Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

BACKGROUND

It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania.

METHODS

This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.

RESULTS

Study findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities.

CONCLUSIONS

We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan

BACKGROUND

Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk.

METHODS/DESIGN

The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics.

DISCUSSION

This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial

OBJECTIVES

Community-based maternal and newborn intervention packages have been shown to reduce neonatal mortality in resource-constrained settings. This analysis uses data from a large community-based cluster-randomized trial to assess the impact of a community-based package on cause-specific neonatal mortality and draws programmatic and policy implications. In addition, the study shows that cause-specific mortality estimates vary substantially based on the hierarchy used in assigning cause of death, which also has important implications for program planning. Therefore, understanding the methods of assigning causes of deaths is important, as is the development of new methodologies that account for multiple causes of death. The objective of this study was to estimate the effect of two service delivery strategies (home care and community care) for a community-based package of maternal and neonatal health interventions on cause-specific neonatal mortality rates in a rural district of Bangladesh.

STUDY DESIGN

Within the general community of the Sylhet district in rural northeast Bangladesh. Pregnancy histories were collected from a sample of women in the study area during the year preceding the study (2002) and from all women who reported a pregnancy outcome during the intervention in years 2004 to 2005. All families that reported a neonatal death during these time periods were asked to complete a verbal autopsy interview. Expert algorithms with two different hierarchies were used to assign causes of neonatal death, varying in placement of the preterm/low birth weight category within the hierarchy (either third or last). The main outcome measure was cause-specific neonatal mortality.

RESULT

Deaths because of serious infections in the home-care arm declined from 13.6 deaths per 1000 live births during the baseline period to 7.2 during the intervention period according to the first hierarchy (preterm placed third) and from 23.6 to 10.6 according to the second hierarchy (preterm placed last).

CONCLUSION

This study confirms the high burden of neonatal deaths because of infection in low resource rural settings like Bangladesh, where most births occur at home in the absence of skilled birth attendance and care seeking for newborn illnesses is low. The study demonstrates that a package of community-based neonatal health interventions, focusing primarily on infection prevention and management, can substantially reduce infection-related neonatal mortality.

Household Animal and Human Medicine Use and Animal Husbandry Practices in Rural Bangladesh: Risk Factors for Emerging Zoonotic Disease and Antibiotic Resistance

Animal antimicrobial use and husbandry practices increase risk of emerging zoonotic disease and antibiotic resistance. We surveyed 700 households to elicit information on human and animal medicine use and husbandry practices. Households that owned livestock (n = 265/459, 57.7%) reported using animal treatments 630 times during the previous 6 months; 57.6% obtained medicines, including antibiotics, from drug sellers. Government animal healthcare providers were rarely visited (9.7%), and respondents more often sought animal health care from pharmacies and village doctors (70.6% and 11.9%, respectively), citing the latter two as less costly and more successful based on past performance. Animal husbandry practices that could promote the transmission of microbes from animals to humans included the following: the proximity of chickens to humans (50.1% of households reported that the chickens slept in the bedroom); the shared use of natural bodies of water for human and animal bathing (78.3%); the use of livestock waste as fertilizer (60.9%); and gender roles that dictate that females are the primary caretakers of poultry and children (62.8%). In the absence of an effective animal healthcare system, villagers must depend on informal healthcare providers for treatment of their animals. Suboptimal use of antimicrobials coupled with unhygienic animal husbandry practices is an important risk factor for emerging zoonotic disease and resistant pathogens.

Testing a scalable community-based approach to improve maternal and neonatal health in rural Nepal

OBJECTIVE

The aim of the study was to determine the feasibility of improved maternal-neonatal care-seeking and household practices using an approach scalable under Nepal's primary health-care services.

STUDY DESIGN

Impact was assessed by pre- and post-intervention surveys of women delivering within the previous 12 months. Each district sample comprised 30 clusters, each with 30 respondents. The intervention consisted primarily of community-based antenatal counseling and dispensing and an early postnatal home visit; most activities were carried out by community-based health volunteers.

RESULT

There were notable improvements in most household practice and service utilization indicators, although results regarding care-seeking for danger signs were mixed.

CONCLUSION

It is feasible in a Nepal setting to significantly improve utilization of maternal-neonatal services and household practices, using the resources available under the government primary health-care system. This has the potential to significantly reduce neonatal mortality.

Can mothers recognize neonatal illness correctly? Comparison of maternal report and assessment by community health workers in rural Bangladesh

OBJECTIVES

To validate maternal recognition of neonatal illnesses at home compared to assessment by community health workers (CHWs) during routine household surveillance for neonatal illness in rural Bangladesh.

METHODS

Surveillance in the intervention arm of two cluster-randomized, controlled trials of newborn interventions conducted in Sylhet and Mirzapur districts of Bangladesh. CHWs promoted birth and newborn care preparedness during two prenatal visits, including recognition of neonatal illnesses. CHWs assessed 8472 neonates on post-natal days 0, 3, and 6 between 2004 and 2005 in Sylhet, and 7587 neonates on post-natal days 0, 2, 5, and 8 between 2004 and 2006 in Mirzapur. In both sites, CHW identified neonates with very severe disease (VSD), using clinical algorithms that included ascertainment of illness history reported by mother and observation of clinical signs of illness. We calculated sensitivity, specificity, positive predictive value and negative predictive value of maternal report of any illness sign compared to CHWs' assessments and classification of VSD. Analysis was restricted to mothers whose neonates were assessed by CHWs at home during the routine visit schedule.

RESULTS

Maternal report of any signs had sensitivity of 24% and 20% and positive predictive value of 45% and 54% in Sylhet and Mirzapur, respectively.

CONCLUSIONS

Maternal recognition of neonatal illnesses at home was poor in two rural areas in Bangladesh. Interventions need to be designed to improve maternal recognition, and routine post-natal assessment by CHWs at home may be an essential component of community-based newborn care to improve care-seeking for newborn illness.

Vitamin D status and acute lower respiratory infection in early childhood in Sylhet, Bangladesh

AIM

Acute lower respiratory tract infection (ALRI) is the most important global cause of childhood death. Micronutrient deficiencies may increase the risk of ALRI. A case-control study was conducted to assess the association between vitamin D status and ALRI in rural Bangladesh.

METHODS

Children aged 1-18 months hospitalized with ALRI (cases) were individually matched to controls on age, sex, and village (N = 25 pairs). The mean serum 25-hydroxyvitamin D concentration [25(OH)D] in cases and controls was compared using paired t-test. The unadjusted and adjusted odds of ALRI were assessed by multivariate conditional logistic regression.

RESULTS

Mean [25(OH)D] was significantly lower among ALRI cases than controls (29.1 nmol/L vs. 39.1 nmol/L; p = 0.015). The unadjusted odds of ALRI was halved for each 10 nmol/L increase in [25(OH)D] (OR 0.53, 95% CI 0.30-0.96). Adjustment for confounders increased the magnitude of the association.

CONCLUSION

Vitamin D status was associated with early childhood ALRI in a matched case-control study in rural Bangladesh. Randomized trials may establish whether interventions to improve vitamin D status can reduce the burden of ALRI in early childhood.

Addition of isovitalex in chocolate agar for the isolation of Haemophilus influenzae

BACKGROUND & OBJECTIVE

The reason for lack of data on burden of Haemophilus influenzae type b (Hib) in developing countries was mainly failure of detection of this fastidious organism in laboratories. Use of isovitalex (IVX) was suggested as an essential supplement for growing this organism. This study was carried out to investigate the impact of IVX supplementation to chocolate agar for detection of Hib.

METHODS

Chocolate agar with and without supplementation of IVX was prepared. Clinical samples as well as reference strains of Hib were simultaneously cultured on both the media.

RESULTS

H. influenzae isolates (N=194) were simultaneously grown on chocolate agar (CA) with and without isovitalex (IVX). Average colony size of H. influenzae on CA with IVX (CA-IVX) was larger only by 0.10 cm (range 0.05 to 0.16 cm) compared to CA alone. Addition of IVX to CA increased the cost of media by 2.1-fold.

INTERPRETATION & CONCLUSION

Isovitalex is not essential for the isolation and growth of H. influenzae almost halving the cost.

Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity.

Validation of accuracy and community acceptance of the BIRTHweigh III scale for categorizing newborn weight in rural India

OBJECTIVE

To determine the accuracy and acceptability of a handheld scale prototype designed for nonliterate users to classify newborns into three weight categories (>or=2,500 g; 2,000 to 2,499 g; and <2,000 g).

STUDY DESIGN

Weights of 1,100 newborns in Uttar Pradesh, India, were measured on the test scale and validated against a gold standard. Mothers, family members and community health stakeholders were interviewed to assess the acceptability of the test scale.

RESULT

The test scale was highly sensitive and specific at classifying newborn weight (normal weight: 95.3 and 96.3%, respectively; low birth weight: 90.4 and 99.2%, respectively; very low birth weight: 91.7 and 98.4%, respectively). It was the overall agreement of the community that the test scale was more practical and easier to interpret than the gold standard.

CONCLUSION

The BIRTHweigh III scale accurately identifies low birth weight and very low birth weight newborns to target weight-specific interventions. The scale is extremely practical and useful for resource-poor settings, especially those with low levels of literacy.

Low-dose weekly supplementation of iron and/or zinc does not affect growth among Bangladeshi infants

OBJECTIVES

To determine the effect of low-dose weekly supplementation with iron, zinc or both on growth of infants from 6 to 12 months of age.

SUBJECTS/METHODS

A total of 645 breastfed infants age 6 months who were not severely anemic (Hb> or = 90 g l(-1)) or severely malnourished (weight-for-age > or = 60% median) were randomized to receive 20 mg iron and 1 mg riboflavin; 20 mg zinc and 1 mg riboflavin; 20 mg iron, 20 mg zinc and 1 mg riboflavin; or riboflavin alone (control) weekly for 6 months.

RESULTS

Baseline characteristics were similar among the four supplementation groups. Weight, length and mid-upper arm circumference were assessed at baseline, 8, 10 and 12 months of age. There was no interaction of iron and zinc when given in a combined supplement on either weight or length (P>0.05). There were no effects of either iron or zinc on the rate of length or weight gain for all infants or when stratified by baseline Hb concentration.

CONCLUSIONS

Weekly supplementation of 20 mg Fe, 20 mg Zn, or both does not benefit growth among infants 6-12 months of age in rural Bangladesh, a region with high rates of anemia and zinc deficiency.

Feasibility of community neonatal death audits in rural Uttar Pradesh, India

OBJECTIVE

Medical audit is a widely promoted strategy in hospitals, but experience within community settings is scant. Community neonatal death audit is a form of audit, which involves a systematic analysis of the quality of care provided in the home, danger sign recognition and care seeking decision making for neonatal illness. This research was conducted in Uttar Pradesh, India, to investigate the feasibility and cultural acceptability of community neonatal death audits.

STUDY DESIGN

During November-December 2004, we conducted three in-depth interviews with family members of deceased neonates, and six focus group discussions with family and community members. Three approaches were evaluated: in-depth interview with the family before engaging them in an audit with the community; preliminary meeting to build rapport with the family and community before conducting an audit; and audit with the family and community in a single focus group. Approaches were interactive processes, involving the community, to identify avoidable factors in a particular death and discuss solutions.

RESULT

Carried out in a culturally sensitive and non-punitive manner, community neonatal death audit was found to be acceptable and feasible. All approaches provoked formal investigation by community members, and stimulated sharing of views, leading to the self-discovery that community perception was a cumulatively amplified effect of individual perceptions. Presence of an educated/experienced community member or health worker served as a catalyst. No one optimal approach was identified.

CONCLUSION

Community neonatal audit is an acceptable approach that shows promise as an effective intervention for improving neonatal health outcomes.

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

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

Newborn care in rural Uttar Pradesh

OBJECTIVES

To describe selected newborn care practices related to cord care, thermal care and breastfeeding in rural Uttar Pradesh and to identify socio-demographic, antenatal and delivery care factors that are associated with these practices.

METHODS

A cross-sectional survey in rural Uttar Pradesh included 13,167 women who had a livebirth at home during the two years preceding data collection. Logistic regression was used to identify socio-demographic, antenatal and delivery care factors that were associated with the three care practices.

RESULTS

Use of antenatal care and skilled attendance at delivery were significantly associated with clean cord care and early breastfeeding, but not with thermal care. Antenatal home visits by a community-based worker were associated only with clean cord care. Women who received counseling from health workers or other sources on each of the newborn care practices during pregnancy were more likely to report the respective care practices, although levels of counseling were low.

CONCLUSION

The association between newborn care practices and antenatal care, counseling and skilled delivery attendance suggest that evidence-based newborn care practices can be promoted through improved coverage with existing health services.

Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes

OBJECTIVE

To assess the rates, timing and causes of neonatal deaths and the burden of stillbirths in rural Uttar Pradesh, India. We discuss the implications of our findings for neonatal interventions.

METHODS

We used verbal autopsy interviews to investigate 1048 neonatal deaths and stillbirths.

FINDINGS

There were 430 stillbirths reported, comprising 41% of all deaths in the sample. Of the 618 live births, 32% deaths were on the day of birth, 50% occurred during the first 3 days of life and 71% were during the first week. The primary causes of death on the first day of life (i.e. day 0) were birth asphyxia or injury (31%) and preterm birth (26%). During days 1-6, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Half of all deaths caused by sepsis or pneumonia occurred during the first week of life. The proportion of deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively.

CONCLUSION

Stillbirths and deaths on the day of birth represent a large proportion of perinatal and neonatal deaths, highlighting an urgent need to improve coverage with skilled birth attendants and to ensure access to emergency obstetric care. Health interventions to improve essential neonatal care and care-seeking behavior are also needed, particularly for preterm neonates in the early postnatal period.

Introduction of community-based skin-to-skin care in rural Uttar Pradesh, India

OBJECTIVE

Two-thirds of women globally give birth at home, yet little data are available on use of skin-to-skin care (STSC) in the community. We describe the acceptability of STSC in rural Uttar Pradesh, India, and measured maternal, newborn, and ambient temperature in the home in order to inform strategies for introduction of STSC in the community.

STUDY DESIGN

Community-based workers in intervention clusters implemented a community mobilization and behavior change communication program that promoted birth preparedness and essential newborn care, including adoption of STSC, with pregnant mothers, their families, and key influential community members. Acceptance of STSC was assessed through in-depth interviews and focus groups, and temperature was measured during home visits on day of life 0 or 1.

RESULTS

Incidence of hypothermia (<36.5 degrees C) was high in both low birth weight (LBW) and normal birth weight (NBW) infants (49.2%, (361/733) and 43% (418/971), respectively). Mean body temperature of newborns was lower (P<0.01) in ambient temperatures <20 degrees C (35.9+/-1.4 degrees C, n=225) compared to > or =20 degrees C (36.5+/-0.9 degrees C, n=1450). Among hypothermic newborns, 42% (331/787) of their mothers had a lower temperature (range -6.7 to 0.1 degrees C, mean difference 0.4+/-1.2 degrees C). Acceptance of STSC was nearly universal. No adverse events from STSC were reported. STSC was perceived to prevent newborn hypothermia, enhance mother's capability to protect her baby from evil spirits, and make the baby more content.

CONCLUSION

STSC was highly acceptable in rural India when introduced through appropriate cultural paradigms. STSC may be of benefit for all newborns and for many mothers as well. New approaches are needed for introduction of STSC in the community compared to the hospital.

Prevalence of sputum smear-positive tuberculosis in a rural area in Bangladesh

The objective of the study was to determine the prevalence of smear-positive tuberculosis (TB) in a rural area in Bangladesh at Matlab. A TB surveillance system was established among 106,000 people in rural Bangladesh at Matlab. Trained field workers interviewed all persons aged > or = 15 years to detect suspected cases of TB (cough > 21 days) and sputum specimens of suspected cases were examined for acid-fast bacilli (AFB). Of 59,395 persons interviewed, 4235 (7.1%) had a cough for > 21 days. Sputum specimens were examined for AFB from 3834 persons, 52 (1.4%) of them were positive for AFB. The prevalence of chronic cough and sputum positivity were significantly higher among males compared to females (P < 0.001). The population-based prevalence rate of smear-positive TB cases was 95/100,000 among persons aged > or = 15 years. Cases of TB clustered geographically (relative risk 5.53, 95% CI 3.19-9.59). The high burden of TB among rural population warrants appropriate measures to control TB in Bangladesh. The higher prevalence of persistent cough and AFB-positive sputum among males need further exploration. Factors responsible for higher prevalence of TB in clusters should be investigated.

Delivery-related complications and early postpartum morbidity in Dhaka, Bangladesh

OBJECTIVE

To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh.

METHOD

From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum.

RESULT

Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions.

CONCLUSION

A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed.

Quality of care for under-fives in first-level health facilities in one district of Bangladesh

OBJECTIVE

The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes.

METHODS

Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers.

FINDINGS

Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver.

CONCLUSION

These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh.

Sexually transmitted infections prevalence rates in slum communities of Dhaka, Bangladesh

The study objective was to estimate the prevalence of selected sexually transmitted infections (STIs) and associated factors among Dhaka slum dwellers. Blood and urine specimens were collected from 1534 men and women. Participants in this cross-sectional study responded to a questionnaire, providing socioeconomic data, symptomatology and treatment-seeking behaviour. Specimens were tested for syphilis, hepatitis B (HBsAg), Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV. Serologic evidence of syphilis infection was found in 6.0% of respondents, HBsAg in 3.8%. Prevalence rates of gonorrhoea and chlamydia were 1.7% and <1%, respectively. No HIV infections were found. Men were more than twice as likely as women to be infected with syphilis or HBsAg carriers. Behaviours facilitating STI transmission were common among men. Syphilis infection is prevalent enough to warrant the initiation of screening programmes in this population. The prevalence rate of hepatitis B carriage suggests that this population would benefit from universal vaccination against hepatitis B.

Children's fluid intake during diarrhoea: a comparison of questionnaire responses with data from observations

Many of the individual questions used by the World Health Organization for household surveys on diarrhoea management have not been systematically assessed. This study assessed the use of simple questions to caretakers of children to estimate the proportion of young children who received increased quantities of fluids during diarrhoeal episodes by comparing caretakers' responses with data obtained by direct observations. Children aged 4-35 mo (n = 215) with diarrhoea starting within the last 24 h were observed for 12 h. These children were observed for 12 h again 2 wk later, when healthy. On the following day the questionnaire was administered to the caretakers. The observation focused on the frequency of feeding episodes, including breastfeeding and the type and quantity of fluids consumed by the child. The same questionnaire was administered to the caretakers of another group of children (n = 421) with diarrhoea in the past 2 wk. The mean number of feedings (6.0 +/- 3.8 vs 5.0 +/- 3.5), breastfeeding episodes (11.2 +/- 3.6 vs 8.4 +/- 3.3), breastfeeding duration (85.8 +/- 36.3 min vs 49.1 +/- 22.8 min), other fluid intake (345.8 +/- 309.6 ml vs 120.9 +/- 136.4 ml) and total fluid consumption (653.9 +/- 240.4 ml vs 399.5 +/- 133.6 ml) were significantly higher (p < 0.0001) during diarrhoea compared with healthy periods. At the population level, the simple questionnaire administered to caretakers was found to have high agreement between the reported increase in fluid consumption and the actual increase in fluid intake (defined as > or = 100 ml). At the individual level, caretakers' questionnaire responses for detecting increased fluid intake were highly sensitive (84.3%), but specificity (36.4%) and agreement (0.22) were low.

CONCLUSION

This study documents that children had higher fluid intake, which included both breast milk and other fluid, during acute episodes of diarrhoea. Further research is warranted to improve the specificity and agreement of caretakers' responses to simple questions regarding change in fluid intake during diarrhoeal episodes.

Rapid identification and antibiotic susceptibility testing of Salmonella enterica serovar Typhi isolated from blood: implications for therapy

The turnaround time (TAT) for Salmonella enterica serovar Typhi identification and reporting of the antibiotic susceptibility profile was determined for 391 cases of typhoid fever, using the lysis direct plating or lysis centrifugation method of blood culture along with rapid antimicrobial susceptibility testing. The TAT was more rapid (TAT for 90% of the patients [TAT(90)] = 30 h; TAT(100) Collapse

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MESH Headings

• Adolescent
• Adult
• Anti-Bacterial Agents/pharmacology
• Anti-Bacterial Agents/therapeutic use
• Bacteremia/drug therapy
• Bacteremia/microbiology
• Blood/microbiology
• Centrifugation
• Child
• Culture Media
• Drug Resistance, Multiple, Bacterial
• Hemolysis
• Humans
• Microbial Sensitivity Tests/methods
• Salmonella typhi/classification
• Salmonella typhi/drug effects
• Time Factors
• Typhoid Fever/drug therapy
• Typhoid Fever/microbiology

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Affiliation(s)

S K Saha Department of Microbiology, Institute of Child Health, Dhaka Shishu Hospital, Dhaka, Bangladesh.
G L Darmstadt
A H Baqui
M Hanif
M Ruhulamin
M Santosham
T Nagatake
R E Black

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Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial

OBJECTIVE

To evaluate the effect of simultaneous zinc and vitamin A supplementation on diarrhoea and acute lower respiratory infections in children.

STUDY DESIGN

Randomised double blind placebo controlled trial.

SETTING

Urban slums of Dhaka, Bangladesh.

PARTICIPANTS AND METHODS

800 children aged 12-35 months were randomly assigned to one of four intervention groups: 20 mg zinc once daily for 14 days; 200 000 IU vitamin A, single dose on day 14; both zinc and vitamin A; placebo. The children were followed up once a week for six months, and morbidity information was collected.

RESULTS

The incidence and prevalence of diarrhoea were lower in the zinc and vitamin A groups than in the placebo group. Zinc and vitamin A interaction had a rate ratio (95% confidence interval) of 0.79 (0.66 to 0.94) for the prevalence of persistent diarrhoea and 0.80 (0.67 to 0.95) for dysentery. Incidence (1.62; 1.16 to 2.25) and prevalence (2.07; 1.76 to 2.44) of acute lower respiratory infection were significantly higher in the zinc group than in the placebo group. The interaction term had rate ratios of 0.75 (0.46 to 1.20) for incidence and 0.58 (0.46 to 0.73) for prevalence of acute lower respiratory infection.

CONCLUSIONS

Combined zinc and vitamin A synergistically reduced the prevalence of persistent diarrhoea and dysentery. Zinc was associated with a significant increase in acute lower respiratory infection, but this adverse effect was reduced by the interaction between zinc and vitamin A.

Causes of childhood deaths in Bangladesh: an update

Knowledge of the causes of child death is important for health-sector planning since they relate to available interventions. Little is known about causes of child death in Bangladesh from the conventional sources since there is no vital registration system and very few deaths are attended by a qualified physician. To determine the cause structure of child deaths, verbal autopsy interviews were conducted in the Bangladesh Demographic and Health Survey (BDHS) 1993/94 national sample. Verbal autopsy is a method of finding out the causes of death based on an interview with the next of kin or other caregivers. Between BDHS 1993/94 and BDHS 1996/97, 1-4-y-old child mortality in Bangladesh declined by about 27.0%. This impressive decline prompted a verbal autopsy study using the BDHS 1996/97 national sample to determine whether the cause structure had changed. The same verbal autopsy instrument and methods to collect the data and the same computer algorithm to assign causes of death were used in both surveys. Comparison of BDHS 1993/94 and 1996/97 cause-specific mortality rates revealed that deaths due to almost all causes had declined, although significantly so only for acute respiratory infections (ARI), persistent diarrhoea and drowning. Deaths due to neonatal tetanus, acute watery diarrhoea and undernutrition had not decreased at all.

CONCLUSION

Despite an impressive decline in deaths due to ARI, this condition remains the most important known cause of death in Bangladeshi children. Neonatal tetanus and measles together account for about 10% of deaths in children under 5 y. Further improvements in child survival are possible by improving access to and quality of available child survival interventions.

Typhoid fever in Bangladesh: implications for vaccination policy

OBJECTIVE

To describe the age-specific distribution of typhoid fever including the degree of Salmonella typhi bacteremia among patients evaluated at a large private diagnostic center in Bangladesh, a highly endemic area.

METHODS

We conducted a prospective-, passive- and laboratory-based study to identify patients with S. typhi bacteremia. Subjects (n = 4,650) from whom blood cultures were obtained during 16-month period were enrolled from private clinics and hospitals throughout Dhaka. Isolation and quantification of S. typhi from blood cultures were performed by the lysis direct plating/ centrifugation method.

RESULTS

Bacterial pathogens were recovered from blood of 538 of 4,650 patients (11.6%) evaluated. S. typhi was the single most common pathogen recovered, comprising nearly three-fourths of isolates (72.7%; 391 of 538). Isolation rate of S. typhi was highest in monsoon and summer seasons and lowest in winter months. The majority (54.5%; 213 of 391) of S. typhi isolates were from children who were younger than 5 years, and 27% (105 of 391) were from children in the first 2 years of life. The isolation rate was highest (17.4%, 68 of 486) in the second year of life. The number of bacteria in blood on the basis of colony-forming units per ml of blood by age group was inversely related to age.

CONCLUSIONS

Detection of S. typhi bacteremia in young children in Dhaka, Bangladesh, was considerably higher than previously appreciated, with a peak detection rate in children < or =2 years of age, indicating the need to reassess the age-specific burden of typhoid fever in the community on a regional basis. Contrary to current recommendations this study suggests that development of new vaccines should target infants and young children.

Zinc supplementation during pregnancy and effects on growth and morbidity in low birthweight infants: a randomised placebo controlled trial

BACKGROUND

Infant malnutrition and mortality rates are high in less-developed countries especially in low-birthweight infants. Zinc deficiency is also widely prevalent in these circumstances. We aimed to assess the effect of daily zinc supplements given to pregnant mothers on their infants' growth and morbidity.

METHODS

We did a double-blind, placebo controlled, randomised trial in 199 and 221 Bangladeshi infants whose mothers took 30 mg daily elemental zinc or placebo, respectively, from 12 to 16 weeks' gestation until delivery. Infants were followed up until 6 months of age. We obtained data for morbidity every week by mothers' recall. Infants' anthropometric measurements were done every month, and their serum zinc was assessed at 1 and 6 months of age.

FINDINGS

Infants of mothers who received zinc during pregnancy had at age 6 months reduced risks compared with those in the placebo group for acute diarrhoea (risk ratio 0.84; 95% CI 0.72-0.98), dysentery (0.36; 0.25-0.84), and impetigo (0.53; 0.34-0.82). These reductions were seen in low-birthweight infants but not in those with normal birthweight. There were no differences in infant growth or serum zinc concentrations between treatment groups.

INTERPRETATION

Maternal zinc supplementation during pregnancy resulted in a reduction of the health risks in Bangladeshi low-birthweight infants, although this intervention did not improve birthweight. Whether zinc should be added to usual antenatal supplements in regions with high rates of low birthweight should be reviewed.

Determinants of infant growth in the slums of Dhaka: size and maturity at birth, breastfeeding and morbidity

OBJECTIVE

To investigate the influences of size at birth, breastfeeding and morbidity on growth during infancy in poor areas of urban Bangladesh.

DESIGN

This was a prospective observational study of a cohort of newborn infants followed until 12 months of age.

SETTING

Slum areas of Dhaka City in Bangladesh.

SUBJECTS

A total of 1654 newborn infants were enrolled at birth, and follow-up was completed for 1207 infants. Repeated anthropometric measurements and interviews of caretakers on infant feeding and morbidity were conducted. A mixed effects regression method was used for modeling infant growth.

RESULTS

After adjusting for other variables, mean differences in body weight by birth weight and length, small-for-gestational age and prematurity categories remained relatively constant throughout infancy. A positive impact of exclusive breastfeeding in the first 3 5 months on infant growth was detectable at 12 months of age. Although the bigger babies in the sample tended to grow relatively even bigger; exclusive breastfeeding appeared to counteract this pattern. Reported diarrhoea was associated with lower body weights and lengths even after adjusting for feeding patterns.

CONCLUSIONS

Size at birth has an important role in determining growth during infancy. Effective strategies for improving birth weight, poorly addressed till now in Bangladesh, are needed. The sustained effect on growth and the even more beneficial effect in lighter infants are compelling reasons for promotion of exclusive breastfeeding in early infancy.

Coping with changing conditions: alternative strategies for the delivery of maternal and child health and family planning services in Dhaka, Bangladesh

The door-to-door distribution of contraceptives and information on maternal and child health and family planning (MCH-FP) services, through bimonthly visits to eligible couples by trained fieldworkers, has been instrumental in increasing the contraceptive prevalence rate and immunization coverage in Bangladesh. The doorstep delivery strategy, however, is labour-intensive and costly. More cost-effective service delivery strategies are needed, not only for family planning services but also for a broader package of reproductive and other essential health services. Against this backdrop, operations research was conducted by the Centre for Health and Population Research at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) from January 1996 to May 1997, in collaboration with government agencies and a leading national nongovernmental organization, with a view to developing and field-testing alternative approaches to the delivery of MCH-FP services in urban areas. Two alternative strategies featuring the withdrawal of home-based distribution and the delivery of basic health care from fixed-site facilities were tested in two areas of Dhaka. The clinic-based service delivery strategy was found to be a feasible alternative to the resource-intensive doorstep system in urban Dhaka. It did not adversely affect programme performance and it allowed the needs of clients to be addressed holistically through a package of essential health and family planning services.

Implications of health care provision on acute lower respiratory infection mortality in Bangladeshi children

This study uses a geographic information system to evaluate the effects of health care provision on acute lower respiratory infection (ALRI) mortality in very young children in rural Bangladesh. Since 1988, an ALRI control program has been operating in a rural area of Bangladesh in an effort to decrease morbidity and mortality of children suffering from ALRI. ALRI-specific mortality data for very young children (<2 years of age) were obtained from a surveillance system of the area from 1988 to 1993. The ALRI mortality data were aggregated by clusters of households called baris. In order to avoid bias in the population size of haris, spatial moving averages of ALRI-specific death rates were calculated. The relationships between ALRI death rates and several environmental and health service provision variables were measured using regression analysis. The results show that the ALRI mortality rate was 54% lower in the community-based ALRI control program area than in a comparison area where there was no intervention. Greater access to allopathic practitioners was related to lower ALRI mortality rates while access to indigenous practitioners was related to higher mortality. In conclusion, the benefit of the community-based ALRI control program, using a simple case management strategy and improved access to allopathic practitioners, should be replicated in other rural areas of Bangladesh in an effort to reduce child ALRI mortality.

Association between clinical type of diarrhoea and growth of children under 5 years in rural Bangladesh

BACKGROUND

The role of diarrhoea in the aetiology of growth retardation in young children remains controversial. To evaluate this, a population-based, longitudinal study of young children aged 6-48 months was conducted in Matlab, a rural area of Bangladesh, between May 1988 and April 1989.

METHODS

Data obtained from 584 children were examined by one-year (n = 412) and 3-month (n = 1220) growth periods. Each growth period was analysed based on clinical types of diarrhoea, namely, non-diarrhoea, non-dysentery diarrhoea (diarrhoea without blood), and dysentery (diarrhoea with blood). Weight and height gains were compared among the study groups initially by one-way analysis of variance followed by multivariate analysis adjusting for potential confounding variables.

RESULTS

Compared to non-diarrhoea and non-dysentery diarrhoea, dysentery was associated with significantly lower annual weight gain (1866 g [P < 0.01] and 1550 g [P < 0.05] versus 1350 g, respectively) and height gain (6.51 cm and 5.87 cm versus 5.27 cm [P < 0.01], respectively). Both 3-month dysentery and non-dysentery intervals were significantly associated with less weight gain compared to non-diarrhoea intervals (490 g and 522 g versus 637 g [P: < 0.05], respectively). Dysentery intervals were also associated with significantly poorer height gain compared to other intervals (2.19 cm versus 2.42 cm [P < 0.05] and 2.46 cm [P < 0.01], respectively).

CONCLUSIONS

The growth of young children is strongly influenced by the clinical type of diarrhoea and the impact is dependent on the proportion of dysentery episodes in the total diarrhoeal burden.

Infant growth patterns in the slums of Dhaka in relation to birth weight, intrauterine growth retardation, and prematurity

BACKGROUND

Relations between size and maturity at birth and infant growth have been studied inadequately in Bangladesh, where the incidence of low birth weight is high and most infants are breast-fed.

OBJECTIVE

This study was conducted to describe infant growth patterns and their relations to birth weight, intrauterine growth retardation, and prematurity.

DESIGN

A total of 1654 infants born in selected low-socioeconomic areas of Dhaka, Bangladesh, were enrolled at birth. Weight and length were measured at birth and at 1, 3, 6, 9, and 12 mo of age.

RESULTS

The infants' mean birth weight was 2516 g, with 46.4% weighing <2500 g; 70% were small for gestational age (SGA) and 17% were premature. Among the SGA infants, 63% had adequate ponderal indexes. The mean weight of the study infants closely tracked the -2 SD curve of the World Health Organization pooled breast-fed sample. Weight differences by birth weight, SGA, or preterm categories were retained throughout infancy. Mean z scores based on the pooled breast-fed sample were -2.38, -1. 72, and -2.34 at birth, 3 mo, and 12 mo. Correlation analysis showed greater plasticity of growth in the first 3 mo of life than later in the first year.

CONCLUSIONS

Infant growth rates were similar to those observed among breast-fed infants in developed countries. Most study infants experienced chronic intrauterine undernourishment. Catch-up growth was limited and weight at 12 mo was largely a function of weight at birth. Improvement of birth weight is likely to lead to significant gains in infant nutritional status in this population, although interventions in the first 3 mo are also likely to be beneficial.

Living with infertility: experiences among Urban slum populations in Bangladesh

This paper explores the perceived causes of infertility, treatment-seeking for infertility and the consequences of childlessness, particularly for women, among a predominantly Muslim population in urban slums of Dhaka in Bangladesh. In-depth interviews were conducted with 60 women and 60 men randomly selected from Urban Surveillance System clusters of the International Centre for Diarrhoeal Disease Research, Bangladesh. Case studies of 20 self-perceived infertile women who had previously participated in a study on the prevalence of sexually transmitted diseases and other reproductive tract infections were taken, and three traditional healers were interviewed as key informants. In both groups of respondents, the leading causes of infertility were perceived to be evil spirits and physiological defects in women and psychosexual problems and physiological defects in men. Herbalists and traditional healers were considered the leading treatment option for women, while for men it was remarriage, followed by herbalists and traditional healers. Childlessness was found to result in perceived role failure, with social and emotional consequences for both men and women, and often resulted in social stigmatisation of the couple, particularly of the woman. Infertility places women at risk of social and familial displacement, and women clearly bear the greatest burden of infertility. Successful programmes for dealing with infertility in Bangladesh need to include both appropriate and effective sources of treatment at community level and community-based interventions to demystify the causes of infertility, so that people know why infertility occurs in both men and women and and where best to seek care.

A randomized, placebo-controlled trial of the effect of zinc supplementation during pregnancy on pregnancy outcome in Bangladeshi urban poor

BACKGROUND

Maternal zinc supplementation has been suggested as a potential intervention to reduce the incidence of low birth weight in developing countries. To date, placebo-controlled trials have all been performed in industrialized countries and the results are inconsistent.

OBJECTIVE

The objective of this study was to evaluate whether zinc supplementation in Bangladeshi urban poor during the last 2 trimesters of pregnancy was associated with pregnancy outcome.

DESIGN

We conducted a double-blind, placebo-controlled trial in which 559 women from Dhaka slums, stratified by parity between 12 and 16 wk of gestation, were randomly assigned to receive 30 mg elemental Zn/d (n = 269) or placebo (n = 290). Supplementation continued until delivery. Serum zinc was estimated at baseline and at 7 mo of gestation. Dietary intake was assessed at baseline and anthropometric measurements were made monthly. Weight, length, and gestational ages of 410 singleton newborns were measured within 72 h of birth.

RESULTS

At 7 mo of gestation, serum zinc concentrations tended to be higher in the zinc-supplemented group than in the placebo group (15.9 +/- 4.4 compared with 15.2 +/- 4.3 micromol/L). No significant effect of treatment was observed on infant birth weight (2513 +/- 390 compared with 2554 +/- 393 g; NS) or on gestational age, infant length, or head, chest, or midupper arm circumference. The incidence and distribution of low birth weight, prematurity, and smallness for gestational age also did not differ significantly after zinc supplementation.

CONCLUSIONS

Supplementation with 30 mg elemental Zn during the last 2 trimesters of pregnancy did not improve birth outcome in Bangladeshi urban poor. These results indicate that interventions with zinc supplementation alone are unlikely to reduce the incidence of low birth weight in Bangladesh.

Detection of Shigellae from stools of dysentery patients by culture and polymerase chain reaction techniques

In Bangladesh, the isolation rates of Shigella spp. range from 11% to 12% by the conventional culture technique. Since the sensitivity of this technique is low, the polymerase chain reaction (PCR) technique was used for detecting small number of Shigellae from patients' stools. Sensitivity and specificity of the two techniques were also compared. Stool samples were collected from 41 patients with dysentery who attended the Clinical Research and Service Centre of the ICDDR,B: Centre for Health and Population Research. All stool specimens were directly plated onto MacConkey, Salmonella-Shigella, Xylose lysin deoxycholate and Hectoen enteric agar media, and Shigellae were detected following standard procedures. DNA was extracted from the stool samples, and the target sequence of invasive plasmid antigen (ipa)H locus was amplified by PCR with 130 ng each of two primers (primer H8 [5'-GTTCCTTGACCGCCTTTCCGATAC-3'] and primer H15 [5'-GCCGGTCAGCCACCCTA-3']) following standard procedures. The amplified product was hybridized using an ipaH probe. The isolation rates of Shigella dysenteriae type 1, S. flexneri, S. sonnei, and S. boydii were, respectively, 17.1%, 19.5%, 4.9% and 2.4% by the conventional method. The results of the PCR technique showed that 700 bp fragment was generated in 18 of the 18 culture-positive and in 7 of the 23 culture-negative stools. One hundred twenty-three strains of Escherichia coli were also tested by PCR for identifying the enteroinvasive E. coli, but none of them yielded any positive result. This study showed that the sensitivity of the culture technique is 72% and specificity is 100%, when the PCR technique was considered as gold standard. Therefore, the PCR may be considered a more sensitive and specific technique than the conventional culture technique and has the potential to be employed in routine diagnosis of dysentery in clinical centres as well as in epidemiologic studies.

Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study

While knowledge of causes of deaths is important for health sector planning, little is known from conventional sources about the causes of deaths in Bangladesh. This is partly due to deficiencies in the registration system and partly because few deaths are attended by qualified physicians. The present study was undertaken to update the information available on causes of deaths among under-5-year-olds, taking advantage of advances in verbal autopsy methodology and of the national Bangladesh Demographic and Health Survey conducted in 1993-94. About 25% of the deaths were associated with acute lower respiratory infections (ALRI) and about 20% with diarrhoea. Neonatal tetanus and measles remained important causes of death, and drowning was a major cause for 1-4-year-olds. Research and programmes to enable mothers to identify ALRI cases, particularly pneumonia, and to encourage timely and appropriate care-seeking and strengthening of ALRI case management at the primary care facilities are important priorities. While promotion of oral rehydration for watery diarrhoea and antibiotic treatment for dysentery should continue, broader preventive interventions including provision of safe water and sanitation, and improvements in personal hygiene require more attention. Further intensification of immunization programmes and innovative experimental interventions to reduce childhood from drowning should be designed and tested.

Malnutrition, cell-mediated immune deficiency and acute upper respiratory infections in rural Bangladeshi children

A community-based longitudinal study conducted in rural Bangladesh investigated the association between nutritional status, cell-mediated immune status and acute upper respiratory infections (URI). A total of 696 children aged 0-59 months was followed prospectively for 1 y yielding 183,865 child-days' observation. Trained field workers visited each child every 4th d and collected morbidity data on symptoms suggesting URI (cough, fever, nasal discharge) for the preceding 3 d by recall. On the day of visit they examined each child reporting cough and/or fever to record the temperature, presence of nasal discharge, rate of respiration and presence of chest indrawing. Anthropometry for all children was conducted monthly. Cell-mediated immune competence was assessed by a multiple antigen skin test at baseline and thereafter every 3 months. The incidence of URI was 5.3 episodes per child-year observed. Approximately three-quarters of the study children were below -2 Z-score weight for age and height for age, and a quarter below -2 Z-score weight for height. During different test periods 9-21% of the study children did not respond to any of the test antigens. In a regression model children < -2 Z-score for weight for height had 16% [odds ratio (OR) 1.16, 95% confidence interval (CI) 1.03-1.31, p = 0.01] higher risk of developing URI. Anergic children had 20% higher risk (OR 1.20, CI 1.05-1.38, p = 0.009) of URI than immunocompetent children. The study demonstrated that wasting and depressed cell-mediated immunity (CMI), but not stunting, were associated with the incidence of URI among rural Bangladeshi children.

Acute respiratory infections in children: a community-based longitudinal study in rural Bangladesh

A community-based logitudinal study conducted in Matlab, a rural area in Bangladesh, investigated acute respiratory infections (ARI) among children. A cohort of 696 children under 5 years of age was followed for 1 year yielding 183,865 child-days of observation. Trained field workers visited the study children every fourth day. Data on symptoms suggesting ARI, such as fever, cough, and nasal discharge, were collected for the preceding 3 days by recall. To determine the type and severity of ARI, the field workers conducted physical examinations (temperature, rate of respiration, and chest indrawing) of children reporting cough and/or fever. The overall incidence of ARI was 5.5 episodes per child-year observed; the prevalence was 35.4 per hundred days observed. Most of the episodes (96 per cent) were upper respiratory infections (URI). The incidence of acute lower respiratory infections (ALRI) was 0.23 per child per year. The incidence of URI was highest in 18-23-month-old children, followed by infants 6-11 months old. The highest incidence of ALRI was observed in 0-5-month-old infants followed by 12-17-month-old children. Among 559 children who were followed for 6 months or longer, about 9 per cent did not suffer any URI episode and about 16 per cent suffered one or more ALRI episodes. About 46 per cent of URI and 65 per cent of ALRI episodes lasted 15 days or more. The incidence rates of URI were higher during the monsoon and pre-winter periods, and that of ALRI at the end of the monsoon and during the pre-winter periods. Sociodemographic variables were not associated with the incidence of URI or ALRI. The study documents ARI to be a major cause of morbidity among rural Bangladeshi children.

Association between nutritional status, cell-mediated immune status and acute lower respiratory infections in Bangladeshi children

OBJECTIVE

To investigate the association between nutritional status, cell-mediated immune status and the incidence of acute lower respiratory infections (ALRI).

DESIGN

Community-based longitudinal study.

SETTING

Three villages in rural Bangladesh at Matlab.

SUBJECT

696 children aged 0-59 months were followed up for a year.

METHODS

Trained field workers visited all children every fourth day and collected morbidity data for the preceding three days by recall. To determine the type and severity of respiratory infections, the field workers physically examined each child reporting a cough. Anthropometric status was determined monthly and cell-mediated immune status by skin tests was assessed at the beginning of the study and thereafter every 3 months.

RESULTS

The incidence of ALRI was 23 episodes per 100 child-years. A total of 73-78% of the children were below -2 z score weight for age, 15-30% were below - 2 z score weight for height, and 68-76% were below -2 z score height for age. In logistic regression models, malnutrition as assessed by weight-for-height status [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.45-0.96, P = 0.03] or weight-for-age status (OR 0.64, 95% CI 0.45-0.92, P = 0.02) was significant predictor of ALRI. Anergic children had a higher risk of ALRI which approached to be statistically significant (OR 1.81, 95% CI 0.92-3.55, P = 0.08).

CONCLUSIONS

Improvement of nutritional and cell-mediated immune status in rural Bangladeshi children should reduce the incidence of ALRI.

Bulging fontanelle after supplementation with 25,000 IU of vitamin A in infancy using immunization contacts

To evaluate the safety of vitamin A supplementation in early infancy using DPT/OPV immunization contracts, a double-blind, randomized, placebo-controlled trial was conducted in Bangladesh. One hundred and sixty-seven infants received three doses of either 25,000 IU of vitamin A or a placebo at about 6.5, 11.8 and 17.0 weeks of age. Trained physicians examined each of the infants on days 1, 2, 3 and 8 after supplementation. Nine infants (10.5%) supplemented with vitamin A had episodes of bulging of the fontanelle compared with two infants (2.5%) in the placebo group (p < 0.05). Twelve of the 14 episodes occurred in infants supplemented with vitamin A. Of these 12 episodes, none occurred with the first dose, 3 occurred with the second and 9 with the third dose. The higher incidence of bulging of the fontanelle in the vitamin A group relative to the placebo group and its temporal association with the vitamin A doses are suggestive of a causal association. The finding that increased numbers of vitamin A doses were associated with a higher probability of bulging of the fontanelle suggests a cumulative effect.