Measuring the effectiveness of an integrated intervention package to improve the level of infection prevention and control: a multi-centre study in Bangladesh

BACKGROUND

Infection prevention and control (IPC) is a critical component of delivering safe, effective and high-quality healthcare services, and eliminating avoidable healthcare-associated infections (HAIs) in health facilities, predominantly in population-dense settings such as Bangladesh.

AIM

Our study aimed to assess the effect of an integrated intervention package in improving the IPC level of the health facilities in Bangladesh.

METHODS

We conducted a pre-post intervention study in six district hospitals (DHs) and 13 Upazila Health Complexes (UHCs) in the six districts of Bangladesh. Baseline and endline assessments were conducted between March and December 2021 using the adapted World Health Organization Infection Prevention and Control Assessment Framework (WHO-IPCAF) tool. The IPCAF score, ranging from 0-800, was calculated by adding the scores of eight components, and the IPC promotion and practice level was categorized as Inadequate (0-200), Basic (201-400), Intermediate (401-600) and Advanced (601-800). The integrated intervention package including IPC committee formation, healthcare provider training, logistics provision, necessary guidelines distribution, triage/flu corners establishment, and infrastructure development was implemented in all facilities.

RESULTS

The average IPCAF score across all the facilities showed a significant increase from 16% (95% CI: 11.5-20.65%) to 54% (95% CI: 51.4-57.1%). Overall, the IPCAF score increased by 34 percentage points (P<0.001) in DHs and 40 percentage points (P<0.001) in UHCs. Following the intervention, 12 (three DHs, nine UHCs) of 19 facilities progressed from inadequate to intermediate, and another three DHs upgraded from basic to intermediate in terms of IPC level.

CONCLUSION

The integrated intervention package improved IPCAF score in all facilities.

'What gets measured gets managed': revisiting the indicators for maternal and newborn health programmes

Background

The health of women and children are critical for global development. The Sustainable Development Goals (SDG) agenda and the Global Strategy for Women’s, Children’s, and Adolescent’s Health 2016–2030 aim to reduce maternal and newborn deaths, disability, and enhancement of well-being. However, information and data on measuring countries’ progress are limited given the variety of methodological challenges of measuring care around the time of birth, when most maternal and neonatal deaths and morbidities occur.

Main body

In 2015, the World Health Organization launched Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR), a technical advisory group to WHO. MoNITOR comprises 14 independent global experts from a variety of disciplines selected in a competitive process for their technical expertise and regional representation. MoNITOR will provide technical guidance to WHO to ensure harmonized guidance, messages, and tools so that countries can collect useful data to track progress toward achieving the Sustainable Development Goals.

Short conclusion

Ultimately, MoNITOR will provide technical guidance to WHO to ensure harmonized guidance, messages, and tools so that countries can collect useful data to track progress toward achieving the Sustainable Development Goals.

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.

Is there any association between parental education and child mortality? A study in a rural area of Bangladesh

OBJECTIVES

To assess the association between parental education and under-five mortality, using the Integrated Management of Childhood Illness (IMCI) data from rural Bangladesh. It also investigated whether the association of parental education with under-five mortality had changed over time.

STUDY DESIGN

This study was nested in the IMCI cluster randomized controlled trial.

METHODS

Participants considered for the analysis were all children aged under five years from the baseline (1995-2000) and the final (2002-2007) IMCI household survey. The analysis sample included 39,875 and 38,544 live births from the baseline and the final survey respectively. The outcome variable was under-five mortality and the exposure variables were mother's and father's education. Data were analysed with logistic regression.

RESULTS

In 2002-2007, the odds of the under-five mortality were 38% lower for the children with mother having secondary education, compared to the children with uneducated mother. For similar educational differences for fathers, at the same time period, the odds of the under-five mortality were 16% lower. The association of mother's education with under-five mortality was significantly stronger in 2002-2007 compared to 1995-2000.

CONCLUSIONS

Mother's education appears to have a strong and significant association with under-five mortality, compared to father's education. The association of mother's education with under-five mortality appears to have increased over time. Our findings indicate that investing on girls' education is a good strategy to combat infant mortality in developing countries.

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.

Critical windows of exposure for arsenic-associated impairment of cognitive function in pre-school girls and boys: a population-based cohort study

BACKGROUND

Exposure to arsenic through drinking water has been associated with impaired cognitive function in school-aged children in a few cross-sectional studies; however, there is little information on critical windows of exposure.

METHODS

We conducted a population-based longitudinal study in rural Bangladesh. We assessed the association of arsenic exposure, based on urinary arsenic (U-As; twice during pregnancy and twice in childhood), with the development of about 1700 children at 5 years of age using Wechsler Pre-school and Primary Scale of Intelligence [intelligence quotient (IQ)].

RESULTS

Median maternal U-As in pregnancy was 80 µg/l (10-90 percentiles: 25-400 µg/l). Children's urine contained 35 (12-155) µg/l and 51 (20-238) µg/l at 1.5 and 5 years, respectively. Using multivariable-adjusted regression analyses, controlling for all potential confounders and loss to follow-up, we found that verbal IQ (VIQ) and full scale IQ (FSIQ) were negatively associated with (log) U-As in girls. The associations were consistent, but somewhat stronger with concurrent arsenic exposure [VIQ: B = -2.4, 95% confidence interval (CI) = -3.8 to -1.1; FSIQ: B = -1.4, 95% CI = -2.7 to -0.1, n = 817), compared with that at 1.5 years (VIQ: B = -0.85, 95% CI = -2.1 to 0.4; FSIQ: B = -0.74, 95% CI = -1.9 to 0.4, n = 902), late gestation (VIQ: B = -1.52, 95% CI = -2.6 to -0.4; FSIQ: B = -1.35, 95% CI = -2.4 to -0.3, n = 874) and early gestation (VIQ: B = -1.23, 95% CI = -2.4 to -0.06; FSIQ: B = -0.92, 95% CI = -2.0 to -0.2, n = 833). In boys, U-As showed consistently low and non-significant associations with all IQ measures. An effect size calculation indicated that 100 µg/l U-As was associated with a decrement of 1-3 points in both VIQ and FSIQ in girls.

CONCLUSION

We found adverse effects of arsenic exposure on IQ in girls, but not boys, at 5 years of age.

Potential Risk Estimation Drowning Index for Children (PREDIC): a pilot study from Matlab, Bangladesh

Childhood drowning is a major public health problem that has been neglected in many low- and middle-income countries. In Matlab, rural Bangladesh, more than 40% of child deaths aged 1-4 years are due to drowning.

AIM

The main objective of this paper was to develop and evaluate a childhood drowning risk prediction index.

METHODOLOGY

A literature review was carried out to document risk factors identified for childhood drowning in Bangladesh. The Newacheck model for special health care needs for children was adapted and applied to construct a childhood drowning risk index called "Potential Risk Estimation Drowning Index for Children" (PREDIC). Finally, the proposed PREDIC Index was applied to childhood drowning deaths and compared with the comparison group from children living in Matlab, Bangladesh. This pilot study used t-tests and Receiver Operating Characteristic (ROC) curve to analyze the results.

RESULTS

The PREDIC index was applied to 302 drowning deaths and 624 children 0-4 years old living in Matlab. The results of t-test indicate that the drowned children had a statistically (t=-8.58, p=0.0001) significant higher mean PREDIC score (6.01) than those in comparison group (5.26). Drowning cases had a PREDIC score of 6 or more for 68% of the children however, the comparison group had 43% of the children with score of 6 or more which was statistically significant (t=-7.36, p<0.001). The area under the curve for the Receiver Operating Characteristic curve was 0.662.

CONCLUSION

Index score construction was scientifically plausible; and the index is relatively complete, fairly accurate, and practical. The risk index can help identify and target high risk children with drowning prevention programs. PREDIC index needs to be further tested for its accuracy, feasibility and effectiveness in drowning risk reduction in Bangladesh and other countries.

Childhood drowning and traditional rescue measures: case study from Matlab, Bangladesh

Recent mortality data indicate that approximately half a million people drown each year worldwide, with more than 97% of such deaths occurring in low-income and middle-income countries. The purpose of this study was to examine verbal autopsy data on the circumstances of childhood drowning in Matlab, Bangladesh. The study analysed 10 years (1996-2005) of data which reported 489 deaths in children under 5 years and recorded preimmersion, immersion and postimmersion events. The data summarised household characteristics, age, gender and time of drowning event. The study also examined traditional rescue methods performed on children who were removed from the water OR found drowning. Of 489 deaths, 57% were aged 1-2 years and had a drowning mortality rate of 521 per 100 000 children. Most drowning events occurred during the morning (68%), in ponds (69%), and while the mother was busy doing household chores (70%). Traditional rescue methods were attempted in 55% of children and the most frequently reported measure was to spin the child over head (35%). Only 3% of families tried to perform resuscitation. Verbal autopsy data for Matlab is a useful resource for childhood injury research in a low-income country. The study is one of the first to publish data on traditional rescue practices performed on drowning children in rural Bangladesh. The findings suggest that interventions should be designed using locally identified risk factors to reduce childhood drowning incidents. Community-based resuscitation techniques and emergency medical systems are needed to improve postimmersion recovery of the child.

Household food security is associated with early childhood language development: results from a longitudinal study in rural Bangladesh

BACKGROUND

Although household food security (HHFS) has been linked to academic performance in school children, its association with early childhood development has received less attention, particularly in low-income countries. We investigated the association of HHFS with subsequent language development of children at 18 months of age in rural Bangladesh.

METHODS

We followed 1439 infants born in 2002-2003 to the mothers in Maternal and Infant Nutrition Intervention in Matlab study, a large intervention trial conducted in rural Bangladesh. A HHFS scale was created from data collected from mothers during pregnancy. At 18 months, children's language (expression and comprehension) development was assessed using a Bengali adaptation of MacArthur's Communicative Development Inventory which was based on mothers' report of their children's ability to comprehend and express words in different categories. General linear regression models were used to examine the association between HHFS and language development at 18 months of age adjusting for potential confounders.

RESULTS

Household food security was associated with language comprehension (B = 0.19, 95% CI = 0.09, 0.30, P < 0.001) and expression (B = 1.01, 95% CI = 1.00, 1.02, P < 0.01) at 18 months of age. Mean language comprehension and expression at 18 months of the children in higher quartiles of HHFS were higher (P < 0.05) than those of the children in lower quartiles.

CONCLUSIONS

Household food security is positively associated with subsequent language development of rural Bangladeshi children. Early language development has been reported to predict later child development. Therefore, strategies to ensure HHFS status in Bangladesh and similar settings should be considered for optimum child development.

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.

Factors influencing intestinal cadmium uptake in pregnant Bangladeshi women--a prospective cohort study

Experimental studies indicate that zinc (Zn) and calcium (Ca) status, in addition to iron (Fe) status, affect gastrointestinal absorption of cadmium (Cd), an environmental pollutant that is toxic to kidneys, bone and endocrine systems. The aim of this study was to evaluate how various nutritional factors influence the uptake of Cd in women, particularly during pregnancy. The study was carried out in a rural area of Bangladesh, where malnutrition is prevalent and exposure to Cd via food appears elevated. The uptake of Cd was evaluated by associations between erythrocyte Cd concentrations (Ery-Cd), a marker of ongoing Cd exposure, and concentrations of nutritional markers. Blood samples, collected in early pregnancy and 6 months postpartum, were analyzed by inductively coupled plasma mass spectrometry (ICPMS). Ery-Cd varied considerably (range: 0.31-5.4microg/kg) with a median of 1.1microg/kg (approximately 0.5microg/L in whole blood) in early pregnancy. Ery-Cd was associated with erythrocyte manganese (Ery-Mn; positively), plasma ferritin (p-Ft; negatively), and erythrocyte Ca (Ery-Ca; negatively) in decreasing order, indicating common transporters for Cd, Fe and Mn. There was no evidence of Cd uptake via Zn transporters, but the association between Ery-Cd and p-Ft seemed to be dependent on adequate Zn status. On average, Ery-Cd increased significantly by 0.2microg/kg from early pregnancy to 6 months postpartum, apparently due to up-regulated divalent metal transporter 1 (DMT1). In conclusion, intestinal uptake of Cd appears to be influenced either directly or indirectly by several micronutrients, in particular Fe, Mn and Zn. The negative association with Ca may suggest that Cd inhibits the transport of Ca to blood.

Early-life nutritional and environmental determinants of thymic size in infants born in rural Bangladesh

Aim:

The aim was to assess the impact of nutritional status and environmental exposures on infant thymic development in the rural Matlab region of Bangladesh.

Methods:

In a cohort of N_max 2094 infants born during a randomized study of combined interventions to improve maternal and infant health, thymic volume (thymic index, TI) was assessed by ultrasonography at birth and at 8, 24 and 52 weeks of age. Data on birth weight, infant anthropometry and feeding status were also collected.

Results:

At all ages, TI was positively associated with infant weight and strongly associated with the month of measurement. Longer duration of exclusive breastfeeding resulted in a larger TI at 52 weeks. TI at birth and at 8 weeks correlated positively with birth weight, but by 24 and 52 weeks and when adjusted for infant weight this effect was no longer present. Thymic size was not affected by pre-natal maternal supplementation or by socioeconomic status but was correlated to arsenic exposure during pregnancy.

Conclusion:

In this population of rural Bangladeshi infants, thymic development is influenced by both nutritional and environmental exposures early in life. The long-term functional implications of these findings warrant further investigation.

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.

High titre of anti-Ascaris immunoglobulin E associated with bronchial asthma symptoms in 5-year-old rural Bangladeshi children

BACKGROUND

Increasing interest has arisen whether helminthic infections protect against asthma and allergy. The prevalence of wheezing among Bangladeshi children is higher in rural areas where helminthic infectious burden is greater, which is contrary to the general assumption.

OBJECTIVE

We therefore examined the association between Ascaris infection, serum level of anti-Ascaris IgE, which should be investigated differently from the infection, and wheezing in 5-year-old children from rural Bangladesh.

METHODS

A total of 219 children who reported wheezing during the previous 12 months and 122 randomly selected age-matched individuals who had never experienced wheezing were tested for serum levels of total and specific Ascaris, Dermatophagoides pteronyssinus, alternaria and cockroach IgEs, and for intestinal helminth infection as well.

RESULTS

Anti-Ascaris IgE levels were significantly and independently associated with current wheezing during the previous 12 months [odds ratio (OR) per log(e) increment is 1.31 (95% confidence interval (CI) 1.08-1.60), P=0.007], a history of at least four episodes of wheezing [OR per log(e) increment is 1.52 (95% CI 1.18-1.96), P=0.001], wheezing with sleep disturbances [OR per log(e) increment is 1.35 (95% CI 1.10-1.64), P=0.011] and wheezing with speech disturbances [OR per log(e) increment is 1.57 (95% CI 1.19-2.08), P=0.001]. These were adjusted for gender, pneumonia history, parental asthma, Trichuris infection, use of dry leaves as fuel and other specific IgE levels. The prevalence of Ascaris infection by the presence of wheezing was not significantly different (76% vs. 72%, respectively).

CONCLUSION

We conclude that a high titre of anti-Ascaris IgE is associated with an increased risk of asthma symptoms among 5-year-old rural Bangladeshi children with a high helminthic infectious load.

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.

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.

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.

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.

Safety and immunogenicity of tetravalent rhesus-based rotavirus vaccine in Bangladesh

BACKGROUND

Rotavirus is the most common cause of severe gastroenteritis among children worldwide.

OBJECTIVES

To compare the safety, immunogenicity and shedding patterns of rhesus rotavirus (RRV)-tetravalent vaccine vs. placebo among infants in rural Bangladesh.

METHODS

A double blinded, placebo-controlled trial was conducted in which infants (n = 120) were randomly assigned to receive three doses of either vaccine or placebo administered at approximately 6, 10 and 14 weeks of age together with routine immunizations. Data on possible adverse effects of vaccinations were collected daily for 7 days after each dose. Stool samples were collected after each dose, and serum samples were obtained before the first and after the third vaccination.

RESULTS

Fever (> or = 38 degrees C), as measured by study assistants, was noted more frequently among vaccinees (15%) than among placebo recipients (2%) during the 7 days after vaccination but was not reported more frequently by parents of vaccinees vs. placebo recipients. Overall 87% of vaccinees had an antibody response (measured by IgA or anti-RRV-neutralizing antibodies) after vaccination compared with 32% of placebo recipients. Rates of seroconversion were higher among subjects with lower levels of prevaccination antibodies and those who shed rotavirus after vaccination. Vaccine strain viruses were detected in stools from placebo vaccine recipients who had evidence of IgA seroconversion.

CONCLUSIONS

In this population RRV-tetravalent vaccine was comparably immunogenic and safe as in trials conducted in developed countries, where this vaccine has been proved effective in preventing severe rotavirus diarrhea. These data support continued evaluation of rotavirus vaccines in developing countries.

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.

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.

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.

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.

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.

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.

Levels and correlates of maternal nutritional status in urban Bangladesh

OBJECTIVE

To determine the levels and correlates of maternal nutritional status.

DESIGN

Cross-sectional maternal weight, height, and mid-upper arm circumference (MUAC) data were correlated with sociodemographic data.

SETTING

Slums of Dhaka, Bangladesh.

SUBJECTS

Weight, height and MUAC were collected from a representative sample of 2417 nonpregnant mothers. Socioeconomic data such as age, education, religion and household economic status was collected from 2048 mothers; data on reproductive experiences such as number of pregnancies and number of children born alive now dead was available from 1314 mothers; and both sets of data from 1185 mothers.

METHODS

Using weight, height, MUAC and body mass index (BMI) data, the levels of maternal nutritional status were estimated. Bivariate and multivariate relationships of maternal nutritional status with socioeconomic and reproductive experiences variables were examined.

RESULTS

Mothers' mean weight, height, MUAC and BMI were 41.8 kg, 148.8 cm, 232.5 mm, and 18.8 respectively. In multivariate regression analyses, mothers' weight, BMI and MUAC were significantly positively correlated with mothers' years of schooling (P < 0.05) and household economic status (P < 0.01). Mothers' height was significantly positively correlated with years of schooling (P < 0.05), but not with household economic status. Maternal height and weight were significantly negatively correlated with number of child deaths (P < 0.05).

CONCLUSIONS

The findings suggest a possible inter-generational effect; thus, improvement of the nutritional status of girls of this generation would improve child survival in the next generation. This, however, will require complex and long-term planning. As an interim measure, shorter mothers should be targeted for appropriate antenatal and obstetric services.