Acceptability, cost-effectiveness, and capacity of a facility-based seasonal influenza vaccination among high-risk groups: a study protocol in selected tertiary care hospitals of Bangladesh

BACKGROUND

In Bangladesh, seasonal influenza imposes considerable disease and economic burden, especially for those at high-risk of severe disease. The most successful approach for influenza prevention is the administration of a vaccine. Many poor and middle-income nations, including Bangladesh, do not have a national strategy or program in place for seasonal influenza vaccines, despite the World Health Organization's (WHO) advice to prioritize high-risk populations. Additionally, there is a scarcity of substantial data on the cost-effectiveness of seasonal influenza vaccination in these countries. The aim of our study is to determine acceptability, health beliefs, barriers, and intention of receiving influenza vaccine among high-risk populations, assess the cost-effectiveness of implementing a facility-based seasonal influenza vaccination programme, and investigate the required capacity for a potential seasonal influenza vaccination programme.

METHODS

We will undertake this study following STROBE guidelines. We will conduct the study in inpatient and outpatient departments of three selected tertiary-level hospitals leveraging the ongoing hospital-based influenza surveillance (HBIS) platform. The study population will include the WHO-defined four high-risk groups excluding healthcare workers: children six months to eight years, pregnant women, elderly ≥ 60 years, and adults with chronic diseases. We will collect quantitative data on participants' acceptability, health beliefs, barriers, and vaccination intentions using the health belief model (HBM) from patients meeting the criteria for high-risk populations attending two public tertiary-level hospitals. In one of the two public tertiary-level hospitals, we will arrange an influenza vaccination campaign before the influenza season, where the vaccine will be offered free of cost to high-risk patients, and in the second hospital, vaccination will not be offered. Both the vaccinated and unvaccinated participants will then be followed-up once a month for one year to record any influenza-like illness, hospitalization, and death. Additional data for objective two will be collected from patients with symptoms of influenza-like illness (ILI) and severe acute respiratory infection (SARI) at one public and one private hospital to determine both direct and indirect costs associated with influenza illness. We will estimate the required number of influenza vaccines, safe injections, and total storage volume utilizing secondary data. We will use a deterministic Markov decision-analytic model to estimate the cost-effectiveness of facility-based influenza vaccination in Bangladesh.

DISCUSSION

The results of this study will enable the National Immunization Technical Advisory Group and the Ministry of Health & Family Welfare of Bangladesh to decide what steps to take to develop and implement an influenza vaccination strategy targeting high-risk populations.

TRIAL REGISTRATION

The Clinicaltrials.gov registration number is NCT05996549. The registration for the protocol version 2.0 took place in August 2023, with the initial participant being enrolled in March 2022.

Respiratory Syncytial Virus-Associated Deaths among Children under Five before and during the COVID-19 Pandemic in Bangladesh

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory infections in young children worldwide. RSV-associated deaths in children are underreported in Bangladesh. We analyzed hospital-based surveillance data on severe acute respiratory infections (SARIs) in under-five children before (August 2009-February 2020) and during the COVID-19 pandemic (March 2020-March 2022). Using the World Health Organization definition, we identified SARI cases in 14 tertiary-level hospitals. Nasopharyngeal and oropharyngeal swabs were collected for real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR) testing of six respiratory viruses, including RSV. SARI deaths during the pandemic (2.6%, 66) were higher than pre-pandemic (1.8%, 159; p < 0.001). Nearly half of pandemic deaths (47%) had underlying respiratory viruses, similar to the pre-pandemic rate (45%). RSV detection in deaths was consistent pre-pandemic (13%, 20/159) and during the pandemic (12%, 8/66). Children aged < 6 months constituted 57% (16) of RSV-related deaths. Evaluating interventions like maternal vaccination and infant monoclonal antibody prophylaxis is crucial to address RSV, a major contributor to under-five SARI deaths.

Nipah virus disease: what can we do to improve patient care?

The year 2023 marked the 25th anniversary of the first detected outbreak of Nipah virus disease. Despite Nipah virus being a priority pathogen in the WHO Research and Development blueprint, the disease it causes still carries high mortality, unchanged since the first reported outbreaks. Although candidate vaccines for Nipah virus disease exist, developing new therapeutics has been underinvested. Nipah virus disease illustrates the typical market failure of medicine development for a high-consequence pathogen. The unpredictability of outbreaks and low number of infections affecting populations in low-income countries does not make an attractive business case for developing treatments for Nipah virus disease-a situation compounded by methodological challenges in clinical trial design. Nipah virus therapeutics development is not motivated by commercial interest. Therefore, we propose a regionally led, patient-centred, and public health-centred, end-to-end framework that articulates a public health vision and a roadmap for research, development, manufacturing, and access towards the goal of improving patient outcomes. This framework includes co-creating a regulatory-compliant, clinically meaningful, and context-specific clinical development plan and establishing quality standards in clinical care and research capabilities at sites where the disease occurs. The success of this approach will be measured by the availability and accessibility of improved Nipah virus treatments in affected communities and reduced mortality.

Characterizing deaths among adult patients with severe acute respiratory infection: during the pre- and COVID-19 pandemic periods in Bangladesh, 2018-2022

BACKGROUND

Severe acute respiratory infection (SARI) is a leading cause of mortality globally, peaking during the COVID-19 pandemic. We analyzed SARI-associated deaths during the pre-and-pandemic periods in Bangladesh to identify the contributing factors.

METHODS

We analyzed data from hospital-based influenza surveillance at nine tertiary-level hospitals in Bangladesh. We considered March 2018-February 2020 as the pre-pandemic period and March 2020-February 2022 as the pandemic period and included adult (≥ 18 years) participants in our study. Surveillance physicians identified WHO-SARI case definition meeting inpatients and collected demographics, clinical characteristics, and outcomes at hospital discharge and 30 days post-discharge. We performed rRT-PCR for influenza and SARS-CoV-2 viruses on collected nasopharyngeal and oropharyngeal swabs. We used multivariable Cox's regression models to calculate the hazard ratio (HR) for factors associated with SARI deaths in these adult patients.

RESULTS

We enrolled 4392 SARI patients during the pre-pandemic and 3824 SARI patients during the pandemic period. Case fatality ratio was higher during the pandemic: 13.62% (521) [in-hospital: 6.45% (247); post-discharge: 7.17% (274)] compared to pre-pandemic, 6.01% (264) [in-hospital: 2.01% (89), post-discharge: 4% (175)] (p < 0.001). Pre-pandemic, influenza was detected in 14% (37/264) of SARI deaths. Influenza was detected during the pandemic in 2.3% (12/521), SARS-CoV-2 in 41.8% (218/521), and both viruses in only one SARI death. History of smoking and the presence of 1 or more co-morbid conditions independently attributed to SARI deaths in adults in the pre-pandemic period. SARI deaths in such patients were also associated with respiratory difficulties on admission in both pre-pandemic (aHR 2.36; 95% CI:1.65-3.36) and pandemic period (aHR 2.30; 95% CI: 1.57-3.35) after accounting for age, sex, smoking status, presence of 1 or more co-morbid conditions, and detection of influenza and SARS-CoV-2 viruses.

CONCLUSIONS

During the pandemic, SARI mortality increased; influenza-associated mortality declined, and SARS-CoV-2 caused over a third of SARI deaths. Post-discharge mortality was higher than in-hospital mortality during both periods. Limiting premature discharge and strengthening post-discharge monitoring and nursing services could reduce unexpected deaths. Formative research to better understand post-discharge mortality is essential to reduce SARI deaths.

Interpretation of molecular detection of avian influenza A virus in respiratory specimens collected from live bird market workers in Dhaka, Bangladesh: infection or contamination?

OBJECTIVES

Interpreting real-time reverse transcription-polymerase chain reaction (rRT-PCR) results for human avian influenza A virus (AIV) detection in contaminated settings like live bird markets (LBMs) without serology or viral culture poses a challenge.

METHODS

During February-March 2012 and November 2012-February 2013, we screened workers at nine LBMs in Dhaka, Bangladesh, to confirm molecular detections of AIV RNA in respiratory specimens with serology. We tested nasopharyngeal (NP) and throat swabs from workers with influenza-like illness (ILI) and NP, throat, and arm swabs from asymptomatic workers for influenza virus by rRT-PCR and sera for seroconversion and antibodies against HPAI A(H5N1) and A(H9N2) viruses.

RESULTS

Among 1273 ILI cases, 34 (2.6%) had A(H5), 56 (4%) had A(H9), and six (0.4%) had both A(H5) and A(H9) detected by rRT-PCR. Of 192 asymptomatic workers, A(H5) was detected in eight (4%) NP and 38 (20%) arm swabs. Of 28 ILI cases with A(H5) or A(H9) detected, none had evidence of seroconversion, but one (3.5%) and 12 (43%) were seropositive for A(H5) and A(H9), respectively.

CONCLUSION

Detection of AIV RNA in respiratory specimens from symptomatic and asymptomatic LBM workers without evidence of seroconversion or virus isolation suggests environmental contamination, emphasizing caution in interpreting rRT-PCR results in high viral load settings.

Lessons learned from identifying clusters of severe acute respiratory infections with influenza sentinel surveillance, Bangladesh, 2009-2020

Background

We explored whether hospital-based surveillance is useful in detecting severe acute respiratory infection (SARI) clusters and how often these events result in outbreak investigation and community mitigation.

Methods

During May 2009-December 2020, physicians at 14 sentinel hospitals prospectively identified SARI clusters (i.e., ≥2 SARI cases who developed symptoms ≤10 days of each other and lived <30 min walk or <3 km from each other). Oropharyngeal and nasopharyngeal swabs were tested for influenza and other respiratory viruses by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR). We describe the demographic of persons within clusters, laboratory results, and outbreak investigations.

Results

Field staff identified 464 clusters comprising 1427 SARI cases (range 0-13 clusters per month). Sixty percent of clusters had three, 23% had two, and 17% had ≥4 cases. Their median age was 2 years (inter-quartile range [IQR] 0.4-25) and 63% were male. Laboratory results were available for the 464 clusters with a median of 9 days (IQR = 6-13 days) after cluster identification. Less than one in five clusters had cases that tested positive for the same virus: respiratory syncytial virus (RSV) in 58 (13%), influenza viruses in 24 (5%), human metapneumovirus (HMPV) in five (1%), human parainfluenza virus (HPIV) in three (0.6%), adenovirus in two (0.4%). While 102/464 (22%) had poultry exposure, none tested positive for influenza A (H5N1) or A (H7N9). None of the 464 clusters led to field deployments for outbreak response.

Conclusions

For 11 years, none of the hundreds of identified clusters led to an emergency response. The value of this event-based surveillance might be improved by seeking larger clusters, with stronger epidemiologic ties or decedents.

Hand hygiene compliance and associated factors among healthcare workers in selected tertiary-care hospitals in Bangladesh

BACKGROUND

Hand hygiene (HH) is a fundamental element of patient safety. Adherence to HH among healthcare workers (HCWs) varies greatly depending on a range of factors, including risk perceptions, institutional culture, auditing mechanisms, and availability of HH supplies.

AIMS

This study aimed to evaluate HH compliance and associated factors among HCWs in selected tertiary-care hospitals in Bangladesh.

METHODS

During September 2020 to May 2021, we conducted non-participatory observations at 10 tertiary-care hospitals using the WHO's '5-moments for hand hygiene tool' to record HH compliance among physicians, nurses and cleaning staff. We also performed semi-structured interviews to determine the key barriers to complying with HH.

RESULTS

We observed 14,668 hand hygiene opportunities. The overall HH compliance was 25.3%, the highest among nurses (28.5%), and the lowest among cleaning staff (9.9%). HCWs in public hospitals had significantly higher odds of complying with HH practices than those in private hospitals (adjusted odds ratio: 1.73, 95% CI: 1.55-1.93). The odds of performing HH after touching a patient were 3.36 times higher compared with before touching a patient (95% CI: 2.90-3.90). The reported key barriers to performing HH were insufficient supplies (57.9%), skin reactions (26.3%), workload (26.3%) and lack of facilities (22.7%). Overall, observed HH supplies were available in 81.7% of wards for physicians and 95.1% of wards for nurses, however, no designated HH facilities were found for the cleaning staff.

CONCLUSIONS

HH compliance among HCWs fell significantly short of the standard for safe patient care. Inadequate HH supplies demonstrate a lack of prioritizing, promoting and investing in infection prevention and control.

Prevalence of Colonization With Antibiotic-Resistant Organisms in Hospitalized and Community Individuals in Bangladesh, a Phenotypic Analysis: Findings From the Antibiotic Resistance in Communities and Hospitals (ARCH) Study

BACKGROUND

Low- and middle-income countries bear a disproportionate burden of antimicrobial resistance (AMR) but often lack adequate surveillance to inform mitigation efforts. Colonization can be a useful metric to understand AMR burden. We assessed the colonization prevalence of Enterobacterales with resistance to extended-spectrum cephalosporins, carbapenems, colistin, and methicillin-resistant Staphylococcus aureus among hospital and community dwellers.

METHODS

Between April and October 2019, we conducted a period prevalence study in Dhaka, Bangladesh. We collected stool and nasal specimens from adults in 3 hospitals and from community dwellers within the hospitals' catchment area. Specimens were plated on selective agar plates. Isolates underwent identification and antibiotic susceptibility testing using Vitek 2. We performed descriptive analysis and determined population prevalence estimates accounting for clustering at the community level.

RESULTS

The majority of both community and hospital participants were colonized with Enterobacterales with resistance to extended-spectrum cephalosporins (78%; 95% confidence interval [95% CI], 73-83; and 82%; 95% CI, 79-85, respectively). Thirty-seven percent (95% CI, 34-41) of hospitalized patients were colonized with carbapenems compared with 9% (95% CI, 6-13) of community individuals. Colistin colonization prevalence was 11% (95% CI, 8-14) in the community versus 7% (95% CI, 6-10) in the hospital. Methicillin-resistant Staphylococcus aureus colonization was similar in both community and hospital participants (22%; 95% CI, 19-26 vs 21% (95% CI, 18-24).

CONCLUSIONS

The high burden of AMR colonization observed among hospital and community participants may increase the risk for developing AMR infections and facilitating spread of AMR in both the community and hospital.

1182. Risk factors for colonization with extended-spectrum cephalosporin resistant and carbapenem resistant Enterobacterales among community adults, Bangladesh: An Antibiotic Resistance in Communities and Hospitals (ARCH) study

Background

Antimicrobial resistant (AMR) organisms are an increasing global health threat that are spreading within communities. Understanding the risk factors for colonization with AMR organisms is critical for implementing prevention and control strategies, particularly in resource-limited settings such as Bangladesh.

Methods

During 2019, we conducted a population-based observational study in Dhaka (surveillance site of icddr,b). We collected stool samples from randomly selected adults and tested for Enterobacterales with extended-spectrum cephalosporin resistance (ESCrE) and carbapenem resistance (CRE) using selective media followed by VITEK-2 confirmation. Participants completed demographic surveys assessing food consumption, animal contact, sanitation, water sources, and healthcare exposure. We identified factors associated with ESCrE and CRE colonization using bivariable and multivariable logistic regression, adjusting for potential confounders and clustering.

Results

Of 714 enrolled individuals, 557 (78%) were colonized with ESCrE and 66 (9%) with CRE. In bivariable analysis, factors associated with ESCrE colonization included fresh fruit consumption in the past week (OR 1.8, 95% CI 1.2-2.9), public tap as main source of drinking water compared with basic improved source (OR 3.3, 1.0-11.0), and unimproved toilet (pour/flush to open drain, pit latrine without slab) compared with basic improved toilet (OR 11, 2.9-42.0). Only consumption of fresh fruit was significant in the multivariable analysis (aOR 2.0, 1.3-3.2). Factors associated with CRE colonization in bivariable analysis were hospitalization in the last 3 months (OR 3.2, 1.2-8.6), limited sanitation facility (improved toilet shared with other households) (OR 2.0, 1.0-3.8), and limited hygiene (availability of handwashing facility on premises without soap and/or water) (OR 3.3, 1.4-7.7). The only factor that was significant in multivariable analysis was hospitalization in the last 3 months (aOR 3.0, 1.0-8.7).

Conclusion

While ESCrE colonization is common in urban communities, hospitals may be contributing to community spread of CRE. Targeted interventions focused on healthcare facilities may be needed to mitigate the transmission of AMR organisms.

Disclosures

All Authors: No reported disclosures.

Rationale and guidance for strengthening infection prevention and control measures and antimicrobial stewardship programs in Bangladesh: a study protocol

BACKGROUND

Hospital-acquired infections (HAIs) and antimicrobial resistance (AMR) are major global health challenges. Drug-resistant infectious diseases continue to rise in developing countries, driven by shortfalls in infection control measures, antibiotic misuse, and scarcity of reliable diagnostics. These escalating global challenges have highlighted the importance of strengthening fundamental infection prevention and control (IPC) measures and implementing effective antimicrobial stewardship programs (ASP). This study aims to present a framework for enhancing IPC measures and ASP efforts to reduce the HAI and AMR burden in Bangladesh.

METHODS

This implementation approach will employ a mixed-methods strategy, combining both quantitative and qualitative data from 12 tertiary hospitals in Bangladesh. A baseline assessment will be conducted using the Infection Prevention and Control Assessment Framework (IPCAF) developed by the WHO. We will record IPC practices through direct observations of hand hygiene, personal protective equipment (PPE) utilization, and hospital ward IPC infrastructure. Additionally, data on healthcare providers' knowledge, attitudes, and practices regarding IPC and antibiotic prescribing will be collected using both structured questionnaires and qualitative interviews. We will also assist the hospital leadership with establishing and/or strengthening IPC and ASP committees. Based on baseline assessments of each healthcare facility, tailored interventions and quality improvement projects will be designed and implemented. An end-line assessment will also be conducted after 12 months of intervention using the same assessment tools. The findings will be compared with the baseline to determine changes in IPC and antibiotic stewardship practices.

DISCUSSION

Comprehensive assessments of healthcare facilities in low-resource settings are crucial for strengthening IPC measures and ASP activities,. This approach to assessing existing IPC and ASP activities will provide policy-relevant data for addressing current shortfalls. Moreover, this framework proposes identifying institutionally-tailored solutions, which will ensure that response activities are appropriately contextualized, aligned with stakeholder priorities, and offer sustainable solutions.

CONCLUSION

Findings from this study can guide the design and implementation of feasible and sustainable interventions in resource-constrained healthcare settings to address gaps in existing IPC and ASP activities. Therefore, this protocol will be applicable across a broad range of settings to improve IPC and ASP and reduce the burden of hospital-acquired infections and AMR.

Infection prevention and control in tertiary care hospitals of Bangladesh: results from WHO infection prevention and control assessment framework (IPCAF)

INTRODUCTION

Infection prevention and control (IPC) in healthcare settings is imperative for the safety of patients as well as healthcare providers. To measure current IPC activities, resources, and gaps at the facility level, WHO has developed the Infection Prevention and Control Assessment Framework (IPCAF). This study aimed to assess the existing IPC level of selected tertiary care hospitals in Bangladesh during the COVID-19 pandemic using IPCAF to explore their strengths and deficits.

METHODS

Between September and December 2020, we assessed 11 tertiary-care hospitals across Bangladesh. We collected the information from IPC focal person and/or hospital administrator from each hospital using the IPCAF assessment tool.. The score was calculated based on eight core components and was used to categorize the hospitals into four distinct IPC levels- Inadequate, Basic, Intermediate, and Advanced. Key performance metrics were summarized within and between hospitals.

RESULTS

The overall median IPCAF score was 355.0 (IQR: 252.5-397.5) out of 800. The majority (73%) of hospitals scored as 'Basic' IPC level, while only 18% of hospitals were categorized as 'Intermediate'. Most hospitals had IPC guidelines as well as environments, materials and equipments. Although 64% of hospitals had IPC orientation and training program for new employees, only 30% of hospitals had regular IPC training program for the staff. None of the hospitals had an IPC surveillance system with standard surveillance case definitions to track HAIs. Around 90% of hospitals did not have an active IPC monitoring and audit system. Half of the hospitals had inadequate staffing considering the workload. Bed occupancy of one patient per bed in all units was found in 55% of hospitals. About 73% of hospitals had functional hand hygiene stations, but sufficient toilets were available in only 37% of hospitals.

CONCLUSION

The majority of sampled tertiary care hospitals demonstrate inadequate IPC level to ensure the safety of healthcare workers, patients, and visitors. Quality improvement programs and feedback mechanisms should be implemented to strengthen all IPC core components, particularly IPC surveillance, monitoring, education, and training, to improve healthcare safety and resilience.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September-November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19-dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

Seasonal influenza vaccine uptake among healthcare workers in tertiary care hospitals, Bangladesh: Study protocol for influenza vaccine supply and awareness intervention

Background

Healthcare workers (HCWs), such as doctors, nurses, and support staffs involved in direct or indirect patient care, are at increased risk of influenza virus infections due to occupational exposures. Vaccination is the most effective way to prevent influenza. Despite the World Health Organization (WHO) recommendations, Bangladesh lacks a seasonal influenza vaccination policy for HCWs, and thus vaccination rates remain low. The current project aims to investigate the effect of interventions on influenza vaccine awareness and availability of vaccine supply, explore HCWs’ knowledge and perceptions about influenza vaccination, understand the barriers and motivators for influenza vaccine uptake, and understand policymakers' views on the practicality of influenza vaccination among HCWs.

Method

We will conduct the study at four tertiary care teaching hospitals in Bangladesh, using a cluster randomized controlled trial approach, with the hospital as the unit of randomization and intervention. The study population will include all types of HCWs.The four different types of intervention will be randomly allocated and implemented in four study hospitals separately. The four interventions will be: i) ensuring the availability of influenza vaccine supply; ii) developing influenza vaccine awareness; iii) both ensuring influenza vaccine supply and developing influenza vaccine awareness and iv) control arm with no intervention. Both quantitative and qualitative approaches will be applied to assess the intervention effect. We will estimate the Difference in Differences (DID) with 95% CI of the proportion of vaccine uptake between each intervention and control (non-intervention) arm, adjusting for the clustering effect. The qualitative data will be summarised using a framework matrix method.

Discussion

The results of this study will inform the development and implementation of a context-specific strategy to enhance influenza vaccination rates among Bangladeshi HCWs.

Trial registration

Clinicaltrials.gov NCT05521763. Version 2.0 was registered in September 2022, and the first participant enrolled in March 2022. Retrospectively registered.

Synthesis, characterization, anti-mycobacterial activity and in silico study of new 2,5-disubstituted-1,3,4-oxadiazole derivatives

A series of new 2,5-disubstituted-1,3,4-oxadiazole derivatives (5a-j and 6a-j) have been designed and synthesized in four-steps. Sixteen compounds among the twenty compounds are reported for the first time. The compounds were characterized and confirmed by the FTIR, 1D- and 2D-NMR and HRMS analyses, and were tested against Mycobacterium smegmatis and Mycobacterium tuberculosis H37Ra. Compound 5d was the most active against M. smegmatis with MIC value of 25 µM, and exhibited cidal activity with MBC of 68 µM, respectively. The time-kill assay showed the good killing rate at 77% with the combination of isoniazid (INH). In addition, checkboard assay confirmed the interaction of compound 5d was categorised as additive. Docking simulation has been performed to position 5d into the pantothenate synthetase active site with binding free energy value -8.6 kcal mol-1. It also occupied the same active site as that of standard native ligand with similar interactions, which clearly indicate their potential as pantothenate synthetase inhibitor.

Identifying the research, advocacy, policy and implementation needs for the prevention and management of respiratory syncytial virus lower respiratory tract infection in low- and middle-income countries

INTRODUCTION

The high burden of respiratory syncytial virus (RSV) infection in young children disproportionately occurs in low- and middle-income countries (LMICs). The PROUD (Preventing RespiratOry syncytial virUs in unDerdeveloped countries) Taskforce of 24 RSV worldwide experts assessed key needs for RSV prevention in LMICs, including vaccine and newer preventive measures.

METHODS

A global, survey-based study was undertaken in 2021. An online questionnaire was developed following three meetings of the Taskforce panellists wherein factors related to RSV infection, its prevention and management were identified using iterative questioning. Each factor was scored, by non-panellists interested in RSV, on a scale of zero (very-low-relevance) to 100 (very-high-relevance) within two scenarios: (1) Current and (2) Future expectations for RSV management.

RESULTS

Ninety questionnaires were completed: 70 by respondents (71.4% physicians; 27.1% researchers/scientists) from 16 LMICs and 20 from nine high-income (HI) countries (90.0% physicians; 5.0% researchers/scientists), as a reference group. Within LMICs, RSV awareness was perceived to be low, and management was not prioritised. Of the 100 factors scored, those related to improved diagnosis particularly access to affordable point-of-care diagnostics, disease burden data generation, clinical and general education, prompt access to new interventions, and engagement with policymakers/payers were identified of paramount importance. There was a strong need for clinical education and local data generation in the lowest economies, whereas upper-middle income countries were more closely aligned with HI countries in terms of current RSV service provision.

CONCLUSION

Seven key actions for improving RSV prevention and management in LMICs are proposed.

152. Use of Antimicrobials among Suspected COVID-19 Patients at Selected 12 Hospitals in Bangladesh: Findings from the First Wave of COVID-19 Pandemic

Background

Antimicrobials are empirically used in COVID-19 patients resulting in inappropriate stewardship and increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients while waiting for the COVID-19 test report.

Methods

From March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; and tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis.

Results

Among 1188 suspected COVID-19 patients, the median age was 34 years (IQR:2–56), 69% were male, 40% had comorbidities, 53% required oxygen, and 1% required ICU or ventilation support after admission. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral, mostly favipiravir (1%) and antiparasitic drugs particularly ivermectin (3%). Third-generation cephalosporin use was the highest (708;60%), followed by macrolide (481;40%), and the majority (853;78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Before admission, 3% patients had two antibiotics, and on admission, 27% received two to four classes of antibiotics at the same time. According to WHO AWaRe classification, the Watch group antibiotics were mostly used before (43%) as well as on admission (80%). Reserve group antibiotic particularly linezolid was used in 1% patients includes mild cases on admission. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7;95%CI:4.5–30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6;95%CI:1.0–2.5).

Antimicrobials used among suspected COVID-19 patients and SARS-CoV-2 positive and negative patients 24 h before and on hospital admission at 12 selected hospitals in Bangladesh, March–August 2020

Antimicrobials used on admission among suspected COVID-19 patients according to disease severity at 12 selected hospitals in Bangladesh, March–August 2020

Conclusion

Antimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with Watch group antibiotics like third-generation cephalosporin and azithromycin among mild to moderately ill patients were common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.

Disclosures

All Authors: No reported disclosures

Prevalence of COVID-19 in Bangladesh, April to October 2020—a cross-sectional study

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This was a cross-sectional survey study.

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The prevalence of COVID-19 in Bangladesh was estimated.

•

The estimated prevalence of COVID-19 was 6.4%.

Objective: The aim of this study was to estimate the proportion of symptomatic and asymptomatic laboratory-confirmed coronavirus disease 2019 (COVID-19) cases among the population of Bangladesh.

Methods: A cross-sectional survey was conducted in Dhaka City and other districts of Bangladesh between April 18 and October 12, 2020. A total of 32 districts outside Dhaka were randomly selected, and one village and one mahalla was selected from each district; 25 mahallas were selected from Dhaka City. From each village or mahalla, 120 households were enrolled through systematic random sampling.

Results: A total of 44 865 individuals were interviewed from 10 907 households. The majority (70%, n = 31 488) of the individuals were <40 years of age. Almost half of the individuals (49%, n = 21 888) reported more than four members in their household. It was estimated that 12.6% (n = 160) of the households had one or more severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected individuals, among whom 0.9% (n = 404) of individuals had at least one COVID-19-like symptom, at the national level. The prevalence of COVID-19 in the general population was 6.4%. Among the SARS-CoV-2-positive individuals, 87% were asymptomatic.

Conclusions: The substantial high number of asymptomatic cases all over Bangladesh suggests that community-level containment and mitigation measures are required to combat COVID-19. Future studies to understand the transmission capability could help to define mitigation and control measures.

Antibiotic use for acute respiratory infections among under-5 children in Bangladesh: a population-based survey

Introduction

Despite acute respiratory infections (ARIs) being the single largest reason for antibiotic use in under-5 children in Bangladesh, the prevalence of antibiotic use in the community for an ARI episode and factors associated with antibiotic use in this age group are unknown.

Methods

We analysed nationally representative, population-based, household survey data from the Bangladesh Demographic and Health Survey 2014 to determine the prevalence of antibiotic use in the community for ARI in under-5 children. Using a causal graph and multivariable logistical regression, we then identified and determined the sociodemographic and antibiotic source factors significantly associated with the use of antibiotics for an episode of ARI.

Results

We analysed data for 2 144 children aged <5 years with symptoms of ARI from 17 300 households. In our sample, 829 children (39%) received antibiotics for their ARI episode (95% CI 35.4% to 42.0%). Under-5 children from rural households were 60% (adjusted OR (aOR): 1.6; 95% CI 1.2 to 2.1) more likely to receive antibiotics compared with those from urban households, largely driven by prescriptions from unqualified or traditional practitioners. Private health facilities were 50% (aOR: 0.5; 95% CI 0.3 to 0.7) less likely to be sources of antibiotics compared with public health facilities and non-governmental organisations. Age of children, sex of children or household wealth had no impact on use of antibiotics.

Conclusion

In this first nationally representative analysis of antibiotic use in under-5 children in Bangladesh, we found almost 40% of children received antibiotics for an ARI episode. The significant prevalence of antibiotic exposure in under-5 children supports the need for coordinated policy interventions and implementation of clinical practice guidelines at point of care to minimise the adverse effects attributed to antibiotic overuse.

MO111PATTERN OF CARDIAC AND RENAL RISK FACTORS PREVAILING IN HYPERTENSIVE SUBJECTS OF RURAL COMMUNITY: PRIMARY RESULTS FROM AN ONGOING SYSTEMATIC SURVEY IN BANGLADESH

Background and Aims

Hypertension is the leading entity of non communicable diseases (NCD). Some 15-30% adult population is identified suffering from hypertension at any given time worldwide. Complications of hypertension cause severe functional deficit and a major decline in quality of life for the patient and family.

This study was carried out to identify the presence and pattern of cardiac and renal risk factors influencing major morbidity and mortality in hypertensive subject by performing relevant clinical and laboratory evaluations.

Method

In this survey adult subjects were selected randomly from a defined rural area. Their demographic, anthropometric and clinical information was recorded by WHO STEP wise approach surveillance-Instrument v.3.1. Information on prevailing NCDs and related risk factor were collected on a short questionnaire by face-to-face interview. Blood Pressure (BP) was measured by digital blood pressure monitor (Omron) with standard sized cuff after 10-15 minutes of rest in sitting posture by taking mean of two readings. Systolic BP ≥140 and/or diastolic BP ≥90mmHg or subjects taking antihypertensive medications were considered for hypertension. Early morning urine and fasting blood sample was collected for glycemic profile, lipid profile, serum creatinine, eGFR (MDRD equation) and urine ACR estimations for identifying diabetes, dyslipidemia and nephropathy. Results from an early group are presented here.

Results

From surveyed population consequative 300 hypertensive subjects with 100 normotensive subjects were analyzed. Male/female distribution was 66% and 34%. Age in 75% was between 25-55 years and BMI overweight to obese in 45%. Etiology wise in 81% it was essential hypertension followed by diabetes 18% and nephropathies in rest. Mean systolic BP was 147±16 and diastolic BP 71±9 mmHg. Comparison of hypertensive vs. normotensives showed FBS 6.7±3 vs. 5.8±1.0 mmol/l, (p&lt;0.001). Lipids as cardiac markers were TG 170±107 vs. 130±76 g/dl, (p&lt;0.001); Cholesterol 195±50 vs. 180±49 g/dl, (p&lt;0.001); LDL 170±107 vs. 130±76 g/dl, (p&lt;0.04); and HDL 42±7 vs. 46±8 g/dl, (p&lt;0.001). Renal parameters like eGFR was 88±22 vs. 98±26 ml/min, (p&lt;0.001); and ACR 99±556 vs. 30±87 mg/g, (p&lt;0.04). These comparisons showed fasting hyperglycemia with most of the lipids higher and HDL lower in hypertensives. Renal parameters like eGFR was lower and albuminuria was significantly higher with similar urinary Na and K excretion in hypertensives. Other cardio renal markers like Uric Acid and hCRP was similar in both groups. Pearson’s correlations showed a positive correlation of systolic and diastolic BP with major components of cardiac, renal and metabolic risk factors.

Conclusion

It is found that hypertension is essential in nature among 81% of rural subjects. Nearly half of the study subjects are overweight. Dyslipidemia, albuminuria and low GFR is more pronounced in hypertensives in comparison to the normotensive counterparts. So, hypertension is mostly associated with adverse cardio-renal risk markers.

MO101ASSESSING EARLY RENAL INVOLVEMENT IN ESSENTIAL HYPERTENSION BY MEASURING URINARY ALBUMIN AND UROMODULIN EXCRETION

Background and Aims

Kidneys are target organs in hypertension. Hypertensive damage results in glomerular as well as tubular dysfunction. Albuminuria is a known marker of glomerular damage. Whereas, urinary uromodulin is increasingly considered as potential biomarker of early tubular dysfunction. The aim of this study was to identify the pattern of early renal involvement based on glomerular and tubular function assessment by measuring urinary albumin and uromodulin in hypertensive patients

Method

In this cross-sectional study 122 hypertensive subjects with age&gt;30 years, duration of hypertension &lt;5years, without accelerated or malignant BP, absence of dipstick proteinuria and eGFR&gt;60ml/min. Subjects with possibility of secondary hypertension were excluded. There were also 33 normotensive volunteers included as healthy referents. Morning spot urine for albumin-creatinine ratio (ACR mg/g), urine uromodulin-creatinine ratio (urUMODµg/g), urinary sodium-creatinine ratio (mEq/g) and potassium-creatinine ratio (mEq/g) were measured in single urine sample. Urine uromodulin was measured by ELISA method.

Results

The hypertensive and healthy subjects were matched for age 48±11 vs. 47±11, years (P=NS). The systolic BP was 145±15 vs. 112±12 mmHg and diastolic BP 86±9 vs. 70±8 mmHg; (p&lt;0.001) and the mean ACR was 29±65 vs. 5.6±2.7 mg/g, (p&lt;0.001) respectively. Around 20% hypertensives had albuminuria. Urinary potassium excretion was lower in hypertensives (51±31 vs. 69±31, mEq/g; p&lt;0.02). The median urUMOD in hypertensive subjects was 3.38 (1.73-9.06) and in normotensives 3.85(2.28-5.69) µg/g (P=NS).Multivariate analysis showed significant inverse association between diastolic blood pressure and urinary uromodulin excretion. An urURMOD cut-off of 2.9 (25th percentile in normotensives) showed eGFR, urinary sodium & potassium excretions were significantly lower at low uromodulin cut-off and this was seen in38%subjects.

Conclusion

The glomerular involvement was found in 20% hypertensives as evidenced by albuminuria. In general urinary uromodulin level was not different between hypertensive and normotensive subjects. Association of low uromodulin cut-off with lower eGFR, Na+ and K+ excretion indicates simultaneous tubule glomerular involvement in 38%.

Pattern of antibiotic use for acute respiratory infections among out-patients in South Asian Region: Protocol for a systematic review

BACKGROUND

South Asian region has been experiencing the increasing burden of antimicrobial resistance (AMR) primarily due to over and irrational prescribing of antibiotics. Acute respiratory infections (ARIs) are the leading cause of out-patients' visits in the region. Despite commonly known viral aetiology, ARI is the single largest reason for antibiotic prescriptions contributing the exponential growth of AMR in the region. Collated data on antibiotic consumption for ARI at outpatients and resistance pattern of respiratory pathogen are lacking in the region.

METHODS

MEDLINE, Cochrane, CINAHL Plus (EBSCO), and Web of Science will be searched for eligible papers. Titles and abstracts, and full texts of the relevant studies will be screened by 2 independent reviewers against the inclusion criteria. Data extraction and quality of the studies will be assessed by 2 reviewers independently using the JBI Critical Appraisal Tools. A third reviewer will resolve any disagreement at any point between 2 reviewers.

RESULTS

The review will assess proportions of ARI patients receiving antibiotic therapy and types of antibiotics prescribed among outpatients of all ages in South Asia. This review will also assess the pattern of antimicrobial resistance among respiratory pathogens causing ARI in the region.

CONCLUSIONS

This systematic review will evaluate published literature, summarize the existing data on the antibiotic prescribing patterns for outpatients with ARI in South Asia. The holistic finding of the proportion of patients receiving antibiotic therapy for ARI, proportion of different types of antibiotic received, and resistance against respiratory pathogen might guide future research. This underscores a need for formulating regional and national policy for AMR mitigation strategy, and revising clinical practice guidelines for the clinician to ensure rational use of antibiotics for ARI.

PROSPERO

registration no: CRD42018116658.

Epidemiology of COVID-19 infection in young children under five years: A systematic review and meta-analysis

INTRODUCTION

Emerging evidence suggests young children are at greater risk of COVID-19 infection than initially predicted. However, a comprehensive understanding of epidemiology of COVID-19 infection in young children under five years, the most at-risk age-group for respiratory infections, remain unclear. We conducted a systematic review and meta-analysis of epidemiological and clinical characteristics of COVID-19 infection in children under five years.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses , we searched several electronic databases (Pubmed, EMBASE, Web of Science, and Scopus) with no language restriction for published epidemiological studies and case-reports reporting laboratory-confirmed COVID-19 infection in children under five years until June 4, 2020. We assessed pooled prevalence for key demographics and clinical characteristics using Freeman-Tukey double arcsine random-effects model for studies except case-reports. We evaluated risk of bias separately for case-reports and other studies.

RESULTS

We identified 1,964 articles, of which, 65 articles were eligible for systematic review that represented 1,214 children younger than five years with laboratory-confirmed COVID-19 infection. The pooled estimates showed that 50% young COVID-19 cases were infants (95% CI: 36% - 63%, 27 studies); 53% were male (95% CI: 41% - 65%, 24 studies); 43% were asymptomatic (95% CI: 15% - 73%, 9 studies) and 7% (95% CI: 0% - 30%, 5 studies) had severe disease that required intensive-care-unit admission. Of 139 newborns from COVID-19 infected mothers, five (3.6%) were COVID-19 positive. There was only one death recorded.

DISCUSSION

This systematic review reports the largest number of children younger than five years with COVID-19 infection till date. Our meta-analysis shows nearly half of young COVID-19 cases were asymptomatic and half were infants, highlighting the need for ongoing surveillance to better understand the epidemiology, clinical pattern, and transmission of COVID-19 to develop effective preventive strategies against COVID-19 disease in young paediatric population.

Influence of height on blood pressure and hypertension among Bangladeshi adults

Background

Recent studies have reported that height is inversely associated with blood pressure and hypertension. However, there is lack of comprehensive findings from Bangladesh in this regard.

Objective

The purpose of this study was to explore the association between height and blood pressure in a Bangladeshi population.

Setting

Rural and urban sites from seven divisions of Bangladesh.

Participants

Participants were 7932 males and females (aged ≥35 years) evaluated in the 2011 Bangladesh Demographic Health Survey. Participants (n = 7647) who had complete height, weight, systolic and diastolic blood pressure (SBP and DBP) measurements and non-missing medication history, were included in the analysis.

Methods

Hypertension was defined as an SBP over 140 mmHg or/and a DBP over 90 mmHg, or current use of antihypertensive medication. Difference between SBP and DBP was calculated to get pulse pressure (PP). Multivariate linear and logistic regression models were used.

Results

PP decreased linearly with increasing height among males (−0.11, P < 0.05) and females (−0.19, P < 0.05) after adjusting for age, BMI, living region, type of occupation, wealth index, and highest level of education. SBP decreased linearly with increasing height among only females (−0.14, P < 0.05), after adjusting for age, BMI, living region, type of occupation, wealth index, and highest level of education. No association was found between quartiles of height and prevalence of hypertension.

Conclusions

Height was found to be inversely associated with pulse pressure in both sexes. Studies with longitudinal design are needed to investigate the association between shortness with blood pressure and hypertension.

866. Assessment of Infection Control Training among Healthcare Workers in Three Tertiary Care Public Hospitals, Bangladesh, 2015-17

Background

Hospital-acquired infections (HAI) are a rising global public health concern that disproportionately affects low and middle-income countries. Healthcare workers (HCWs) are the frontline work-stream against HAIs in healthcare settings. As part of a pilot infection prevention and control (IPC) program, we assessed the acceptability of infection control training in practice among HCWs in three public hospitals in Bangladesh to better mitigate HAI risks and occupational exposures.

Methods

We piloted an IPC intervention, as a part of the emergency preparedness, from 2015 to 2017 and IPC training was one of the key components. Trained IPC staff conducted a half-day training session for each three different level HCW groups, doctors, nurses and support staff. The training comprised of instructive method on standard and transmission-based precautions with infection control techniques. A practical demonstration was held followed by hands-on training on hand hygiene steps and mask, gloves use. The participants’ attitudes and practices on infection control measures were obtained through structured observation and qualitative interviews.

Training on Infection Control And Prevention with Healthcare workers (Nurses)

Training on Infection Control And Prevention with Healthcare workers (Doctors)

Results

A total of 1562 HCW’s participated in the training: 804 doctors, 445 nurses and 313 support staff in 26 training sessions. Majority of the participants (85%) did not receive any formal training earlier on infection control and often provided incorrect responses on basic IPC during interactive session. None of the hospitals had an IPC committee. After the training, we found a significant increase from 0% at baseline to 24% (p< 0.001) in hand hygiene including 43% (p< 0.001) and 45% (p< 0.001) in mask and gloves use respectively. All respondents (n=84) from the qualitative assessment, reported the training as highly effective which reinforce their learning in action in the hospitals. Participants from all three groups urged to arrange refresher training more frequently and in small groups to uphold the practices.

Conclusion

This pilot program demonstrated HCWs lack basic IPC principals and tailored IPC training sessions can significantly improve HCWs IPC practice. Formation of active IPC committee could enable arranging periodic refresher and in-service training updates for HCWs with the reallocation of resources to adopt regular IPC practices.

Disclosures

All Authors: No reported disclosures

Isolation and molecular identification of Lumpy Skin Disease (LSD) virus from infected cattle in Bangladesh

Lumpy Skin Disease (LSD) is a new disease of cattle in Bangladesh. It is endemic in Africa but through the last few years disease beings to spread to other countries of the world. The disease was widely spreaded in the many other countries in Asia and some parts of Europe. In Bangladesh, the disease was first time detected in April 2019, in southern part and then continued to spread all over the country.The disease caused enormous economic losses causing cutaneous and internal lesions, affecting milk production, hide quality and in some cases death of infected animal. LSD suspected samples were collected from different areas of the country during the period from July 2019 to January 2020. In this study, a total of 36 clinically suspected LSD samples of skin crustnodules, pus and ocular discharge were collected. Samples were examined by the published PCR protocol for LSD virus, GPV and SPV. Around 78% samples were found positive for LSD virus in PCR test. LSD virus was also identified from pus and ocular discharge of infected cattle. The virus can grow in the lamb testicular cell and clinically the disease is characterized by distinctive nodular lesions mostly on the skin of the affected animals.The results indicated that the LSD virus is circulating in the outbreak are as and is an emerging transboundary cattle disease in Bangladesh. Bang. J. Livs. Res. Vol. 26 (1&2), 2019: P. 15-20

Clinical and laboratory predictors of 30-day mortality in severe acute malnourished children with severe pneumonia

OBJECTIVE

To determine the predictors of mortality within 30 days of hospital admission in a diarrhoeal disease hospital in Bangladesh.

METHODS

Cohort study of hospitalised children aged 0-59 months with severe acute malnutrition (SAM) and severe pneumonia in Dhaka Hospital, icddr,b, Bangladesh from April 2015 to March 2017. Those discharged were followed up, and survival status at 30 days from admission was determined. Children who died were compared with the survivors in terms of clinical and laboratory biomarkers. Multivariable logistic regression analysis was used for calculating adjusted odds ratio for death within 30 days of hospital admission.

RESULTS

We enrolled 191 children. Mortality within 30 days of admission was 6% (14/191). After adjusting for potential confounders (hypoxia, CRP and haematocrit) in logistic regression analysis, independent factors associated with death were female sex (aOR = 5.80, 95% CI: 1.34-25.19), LAZ <-4 (aOR = 6.51, 95% CI: 1.49-28.44) and Polymorphonuclear Leucocytes (PMNL) (>6.0 × 10⁹ /L) (aOR = 1.06, 95% CI: 1.01-1.11). Using sex, Z-score for length for age (LAZ), and PMNL percentage, we used random forest and linear regression models to achieve a cross-validated AUC of 0.83 (95% CI: 0.82, 0.84) for prediction of 30-day mortality.

CONCLUSIONS

The results of our data suggest that female sex, severe malnutrition (<-4 LAZ) and higher PMNL percentage were prone to be associated with 30-day mortality in children with severe pneumonia. Association of these factors may be used in clinical decision support for prompt identification and appropriate management for prevention of mortality in this population.

P0835IDENTIFYING THE FREQUENCY OF CHRONIC KIDNEY DISEASE OF UNKNOWN ETIOLOGY (CKDU) IN A RURAL POPULATION OF BANGLADESH

Background and Aims

The common etiologies of CKD are diabetes, hypertension and glomerulonephritis. Prevalence of CKD of unknown (CKDu) etiology is being increasingly considered as an emerging etiology, especially in the developing countries, with environmental predisposition to hot humid climate, dehydration and toxic metal contaminations. The aim was to identify the frequency of CKDu as an etiology in a rural population with environmental exposure.

Method

In this observational study subjects were selected from a geographically defined rural population in Bangladesh. Baseline information was recorded by the translated WHO STEP wise approach surveillance- Instrument v.3.1 (Core and Expanded). Blood Pressure was measured by digital blood pressure monitor. Serum creatinine was measured by enzymatic method using assays traceable to isotope dilution mass spectrometry (IDMS). A fasting blood sample and spot urine was collected. BP ≥140/90mmHg; FBS &gt; 5.6 mmol/l and HbA1c ≥6.5%; and eGFR&lt; 60ml/min (CKD-EPI equation) or urine ACR &gt; 30mg/g was taken as diagnostic cut-offs for hypertension, diabetes and nephropathy respectively. From diagnosed CKD patients CKDu group was further identified by stepwise approach of WHO criteria as suspected and probable stages.

Results

The mean age was 41.3 ± 12.7 years with male/female ratio 37/63 in preliminary 303 study subjects. They were 12.5% diabetic, 21% hypertensive and 75% had some form of dyslipidemia. Among all 51 subjects (16.8%) were diagnosed as CKD based on single measurement of eGFR and ACR. Of these 30 study subjects (58%) met the criteria of suspected CKDu. After repeat measures of eGFR and ACR at 3 months, prevalence of CKD came down to 10.2% persisting in 31 subjects (G1:5.3%, G2:2.3% and G3: 2.6%). Of these 7 study subjects (23%) met the criteria of probable CKDu. The main etiologies of CKD among these subjects were diabetic nephropathy (48%) followed by CKDu. The frequency of CKDu in total study population as a whole was 2.3%.The pattern of environmental exposures like types of farming, use of pesticide-fertilizer, NSAIDs intakes, water sources, amount of drinking water per day, duration of work under direct sun, pattern of fish-meat intakes, etc. were not different between subjects with CKDu versus the others.

Conclusion

The prevalence of chronic kidney disease in a rural area of Bangladesh is one in ten (10.2%). Among these nearly one-fourth (23%) of the subjects belonged to probable CKDu category. This alarmingly high frequency of CKDu needs further extensive evaluation to identify the predisposing factors responsible.

Genomic profiling of Nipah virus using NGS driven RNA-Seq expression data

Nipah virus (NiV) is an ssRNA, enveloped paramyxovirus in the genus Henipaveridae with a case fatality rate >70%. We analyzed the NGS RNA-Seq gene expression data of NiV to detect differentially expressed genes (DEGs) using the statistical R package limma. We used the Cytoscape, Ensembl, and STRING tools to construct the gene-gene interaction tree, phylogenetic gene tree and protein-protein interaction networks towards functional annotation. We identified 2707 DEGs (p-value <0.05) among 54359 NiV genes. The top-up and down-regulated DEGs were EPST1, MX1, IFIT3, RSAD2, OAS1, OASL, CMPK2 and SLFN13, SPAC977.17 using log2FC criteria with optimum threshold 1.0. The top 20 up-regulated gene-gene interaction trees showed no significant association between Nipah and Tularemia virus. Similarly, the top 20 down-regulated genes of neither Ebola nor Tularemia virus showed an association with the Nipah virus. Hence, we document the top-up and down-regulated DEGs for further consideration as biomarkers and candidates for vaccine or drug design against Nipah virus to combat infection.

Respiratory viral infection in early life and development of asthma in childhood: A protocol for systematic review and meta-analysis

BACKGROUND

Respiratory viruses are the leading cause of early life wheezing that may contribute to the development of childhood asthma leading to increasing morbidity and socioeconomic burden. The aim of this review is to identify whether respiratory viral infections during first year of life were associated with development of childhood asthma.

METHODS

We will search major scientific databases (MEDLINE, CINAHL, Web of Science, Cochrane Library, and ClinicalTrials.gov) using truncated and phrase-searched keywords and relevant subject headings. Observational studies including case-control studies, cohort studies, and randomized control trails published in English will be included in this review. Case reports, qualitative studies, and narrative overviews will be excluded. Exposure will be defined as laboratory-confirmed viral respiratory tract infection in the first year of life and outcome will be defined as development of asthma between ages 5 and 18 years. Effect sizes in bivariate and multivariate analyses will be presented as odds or prevalence ratios. We will explore for heterogeneity of the standard errors across the studies, and if appropriate, we will perform a meta-analysis using a random-effects model to present a summary estimate of the odds or prevalence ratios.

RESULTS

This review will assess whether respiratory viral infections during first year of life increases the risk of childhood asthma development.

CONCLUSIONS

This systematic review will evaluate published literature, assessing the link between early life viral infection and childhood asthma. Pooled data may provide evidence that infantile respiratory viral infection results in higher incidence of recurrent wheezing and asthma, thereby stimulating further research into the cost-effectiveness of pharmaceutical interventions such as vaccines and nonpharmaceutical interventions such as hand-washing and respiratory hygiene promotion to young children. Implementing the results of such research may then reduce the burden of acute viral respiratory infections and subsequent recurrent wheezing and asthma.

SYSTEMATIC REVIEW REGISTRATION

This systematic review has been registered on PROSPERO (CRD42018105519).

Severe anti-D haemolytic disease of fetal and newborn in rhesus D negative primigravida

INTRODUCTION

Anti-D alloimmunisation may occur from the blood transfusion or fetomaternal haemorrhage which can lead to haemolytic disease of fetal and newborn (HDFN). The morbidity and mortality of HDFN related to anti-D is significantly reduced after introduction of anti-D prophylaxis and furthermore, anti-D HDFN in RhD negative primigravida is uncommonly seen.

CASE REPORT

A case of unusual severe HDFN due to anti-D alloimmunisation in undiagnosed RhD negative primigravida Malay woman is reported here. This case illustrates the possibility of an anamnestic response from previous unknown sensitisation event or the development of anti-D in mid trimester. The newborn expired due to hydrops fetalis and severe anaemia. Antenatally, the mother was identified as RhD positive and thus there was no antenatal antibody screening, antepartum anti-D prophylaxis or close fetal monitoring for HDFN.

DISCUSSION

The thorough antenatal ABO and RhD blood grouping with antibody screening is mandatory as part of prevention and early detection of HDFN especially due to anti-D alloimmunisation. Improper management of RhD negative women might lead to severe HDFN including in primigravida.

Role of Qualified Physicians as Antenatal Care Providers in Reducing Birth Complications in Home-delivered Rural Women in Bangladesh

Introduction

Bangladesh has made significant strides in maternal and neonatal death by ensuring qualified antenatal care (ANC) visits during the pregnancy period of women. To ensure this qualified ANC, the government of Bangladesh has increased the number of qualified physicians and skilled birth attendants at health facilities and encouraged pregnant women to take this eligible ANC during pregnancy. Despite this progress, the majority of deliveries among rural women still occur at home, assisted by traditional birth attendants. These traditional birth attendants at home or even skilled birth attendants at the health facility or home are not always cable of helping women to overcome severe delivery complications. Proper birth preparation before pregnancy through qualified ANC might be a solution here. Taking advice for appropriate birth preparation from a qualified physician (medical doctor) would ensure qualified ANC. In this study, we examined how ANC from a qualified physician, as compared to other trained providers, influences rural women delivering at home to prepare for birth and reduces severe delivery complications.

Methods

The data of 1554 rural women who delivered at home were extracted from the 2014 Bangladesh Demographic and Health Survey data. A mixed-effects logistic regression model was carried out for the binary delivery complications data, to assess the influence of qualified physicians as ANC providers on delivery complications by adjusting the effect of other socio-demographic covariates and clustering.

Results

Of the women from rural areas who delivered at home, 42% reported delivery complications. Those who received ANC from a qualified physician were 32% less likely (OR 0.68; 95% CI 0.50, 0.91) to report facing delivery complications as compared to those who had received ANC from other trained or unqualified providers adjusted by socio-demographic determinants in Bangladesh.

Conclusions

Developing a sustained and effective strategy could be a precedent for promoting ANC from qualified physicians for rural women delivering at home, to decrease delivery complications as well as creating healthy environments for safe deliveries.

Iceberg of workplace violence in health sector of Bangladesh

Objectives

‘Negligence of Physicians’ and ‘Wrong Treatment’ have become commonly-used phrases in print and electronic media of Bangladesh, while violence against healthcare workers has always been under-reported. Unfortunately, there is little evidence regarding physical violence against healthcare workers, while there is no data on the magnitude of psychological violence. The objective of this study was to quantify and explore the magnitude of workplace violence in health sector of Bangladesh to guide future research and adopt preventive policies.

Results

The Majority (96%, n = 54) of the violence cases were physical in nature and 91% violence (n = 51) took place in public healthcare settings. More than one-third (39%) of the violence cases occurred at primary healthcare level and one-third (39%) at tertiary healthcare level. It was mostly (61%) the entry-level physicians who were affected by violence. The report reveals the tip of the iceberg of workplace violence in health sector of Bangladesh. Further studies should be undertaken to assess the prevalence, magnitude, and associated factors for workplace violence against healthcare workers.

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.

Nipah Virus Contamination of Hospital Surfaces during Outbreaks, Bangladesh, 2013-2014

Nipah virus (NiV) has been transmitted from patient to caregivers in Bangladesh presumably through oral secretions. We aimed to detect whether NiV-infected patients contaminate hospital surfaces with the virus. During December 2013–April 2014, we collected 1 swab sample from 5 surfaces near NiV-infected patients and tested surface and oral swab samples by real-time reverse transcription PCR for NiV RNA. We identified 16 Nipah patients; 12 cases were laboratory-confirmed and 4 probable. Of the 12 laboratory-confirmed cases, 10 showed NiV RNA in oral swab specimens. We obtained surface swab samples for 6 Nipah patients; 5 had evidence of NiV RNA on >1 surface: 4 patients contaminated towels, 3 bed sheets, and 1 the bed rail. Patients with NiV RNA in oral swab samples were significantly more likely than other Nipah patients to die. To reduce the risk for fomite transmission of NiV, infection control should target hospital surfaces.

Trends, prevalence and risk factors of overweight and obesity among women of reproductive age in Bangladesh: a pooled analysis of five national cross-sectional surveys

OBJECTIVE

To determine the trends, prevalence and risk factors of overweight and obesity among Bangladeshi women of reproductive age from 1999 to 2014.

DESIGN

We analysed nationally representative data from the 1999, 2004, 2007, 2011 and 2014 cross-sectional Bangladesh Demographic and Health Surveys.

SETTING

Bangladesh.

PARTICIPANTS

Women aged 15-49 years.

PRIMARY OUTCOME

Overweight/obesity.

RESULTS

A total of 58 192 women were included in the analysis. The prevalence of overweight and obesity among women of reproductive age increased significantly from 7.53% (95% CI 6.83 to 8.29) and 1.82% (95% CI 1.48 to 2.24) in 1999 to 28.37% (95% CI 27.49 to 29.28) and 10.77% (95% CI 10.22 to 11.35) in 2014, respectively. Age, education, wealth index, watching television and contraceptive use were associated with overweight and obesity in both urban and rural areas.

CONCLUSIONS

Overweight and obesity prevalence increased significantly among Bangladeshi women of reproductive age between 1999 and 2014. Development of effective low-cost strategies to address the increasing burden of obesity should be a high priority.

Food Safety Knowledge, Attitudes and Practices of Chotpoti Vendors in Dhaka, Bangladesh

Background: Chotpoti is a popular street food among all groups of people from low to high income in most cities of Bangladesh.Objective: This study was conducted to describe the vending sites, the stalls and equipments used for food preparation, current level of food safety knowledge of vendors and the way to prepare foods to understand the risks of food contamination and opportunities for prevention.Materials and Methods: This cross-sectional study was conducted between July and October, 2012. We selected 18 popular chotpoti vending sites including market places, bus stops, road sides and amusement parks located under Dhaka city corporation areas by judgment sampling. From each study site we randomly selected six vendors for interview. A structured pretested questionnaire was used for data collection. Data were collected on (i) socio-economic and demographic characteristics of the respondents; (ii) health and personal hygiene knowledge of vendors; (iii) vendors’ food handling practices and (iv) source of ingredients and process of chotpoti making. Location of the chotpoti vendors, utensils used, handling of food, place of preparation of chotpoti, environment surroundings of the stall, general processing of chotpoti and hygienic practices were observed and recorded through an observation checklist.Results: We interviewed a total of 110 vendors. All vendors were male, the majority was between 21 and 30 years of age. Majority (58.2%) of the vendors acquired the knowledge of chotpoti preparation through observation. Nearly all vendors (99%) handled food with bare hands, 95% did not use aprons and hair covering and 94% handled money while serving chotpoti. Most vendors had leftovers; out of those 30% reported discarding them and the rest stored them for following day’s sale with inappropriate storage. Nearly one-third (32.7%) of the vendors washed their utensils with dirty water which is recycled. Majority reported that they changed the bucket water only once per 12 hours. Presence of flies was observed on food and surroundings of 33% of the stalls. Of the vendors interviewed, most of them did not have garbage receptacles and 23% disposed wastes nearby their stalls and 76% disposed in nearby dustbin.Conclusion: This study demonstrates that chotpoti vendors do not have formal education and formal training on food preparation. Moreover, lack of hand hygiene knowledge, infrequent cleaning of utensils with soap, inappropriate management of leftover foods, and lack of proper waste management create numerous possibilities for food contamination. Consumption of street vended chotpoti may pose a risk of food borne diseases and steps should be taken to educate and train the vendors on personal hygiene and food handling practices.J Enam Med Col 2017; 7(2): 69-76

Detection of enteric bacteria in the popular street food chotpoti in Dhaka, Bangladesh

Contaminated street food has been linked to food-borne illness and food-borne outbreak. Chotpoti is a popular street food in Bangladesh. This study was conducted to identify enteric bacteria in chotpoti sold in different parts of the capital city Dhaka. From July to October, 2012 we purposively selected 18 sites where chotpoti was sold in Dhaka city. From each site we randomly selected six chotpoti stalls for sample collection. At each stall we aseptically collected approximately 100 gm of a combined sample of chotpoti, chili sauce and water used for cleaning utensils. The combined sample was homogenized and was serially diluted in a sterile test tube with normal saline to obtain a dilution up to 10-5. From each test tube 0.1 ml of dilution was plated on to MacConkey and Blood agar plates under aerobic conditions at 37?C for 24 to 48 hours. Bacterial growth was identified by the colonial morphology, Gram stain, and biochemical tests. Of the 108 samples we analyzed, 84 (78%) were contaminated with bacterial pathogens. Among isolated organisms Acinetobacter (66%) was the most dominant followed by Klebsiella spp. (54%), E. coli (3%) and Proteus spp. (0.9%). Two different organisms were present in 47 (44%) samples. In half of the study sites, every sample was contaminated; in only one site bacterial contamination was absent in all samples. Contaminated street food like chotpoti may cause food borne illness and pose risk of food borne epidemics. Further studies are required for quantitative assessment of pathogens to detect potential sources of contamination and to develop interventions that can effectively reduce street food contamination.Asian J. Med. Biol. Res. December 2016, 2(4): 596-602

Healthcare Financing in Bangladesh: Challenges and Recommendations

Bangladesh has achieved remarkable success in improving most of the health indicators over the last couple of decades despite pervasive economic poverty. However, for a sustainable growth health sector should be among the top lists at Government’s policy table. Unfortunately, the recent trend in budget allocation portrayed just the opposite and is concerning as expressed by health experts. Over the last seven fiscal years, budgetary allocation for health dropped from 6.2% to 4.3% of total government expenditure. Due to insufficient public spending, out of pocket payment (OPP) is much higher which is about two-third (64.7%) of total health care spending in Bangladesh. Inadequate and inefficient public healthcare and profiteering tendency of the private healthcare sector are two major factors behind such high private spending. Suffering from a massive shortage of health workforce and with such low public funding it would be very difficult for Bangladesh to fight against upcoming challenges like increasing burden of non communicable diseases (NCDs) and emerging threats due to climate change.Bangladesh Journal of Medical Science Vol.15(4) 2016 p.505-510

Emergence of fractal behavior in condensation-driven aggregation

We investigate the condensation-driven aggregation model that we recently proposed whereby an initial ensemble of chemically identical Brownian particles are continuously growing by condensation and at the same time undergo aggregation upon collision. We solved the model exactly by using scaling theory for the case when a particle, say of size x , grows by an amount alphax over the time it takes to collide with another particle of any size. It is shown that the particle size spectra exhibit transition to scaling c(x,t) approximately t;{-beta}varphi(xt{z}) accompanied by the emergence of a fractal of dimension d {f}=1/(1+2alpha) . A remarkable feature of this model is that it is governed by a nontrivial conservation law, namely, the d {f}th moment of c(x,t) is time invariant. The reason why it remains conserved is explained. Exact values for the exponents beta , z , and d{f} are obtained and it is shown that they obey a generalized scaling relation beta=(1+d{f})z .

Condensation-driven aggregation in one dimension

We propose a model for aggregation where particles are continuously growing by heterogeneous condensation in one dimension, and solve it exactly. We show that the particle size spectra exhibit a transition to dynamic scaling c(x,t) approximately t-beta phi(x/tz) . The exponents beta and z satisfy a generalized scaling relation beta=(1+q)z where the value of q is fixed by a nontrivial conservation law. We show that the value of 1+q is always less than the value 2 for aggregation without condensation.

The improvement effect of L-Lys as a chemical chaperone on STZ-induced diabetic rats, protein structure and function

BACKGROUND

L-Lysine (L-Lys) has been known as an inhibitor of protein glycation; however, its long-term use for diabetes treatment considering different aspects of diabetic complication is not seen in the literature. In addition, the effect of L-Lys, as a chemical chaperone, was considered on protein folding and activity.

METHODS

The streptozotocin-induced diabetic rats were used as a model of diabetes. Normal and diabetic rats were studied for 5 months with and without 0.1% of L-Lys in drinking water. Serum glucose, advanced glycation end product (AGEs), haemoglobin A(1C) (HbA(1c)), triglyceride, total cholesterol, HDL-cholesterol, antioxidant activity, advanced oxidation protein products, fasting insulin level and body weight were determined at 4-week intervals. Heat shock protein (HSP)70, Lecithin: cholesterol acyl transferase (LCAT) and paraoxonase activity were determined 1 week after diabetes induction (time 0), and after 3 and 5 months. The structure of glycated and normal serum albumin (Alb) in the presence and absence of L-Lys was also investigated in an in vitro study using spectrofluorometry and circular dichroism (CD).

RESULTS

We found that L-Lysine therapy prevented diabetic- induced increases in Glc, AGE, HbA(1c), triglyceride, total- and LDL- cholesterol, and it caused an increase in the decreased antioxidant capacity, HDL-c, HDL functionality and HSP70. L-Lys had no effect on serum insulin level. The conformation of Alb changed due to glycation and L-Lys retained it similar to the native.

CONCLUSIONS

L-Lys, not only as an inhibitor of glycation but also as a chemical chaperone and a protein chaperone inducer, causes effective changes in many parameters of the model animals. However, it is not enough to achieve complete improvement.

Effect of spermine on lipid profile and HDL functionality in the streptozotocin-induced diabetic rat model

This study aimed to investigate the effect of spermine (Spm) as a chemical chaperone and glycation inhibitor on the lipid profile and HDL functionality in the short- and long-term treatment of the STZ-induced diabetic rats. Male Wistar rats were divided into 4 groups (control, n=7; diabetic, n=9). Two groups (named 2 and 3) were injected intraperitoneally with streptozotocin. Control rats (named 1 and 4) were injected with vehicle alone. The treatment of diabetic and control animals (groups 3 and 4) with 60 micromol/l of Spm in drinking water was begun. The study continued up to the end of the fifth month. The serum glucose and insulin level, AGE formation, lipid profile, paraoxonase 1 (PON1), and lecithin: cholesterol acyl transferase (LCAT) activities were measured. Significantly lower plasma PON1, and LCAT activities and higher serum AGE, TG, TC and LDL-c, and lower HDL-c were seen in diabetic rats as compared to control groups (P<0.01). The increased AGE, TG, TC and LDL-c levels in diabetic groups decreased gradually after receiving Spm. In addition, due to Spm administration, an increase in the HDL-c level was observed after the first month of the experiment (P<0.01). The increase in the PON1 and LCAT activities in the diabetic group that received Spm was significant after the second and the forth month of the experiment, P<0.02 and P<0.05, respectively. In conclusion, spermine administration attenuated the changed parameters to near normal values in diabetic rats. Spermine, despite a lack of significant changes on glucose metabolism and insulin secretion, was found to improve diabetes complications.