022021) and Edinburgh Medical School Research Ethics Committee (EMREC), Edinburgh, UK (REC Reference: 21-EMREC-040). Dissemination of the study findings will be through conference presentations and publications in peer-reviewed scientific journals.

A Case of Brain Tuberculosis With an Unusual Presentation Mimicking Viral Fever During a Dengue Outbreak in Bangladesh.

Both dengue and tuberculosis are endemic in South Asian countries, including Bangladesh. Here we report an interesting case presenting as suspected dengue fever and eventually diagnosed as a case of brain tuberculosis. A 27-year-old immunocompetent male presented to us with fever, headache, retro-orbital pain, and photophobia for five days. He had no other complaints, and clinical examination findings were normal. Full blood count revealed neutrophilic leukocytosis; dengue antigen test and anti-dengue antibody test were negative. Magnetic resonance imaging (MRI) of the brain showed both supra and infra-tentorial multiple small (2-4 mm) gadolinium-enhancing lesions suggestive of tuberculomas. A cerebrospinal fluid study revealed lymphocytic pleocytosis with raised protein, low sugar level, and positive Gene Xpert MTB/RIF (Cepheid, California, US) assay test. Investigations did not reveal the involvement of other organs except for the brain. We started standard anti-tuberculosis therapy (HRZE) along with steroids and pyridoxine, and the patient became symptom-free within one week. The patient was discharged with the advice of follow-up after one month. The clinical course and all investigation findings of this case are presented. Central nervous system tuberculosis may present with non-specific signs and symptoms and may be misdiagnosed as other infections, including dengue, particularly during an ongoing epidemic. It may cause significant morbidity and mortality when the diagnosis is delayed due to its vague clinical presentation.

Digital auscultation as a novel childhood pneumonia diagnostic tool for community clinics in Sylhet, Bangladesh: protocol for a cross-sectional study.

INTRODUCTION: The WHO's Integrated Management of Childhood Illnesses (IMCI) algorithm for diagnosis of child pneumonia relies on counting respiratory rate and observing respiratory distress to diagnose childhood pneumonia. IMCI case defination for pneumonia performs with high sensitivity but low specificity, leading to overdiagnosis of child pneumonia and unnecessary antibiotic use. Including lung auscultation in IMCI could improve specificity of pneumonia diagnosis. Our objectives are: (1) assess lung sound recording quality by primary healthcare workers (HCWs) from under-5 children with the Feelix Smart Stethoscope and (2) determine the reliability and performance of recorded lung sound interpretations by an automated algorithm compared with reference paediatrician interpretations. METHODS AND ANALYSIS: In a cross-sectional design, community HCWs will record lung sounds of ~1000 under-5-year-old children with suspected pneumonia at first-level facilities in Zakiganj subdistrict, Sylhet, Bangladesh. Enrolled children will be evaluated for pneumonia, including oxygen saturation, and have their lung sounds recorded by the Feelix Smart stethoscope at four sequential chest locations: two back and two front positions. A novel sound-filtering algorithm will be applied to recordings to address ambient noise and optimise recording quality. Recorded sounds will be assessed against a predefined quality threshold. A trained paediatric listening panel will classify recordings into one of the following categories: normal, crackles, wheeze, crackles and wheeze or uninterpretable. All sound files will be classified into the same categories by the automated algorithm and compared with panel classifications. Sensitivity, specificity and predictive values, of the automated algorithm will be assessed considering the panel's final interpretation as gold standard. ETHICS AND DISSEMINATION: The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 09630012018) and Academic and Clinical Central Office for Research and Development Medical Research Ethics Committee, Edinburgh, UK (REC Reference: 18-HV-051). Dissemination will be through conference presentations, peer-reviewed journals and stakeholder engagement meetings in Bangladesh. TRIAL REGISTRATION NUMBER: NCT03959956.

Maternal mental health and child nutritional status in an urban slum in Bangladesh: A cross-sectional study.

Poor mental health may diminish a mother's capacity to adequately care for her child, resulting in a negative impact on the child's nutrition. This study aims to determine the association between maternal mental health and child nutritional status in a poor urban population in Bangladesh. We carried out a cross-sectional study among 264 mother-child pairs in an urban slum area of Bangladesh. The Self-Reporting Questionnaire-20 (SRQ-20) was used to assess maternal mental health. An SRQ-20 score ≥7 was considered a common mental disorder (CMD). Anthropometric measurements were performed to assess nutritional status of the children. The prevalence of maternal CMD was 46.2%. Maternal CMD was associated with poorer child feeding practice (p<0.001), poorer hygiene practice (p<0.001), poorer preventive care service use (p = 0.016), and suffering from diarrheal diseases (p = 0.049). The prevalence of stunting, wasting and underweight in children was 44.3%, 18.2% and 33.7%, respectively. A poorer child feeding practice was associated with wasting (p = 0.004) and underweight (p<0.001) but not with stunting. Poorer hygiene practices and suffering from diarrheal diseases were associated with stunting and underweight, but not with wasting. In multivariable analysis, maternal CMD was associated with child wasting (adjusted odds ratio, aOR = 2.25, 95% CI = 1.15-4.43). The association between maternal CMD and child underweight found in the bivariate analysis was attenuated and no longer statistically significant after multivariable analysis (aOR = 1.77, 95% CI = 0.94-3.33). No statistically significant association was observed between maternal CMD and stunting in this study (aOR = 1.46, 95% CI = 0.84-2.54). Maternal mental health affects nutritional status of the children where child feeding practice, hygiene practice and preventive care use might play a role. Interventions to address maternal mental health in child nutrition programs might improve child nutritional status.

Accuracy of Mid-Upper Arm Circumference for Detecting Acute Malnutrition in Children Aged 6-59 Months in an Urban Slum in Bangladesh: A Cross-Sectional Analysis.

Background The weight-for-height z-score (WHZ) is considered the gold standard for detecting acute malnutrition in children. However, an accurate assessment of WHZ can often be challenging, especially in community settings. Mid-upper arm circumference (MUAC) is a simple and easy-to-perform method to identify children with acute malnutrition. The objective of the study was to evaluate the accuracy of MUAC in detecting acute malnutrition compared to WHZ among children aged 6-59 months in Bangladesh. Methods We used anthropometric data for 239 children aged 6-59 months from a cross-sectional study conducted in 2013 in an urban slum in Dhaka, Bangladesh. The sensitivity and specificity of MUAC to detect acute malnutrition were calculated, considering WHZ as the gold standard. Results The mean age of the children was 29.4 ± 12.7 months, with a male-to-female ratio of 1:1.2. The prevalence of acute malnutrition was 17.1% and 22.5% based on WHZ and MUAC, respectively. The total area under the receiver operating characteristic curve was 0.816. For detecting acute malnutrition, the sensitivity of MUAC was 61.0% and the specificity was 85.4% for the World Health Organization (WHO) recommended cutoff of <125 mm. Using the Youden index, the best MUAC cutoff point to detect acute malnutrition was <128 mm with a sensitivity of 75.6% and a specificity of 74.7%. Conclusions Our study demonstrated a low sensitivity of MUAC to identify acute malnutrition at the WHO cutoff of <125 mm. The cutoff could be increased to <128 mm to capture more children with acute malnutrition.

Adverse Events Following COVISHIELD Vaccination Among Adult Population in Bangladesh.

The study aimed to determine how frequently the adverse events of the COVISHIELD vaccine occur among the Bangladeshi population. This cross-sectional study was conducted at Sheikh Russel Gastroliver Institute and Hospital, Mohakhali, Dhaka, Bangladesh, in May 2021. The inclusion criteria were the adult populations who received the 2nd dose of the COVISHELD vaccine and had passed 28 days following the completion of the 2nd dose. Three hundred and five persons fulfilling the inclusion criteria were asked over the telephone-based on a predesigned questionnaire. The rates of adverse events were 54.1% and 41.3% after the 1st and 2nd dose of vaccine, respectively, and the difference was statistically significant (p < 0.001). Pain at the injection site was the most common adverse event (32.5% following the 1st dose and 27.9% following the 2nd dose). All of the symptoms were mild and lasted for about 2 days. Age and comorbidities were significantly associated with the adverse events (p < 0.001). Neither doses had any vaccine-related life-threatening adverse event nor had any symptoms related to vaccine-related blood clotting. Nineteen persons (6.2%) had been diagnosed with COVID-19 after the 1st dose of vaccination, and three (1%) persons had been diagnosed with COVID-19 after the 2nd dose of vaccination. As no significant life-threatening adverse event was observed, this study might help reduce the hesitancy for vaccination among the population and thus help reduce transmission of this highly contagious virus.

Proximal Myopathy With Hypercalcemic Crisis and Papillary Thyroid Carcinoma in a 38-Year-Old Female.

Although proximal myopathy is a well-known manifestation of primary hyperparathyroidism (PHP), it is usually not the first one. Here, we present the case of a 38-year-old female who presented to the neurology outpatient department with proximal myopathy as the presenting feature of PHP along with a hypercalcemic crisis. Her serum calcium and intact parathyroid hormone levels were very high. Her symptoms and calcium levels improved with adequate hydration and bisphosphonate therapy. Ultrasonography of the thyroid and parathyroid glands and Tc99m sestamibi single-photon emission computed tomography-computed tomography of the parathyroid glands suggested adenoma or carcinoma of the parathyroid gland on the right side with another irregular right-sided thyroid nodule. Electromyography showed low-amplitude polyphasic potentials suggestive of myopathy. Subsequently, the patient underwent surgical resection of both the right parathyroid glands and the thyroid nodule. Histopathology report was suggestive of parathyroid adenoma and papillary thyroid carcinoma. Hypercalcemic crisis is a rare clinical scenario, which needs prompt diagnosis and treatment. Otherwise, the condition may have a fatal outcome. Due to its diverse presentation, physicians should be aware of this condition. Moreover, we need to be cautious in treating a patient having hyperparathyroidism with thyroid nodule due to possible concomitant thyroid malignancy.

A Rare Case of Severe Neutropenia Due to Chikungunya Fever Which Improved With Filgrastim.

Chikungunya fever is a re-emerging viral illness affecting different parts of the world. Most patients recover without any serious complications. Here, we present a rare case of chikungunya fever with severe neutropenia and moderate thrombocytopenia. A 31-year-old male presented with a fever, body aches, and rash. Serial full blood counts revealed a very low neutrophil count (0.273 × 109/L) with a low platelet count (56 × 109/L). Dengue fever was excluded by doing both antigen and antibody tests. The IgM antibody against the chikungunya virus was positive. After giving one dose of granulocyte colony-stimulating factor (G-CSF) filgrastim, the neutropenia resolved. A few days later, the thrombocytopenia resolved as well. Other than episodic attacks of arthritis, he recovered completely. The absence of severe neutropenia and thrombocytopenia is considered a major demarcating feature between chikungunya fever and dengue fever. Cases like this one put physicians in a difficult position regarding accurate diagnosis and appropriate management plans. The use of filgrastim may be considered as rescue therapy in a situation like this.

Role of Personal Protective Measures in Prevention of COVID-19 Spread Among Physicians in Bangladesh: a Multicenter Cross-Sectional Comparative Study.

This study aims to determine the role of personal protective measures in the prevention of COVID-19 spread among the physicians working at different health facilities in Bangladesh. This hospital-based cross-sectional comparative study was conducted from May to June 2020. A total of 98 COVID-19 positive physicians and 92 COVID-19 negative physicians (physicians with no symptoms of COVID-19 or who tested negative) were enrolled. The questionnaire was adapted from a tool developed by the World Health Organization (WHO) for risk assessment and management of exposure of healthcare workers in the context of COVID-19. Data were collected from the respondents online using Google forms. There was no significant difference in baseline information between COVID-19 positive and COVID-19 negative physicians. The physicians, who were unaware of direct participation in COVID-19 patient care, had higher odds of being COVID-19 positive (OR = 4.018; CI: 1.532-10.535). Additionally, the physicians, who were unaware of the COVID-19 status while performing the aerosol-generated procedure (AGP), had a higher chance of being COVID-19 positive (OR = 2.522; CI: 1.020-6.233). Using face shields/goggles (OR = 0.437; CI:0.228-0.837) and regular decontamination of the patient's surroundings (OR = 0.392; CI:0.176-0.873) while usual take care of patients and use of N95 masks while performing AGP (OR = 0.372; CI:0.159-0.873) had protective roles against COVID-19 among the physicians. The physicians who had reused the medical gown had two times more chances of being tested positive for COVID-19 than those who had not reused it (OR = 2.3; CI:1.251-4.259). The use of face shields/goggles and N95 masks and decontamination of the patient's surroundings may give protection against COVID-19. Additionally, reusing medical gowns should be avoided as much as possible.

Implementation research to support Bangladesh Ministry of Health and Family Welfare to implement its national guidelines for management of infections in young infants in two rural districts.

BACKGROUND: World Health Organization revised the global guidelines for management of possible serious bacterial infection (PSBI) in young infants to recommend the use of simplified antibiotic therapy in settings where access to hospital care is not possible. The Bangladesh Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GOB) adopted these guidelines, allowing treatment at first-level facilities. During the first year of implementation, the Projahnmo Study Group and USAID/MaMoni Health Systems Strengthening (HSS) Project supported the MoHFW to operationalize the new guidelines and conducted an implementation research study in selected districts to assess challenges and identify solutions to facilitate scale-up across the country. IMPLEMENTATION SUPPORT: Projahnmo and MaMoni HSS teams supported implementation in three areas: building capacity, strengthening service delivery, and mobilizing communities. Capacity building focused on training paramedics to conduct outpatient management of PSBI cases and developing monitoring and supervision systems. The teams also filled gaps in government supply of essential drugs, equipment, and logistics. Community mobilization strategies to promote care-seeking and referrals to facilities varied across districts; in one district community, health workers made home visits while in another district, the promotion was carried out through community volunteers, village doctors, and through existing community structures. METHODS: We followed a plan-do-study-act (PDSA) cycle to identify and address implementation challenges. Three cycles-1 every 4 months-were conducted. We collected data utilizing quantitative and qualitative methods in both the community and facilities. The total sample size for this study was 13,590. DISCUSSION: This article provides implementation research design details for program managers intending to implement new guidelines on management of young infant infections. Results of this research will be reported in the forthcoming papers. Preliminary findings indicate that the management of PSBI cases at the UH&FWCs is feasible. However, MoHFW, GOB needs to address the implementation challenges before scale-up of this policy to the national level.

Prevalence and factors associated with hypertension among adults in rural Sylhet district of Bangladesh: a cross-sectional study.

OBJECTIVES: Low-income and middle-income countries are undergoing epidemiological transition, however, progression is varied. Bangladesh is simultaneously experiencing continuing burden of communicable diseases and emerging burden of non-communicable diseases (NCDs). For effective use of limited resources, an increased understanding of the shifting burden and better characterisation of risk factors of NCDs, including hypertension is needed. This study provides data on prevalence and factors associated with hypertension among males and females 35 years and older in rural Bangladesh. METHODS: This is a population-based cross-sectional study conducted in Zakiganj and Kanaighat subdistricts of Sylhet district of Bangladesh. Blood pressure was measured and data on risk factors were collected using STEPS instrument from 864 males and 946 females aged 35 years and older between August 2017 and January 2018. Individuals with systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg or taking antihypertensive drugs were considered hypertensive. Bivariate and multivariate analyses were performed to identify factors associated with hypertension. RESULTS: The prevalence of hypertension was 18.8% (95% CI 16.3 to 21.5) and 18.7% (95% CI 16.3 to 21.3) in adult males and females, respectively. Among those who were hypertensive, the prevalence of controlled, uncontrolled and unaware/newly identified hypertension was 23.5%, 25.9% and 50.6%, respectively among males and 38.4%, 22.6% and 39.0%, respectively among females. Another 22.7% males and 17.8% females had prehypertension. Increasing age and higher waist circumference (≥90 cm for males and ≥80 cm for females) were positively associated with hypertension both in males (OR 4.0, 95% CI 2.5 to 6.4) and females (OR 2.8, 95% CI 2.0 to 4.1). CONCLUSIONS: In view of the high burden of hypertension and prehypertension, a context-specific scalable public health programme including behaviour change communications, particularly to increase physical activity and consumption of healthy diet, as well as identification and management of hypertension needs to be developed and implemented.

Parenchymal asbestosis due to primary asbestos exposure among ship-breaking workers: report of the first cases from Bangladesh.

We report for the first time asbestosis among ship-breaking workers of Sitakunda in Bangladesh who were exposed to asbestos during ship-based and beach-based operations for at least 10 years. Asbestosis was present among 35% of workers. Years of work (>20) and forced vital capacity (<80% of predicted) were significantly associated with the disease. Currently, global ship-breaking operations are mainly concentrated in the Indian subcontinent, and Bangladesh has the majority share. Ninety per cent of domestic steel is produced in the ship-breaking operations in Bangladesh and is an important contributor to the economy. It also gives employment to more than 100 000 people. It is imperative to medically check up all the workers for benign and malignant diseases causally related to asbestos among these vulnerable population of workers.

Maternal common mental disorders and associated factors: a cross-sectional study in an urban slum area of Dhaka, Bangladesh.

BACKGROUND: Poor maternal mental health has a negative impact on child growth and development. The objective of the study was to find out the associated factors of maternal common mental disorders (CMD) in an urban slum area of Bangladesh. METHODS: This cross-sectional study was carried out from September to November 2013 among conveniently selected 264 mothers having under-five children at Kamrangirchar area of Dhaka. A structured questionnaire based on Self-Reporting Questionnaire-20 (SRQ-20) was used for data collection where a cut-off of 7 was considered to ascertain CMD. RESULTS: Majority of the mothers were housewives (89.8%), educated up to primary level (40.9%) and lived in nuclear families (83.0%) with low socioeconomic status (64.4%) and moderate household food insecurity (57.5%). The prevalence of maternal CMD was 46.2%. In bivariate analysis, the associated factors of CMD were higher maternal age (p = 0.043), lower educational qualification (p = 0.015), low socioeconomic status (p = 0.004), household food insecurity (p < 0.001), maternal undernutrition (p = 0.001), child wasting (p = 0.005) and child underweight (p < 0.001). Household food insecurity (p < 0.001) and maternal undernutrition (p = 0.004) were identified as associated factors of maternal CMD after controlling for socio-demographic variables. There were about 5 times and 12 times increased odds of having maternal CMD in moderately (adjusted OR = 4.8, 95% CI 2.0-11.7) and severely food insecure household (adjusted OR = 11.6, 95% CI 3.5-38.1), respectively, than food secure one. Underweight mothers had 2.5 times increased odds of experiencing CMD as compared with mothers who were not underweight (adjusted OR = 2.6, 95% CI 1.4-5.0). CONCLUSION: The prevalence of maternal CMD was relatively higher than other developing countries studied so far. Household food insecurity and maternal under-nutrition were the associated factors of maternal CMD. Therefore, interventions to improve household food security and maternal nutrition can improve maternal CMD and thus make useful contributions to child growth and development.

Basic occupational health services (BOHS) in community primary care: the MSF (Dhaka) model.

The Médecins Sans Frontiérs (MSF) established basic occupational health services to diagnose and treat work-related diseases among tannery, metal, plastics and garment workers and families in one of the more polluted areas of the world populated by 600 000 people. In spite of project limitations, an analysis of the 6-month data showed that of the original cohort of 5000, 3200 (64%) came for at least 1 consultation. Among them, 468 (14.6%) were diagnosed with suspected work-related diseases as per defined protocols. Follow-up consultation was performed for 1447 cases of occupational diseases and work-related injuries. The MSF experience begs the need for replication of such services in densely populated urban areas in developing nations like Bangladesh and India, where no specialty occupational health clinics exist in primary care but are desperately needed and where occupational health clinics on factory premises are exclusive to industry workers and are not accessible to communities.