Effectiveness, safety and economic viability of daycare versus usual hospital care management of severe pneumonia with or without malnutrition in children using the existing health system of Bangladesh: a cluster randomised controlled trial.

Background: We aimed to define clinical and cost-effectiveness of a Day Care Approach (DCA) alternative to Usual Care (UC, comparison group) within the Bangladesh health system to manage severe childhood pneumonia. Methods: This was a cluster randomised controlled trial in urban Dhaka and rural Bangladesh between November 1, 2015 and March 23, 2019. Children aged 2-59 months with severe pneumonia with or without malnutrition received DCA or UC. The DCA treatment settings comprised of urban primary health care clinics run by NGO under Dhaka South City Corporation and in rural Union health and family welfare centres under the Ministry of Health and Family welfare Services. The UC treatment settings were hospitals in these respective areas. Primary outcome was treatment failure (persistence of pneumonia symptoms, referral or death). We performed both intention-to-treat and per-protocol analysis for treatment failure. Registered at www.ClinicalTrials.gov, NCT02669654. Findings: In total 3211 children were enrolled, 1739 in DCA and 1472 in UC; primary outcome data were available in 1682 and 1357 in DCA and UC, respectively. Treatment failure rate was 9.6% among children in DCA (167 of 1739) and 13.5% in the UC (198 of 1472) (group difference, -3.9 percentage point; 95% confidence interval (CI), -4.8 to -1.5, p = 0.165). Treatment success within the health care systems [DCA plus referral vs. UC plus referral, 1587/1739 (91.3%) vs. 1283/1472 (87.2%), group difference 4.1 percentage point, 95% CI, 3.7 to 4.1, p = 0.160)] was better in DCA. One child each in UC of both urban and rural sites died within day 6 after admission. Average cost of treatment per child was US$94.2 (95% CI, 92.2 to 96.3) and US$184.8 (95% CI, 178.6 to 190.9) for DCA and UC, respectively. Interpretation: In our population of children with severe pneumonia with or without malnutrition, >90% were successfully treated at Day care Clinics at 50% lower cost. A modest investment to upgrade Day care facilities may provide a cost-effective, accessible alternative to hospital management. Funding: UNICEF, Botnar Foundation, UBS Optimus Foundation, and EAGLE Foundation, Switzerland.

Long-term neurological and functional outcome in Nipah virus infection.

OBJECTIVE: Nipah virus (NiV) is an emerging zoonosis. Central nervous system disease frequently results in high case-fatality. Long-term neurological assessments of survivors are limited. We assessed long-term neurologic and functional outcomes of 22 patients surviving NiV illness in Bangladesh. METHODS: During August 2005 and May 2006, we administered a questionnaire on persistent symptoms and functional difficulties to 22 previously identified NiV infection survivors. We performed neurologic evaluations and brain magnetic resonance imaging (MRI). RESULTS: Twelve (55%) subjects were male; median age was 14.5 years (range 6-50). Seventeen (77%) survived encephalitis, and 5 survived febrile illness. All but 1 subject had disabling fatigue, with a median duration of 5 months (range, 8 days-8 months). Seven encephalitis patients (32% overall), but none with febrile illness had persistent neurologic dysfunction, including static encephalopathy (n = 4), ocular motor palsies (2), cervical dystonia (2), focal weakness (2), and facial paralysis (1). Four cases had delayed-onset neurologic abnormalities months after acute illness. Behavioral abnormalities were reported by caregivers of over 50% of subjects under age 16. MRI abnormalities were present in 15, and included multifocal hyperintensities, cerebral atrophy, and confluent cortical and subcortical signal changes. INTERPRETATION: Although delayed progression to neurologic illness following Nipah fever was not observed, persistent fatigue and functional impairment was frequent. Neurologic sequelae were frequent following Nipah encephalitis. Neurologic dysfunction may persist for years after acute infection, and new neurologic dysfunction may develop after acute illness. Survivors of NiV infection may experience substantial long-term neurologic and functional morbidity.

Prevalence of Chlamydophila pneumoniae among Bangladeshi children under age 5 years with acute respiratory infections.

Despite major improvements in the diagnosis of pathogenic organisms causing acute respiratory infections (ARIs), details of infections caused by atypical pathogens are not well understood, particularly in developing countries. This clinical and epidemiological research was conducted in Bangladesh to explore the prevalence of atypical pathogens in causing childhood pneumonia. Sixty-four children with ARI were studied at the Pediatric Outpatient Department of Dhaka Medical College Hospital, Bangladesh, during September through December 2000. In addition to clinical examination, hematological, radiological, and bacteriological examinations were performed. Antibody titers from paired sera against Mycoplasma pneumoniae and Legionella spp. in the acute and convalescent phases revealed that none of these children were infected with M. pneumoniae, while only one serum sample was positive for L. pneumophila serogroup 4. Antibody titers against Chlamydophila (Chlamydia) pneumoniae, determined by an indirect microimmunofluorescence method, and by an enzyme-linked immunosorbent assay (ELISA) kit (HITAZYME C. pneumoniae kit) indicated that 13 children (20.3%) were infected with C. pneumoniae. Our results indicate a high prevalence rate of C. pneumoniae, suggesting it is as an important causative pathogen of childhood pneumonia in Bangladesh.

Common transfusion-transmitted infectious agents among thalassaemic children in Bangladesh.

Transfusion-dependent children are more prone to acquiring various transfusion-transmitted infections (TTIs), such as hepatitis B (HBV), hepatitis C (HCV), HIV, and others. Since the magnitude of these infections among thalassaemic children in Bangladesh is not well-known, this study was conducted to assess the prevalence of TTIs among them (who received more than three blood transfusions) compared to their age- and sex-matched controls (non-thalassaemics and those who had never had a transfusion). Seromarkers for HBV, HCV, HDV, Treponema pallidum, and HIV were tested, and the results were analyzed using SPSS/Windows 10.5. Of 259 children studied, 152 (58.69%) were thalassaemic (mean age 6.8 +/- 3.6 years), and 107 were controls (mean age 6.7 +/- 3.53 years). The HBV and HCV-markers were found significantly more often among multi-transfused thalassaemic children than among the controls in terms of HBsAg (13.8% vs 6.5%, p < 0.04), anti-HBc total (39.5% vs 9.4%, p < 0.0001), and anti-HCV (12.5% vs 0.9%, p < 0.0001). HBeAg did not differ (p = 0.82) between the thalassaemics (9.52%) and the controls (14.28%), whereas anti-HBe differed (0% vs 57.14%, p < 0.003). Neither the thalassaemics nor the controls were positive for HDV, HIV, or T. pallidum. Since more thalassaemic children acquired hepatitis B and C infections through multiple blood transfusions, it is recommended that the safe blood-transfusion programme be strengthened and mass vaccination against HBV (even who suffer from HCV) in Bangladesh be undertaken.

Vertical transmission of dengue: first case report from Bangladesh.

We report a case of vertical transmission of dengue infection in a new born from Bangladesh. The mother was primigravida with an uneventful antenatal period except the fever she developed at 37 weeks of gestation. She underwent cesarean section for decreased fetal movement. The fever lasted for 7 days and was associated with intense bodyache, and a positive tourniquet test. She did not experience any hemorrhages including from the surgical wound. Her platelet count fell at its lowest to 100,000/mm3. She had bilateral mild pleural effusions and positive anti-dengue antibodies (both IgG and IgM). She received symptomatic treatment. The baby was deeply meconium stained and was resuscitated by a pediatrician. His postnatal period went well until day-3 of life when he developed fever and respiratory distress. There were no signs of meconiun aspiration syndrome (MAS) and the septic work up was negative. The platelets count fell to its lowest of 40,000/mm3 on day-3 and day-5 of his illness. Anti-dengue antibodies (both IgG and IgM) were positive with a nearly four-fold rise of IgM antibodies in the convalescent sera. The boy was treated with platelet transfusions and was discharged on day-6 after becoming ill. This report emphasizes that in a dengue epidemic or when dengue is endemic (which Bangladesh has experienced recently), a pregnant woman with fever, myalgia and/or bleeding manifestations should raise a high suspicion that the baby may develop the disease, and both the mother and baby should be closely followed-up. Viral isolation could not be done due to the unavailability of the test.