Dr. Luby studied philosophy and earned a Bachelor of Arts summa cum laude from Creighton University. He earned his medical degree from the University of Texas Southwestern Medical School at Dallas and completed his residency in internal medicine at the University of Rochester-Strong Memorial Hospital. He studied epidemiology and preventive medicine at the Centers for Disease Control and Prevention.

Dr. Luby's previous positions include directing the Centre for Communicable Diseases at the International Centre for Diarrhoeal Diseases Research, Bangladesh in Dhaka, Bangladesh from 2004 - 2012, conducting research and teaching epidemiology at the Aga Khan University in Karachi, Pakistan from 1993 - 1998, and working as an epidemiologist in the Foodborne and Diarrheal Diseases Branch of the U.S. Centers for Disease Control and Prevention.

Administrative Appointments

  • Director of Research, Stanford Center for Innovation in Global Health (2012 - Present)

Honors & Awards

  • Alexander D. Langmuir Prize, Centers for Disease Control and Prevention (2001)
  • Favourite paper in infectious diseases, Lancet Infectious Diseases (2005)
  • Shepard Award, Centers for Disease Control and Prevention (2006, 2014 & 2015)
  • International WaTER Prize, Oklahoma University (2009)
  • Medal of Excellence in Global Health, Center for Global Health, Centers for Disease Control and Prevention (2012)
  • Begum Rokeya Sakhawat Hossain Teaching Excellence Award, James P Grant School of Public Health (2012, 2014, 2015)

Professional Education

  • Fellowship, Centers for Disease Control and Prevention, Epidemiology (1992)
  • Residency, Strong Memorial Hospital, Internal Medicine (1989)
  • Internship, Strong Memorial Hospital, Internal Medicine (1987)
  • MD, University of Texas, Southwestern, Medicine (1986)
  • BA, Creighton University, Philosophy (1981)
  • Board Certification, American Board of Internal Medicine, Internal Medicine (1989)

Community and International Work

  • WASH Benefits, Rural Bangladesh


    Water, sanitation, hygiene, nutrition

    Partnering Organization(s)

    icddrb, UC Berkeley

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Lotus Water, Dhaka, Bangladesh


    Water quality and health

    Partnering Organization(s)


    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Improving communal toilets, Dhaka, Bangladesh


    urban sanitation, behavior change

    Partnering Organization(s)

    icddr,b, Johns Hopkins Bloomberg School of Public Health

    Populations Served

    Low income urban residents



    Ongoing Project


    Opportunities for Student Involvement


  • Leveraging social networks to improve child immunizations, Bangladesh


    social networks, child immunization

    Partnering Organization(s)


    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Burden of pneumococcal disease, Bangladesh


    pneumococcal disease, immunization, surveillance

    Partnering Organization(s)

    Child Health Research Foundation

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Lead exposure in rural Bangladesh, Bangladesh



    Partnering Organization(s)




    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Dr. Luby’s research interests include identifying and interrupting pathways of infectious disease transmission in low income countries. He works primarily in Bangladesh but also has projects in Western China and Liberia. His ongoing work includes 1) assessing the impact on health and child cognitive development of scalable strategies to improve water, sanitation and hygiene; 2) efforts to better understand the burden of disease from typhoid fever and evaluating approaches to reduce that burden; 3) developing and evaluating interventions to reduce the risk of a Nipah virus pandemic; 4) evaluating the impact of the Bangladesh national vaccine program on the burden of pneumococcal and Haemophilus influenzae type B infection..

2016-17 Courses

Stanford Advisees

Graduate and Fellowship Programs

All Publications

  • Nipah Virus Transmission from Bats to Humans Associated with Drinking Traditional Liquor Made from Date Palm Sap, Bangladesh, 2011-2014 EMERGING INFECTIOUS DISEASES Islam, M. S., Sazzad, H. M., Satter, S. M., Sultana, S., Hossain, M. J., Hasan, M., Rahman, M., Campbell, S., Cannon, D. L., Stroeher, U., Daszak, P., Luby, S. P., Gurley, E. S. 2016; 22 (4): 664-670
  • Evolving epidemiology of Nipah virus infection in Bangladesh: evidence from outbreaks during 2010-2011 EPIDEMIOLOGY AND INFECTION Chakraborty, A., Sazzad, H. M., Hossain, M. J., Islam, M. S., PARVEEN, S., Husain, M., Banu, S. S., Podder, G., Afroj, S., ROLLIN, P. E., Daszak, P., Luby, S. P., Rahman, M., Gurley, E. S. 2016; 144 (2): 371-380


    Drinking raw date palm sap is the primary route of Nipah virus (NiV) transmission from bats to people in Bangladesh; subsequent person-to-person transmission is common. During December 2010 to March 2011, we investigated NiV epidemiology by interviewing cases using structured questionnaires, in-depth interviews, and group discussions to collect clinical and exposure histories. We conducted a case-control study to identify risk factors for transmission. We identified 43 cases; 23 were laboratory-confirmed and 20 probable. Thirty-eight (88%) cases died. Drinking raw date palm sap and contact with an infected person were major risk factors; one healthcare worker was infected and for another case transmission apparently occurred through contact with a corpse. In absence of these risk factors, apparent routes of transmission included drinking fermented date palm sap. For the first time, a case was detected in eastern Bangladesh. Identification of new epidemiological characteristics emphasizes the importance of continued NiV surveillance and case investigation.

    View details for DOI 10.1017/S0950268815001314

    View details for Web of Science ID 000368638100019

    View details for PubMedID 26122675

  • Towards sustainable public health surveillance for enteric fever. Vaccine Luby, S. P., Saha, S., Andrews, J. R. 2015; 33: C3-7


    Enteric fever that results from infection by the typhoidal Salmonellas (Salmonella Typhi and Salmonella Paratyphi A, B and C) is a life-threatening preventable illness. Surveillance of enteric fever is important to understand current burden of disease, to track changes in human health burden from increasing antimicrobial resistance and to assess the impact of efforts to reduce disease burden. Since enteric fever occurs predominantly in low income communities, expensive surveillance is not sustainable. Traditional hospital-based surveillance does not estimate population burden and intensive community-based cohort studies do not capture the severe disease that is crucial to policy decisions. While cohort studies have been considered the gold standard for incidence estimates, the resources required to conduct them are great; as a consequence, estimates of enteric fever burden have been highly geographically and temporally restricted. A hybrid approach combining laboratory diagnosis that is already being conducted in healthcare centers with community-based surveillance of health care facility use offers a low-cost, sustainable approach to generate policy relevant data.

    View details for DOI 10.1016/j.vaccine.2015.02.054

    View details for PubMedID 25912287

  • Effects of Source- versus Household Contamination of Tubewell Water on Child Diarrhea in Rural Bangladesh: A Randomized Controlled Trial PLOS ONE Ercumen, A., Naser, A. M., Unicomb, L., Arnold, B. F., Colford, J. M., Luby, S. P. 2015; 10 (3)


    Shallow tubewells are the primary drinking water source for most rural Bangladeshis. Fecal contamination has been detected in tubewells, at low concentrations at the source and at higher levels at the point of use. We conducted a randomized controlled trial to assess whether improving the microbiological quality of tubewell drinking water by household water treatment and safe storage would reduce diarrhea in children <2 years in rural Bangladesh.We randomly assigned 1800 households with a child aged 6-18 months (index child) into one of three arms: chlorine plus safe storage, safe storage and control. We followed households with monthly visits for one year to promote the interventions, track their uptake, test participants' source and stored water for fecal contamination, and record caregiver-reported child diarrhea prevalence (primary outcome). To assess reporting bias, we also collected data on health outcomes that are not expected to be impacted by our interventions.Both interventions had high uptake. Safe storage, alone or combined with chlorination, reduced heavy contamination of stored water. Compared to controls, diarrhea in index children was reduced by 36% in the chlorine plus safe storage arm (prevalence ratio, PR = 0.64, 0.55-0.73) and 31% in the safe storage arm (PR = 0.69, 0.60-0.80), with no difference between the two intervention arms. One limitation of the study was the non-blinded design with self-reported outcomes. However, the prevalence of health outcomes not expected to be impacted by water interventions did not differ between study arms, suggesting minimal reporting bias.Safe storage significantly improved drinking water quality at the point of use and reduced child diarrhea in rural Bangladesh. There was no added benefit from combining safe storage with chlorination. Efforts should be undertaken to implement and evaluate long-term efforts for safe water storage in NCT01350063.

    View details for DOI 10.1371/journal.pone.0121907

    View details for Web of Science ID 000352133600126

    View details for PubMedID 25816342

  • Differences in field effectiveness and adoption between a novel automated chlorination system and household manual chlorination of drinking water in Dhaka, Bangladesh: a randomized controlled trial. PloS one Pickering, A. J., Crider, Y., Amin, N., Bauza, V., Unicomb, L., Davis, J., Luby, S. P. 2015; 10 (3)


    The number of people served by networked systems that supply intermittent and contaminated drinking water is increasing. In these settings, centralized water treatment is ineffective, while household-level water treatment technologies have not been brought to scale. This study compares a novel low-cost technology designed to passively (automatically) dispense chlorine at shared handpumps with a household-level intervention providing water disinfection tablets (Aquatab), safe water storage containers, and behavior promotion. Twenty compounds were enrolled in Dhaka, Bangladesh, and randomly assigned to one of three groups: passive chlorinator, Aquatabs, or control. Over a 10-month intervention period, the mean percentage of households whose stored drinking water had detectable total chlorine was 75% in compounds with access to the passive chlorinator, 72% in compounds receiving Aquatabs, and 6% in control compounds. Both interventions also significantly improved microbial water quality. Aquatabs usage fell by 50% after behavioral promotion visits concluded, suggesting intensive promotion is necessary for sustained uptake. The study findings suggest high potential for an automated decentralized water treatment system to increase consistent access to clean water in low-income urban communities.

    View details for DOI 10.1371/journal.pone.0118397

    View details for PubMedID 25734448

  • Differences in Field Effectiveness and Adoption between a Novel Automated Chlorination System and Household Manual Chlorination of Drinking Water in Dhaka, Bangladesh: A Randomized Controlled Trial. PloS one Pickering, A. J., Crider, Y., Amin, N., Bauza, V., Unicomb, L., Davis, J., Luby, S. P. 2015; 10 (3)

    View details for DOI 10.1371/journal.pone.0118397

    View details for PubMedID 25734448

  • Is targeting access to sanitation enough? The Lancet. Global health Luby, S. 2014; 2 (11): e619-20

    View details for DOI 10.1016/S2214-109X(14)70326-2

    View details for PubMedID 25442678

  • Microbiological evaluation of the efficacy of soapy water to clean hands: a randomized, non-inferiority field trial. The American journal of tropical medicine and hygiene Amin, N., Pickering, A. J., Ram, P. K., Unicomb, L., Najnin, N., Homaira, N., Ashraf, S., Abedin, J., Islam, M. S., Luby, S. P. 2014; 91 (2): 415-423


    We conducted a randomized, non-inferiority field trial in urban Dhaka, Bangladesh among mothers to compare microbial efficacy of soapy water (30 g powdered detergent in 1.5 L water) with bar soap and water alone. Fieldworkers collected hand rinse samples before and after the following washing regimens: scrubbing with soapy water for 15 and 30 seconds; scrubbing with bar soap for 15 and 30 seconds; and scrubbing with water alone for 15 seconds. Soapy water and bar soap removed thermotolerant coliforms similarly after washing for 15 seconds (mean log10 reduction = 0.7 colony-forming units [CFU], P < 0.001 for soapy water; mean log10 reduction = 0.6 CFU, P = 0.001 for bar soap). Increasing scrubbing time to 30 seconds did not improve removal (P > 0.05). Scrubbing hands with water alone also reduced thermotolerant coliforms (mean log10 reduction = 0.3 CFU, P = 0.046) but was less efficacious than scrubbing hands with soapy water. Soapy water is an inexpensive and microbiologically effective cleansing agent to improve handwashing among households with vulnerable children.

    View details for DOI 10.4269/ajtmh.13-0475

    View details for PubMedID 24914003

  • The Role of Landscape Composition and Configuration on Pteropus giganteus Roosting Ecology and Nipah Virus Spillover Risk in Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Hahn, M. B., Gurley, E. S., Epstein, J. H., Islam, M. S., Patz, J. A., Daszak, P., Luby, S. P. 2014; 90 (2): 247-255


    Nipah virus has caused recurring outbreaks in central and northwest Bangladesh (the "Nipah Belt"). Little is known about roosting behavior of the fruit bat reservoir, Pteropus giganteus, or factors driving spillover. We compared human population density and ecological characteristics of case villages and control villages (no reported outbreaks) to understand their role in P. giganteus roosting ecology and Nipah virus spillover risk. Nipah Belt villages have a higher human population density (P < 0.0001), and forests that are more fragmented than elsewhere in Bangladesh (0.50 versus 0.32 patches/km(2), P < 0.0001). The number of roosts in a village correlates with forest fragmentation (r = 0.22, P = 0.03). Villages with a roost containing Polyalthia longifolia or Bombax ceiba trees were more likely case villages (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 1.3-90.6). This study suggests that, in addition to human population density, composition and structure of the landscape shared by P. giganteus and humans may influence the geographic distribution of Nipah virus spillovers.

    View details for DOI 10.4269/ajtmh.13-0256

    View details for Web of Science ID 000331009000010

    View details for PubMedID 24323516

  • The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings BMC PUBLIC HEALTH Dreibelbis, R., Winch, P. J., Leontsini, E., Hulland, K. R., Ram, P. K., Unicomb, L., Luby, S. P. 2013; 13


    Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance.We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH).We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual).A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.

    View details for DOI 10.1186/1471-2458-13-1015

    View details for Web of Science ID 000329290200003

    View details for PubMedID 24160869

  • The pandemic potential of Nipah virus. Antiviral research Luby, S. P. 2013; 100 (1): 38-43


    Nipah virus, a paramyxovirus whose wildlife reservoir is Pteropus bats, was first discovered in a large outbreak of acute encephalitis in Malaysia in 1998 among persons who had contact with sick pigs. Apparently, one or more pigs was infected from bats, and the virus then spread efficiently from pig to pig, then from pigs to people. Nipah virus outbreaks have been recognized nearly every year in Bangladesh since 2001 and occasionally in neighboring India. Outbreaks in Bangladesh and India have been characterized by frequent person-to-person transmission and the death of over 70% of infected people. Characteristics of Nipah virus that increase its risk of becoming a global pandemic include: humans are already susceptible; many strains are capable of limited person-to-person transmission; as an RNA virus, it has an exceptionally high rate of mutation: and that if a human-adapted strain were to infect communities in South Asia, high population densities and global interconnectedness would rapidly spread the infection. Appropriate steps to estimate and manage this risk include studies to explore the molecular and genetic basis of respiratory transmission of henipaviruses, improved surveillance for human infections, support from high-income countries to reduce the risk of person-to-person transmission of infectious agents in low-income health care settings, and consideration of vaccination in communities at ongoing risk of exposure to the secretions and excretions of Pteropus bats.

    View details for DOI 10.1016/j.antiviral.2013.07.011

    View details for PubMedID 23911335

  • Household environmental conditions are associated with enteropathy and impaired growth in rural Bangladesh. The American journal of tropical medicine and hygiene Lin, A., Arnold, B. F., Afreen, S., Goto, R., Huda, T. M., Haque, R., Raqib, R., Unicomb, L., Ahmed, T., Colford, J. M., Luby, S. P. 2013; 89 (1): 130-137


    We assessed the relationship of fecal environmental contamination and environmental enteropathy. We compared markers of environmental enteropathy, parasite burden, and growth in 119 Bangladeshi children (≤ 48 months of age) across rural Bangladesh living in different levels of household environmental cleanliness defined by objective indicators of water quality and sanitary and hand-washing infrastructure. Adjusted for potential confounding characteristics, children from clean households had 0.54 SDs (95% confidence interval [CI] = 0.06, 1.01) higher height-for-age z scores (HAZs), 0.32 SDs (95% CI = -0.72, 0.08) lower lactulose:mannitol (L:M) ratios in urine, and 0.24 SDs (95% CI = -0.63, 0.16) lower immunoglobulin G endotoxin core antibody (IgG EndoCAb) titers than children from contaminated households. After adjusting for age and sex, a 1-unit increase in the ln L:M was associated with a 0.33 SDs decrease in HAZ (95% CI = -0.62, -0.05). These results are consistent with the hypothesis that environmental contamination causes growth faltering mediated through environmental enteropathy.

    View details for DOI 10.4269/ajtmh.12-0629

    View details for PubMedID 23629931

  • Nipah virus outbreak in Bangladesh with nosocomial and corpse to human transmission. Emerging Infectious Diseases Sazzad HMS, Hossain MJ, Gurley ES, Ameen KMH, Parveen S, Islam MS, Faruque LI, Podder G, Banu SS, Lo MK, Rollin PE, Rota PA, Daszak P, Rahman M, Luby SP. 2013; 19 (2): 210-17
  • Improvements in child development following a cluster-randomized, controlled trial of intensive handwashing promotion in Karachi, Pakistan. Arch PediatrAdolesct Med Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra RM. 2012; 166 (11): 1037-44
  • Unusually High Mortality in Waterfowl Caused by Highly Pathogenic Avian Influenza A(H5N1) in Bangladesh TRANSBOUNDARY AND EMERGING DISEASES Haider, N., Sturm-Ramirez, K., KHAN, S. U., Rahman, M. Z., Sarkar, S., Poh, M. K., Shivaprasad, H. L., Kalam, M. A., Paul, S. K., Karmakar, P. C., Balish, A., Chakraborty, A., Mamun, A. A., Mikolon, A. B., Davis, C. T., Rahman, M., Donis, R. O., Heffelfinger, J. D., Luby, S. P., Zeidner, N. 2017; 64 (1): 144-156

    View details for DOI 10.1111/tbed.12354

    View details for Web of Science ID 000392275600015

  • Can Sanitary Inspection Surveys Predict Risk of Microbiological Contamination of Groundwater Sources? Evidence from Shallow Tubewells in Rural Bangladesh. The American journal of tropical medicine and hygiene Ercumen, A., Naser, A. M., Arnold, B. F., Unicomb, L., Colford, J. M., Luby, S. P. 2017


    AbstractAccurately assessing the microbiological safety of water sources is essential to reduce waterborne fecal exposures and track progress toward global targets of safe water access. Sanitary inspections are a recommended tool to assess water safety. We collected 1,684 water samples from 902 shallow tubewells in rural Bangladesh and conducted sanitary surveys to assess whether sanitary risk scores could predict water quality, as measured by Escherichia coli. We detected E. coli in 41% of tubewells, mostly at low concentrations. Based on sanitary scores, 31% of wells were low risk, 45% medium risk, and 25% high or very high risk. Older wells had higher risk scores. Escherichia coli levels were higher in wells where the platform was cracked or broken (Δlog10 = 0.09, 0.00-0.18) or undercut by erosion (Δlog10 = 0.13, 0.01-0.24). However, the positive predictive value of these risk factors for E. coli presence was low (< 50%). Latrine presence within 10 m was not associated with water quality during the wet season but was associated with less frequent E. coli detection during the dry season (relative risk = 0.72, 0.59-0.88). Sanitary scores were not associated with E. coli presence or concentration. These findings indicate that observed characteristics of a tubewell, as measured by sanitary inspections in their current form, do not sufficiently characterize microbiological water quality, as measured by E. coli. Assessments of local groundwater and geological conditions and improved water quality indicators may reveal more clear relationships. Our findings also suggest that the dominant contamination route for shallow groundwater sources is short-circuiting at the wellhead rather than subsurface transport.

    View details for DOI 10.4269/ajtmh.16-0489

    View details for PubMedID 28115666

    View details for PubMedCentralID PMC5361528

  • Potential sources of bias in the use of Escherichia coli to measure waterborne diarrhoea risk in low-income settings TROPICAL MEDICINE & INTERNATIONAL HEALTH Ercumen, A., Arnold, B. F., Naser, A. M., Unicomb, L., Colford, J. M., Luby, S. P. 2017; 22 (1): 2-11

    View details for DOI 10.1111/tmi.12803

    View details for Web of Science ID 000392528900001

  • Is pregnancy a teachable moment to promote handwashing with soap among primiparous women in rural Bangladesh? Follow-up of a randomised controlled trial TROPICAL MEDICINE & INTERNATIONAL HEALTH Kamm, K. B., Vujcic, J., Nasreen, S., Luby, S. P., Zaman, K., El Arifeen, S., Ram, P. K. 2016; 21 (12): 1562-1571


    Promoting handwashing with soap to mothers of young children can significantly reduce diarrhoea and pneumonia morbidity among children, but studies that measured long-term behaviour after interventions rarely found improvements in handwashing habits. Expecting mothers may experience emotional and social changes that create a unique environment that may encourage adoption of improved handwashing habits. The objective of this study was to determine whether exposure to an intensive handwashing intervention in the perinatal period (perinatal arm) was associated with improved maternal handwashing behaviour vs. exposure to the same intervention after the end of the perinatal period (post-neonatal arm).We identified primiparous women previously enrolled a randomised controlled handwashing intervention trial (November 2010-December 2011) and observed handwashing behaviours at the home 1-14 months after completion of the RCT (January-May 2012). We observed maternal handwashing and estimated the prevalence ratio (PR) of maternal handwashing using log-binomial regression.We enrolled 107 mothers in the perinatal arm and 105 mothers in the post-neonatal arm. Handwashing with soap at recommended times was low overall (4.6%) and comparable between arms (PR = 0.9, 95% CI 0.5, 1.5).This handwashing intervention was unable to develop and establish improved handwashing practices in primiparous women in rural Bangladesh. While pregnancy may present an opportunity and motivation to do so, further studies should assess whether social, individual and environmental influences overcome this motivation and prevent handwashing with soap among new mothers.

    View details for DOI 10.1111/tmi.12782

    View details for Web of Science ID 000389341700010

    View details for PubMedID 27644068

  • Healthcare worker and family caregiver hand hygiene in Bangladeshi healthcare facilities: results from the Bangladesh National Hygiene Baseline Survey JOURNAL OF HOSPITAL INFECTION Horng, L. M., Unicomb, L., Alam, M., Halder, A. K., Shoab, A. K., Ghosh, P. K., OPEL, A., Islam, M. K., Luby, S. P. 2016; 94 (3): 286-294


    Healthcare facility hand hygiene impacts patient care, healthcare worker safety, and infection control, but low-income countries have few data to guide interventions.To conduct a nationally representative survey of hand hygiene infrastructure and behaviour in Bangladeshi healthcare facilities to establish baseline data to aid policy.The 2013 Bangladesh National Hygiene Baseline Survey examined water, sanitation, and hand hygiene across households, schools, restaurants and food vendors, traditional birth attendants, and healthcare facilities. We used probability proportional to size sampling to select 100 rural and urban population clusters, and then surveyed hand hygiene infrastructure in 875 inpatient healthcare facilities, observing behaviour in 100 facilities.More than 96% of facilities had 'improved' water sources, but environmental contamination occurred frequently around water sources. Soap was available at 78-92% of handwashing locations for doctors and nurses, but just 4-30% for patients and family. Only 2% of 4676 hand hygiene opportunities resulted in recommended actions: using alcohol sanitizer or washing both hands with soap, then drying by air or clean cloth. Healthcare workers performed recommended hand hygiene in 9% of 919 opportunities: more after patient contact (26%) than before (11%). Family caregivers frequently washed hands with only water (48% of 2751 opportunities), but with little soap (3%).Healthcare workers had more access to hand hygiene materials and performed better hand hygiene than family, but still had low adherence. Increasing hand hygiene materials and behaviour could improve infection control in Bangladeshi healthcare facilities.

    View details for DOI 10.1016/j.jhin.2016.08.016

    View details for Web of Science ID 000388542500020

    View details for PubMedID 27665311

  • Occurrence of Host-Associated Fecal Markers on Child Hands, Household Soil, and Drinking Water in Rural Bangladeshi Households ENVIRONMENTAL SCIENCE & TECHNOLOGY LETTERS Boehm, A. B., Wang, D., Ercumen, A., Shea, M., Harris, A. R., Shanks, O. C., Kelty, C., Ahmed, A., Mahmud, Z. H., Arnold, B. F., Chase, C., Kullmann, C., Colford, J. M., Luby, S. P., Pickering, A. J. 2016; 3 (11): 393-398
  • Potential sources of bias in the use of Escherichia coli to measure waterborne diarrhea risk in low-income settings. Tropical medicine & international health Ercumen, A., Arnold, B. F., Naser, A. M., Unicomb, L., Colford, J. M., Luby, S. P. 2016


    Escherichia coli is the standard water quality indicator for diarrhoea risk. Yet, the association between E. coli and diarrhoea is inconsistent across studies without a systematic assessment of methodological differences behind this variation. Most studies measure water quality cross-sectionally with diarrhoea, risking exposure misclassification and reverse causation. Studies use different recall windows for self-reported diarrhoea; longer periods increase potential outcome misclassification through misrecall. Control of confounding is inconsistent across studies. Additionally, diarrhoea measured in unblinded intervention trials can present courtesy bias. We utilised measurements from a randomised trial of water interventions in Bangladesh to assess how these factors affect the E. coli-diarrhoea association.We compared cross-sectional versus prospective measurements of water quality and diarrhoea, 2-versus 7-day symptom recall periods, estimates with and without controlling for confounding and using measurements from control versus intervention arms of the trial.In the control arm, 2-day diarrhoea prevalence, measured prospectively 1 month after water quality, significantly increased with log10 E. coli (PR = 1.50, 1.02-2.20). This association weakened when we used 7-day recall (PR = 1.18, 0.88-1.57), cross-sectional measurements of E. coli and diarrhoea (PR = 1.11, 0.79-1.56) or did not control for confounding (PR = 1.20, 0.88-1.62). Including data from intervention arms led to less interpretable associations, potentially due to courtesy bias, effect modification and/or reverse causation.By systematically addressing potential sources of bias, our analysis demonstrates a clear relationship between E. coli in drinking water and diarrhoea, suggesting that the continued use of E. coli as an indicator of waterborne diarrhoea risk is justified.

    View details for DOI 10.1111/tmi.12803

    View details for PubMedID 27797430

  • Investigating Rare Risk Factors for Nipah Virus in Bangladesh: 2001-2012. EcoHealth Hegde, S. T., Sazzad, H. M., Hossain, M. J., Alam, M., Kenah, E., Daszak, P., Rollin, P., Rahman, M., Luby, S. P., Gurley, E. S. 2016: -?


    Human Nipah encephalitis outbreaks have been identified almost yearly in Bangladesh since 2001. Though raw date palm sap consumption and person-to-person contact are recognized as major transmission pathways, alternative pathways of transmission are plausible and may not have been identified due to limited statistical power in each outbreak. We conducted a risk factor analysis using all 157 cases and 632 controls surveyed in previous investigations during 2004-2012 to identify exposures independently associated with Nipah, since date palm sap was first asked about as an exposure in 2004. To further explore possible rare exposures, we also conducted in-depth interviews with all cases, or proxies, since 2001 that reported no exposure to date palm sap or contact with another case. Cases were 4.9 (95% 3.2-7.7) times more likely to consume raw date palm sap and 7.3 (95% 4.0-13.4) times more likely to have contact with a Nipah case than controls. In-depth interviews revealed that 39/182 (21%) of Nipah cases reporting neither date palm sap consumption nor contact with another case were misclassified. Prevention efforts should be focused on interventions to interrupt transmission through date palm sap consumption and person-to-person contact. Furthermore, pooling outbreak investigation data is a good method for assessing rare exposures.

    View details for PubMedID 27738775

  • Hygiene Practices During Food Preparation in Rural Bangladesh: Opportunities to Improve the Impact of Handwashing Interventions. The American journal of tropical medicine and hygiene Nizame, F. A., Leontsini, E., Luby, S. P., Nuruzzaman, M., Parveen, S., Winch, P. J., Ram, P. K., Unicomb, L. 2016; 95 (2): 288-297


    This study explored the steps of food preparation, related handwashing opportunities, current practices, and community perceptions regarding foods at high-risk of contamination such as mashed foods and salads. In three rural Bangladeshi villages, we collected qualitative and observational data. Food preparation was a complex and multistep process. Food preparation was interrupted by tasks that could contaminate the preparers' hands, after which they continued food preparation without washing hands. Community members typically ate hand-mixed, uncooked mashed food and salad as accompaniments to curry and rice at meals. Hand-mixed dried foods were mostly consumed as a snack. Observers recorded handwashing during preparation of these foods. Among 24 observed caregivers, of 85 opportunities to wash hands with soap during food preparation, washing hands with soap occurred twice, both times after cutting fish, whereas washing hands with water alone was common. A simple and feasible approach is promotion of handwashing with soap upon entering and re-entering the food preparation area, and ensuring that everything needed for handwashing should be within easy reach.

    View details for DOI 10.4269/ajtmh.15-0377

    View details for PubMedID 27296388

  • Epidemiology of Invasive Pneumococcal Disease in Bangladeshi Children Before Introduction of Pneumococcal Conjugate Vaccine PEDIATRIC INFECTIOUS DISEASE JOURNAL Saha, S. K., Hossain, B., Islam, M., Hasanuzzaman, M., Saha, S., Hasan, M., Darmstadt, G. L., Chowdury, M., El Arifeen, S., Baqui, A. H., Breiman, R. F., Santosham, M., Luby, S. P., Whitney, C. G. 2016; 35 (6): 655-661


    Because Bangladesh intended to introduce pneumococcal conjugate vaccine (PCV)-10 in 2015, we examined the baseline burden of invasive pneumococcal disease (IPD) to measure impact of PCV.During 2007-2013, we performed blood and cerebrospinal fluid cultures in children <5 years old with suspected IPD identified through active surveillance at 4 hospitals. Isolates were serotyped by quellung and tested for antibiotic susceptibility by disc diffusion and E-test. Serotyping of culture-negative cases, detected by Binax or polymerase chain reaction, was done by sequential multiplex polymerase chain reaction. Trends in IPD case numbers were analyzed by serotype and clinical syndrome.The study identified 752 IPD cases; 78% occurred in children <12 months old. Serotype information was available for 78% (442/568), including 197 of 323 culture-negative cases available for serotyping. We identified 50 serotypes; the most common serotypes were 2 (16%), 1 (10 %), 6B (7%), 14 (7%) and 5 (7%). PCV-10 and PCV-13 serotypes accounted for 46% (range 29%-57% by year) and 50% (range 37%-64% by year) of cases, respectively. Potential serotype coverage for meningitis and nonmeningitis cases was 45% and 49% for PCV-10, and 48% and 57% for PCV-13, respectively. Eighty-two percent of strains were susceptible to all antibiotics except cotrimoxazole.The distribution of serotypes causing IPD in Bangladeshi children is diverse, limiting the proportion of IPD cases PCV can prevent. However, PCV introduction is expected to have major benefits as the country has a high burden of IPD-related mortality, morbidity and disability.

    View details for DOI 10.1097/INF.0000000000001037

    View details for Web of Science ID 000379343700016

    View details for PubMedID 26658530

  • Hand- and Object-Mouthing of Rural Bangladeshi Children 3-18 Months Old INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Kwong, L. H., Ercumen, A., Pickering, A. J., Unicomb, L., Davis, J., Luby, S. P. 2016; 13 (6)


    Children are exposed to environmental contaminants by placing contaminated hands or objects in their mouths. We quantified hand- and object-mouthing frequencies of Bangladeshi children and determined if they differ from those of U.S. children to evaluate the appropriateness of applying U.S. exposure models in other socio-cultural contexts. We conducted a five-hour structured observation of the mouthing behaviors of 148 rural Bangladeshi children aged 3-18 months. We modeled mouthing frequencies using 2-parameter Weibull distributions to compare the modeled medians with those of U.S. children. In Bangladesh the median frequency of hand-mouthing was 37.3 contacts/h for children 3-6 months old, 34.4 contacts/h for children 6-12 months old, and 29.7 contacts/h for children 12-18 months old. The median frequency of object-mouthing was 23.1 contacts/h for children 3-6 months old, 29.6 contacts/h for children 6-12 months old, and 15.2 contacts/h for children 12-18 months old. At all ages both hand- and object-mouthing frequencies were higher than those of U.S. children. Mouthing frequencies were not associated with child location (indoor/outdoor). Using hand- and object-mouthing exposure models from U.S. and other high-income countries might not accurately estimate children's exposure to environmental contaminants via mouthing in low- and middle-income countries.

    View details for DOI 10.3390/ijerph13060563

    View details for Web of Science ID 000378860100042

    View details for PubMedID 27271651

  • Toward a Scalable and Sustainable Intervention for Complementary Food Safety FOOD AND NUTRITION BULLETIN Rahman, M. J., Nizame, F. A., Nuruzzaman, M., Akand, F., Islam, M. A., Parvez, S. M., Stewart, C. P., Unicomb, L., Luby, S. P., Winch, P. J. 2016; 37 (2): 186-201


    Contaminated complementary foods are associated with diarrhea and malnutrition among children aged 6 to 24 months. However, existing complementary food safety intervention models are likely not scalable and sustainable.To understand current behaviors, motivations for these behaviors, and the potential barriers to behavior change and to identify one or two simple actions that can address one or few food contamination pathways and have potential to be sustainably delivered to a larger population.Data were collected from 2 rural sites in Bangladesh through semistructured observations (12), video observations (12), in-depth interviews (18), and focus group discussions (3).Although mothers report preparing dedicated foods for children, observations show that these are not separate from family foods. Children are regularly fed store-bought foods that are perceived to be bad for children. Mothers explained that long storage durations, summer temperatures, flies, animals, uncovered food, and unclean utensils are threats to food safety. Covering foods, storing foods on elevated surfaces, and reheating foods before consumption are methods believed to keep food safe. Locally made cabinet-like hardware is perceived to be acceptable solution to address reported food safety threats.Conventional approaches that include teaching food safety and highlighting benefits such as reduced contamination may be a disincentive for rural mothers who need solutions for their physical environment. We propose extending existing beneficial behaviors by addressing local preferences of taste and convenience.

    View details for DOI 10.1177/0379572116631641

    View details for Web of Science ID 000376667800007

    View details for PubMedID 26944506

  • Ruminants Contribute Fecal Contamination to the Urban Household Environment in Dhaka, Bangladesh ENVIRONMENTAL SCIENCE & TECHNOLOGY Harris, A. R., Pickering, A. J., Harris, M., Doza, S., Islam, M. S., Unicomb, L., Luby, S., Davis, J., Boehm, A. B. 2016; 50 (9): 4642-4649


    In Dhaka, Bangladesh, the sensitivity and specificity of three human, three ruminant, and one avian source-associated QPCR microbial source tracking assays were evaluated using fecal samples collected on site. Ruminant-associated assays performed well, whereas the avian and human assays exhibited unacceptable cross-reactions with feces from other hosts. Subsequently, child hand rinses (n = 44) and floor sponge samples (n = 44) from low-income-households in Dhaka were assayed for fecal indicator bacteria (enterococci, Bacteroidales, and Escherichia coli) and a ruminant-associated bacterial target (BacR). Mean enterococci concentrations were of 100 most probable number (MPN)/2 hands and 1000 MPN/225 cm(2) floor. Mean concentrations of Bacteroidales were 10(6) copies/2 hands and 10(5) copies/225 cm(2) floor. E. coli were detected in a quarter of hand rinse and floor samples. BacR was detected in 18% of hand rinse and 27% of floor samples. Results suggest that effective household fecal management should account not only for human sources of contamination but also for animal sources. The poor performance of the human-associated assays in the study area calls into the question the feasibility of developing a human-associated marker in urban slum environments, where domestic animals are exposed to human feces that have been disposed in pits and open drains.

    View details for DOI 10.1021/acs.est.5b06282

    View details for Web of Science ID 000375521400007

    View details for PubMedID 27045990

  • Bat Hunting and Bat-Human Interactions in Bangladeshi Villages: Implications for Zoonotic Disease Transmission and Bat Conservation. Transboundary and emerging diseases Openshaw, J. J., Hegde, S., Sazzad, H. M., KHAN, S. U., Hossain, M. J., Epstein, J. H., Daszak, P., Gurley, E. S., Luby, S. P. 2016: -?


    Bats are an important reservoir for emerging zoonotic pathogens. Close human-bat interactions, including the sharing of living spaces and hunting and butchering of bats for food and medicines, may lead to spillover of zoonotic disease into human populations. We used bat exposure and environmental data gathered from 207 Bangladeshi villages to characterize bat exposures and hunting in Bangladesh. Eleven percent of households reported having a bat roost near their homes, 65% reported seeing bats flying over their households at dusk, and 31% reported seeing bats inside their compounds or courtyard areas. Twenty percent of households reported that members had at least daily exposure to bats. Bat hunting occurred in 49% of the villages surveyed and was more likely to occur in households that reported nearby bat roosts (adjusted prevalence ratio [aPR] 2.3, 95% CI 1.1-4.9) and villages located in north-west (aPR 7.5, 95% CI 2.5-23.0) and south-west (aPR 6.8, 95% CI 2.1-21.6) regions. Our results suggest high exposure to bats and widespread hunting throughout Bangladesh. This has implications for both zoonotic disease spillover and bat conservation.

    View details for DOI 10.1111/tbed.12505

    View details for PubMedID 27125493

  • Incidence of severe diarrhoea due to Vibrio cholerae in the catchment area of six surveillance hospitals in Bangladesh EPIDEMIOLOGY AND INFECTION Paul, R. C., Faruque, A. S., Alam, M., Iqbal, A., Zaman, K., Islam, N., SOBHAN, A., Das, S. K., Malek, M. A., Qadri, F., Cravioto, A., Luby, S. P. 2016; 144 (5): 927-939


    Cholera is an important public health problem in Bangladesh. Interventions to prevent cholera depend on their cost-effectiveness which in turn depends on cholera incidence. Hospital-based diarrhoeal disease surveillance has been ongoing in six Bangladeshi hospitals where a systematic proportion of patients admitted with diarrhoea were enrolled and tested for Vibrio cholerae. However, incidence calculation using only hospital data underestimates the real disease burden because many ill persons seek treatment elsewhere. We conducted a healthcare utilization survey in the catchment areas of surveillance hospitals to estimate the proportion of severe diarrhoeal cases that were admitted to surveillance hospitals and estimated the population-based incidence of severe diarrhoea due to V. cholerae by combining both hospital surveillance and catchment area survey data. The estimated incidence of severe diarrhoea due to cholera ranged from 0·3 to 4·9/1000 population in the catchment area of surveillance hospitals. In children aged <5 years, incidence ranged from 1·0 to 11·0/1000 children. Diarrhoeal deaths were most common in the Chhatak Hospital's catchment area (18·5/100 000 population). This study provides a credible estimate of the incidence of severe diarrhoea due to cholera in Bangladesh, which can be used to assess the cost-effectiveness of cholera prevention activities.

    View details for DOI 10.1017/S0950268815002174

    View details for Web of Science ID 000371720700004

    View details for PubMedID 26391481

  • Low-Cost National Media-Based Surveillance System for Public Health Events, Bangladesh EMERGING INFECTIOUS DISEASES Ao, T. T., Rahman, M., Haque, F., Chakraborty, A., Hossain, M. J., Haider, S., Alamgir, A. S., Sobel, J., Luby, S. P., Gurley, E. S. 2016; 22 (4): 720-722


    We assessed a media-based public health surveillance system in Bangladesh during 2010-2011. The system is a highly effective, low-cost, locally appropriate, and sustainable outbreak detection tool that could be used in other low-income, resource-poor settings to meet the capacity for surveillance outlined in the International Health Regulations 2005.

    View details for DOI 10.3201/eid2204.150330

    View details for Web of Science ID 000372688500022

    View details for PubMedID 26981877

  • Genetically Diverse Low Pathogenicity Avian Influenza A Virus Subtypes Co-Circulate among Poultry in Bangladesh PLOS ONE Gerloff, N. A., Khan, S. U., Zanders, N., Balish, A., Haider, N., Islam, A., Chowdhury, S., Rahman, M. Z., Haque, A., Hosseini, P., Gurley, E. S., Luby, S. P., Wentworth, D. E., Donis, R. O., Sturm-Ramirez, K., Davis, C. T. 2016; 11 (3)


    Influenza virus surveillance, poultry outbreak investigations and genomic sequencing were assessed to understand the ecology and evolution of low pathogenicity avian influenza (LPAI) A viruses in Bangladesh from 2007 to 2013. We analyzed 506 avian specimens collected from poultry in live bird markets and backyard flocks to identify influenza A viruses. Virus isolation-positive specimens (n = 50) were subtyped and their coding-complete genomes were sequenced. The most frequently identified subtypes among LPAI isolates were H9N2, H11N3, H4N6, and H1N1. Less frequently detected subtypes included H1N3, H2N4, H3N2, H3N6, H3N8, H4N2, H5N2, H6N1, H6N7, and H7N9. Gene sequences were compared to publicly available sequences using phylogenetic inference approaches. Among the 14 subtypes identified, the majority of viral gene segments were most closely related to poultry or wild bird viruses commonly found in Southeast Asia, Europe, and/or northern Africa. LPAI subtypes were distributed over several geographic locations in Bangladesh, and surface and internal protein gene segments clustered phylogenetically with a diverse number of viral subtypes suggesting extensive reassortment among these LPAI viruses. H9N2 subtype viruses differed from other LPAI subtypes because genes from these viruses consistently clustered together, indicating this subtype is enzootic in Bangladesh. The H9N2 strains identified in Bangladesh were phylogenetically and antigenically related to previous human-derived H9N2 viruses detected in Bangladesh representing a potential source for human infection. In contrast, the circulating LPAI H5N2 and H7N9 viruses were both phylogenetically and antigenically unrelated to H5 viruses identified previously in humans in Bangladesh and H7N9 strains isolated from humans in China. In Bangladesh, domestic poultry sold in live bird markets carried a wide range of LPAI virus subtypes and a high diversity of genotypes. These findings, combined with the seven year timeframe of sampling, indicate a continuous circulation of these viruses in the country.

    View details for DOI 10.1371/journal.pone.0152131

    View details for Web of Science ID 000372708000094

    View details for PubMedID 27010791

  • Increased Morbidity and Mortality in Domestic Animals Eating Dropped and Bitten Fruit in Bangladeshi Villages: Implications for Zoonotic Disease Transmission. EcoHealth Openshaw, J. J., Hegde, S., Sazzad, H. M., Khan, S. U., Hossain, M. J., Epstein, J. H., Daszak, P., Gurley, E. S., Luby, S. P. 2016; 13 (1): 39-48


    We used data on feeding practices and domestic animal health gathered from 207 Bangladeshi villages to identify any association between grazing dropped fruit found on the ground or owners directly feeding bat- or bird-bitten fruit and animal health. We compared mortality and morbidity in domestic animals using a mixed effects model controlling for village clustering, herd size, and proxy measures of household wealth. Thirty percent of household heads reported that their animals grazed on dropped fruit and 20% reported that they actively fed bitten fruit to their domestic herds. Household heads allowing their cattle to graze on dropped fruit were more likely to report an illness within their herd (adjusted prevalence ratio 1.17, 95% CI 1.02-1.31). Household heads directly feeding goats bitten fruit were more likely to report illness (adjusted prevalence ratio 1.35, 95% CI 1.16-1.57) and deaths (adjusted prevalence ratio 1.64, 95% CI 1.13-2.4). Reporting of illnesses and deaths among goats rose as the frequency of feeding bitten fruit increased. One possible explanation for this finding is the transmission of bat pathogens to domestic animals via bitten fruit consumption.

    View details for DOI 10.1007/s10393-015-1080-x

    View details for PubMedID 26668032

  • Field trial of an automated batch chlorinator system at shared water points in an urban community of Dhaka, Bangladesh JOURNAL OF WATER SANITATION AND HYGIENE FOR DEVELOPMENT Amin, N., Crider, Y. S., Unicomb, L., Das, K. K., Gope, P. S., Mahmud, Z. H., Islam, M. S., Davis, J., Luby, S. P., Pickering, A. J. 2016; 6 (1): 32-41
  • Respiratory Viruses Associated Hospitalization among Children Aged < 5 Years in Bangladesh: 2010-2014 PLOS ONE Homaira, N., Luby, S. P., Hossain, K., Islam, K., Ahmed, M., Rahman, M., Rahman, Z., Paul, R. C., Bhuiyan, M. U., Brooks, W. A., Sohel, B. M., Banik, K. C., Widdowson, M., Willby, M., Rahman, M., Bresee, J., Ramirez, K., Azziz-Baumgartner, E. 2016; 11 (2)


    We combined hospital-based surveillance and health utilization survey data to estimate the incidence of respiratory viral infections associated hospitalization among children aged < 5 years in Bangladesh.Surveillance physicians collected respiratory specimens from children aged <5 years hospitalized with respiratory illness and residing in the primary hospital catchment areas. We tested respiratory specimens for respiratory syncytial virus, parainfluenza viruses, human metapneumovirus, influenza, adenovirus and rhinoviruses using rRT-PCR. During 2013, we conducted a health utilization survey in the primary catchment areas of the hospitals to determine the proportion of all hospitalizations for respiratory illness among children aged <5 years at the surveillance hospitals during the preceding 12 months. We estimated the respiratory virus-specific incidence of hospitalization by dividing the estimated number of hospitalized children with a laboratory confirmed infection with a respiratory virus by the population aged <5 years of the catchment areas and adjusted for the proportion of children who were hospitalized at the surveillance hospitals.We estimated that the annual incidence per 1000 children (95% CI) of all cause associated respiratory hospitalization was 11.5 (10-12). The incidences per 1000 children (95% CI) per year for respiratory syncytial virus, parainfluenza, adenovirus, human metapneumovirus and influenza infections were 3(2-3), 0.5(0.4-0.8), 0.4 (0.3-0.6), 0.4 (0.3-0.6), and 0.4 (0.3-0.6) respectively. The incidences per 1000 children (95%CI) of rhinovirus-associated infections among hospitalized children were 5 (3-7), 2 (1-3), 1 (0.6-2), and 3 (2-4) in 2010, 2011, 2012 and 2013, respectively.Our data suggest that respiratory viruses are associated with a substantial burden of hospitalization in children aged <5 years in Bangladesh.

    View details for DOI 10.1371/journal.pone.0147982

    View details for Web of Science ID 000369550200074

    View details for PubMedID 26840782

  • Safety and acceptability of Lactobacillus reuteri DSM 17938 and Bifidobacterium longum subspecies infantis 35624 in Bangladeshi infants: a phase I randomized clinical trial. BMC complementary and alternative medicine Hoy-Schulz, Y. E., Jannat, K., Roberts, T., Zaidi, S. H., Unicomb, L., Luby, S., Parsonnet, J. 2016; 16 (1): 44-?


    Probiotics have rarely been studied in young healthy infants from low-income countries. This phase I study investigated the safety and acceptability of two probiotics in Bangladesh.Healthy infants aged four to twelve weeks from urban slums in Bangladesh were randomized to one of three different intervention dosing arms (daily, weekly, biweekly - once every two weeks) of Lactobacillus reuteri DSM 17938 and Bifidobacterium longum subspecies infantis 35624 over one month or to a fourth arm that received no probiotics. All subjects were followed for two additional months. Reported gastrointestinal and respiratory symptoms as well as breastfeeding rates, hospitalizations, differential withdrawals, and caretakers' perception of probiotic use were compared among arms.In total, 160 infants were randomized (40 to each arm) with 137 (Daily n = 35, Weekly n = 35, Biweekly n = 35, Control n = 32) followed up for a median of twelve weeks; 113 completed the study. Illness and breastfeeding rates were similar across all arms. Ten hospitalizations unrelated to probiotic use occurred. Forty eight percent of the caretakers of infants in intervention arms believed that probiotics improved their baby's health.These two commonly used probiotics appeared safe and well-accepted by Bangladeshi NCT01899378 . Registered July 10, 2013.

    View details for DOI 10.1186/s12906-016-1016-1

    View details for PubMedID 26832746

  • Understanding the failure of a behavior change intervention to reduce risk behaviors for avian influenza transmission among backyard poultry raisers in rural Bangladesh: a focused ethnography. BMC public health Rimi, N. A., Sultana, R., Ishtiak-Ahmed, K., Rahman, M. Z., Hasin, M., Islam, M. S., Azziz-Baumgartner, E., Nahar, N., Gurley, E. S., Luby, S. P. 2016; 16 (1): 858-?


    The spread of the highly pathogenic avian influenza (HPAI) H5N1 virus among poultry and humans has raised global concerns and has motivated government and public health organizations to initiate interventions to prevent the transmission of HPAI. In Bangladesh, H5N1 became endemic in poultry and seven human H5N1 cases have been reported since 2007, including one fatality. This study piloted messages to increase awareness about avian influenza and its prevention in two rural communities, and explored change in villagers' awareness and behaviors attributable to the intervention.During 2009-10, a research team implemented the study in two rural villages in two districts of Bangladesh. The team used a focused ethnographic approach for data collection, including informal interviews and observations to provide detailed contextual information about community response to a newly emerging disease. They collected pre-intervention qualitative data for one month. Then another team disseminated preventive messages focused on safe slaughtering methods, through courtyard meetings and affixed posters in every household. After dissemination, the research team collected post-intervention data for one month.More villagers reported hearing about 'bird flu' after the intervention compared to before the intervention. After the intervention, villagers commonly recalled changes in the color of combs and shanks of poultry as signs of avian influenza, and perceived zoonotic transmission of avian influenza through direct contact and through inhalation. Consequently the villagers valued covering the nose and mouth while handling sick and dead poultry as a preventive measure. Nevertheless, the team did not observe noticeable change in villagers' behavior after the intervention. Villagers reported not following the recommended behaviors because of the perceived absence of avian influenza in their flocks, low risk of avian influenza, cost, inconvenience, personal discomfort, fear of being rebuked or ridiculed, and doubt about the necessity of the intervention.The villagers' awareness about avian influenza improved after the intervention, however, the intervention did not result in any measurable improvement in preventive behaviors. Low cost approaches that promote financial benefits and minimize personal discomfort should be developed and piloted.

    View details for DOI 10.1186/s12889-016-3543-6

    View details for PubMedID 27552983

  • It's not only what you say, it's also how you say it: communicating nipah virus prevention messages during an outbreak in Bangladesh. BMC public health Parveen, S., Islam, M. S., Begum, M., Alam, M., Sazzad, H. M., Sultana, R., Rahman, M., Gurley, E. S., Hossain, M. J., Luby, S. P. 2016; 16: 726-?


    During a fatal Nipah virus (NiV) outbreak in Bangladesh, residents rejected biomedical explanations of NiV transmission and treatment and lost trust in the public healthcare system. Field anthropologists developed and communicated a prevention strategy to bridge the gap between the biomedical and local explanation of the outbreak.We explored residents' beliefs and perceptions about the illness and care-seeking practices and explained prevention messages following an interactive strategy with the aid of photos showed the types of contact that can lead to NiV transmission from bats to humans by drinking raw date palm sap and from person-to-person.The residents initially believed that the outbreak was caused by supernatural forces and continued drinking raw date palm sap despite messages from local health authorities to stop. Participants in community meetings stated that the initial messages did not explain that bats were the source of this virus. After our intervention, participants responded that they now understood how NiV could be transmitted and would abstain from raw sap consumption and maintain safer behaviours while caring for patients.During outbreaks, one-way behaviour change communication without meaningful causal explanations is unlikely to be effective. Based on the cultural context, interactive communication strategies in lay language with supporting evidence can make biomedical prevention messages credible in affected communities, even among those who initially invoke supernatural causal explanations.

    View details for DOI 10.1186/s12889-016-3416-z

    View details for PubMedID 27495927

  • Cultural and Economic Motivation of Pig Raising Practices in Bangladesh ECOHEALTH Nahar, N., Uddin, M., Gurley, E. S., Hossain, M. J., Sultana, R., Luby, S. P. 2015; 12 (4): 611-620


    The interactions that pig raisers in Bangladesh have with their pigs could increase the risk of zoonotic disease transmission. Since raising pigs is a cultural taboo to Muslims, we aimed at understanding the motivation for raising pigs and resulting practices that could pose the risk of transmitting disease from pigs to humans in Bangladesh, a predominantly Muslim country. These understandings could help identify acceptable strategies to reduce the risk of disease transmission from pigs to people. To achieve this objective, we conducted 34 in-depth interviews among pig herders and backyard pig raisers in eight districts of Bangladesh. Informants explained that pig raising is an old tradition, embedded in cultural and religious beliefs and practices, the primary livelihood of pig herders, and a supplemental income of backyard pig raisers. To secure additional income, pig raisers sell feces, liver, bile, and other pig parts often used as traditional medicine. Pig raisers have limited economic ability to change the current practices that may put them at risk of exposure to diseases from their pigs. An intervention that improves their financial situation and reduces the risk of zoonotic disease may be of interest to pig raisers.

    View details for DOI 10.1007/s10393-015-1046-z

    View details for Web of Science ID 000367627300010

    View details for PubMedID 26122206

  • The Interaction of Deworming, Improved Sanitation, and Household Flooring with Soil-Transmitted Helminth Infection in Rural Bangladesh PLOS NEGLECTED TROPICAL DISEASES Benjamin-Chung, J., Nazneen, A., Halder, A. K., Haque, R., Siddique, A., Uddin, M. S., Koporc, K., Arnold, B. F., Hubbard, A. E., Unicomb, L., Luby, S. P., Addiss, D. G., Colford, J. M. 2015; 9 (12)
  • Early priming with inactivated poliovirus vaccine (IPV) and intradermal fractional dose IPV administered by a microneedle device: A randomized controlled trial VACCINE Anand, A., Zaman, K., Estivariz, C. F., Yunus, M., Gary, H. E., Weldon, W. C., Bari, T. I., Oberste, M. S., Wassilak, S. G., Luby, S. P., Heffelfinger, J. D., Pallansch, M. A. 2015; 33 (48): 6816-6822
  • Early priming with inactivated poliovirus vaccine (IPV) and intradermal fractional dose IPV administered by a microneedle device: A randomized controlled trial. Vaccine Anand, A., Zaman, K., Estívariz, C. F., Yunus, M., Gary, H. E., Weldon, W. C., Bari, T. I., Steven Oberste, M., Wassilak, S. G., Luby, S. P., Heffelfinger, J. D., Pallansch, M. A. 2015; 33 (48): 6816-6822


    Inactivated poliovirus vaccine (IPV) introduction and phased oral poliovirus vaccine (OPV) cessation are essential for eradication of polio.Healthy 6-week old infants in Bangladesh were randomized to one of five study arms: receipt of trivalent OPV (tOPV) or bivalent OPV (bOPV) at ages 6, 10 and 14 weeks, intramuscular IPV or intradermal one-fifth fractional dose IPV (f-IPV) at ages 6 and 14 weeks, or f-IPV at ages 6 and 14 weeks with bOPV at age 10 weeks (f-IPV/bOPV). All participants received tOPV at age 18 weeks.Of 975 infants randomized, 95% (922) completed follow-up. Type 1 seroconversion after 3 doses at 6, 10 and 14 weeks was higher with bOPV compared with tOPV (99% vs 94%, p=0.019). Seroconversions to types 1 and 3 after 2 IPV doses at ages 6 and 14 weeks were no different than after 3 doses of tOPV or bOPV at ages 6, 10 and 14 weeks. A priming response, seroconversion 1 week after IPV at 14 weeks among those who did not seroconvert after IPV at 6 weeks, was observed against poliovirus types 1, 2 and 3 in 91%, 84% and 97%, respectively. Compared with IPV, f-IPV failed non-inferiority tests for seroconversion with 1 or 2 doses and priming after 1 dose.The findings demonstrate considerable priming with IPV at age 6 weeks, comparable immunogenicity of tOPV and bOPV, and inferior immunogenicity of one-fifth f-IPV compared with IPV. If IPV induced priming at age 6 weeks is similar to that at age 14 weeks, IPV could be administered at a younger age and possibly with a higher coverage.

    View details for DOI 10.1016/j.vaccine.2015.09.039

    View details for PubMedID 26476367

  • Raw Sap Consumption Habits and Its Association with Knowledge of Nipah Virus in Two Endemic Districts in Bangladesh PLOS ONE Nahar, N., Paul, R. C., Sultana, R., Gurley, E. S., Garcia, F., Abedin, J., Sumon, S. A., Banik, K. C., Asaduzzaman, M., Rimi, N. A., Rahman, M., Luby, S. P. 2015; 10 (11)

    View details for DOI 10.1371/journal.pone.0142292

    View details for Web of Science ID 000364422800023

    View details for PubMedID 26551202

  • An outbreak of hepatitis E in an urban area of Bangladesh JOURNAL OF VIRAL HEPATITIS Haque, F., Banu, S. S., Ara, K., Chowdhury, I. A., Chowdhury, S. A., Kamili, S., Rahman, M., Luby, S. P. 2015; 22 (11): 948-956


    We investigated an outbreak of jaundice in urban Bangladesh in 2010 to examine the cause and risk factors and assess the diagnostic utility of commercial assays. We classified municipal residents reporting jaundice during the preceding 4 weeks as probable hepatitis E cases and their neighbours without jaundice in the previous 6 months as probable controls. We tested the sera collected from probable cases and probable controls for IgM anti-hepatitis E virus (HEV), and the IgM-negative sera for IgG anti-HEV using a commercial assay locally. We retested the IgM-positive sera for both IgM and IgG anti-HEV using another assay at the Centre for Disease Control and Prevention (CDC), USA. Probable cases positive for IgM anti-HEV were confirmed cases; probable controls negative for both IgM and IgG anti-HEV were confirmed controls. We explored the local water supply and sanitation infrastructure and tested for bacterial concentration of water samples. Probable cases were more likely than probable controls to drink tap water (adjusted odds ratio: 3.4; 95% CI: 1.2-9.2). Fifty-eight percentage (36/62) of the case sera were IgM anti-HEV positive; and 75% of the IgM-positive samples were confirmed positive on retesting with another assay at CDC. Compared to confirmed controls, cases confirmed using either or both assays also identified drinking tap water as the risk factor. Two tap water samples had detectable thermotolerant coliforms. Research exploring decentralized water treatment technologies for sustainable safe water might prevent HEV transmission in resource-poor cities. Detection of serological markers in a majority of probable cases implied that available diagnostic assays could adequately identify HEV infection during outbreaks.

    View details for DOI 10.1111/jvh.12407

    View details for Web of Science ID 000362450600010

    View details for PubMedID 25817821

  • Microbiological Contamination of Drinking Water Associated with Subsequent Child Diarrhea AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Halder, A. K., Huda, T. M., Unicomb, L., Islam, M. S., Arnold, B. F., Johnston, R. B. 2015; 93 (5): 904-911

    View details for DOI 10.4269/ajtmh.15-0274

    View details for Web of Science ID 000364437500005

    View details for PubMedID 26438031

  • Feasibility and effectiveness of oral cholera vaccine in an urban endemic setting in Bangladesh: a cluster randomised open-label trial LANCET Qadri, F., Ali, M., Chowdhury, F., Khan, A. I., Saha, A., Khan, I. A., Begum, Y. A., Bhuiyan, T. Q., Chowdhury, M. I., Uddin, M. J., Khan, J. A., Chowdhury, A. I., Rahman, A., Siddique, S. A., Asaduzzaman, M., Akter, A., Khan, A., You, Y. A., Siddik, A. U., Saha, N. C., Kabir, A., Riaz, B. K., Biswas, S. K., Begum, F., Unicomb, L., Luby, S. P., Cravioto, A., Clemens, J. D. 2015; 386 (10001): 1362-1371
  • Why highly polluting methods are used to manufacture bricks in Bangladesh ENERGY FOR SUSTAINABLE DEVELOPMENT Luby, S. P., Biswas, D., Gurley, E. S., Hossain, I. 2015; 28: 68-74
  • Immunogenicity of three doses of bivalent, trivalent, or type 1 monovalent oral poliovirus vaccines with a 2 week interval between doses in Bangladesh: an open-label, non-inferiority, randomised, controlled trial LANCET INFECTIOUS DISEASES Estivariz, C. F., Anand, A., Gary, H. E., Rahman, M., Islam, J., Bari, T. I., Wassilak, S. G., Chu, S. Y., Weldon, W. C., Pallansch, M. A., Heffellfinger, J. D., Luby, S. P., Zaman, K. 2015; 15 (8): 898-904


    The provision of several doses of monovalent type 1 oral poliovirus vaccine (mOPV1) and bivalent OPV1 and 3 (bOPV) vaccines through campaigns is essential to stop the circulation of remaining wild polioviruses. Our study aimed to assess the shortening of intervals between campaigns with bOPV and mOPV1 and to assess the immunogenicity of bOPV in routine immunisation schedules.We did an open-label, non-inferiority, five-arm, randomised controlled trial in Bangladesh. We recruited healthy infants aged 6 weeks at 42 immunisation clinics and randomly assigned them (with blocks of 15, three per group) to receive a short three-dose schedule of bOPV (bOPV short) or mOPV1 (mOPV1 short) with the first dose given at age 6 weeks, the second at age 8 weeks, and the third at age 10 weeks; or to a standard three-dose schedule of bOPV (bOPV standard) or mOPV1 (mOPV1 standard) or trivalent OPV (tOPV standard) with the first dose given at age 6 weeks, the second at 10 weeks, and the third at age 14 weeks. The primary outcome was the proportion of infants with antibody seroconversion for type 1, type 2, and type 3 polioviruses. The primary, modified intention-to-treat analysis included all patients who had testable serum samples before and after receiving at least one OPV dose. We used a 10% margin to establish non-inferiority for bOPV groups versus mOPV1 groups in seroconversion for type 1 poliovirus, and for bOPV1 short versus bOPV1 standard for types 1 and 3. This trial is registered at, number NCT01633216, and is closed to new participants.Between May 13, 2012, and Jan 21, 2013, we randomly assigned 1000 infants to our study groups. 927 completed all study visits and were included in the primary analysis. Seroconversion for type-1 poliovirus was recorded in 183 (98%, 95% CI 95-100) of 186 infants given bOPV short, 179 (97%, 94-99) of 184 given bOPV standard, 180 (96%, 92-98) of 188 given mOPV short, 178 (99%, 97-100) of 179 given mOPV1 standard, and 175 (92%, 87-96) of 190 given tOPV standard. Seroconversion for type 2 was noted in 16 infants (9%, 5-14) on bOPV short, 29 (16%, 11-22) on bOPV standard, 19 (10%, 7-15) on mOPV short, 33 (18%, 13-25) on mOPV1 standard, and 182 (96%, 92-98) on tOPV standard. Seroconversion for type 3 was noted in 175 infants (94%, 90-97) on bOPV short, 176 (96%, 92-98) on bOPV standard, 18 (10%, 6-15) on mOPV short, 25 (14%, 10-20) on mOPV1 standard, and 167 (88%, 83-92) on tOPV standard. The short schedules for mOPV1 and bOPV elicited a non-inferior antibody response compared with the bOPV standard schedule. 104 adverse events were reported in 100 infants during follow up. 36 of these events needed admission to hospital (32 were pneumonia, two were vomiting or feeding disorders, one was septicaemia, and one was diarrhoea with severe malnutrition). One of the infants admitted to hospital for pneumonia died 5 days after admission. No adverse event was attributed to the vaccines.Our trial showed that three doses of mOPV1 or bOPV with a short schedule of 2 week intervals between doses induces an immune response similar to that obtained with the standard schedule of giving doses at 4 week intervals. These findings support the use of these vaccines in campaigns done at short intervals to rapidly increase population immunity against polioviruses to control outbreaks or prevent transmission in high-risk areas.Centers for Disease Control and Prevention and UNICEF.

    View details for DOI 10.1016/S1473-3099(15)00094-8

    View details for Web of Science ID 000358182500028

    View details for PubMedID 26093980

  • Integrated cluster- and case-based surveillance for detecting stage III zoonotic pathogens: an example of Nipah virus surveillance in Bangladesh EPIDEMIOLOGY AND INFECTION Naser, A. M., Hossain, M. J., Sazzad, H. M., Homaira, N., Gurley, E. S., Podder, G., Afroj, S., Banu, S., ROLLIN, P. E., Daszak, P., Ahmed, B., Rahman, M., Luby, S. P. 2015; 143 (9): 1922-1930


    This paper explores the utility of cluster- and case-based surveillance established in government hospitals in Bangladesh to detect Nipah virus, a stage III zoonotic pathogen. Physicians listed meningo-encephalitis cases in the 10 surveillance hospitals and identified a cluster when ⩾2 cases who lived within 30 min walking distance of one another developed symptoms within 3 weeks of each other. Physicians collected blood samples from the clustered cases. As part of case-based surveillance, blood was collected from all listed meningo-encephalitis cases in three hospitals during the Nipah season (January-March). An investigation team visited clustered cases' communities to collect epidemiological information and blood from the living cases. We tested serum using Nipah-specific IgM ELISA. Up to September 2011, in 5887 listed cases, we identified 62 clusters comprising 176 encephalitis cases. We collected blood from 127 of these cases. In 10 clusters, we identified a total of 62 Nipah cases: 18 laboratory-confirmed and 34 probable. We identified person-to-person transmission of Nipah virus in four clusters. From case-based surveillance, we identified 23 (4%) Nipah cases. Faced with thousands of encephalitis cases, integrated cluster surveillance allows targeted deployment of investigative resources to detect outbreaks by stage III zoonotic pathogens in resource-limited settings.

    View details for DOI 10.1017/S0950268814002635

    View details for Web of Science ID 000355760600016

    View details for PubMedID 25342551

  • An Outbreak of Chikungunya in Rural Bangladesh, 2011. PLoS neglected tropical diseases Khatun, S., Chakraborty, A., Rahman, M., Nasreen Banu, N., Rahman, M. M., Hasan, S. M., Luby, S. P., Gurley, E. S. 2015; 9 (7)

    View details for DOI 10.1371/journal.pntd.0003907

    View details for PubMedID 26161995

  • An Outbreak of Chikungunya in Rural Bangladesh, 2011. PLoS neglected tropical diseases Khatun, S., Chakraborty, A., Rahman, M., Nasreen Banu, N., Rahman, M. M., Hasan, S. M., Luby, S. P., Gurley, E. S. 2015; 9 (7)


    The first identified Chikungunya outbreak occurred in Bangladesh in 2008. In late October 2011, a local health official from Dohar Sub-district, Dhaka District, reported an outbreak of undiagnosed fever and joint pain. We investigated the outbreak to confirm the etiology, describe the clinical presentation, and identify associated vectors.During November 2-21, 2011, we conducted house-to-house surveys to identify suspected cases, defined as any inhabitant of Char Kushai village with fever followed by joint pain in the extremities with onset since August 15, 2011. We collected blood specimens and clinical histories from self-selected suspected cases using a structured questionnaire. Blood samples were tested for IgM antibodies against Chikungunya virus. The village was divided into nine segments and we collected mosquito larvae from water containers in seven randomly selected houses in each segment. We calculated the Breteau index for the village and identified the mosquito species.The attack rate was 29% (1105/3840) and 29% of households surveyed had at least one suspected case: 15% had ≥3. The attack rate was 38% (606/1589) in adult women and 25% in adult men (320/1287). Among the 1105 suspected case-patients, 245 self-selected for testing and 80% of those (196/245) had IgM antibodies. In addition to fever and joint pain, 76% (148/196) of confirmed cases had rash and 38%(75/196) had long-lasting joint pain. The village Breteau index was 35 per 100 and 89%(449/504) of hatched mosquitoes were Aedes albopictus.The evidence suggests that this outbreak was due to Chikungunya. The high attack rate suggests that the infection was new to this area, and the increased risk among adult women suggests that risk of transmission may have been higher around households. Chikungunya is an emerging infection in Bangladesh and current surveillance and prevention strategies are insufficient to mount an effective public health response.

    View details for DOI 10.1371/journal.pntd.0003907

    View details for PubMedID 26161995

  • Towards sustainable public health surveillance for enteric fever VACCINE Luby, S. P., Saha, S., Andrews, J. R. 2015; 33: C3-C7
  • Impact of Intensive Handwashing Promotion on Secondary Household Influenza-Like Illness in Rural Bangladesh: Findings from a Randomized Controlled Trial PLOS ONE Ram, P. K., DiVita, M. A., Khatun-E-Jannat, K., Islam, M., Krytus, K., Cercone, E., Sohel, B. M., Ahmed, M., Rahman, A. M., Rahman, M., Yu, J., Brooks, W. A., Azziz-Baumgartner, E., Fry, A. M., Luby, S. P. 2015; 10 (6)


    There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh.In 2009-10, we identified index case-patients with influenza-like illness (fever with cough or sore throat) who were the only symptomatic person in their household. Household compounds of index case-patients were randomized to control or intervention (soap and daily handwashing promotion). We conducted daily surveillance and collected oropharyngeal specimens. Secondary attack ratios (SAR) were calculated for influenza and ILI in each arm. Among controls, we investigated individual risk factors for ILI among household contacts of index case-patients.Among 377 index case-patients, the mean number of days between fever onset and study enrollment was 2.1 (SD 1.7) among the 184 controls and 2.6 (SD 2.9) among 193 intervention case-patients. Influenza infection was confirmed in 20% of controls and 12% of intervention index case-patients. The SAR for influenza-like illness among household contacts was 9.5% among intervention (158/1661) and 7.7% among control households (115/1498) (SAR ratio 1.24, 95% CI 0.92-1.65). The SAR ratio for influenza was 2.40 (95% CI 0.68-8.47). In the control arm, susceptible contacts <2 years old (RRadj 5.51, 95% CI 3.43-8.85), those living with an index case-patient enrolled ≤24 hours after symptom onset (RRadj 1.91, 95% CI 1.18-3.10), and those who reported multiple daily interactions with the index case-patient (RRadj 1.94, 95% CI 1.71-3.26) were at increased risk of influenza-like illness.Handwashing promotion initiated after illness onset in a household member did not protect against influenza-like illness or influenza. Behavior may not have changed rapidly enough to curb transmission between household members. A reactive approach to reduce household influenza transmission through handwashing promotion may be ineffective in the context of rural NCT00880659.

    View details for DOI 10.1371/journal.pone.0125200

    View details for Web of Science ID 000356100900004

    View details for PubMedID 26066651

  • Household-level risk factors for influenza among young children in Dhaka, Bangladesh: a case-control study TROPICAL MEDICINE & INTERNATIONAL HEALTH Doshi, S., Silk, B. J., Dutt, D., Ahmed, M., Cohen, A. L., Taylor, T. H., Brooks, W. A., Goswami, D., Luby, S. P., Fry, A. M., Ram, P. K. 2015; 20 (6): 719-729


    To identify household-level factors associated with influenza among young children in a crowded community in Dhaka, Bangladesh.We conducted a case-control study using existing active surveillance for respiratory illness. Cases were children aged 12-59 months with laboratory-confirmed influenza. Controls were children frequency-matched by age group with no respiratory illness in the prior 6 months. We interviewed caregivers and observed household handwashing behaviour. Soap consumption was estimated by summing weight differences of three bars of soap sequentially left in each household. We measured concentrations of airborne particulate matter <2.5 μg in diameter (PM2.5) in a subset of households. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI).We enrolled 145 cases and 341 controls between March 2009 and April 2010. Case and control household members were observed to wash hands with similar frequency during a 5-h period (mean, 0.64 events vs. 0.63, P = 0.87), and similar daily soap consumption per capita (mean 2.92 grams vs. 2.93, P = 0.92). Case households were more likely than controls to have crowded (≥4 persons) sleeping areas (aOR = 1.67, CI: 1.06-2.63) and cross-ventilated cooking spaces (aOR = 1.75, CI: 1.16-2.63). Case and control households had similar median 24-h geometric mean PM2.5 concentrations in the cooking (69.2 vs. 69.6 μg/m(3), P = 0.45) and sleeping (65.4 vs. 67.4 μg/m(3), P = 0.19) spaces.Handwashing with soap was practiced infrequently and was not associated with paediatric influenza in this community. Interventions aimed at crowded households may reduce influenza incidence in young children.

    View details for DOI 10.1111/tmi.12475

    View details for Web of Science ID 000354186900004

    View details for PubMedID 25682788

  • Serological Evidence of Coxiella burnetii Infection in Cattle and Goats in Bangladesh. EcoHealth Haider, N., Rahman, M. S., Khan, S. U., Mikolon, A., Osmani, M. G., Gurley, E. S., Shanta, I. S., Paul, S. K., MacFarlane-Berry, L., Islam, A., Islam, A., Desmond, J., Epstein, J. H., Priestley, R. A., Kersh, G. J., Rahman, M. Z., Daszak, P., Luby, S. P., Massung, R. F., Zeidner, N. 2015; 12 (2): 354-358


    We tested 1149 ruminant sera conveniently collected from three districts of Bangladesh to identify the serological evidence of Coxiella burnetii infection in cattle and goats by enzyme-linked immunosorbent assay. We found that 0.7% (8/1149) of ruminants had detectable immunoglobulin G for C. burnetii: 0.65% (4/620) in cattle and 0.76% (4/529) in goats. A sub-set of ruminant samples was retested and confirmed by immunofluorescence assay (18/112). Although we cannot rule out false-positive reactions, our study suggests the presence of C. burnetii in cattle and goats in Bangladesh. Further studies are required to estimate disease burden at the population level and identify risk factors for Q fever in ruminants in Bangladesh.

    View details for DOI 10.1007/s10393-015-1011-x

    View details for PubMedID 25649716

  • Effects of oseltamivir treatment of index patients with influenza on secondary household illness in an urban setting in Bangladesh: secondary analysis of a randomised, placebo-controlled trial LANCET INFECTIOUS DISEASES Fry, A. M., Goswami, D., Nahar, K., Sharmin, A. T., Rahman, M., Gubareva, L., Trujillo, A., Barnes, J., Azim, T., Bresee, J., Luby, S. P., Brooks, W. A. 2015; 15 (6): 654-662


    Antiviral drugs are a proposed medical intervention to reduce household transmission of influenza viruses. In a previously described randomised, placebo-controlled trial in Dhaka, Bangladesh, we showed that oseltamivir treatment of index patients was able to reduce influenza symptom duration and virus shedding. In a further analysis that is part of the same study, we aimed to assess efficacy of oseltamivir to reduce secondary household illnesses in the same cohort.In this double-blind oseltamivir efficacy trial, we identified index patients aged older than 1 year through surveillance of households in Dhaka, Bangladesh. We randomly allocated eligible patients (1:1) to receive oseltamivir or placebo twice-daily for 5 days, and we stratified them by enrolment 48 h versus 48-120 h since illness onset. Participants provided nasal wash specimens at enrolment and 2, 4, and 7 days after enrolment and were visited daily by a research assistant to record symptoms, both in index patients and in household members. For this part of the study, household members were asked to give respiratory specimens for influenza PCR testing. Our primary outcomes were household secondary illness and PCR-confirmed influenza virus infection, assessed in household members of all randomly allocated index patients. This trial is registered with, number NCT00707941.From May 11, 2008, to Dec 31, 2010, we enrolled 1190 index patients with 4694 household members. 592 patients were allocated to placebo (2292 household members) and 598 to oseltamivir (2402 household members). Household secondary illness was lower in the oseltamivir group (196 [8%] influenza cases) than in the placebo group (233 [10%]; odds ratio [OR] 0·77, 95% CI 0·60-0·98, p=0·031). PCR-confirmed influenza virus infection did not differ between the placebo (103 [5%]) and oseltamivir groups (92 [4%]; 0·84, 0·59-1·19, p=0·319); however, only 243 (57%) of ill household members gave a specimen for analysis.In a crowded, low income setting, oseltamivir treatment of index patients resulted in a small reduction of secondary influenza in their households. Even this slight reduction, in the setting of widespread antiviral use during a community influenza outbreak, might result in reductions in overall disease burden.Centers for Disease Control and Prevention (in an agreement with the International Centre for Diarrhoeal Disease Research, Bangladesh).

    View details for DOI 10.1016/S1473-3099(15)70041-1

    View details for Web of Science ID 000354638000030

    View details for PubMedID 25788164

  • Observed Practices and Perceived Advantages of Different Hand Cleansing Agents in Rural Bangladesh: Ash, Soil, and Soap AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Nizame, F. A., Nasreen, S., Halder, A. K., Arman, S., Winch, P. J., Unicomb, L., Luby, S. P. 2015; 92 (6): 1111-1116


    Bangladeshi communities have historically used ash and soil as handwashing agents. A structured observation study and qualitative interviews on the use of ash/soil and soap as handwashing agents were conducted in rural Bangladesh to help develop a handwashing promotion intervention. The observations were conducted among 1,000 randomly selected households from 36 districts. Fieldworkers observed people using ash/soil to wash their hand(s) on 13% of occasions after defecation and on 10% after cleaning a child's anus. This compares with 19% of people who used soap after defecation and 27% after cleaning a child who defecated. Using ash/soil or soap was rarely (< 1%) observed at other times recommended for handwashing. The qualitative study enrolled 24 households from three observation villages, where high usage of ash/soil for handwashing was detected. Most informants reported that ash/soil was used only for handwashing after fecal contact, and that ash/soil could clean hands as effectively as soap.

    View details for DOI 10.4269/ajtmh.14-0378

    View details for Web of Science ID 000355785400005

    View details for PubMedID 25870425

  • Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh TROPICAL MEDICINE & INTERNATIONAL HEALTH Najnin, N., Arman, S., Abedin, J., Unicomb, L., Levine, D. I., Mahmud, M., Leder, K., Yeasmin, F., Luoto, J. E., Albert, J., Luby, S. P. 2015; 20 (4): 471-483


    To assess sustained siphon filter usage among a low-income population in Bangladesh and study relevant motivators and barriers.After a randomised control trial in Bangladesh during 2009, 191 households received a siphon water filter along with educational messages. Researchers revisited households after 3 and 6 months to assess filter usage and determine relevant motivators and barriers. Regular users were defined as those who reported using the filter most of the time and were observed to be using the filter at follow-up visits. Integrated behavioural model for water, sanitation and hygiene (IBM-WASH) was used to explain factors associated with regular filter use.Regular filter usage was 28% at the 3-month follow-up and 21% at the 6-month follow-up. Regular filter users had better quality water at the 6-month, but not at the 3-month visit. Positive predictors of regular filter usage explained through IBM-WASH at both times were willingness to pay >US$1 for filters, and positive attitude towards filter use (technology dimension at individual level); reporting boiling drinking water at baseline (psychosocial dimension at habitual level); and Bengali ethnicity (contextual dimension at individual level). Frequently reported barriers to regular filter use were as follows: considering filter use an additional task, filter breakage and time required for water filtering (technology dimension at individual level).The technological, psychosocial and contextual dimensions of IBM-WASH contributed to understanding the factors related to sustained use of siphon filter. Given the low regular usage rate and the hardware-related problems reported, the contribution of siphon filters to improving water quality in low-income urban communities in Bangladesh is likely to be minimal.

    View details for DOI 10.1111/tmi.12448

    View details for Web of Science ID 000350755800008

    View details for PubMedID 25495859

  • Highly Pathogenic Avian Influenza A(H5N1) Virus Infection among Workers at Live Bird Markets, Bangladesh, 2009-2010 EMERGING INFECTIOUS DISEASES Nasreen, S., Khan, S. U., Luby, S. P., Gurley, E. S., Abedin, J., Zaman, R. U., Sohel, B. M., Rahman, M., Hancock, K., Levine, M. Z., Veguilla, V., Wang, D., Holiday, C., Gillis, E., Sturm-Ramirez, K., Bresee, J. S., Rahman, M., Uyeki, T. M., Katz, J. M., Azziz-Baumgartner, E. 2015; 21 (4): 629-637


    The risk for influenza A(H5N1) virus infection is unclear among poultry workers in countries where the virus is endemic. To assess H5N1 seroprevalence and seroconversion among workers at live bird markets (LBMs) in Bangladesh, we followed a cohort of workers from 12 LBMs with existing avian influenza surveillance. Serum samples from workers were tested for H5N1 antibodies at the end of the study or when LBM samples first had H5N1 virus-positive test results. Of 404 workers, 9 (2%) were seropositive at baseline. Of 284 workers who completed the study and were seronegative at baseline, 6 (2%) seroconverted (7 cases/100 poultry worker-years). Workers who frequently fed poultry, cleaned feces from pens, cleaned food/water containers, and did not wash hands after touching sick poultry had a 7.6 times higher risk for infection compared with workers who infrequently performed these behaviors. Despite frequent exposure to H5N1 virus, LBM workers showed evidence of only sporadic infection.

    View details for DOI 10.3201/eid2104.141281

    View details for Web of Science ID 000351652100010

    View details for PubMedID 25811942

  • Piloting the promotion of bamboo skirt barriers to prevent Nipah virus transmission through date palm sap in Bangladesh GLOBAL HEALTH PROMOTION Nahar, N., Mondal, U. K., Hossain, M. J., Khan, M. S., Sultana, R., Gurley, E. S., Luby, S. P. 2014; 21 (4): 7-15


    Drinking raw date palm sap contaminated with infected fruit bat saliva or urine is an important mode of Nipah virus transmission to humans in Bangladesh. Bamboo skirts are an effective way to interrupt bat access to the sap. We conducted a study from November 2008 to March 2009 to explore the effectiveness of higher- and lower-intensity interventions by promoting bamboo skirt preparation and use among sap harvesters (gachhis). We spent 280 person-hours in two villages for the higher-intensity intervention and half that amount of time in two other villages for the lower-intensity intervention. To evaluate the interventions we followed up all gachhis once a month for three months. A high percentage of gachhis (83% in higher-, 65% in lower-intensity interventions) prepared and used a skirt of bamboo or other materials - jute stalk, dhoincha (Sesbania aculeata), or polythene - at least once after intervention. In general, 15% of gachhis consistently used skirts throughout the sap collection season. The intensive nature of this intervention is very expensive for a large-scale programme. Future efforts should focus on developing a low-cost behaviour change intervention and evaluate if it reduces the human exposure to potentially contaminated fresh date palm sap.

    View details for DOI 10.1177/1757975914528249

    View details for Web of Science ID 000345533700002

    View details for PubMedID 24755262

  • Screening for long-term poliovirus excretion among children with primary immunodeficiency disorders: preparation for the polio posteradication era in Bangladesh. journal of infectious diseases Sazzad, H. M., Rainey, J. J., Kahn, A., Mach, O., Liyanage, J. B., Alam, A. N., Kawser, C. A., Hossain, A., Sutter, R., Luby, S. P. 2014; 210: S373-9


    Persons with primary immune deficiency disorders (PIDD) who receive oral poliovirus vaccine (OPV) may transmit immunodeficiency-associated vaccine-derived polioviruses (iVDPVs) and cause paralytic polio. The objective of this study was to identify children with PIDD in Bangladesh, and estimate the proportion with chronic poliovirus excretion.Patients admitted at 5 teaching hospitals were screened for PIDD according to standardized clinical case definitions. PIDD was confirmed by age-specific quantitative immunoglobulin levels. Stool specimens were collected from patients with confirmed PIDD.From February 2011 through January 2013, approximately 96 000 children were screened, and 53 patients were identified who met the clinical case definition for PIDD. Thirteen patients (24%) had age-specific quantitative immunoglobulins results that confirmed PIDD. Of these, 9 (69%) received OPV 3-106 months before stool specimen collection. Among 11 patients, stool specimens from 1 patient tested positive for polioviruses 34 months after OPV ingestion. However, the poliovirus isolate was not available for genetic sequencing, and a subsequent stool specimen 45 days later was negative.The risk of chronic poliovirus excretion among children with PIDD in Bangladesh seems to be low. The national polio eradication program should incorporate strategies for screening for poliovirus excretion among patients with PIDD.

    View details for DOI 10.1093/infdis/jiu221

    View details for PubMedID 25316858

  • Serological evidence of henipavirus exposure in cattle, goats and pigs in Bangladesh. PLoS neglected tropical diseases Chowdhury, S., Khan, S. U., Crameri, G., Epstein, J. H., Broder, C. C., Islam, A., Peel, A. J., Barr, J., Daszak, P., Wang, L., Luby, S. P. 2014; 8 (11)


    Nipah virus (NiV) is an emerging disease that causes severe encephalitis and respiratory illness in humans. Pigs were identified as an intermediate host for NiV transmission in Malaysia. In Bangladesh, NiV has caused recognized human outbreaks since 2001 and three outbreak investigations identified an epidemiological association between close contact with sick or dead animals and human illness.We examined cattle and goats reared around Pteropus bat roosts in human NiV outbreak areas. We also tested pig sera collected under another study focused on Japanese encephalitis.We detected antibodies against NiV glycoprotein in 26 (6.5%) cattle, 17 (4.3%) goats and 138 (44.2%) pigs by a Luminex-based multiplexed microsphere assay; however, these antibodies did not neutralize NiV. Cattle and goats with NiVsG antibodies were more likely to have a history of feeding on fruits partially eaten by bats or birds (PR=3.1, 95% CI 1.6-5.7) and drinking palmyra palm juice (PR=3.9, 95% CI 1.5-10.2).This difference in test results may be due to the exposure of animals to one or more novel viruses with antigenic similarity to NiV. Further research may identify a novel organism of public health importance.

    View details for DOI 10.1371/journal.pntd.0003302

    View details for PubMedID 25412358

  • Lot-to-lot consistency of live attenuated SA 14-14-2 Japanese encephalitis vaccine manufactured in a good manufacturing practice facility and non-inferiority with respect to an earlier product. Vaccine Zaman, K., Naser, A. M., Power, M., Yaich, M., Zhang, L., Ginsburg, A. S., Luby, S. P., Rahman, M., Hills, S., Bhardwaj, M., Flores, J. 2014; 32 (46): 6061-6066


    We conducted a four-arm, double-blind, randomized controlled trial among 818 Bangladeshi infants between 10 and 12 months of age to establish equivalence among three lots of live attenuated SA 14-14-2 JE vaccine manufactured by the China National Biotec Group's Chengdu Institute of Biological Products (CDIBP) in a new Good Manufacturing Practice (GMP) facility and to evaluate non-inferiority of the product with a lot of the same vaccine manufactured in CDIBP's original facility. The study took place in two sites in Bangladesh, rural Matlab and Mirpur in urban Dhaka. We collected pre-vaccination (Day 0) and post-vaccination Day 28 (-4 to +14 days) blood samples to assess neutralizing anti-JE virus antibody titers in serum by plaque reduction neutralization tests (PRNT). Seroprotection following vaccination was defined as a PRNT titer ≥1:10 at Day 28 in participants non-immune at baseline. Follow-up for reactogenicity and safety was conducted through home visits at Day 7 and monitoring for serious adverse events through Day 28. Seroprotection rates ranged from 80.2% to 86.3% for all four lots of vaccine. Equivalence of the seroprotection rates between pairs of vaccine lots produced in the new GMP facility was satisfied at the pre-specified 10% margin of the 95% confidence interval (CI) for two of the three pairwise comparisons, but not for the third (-4.3% observed difference with 95% CI of -11.9 to 3.3%). Nevertheless, the aggregate seroprotection rate for all three vaccine lots manufactured in the GMP facility was calculated and found to be within the non-inferiority margin (within 10%) to the vaccine lot produced in the original facility. All four lots of vaccine were safe and well tolerated. These study results should facilitate the use of SA 14-14-2 JE vaccine as a routine component of immunization programs in Asian countries.

    View details for DOI 10.1016/j.vaccine.2014.09.012

    View details for PubMedID 25239483

  • A duplex recombinant viral nucleoprotein microbead immunoassay for simultaneous detection of seroresponses to human respiratory syncytial virus and metapneumovirus infections. Journal of virological methods Zhang, Y., Brooks, W. A., Goswami, D., Rahman, M., Luby, S. P., Erdman, D. D. 2014; 206: 55-62


    Serologic diagnosis of human respiratory syncytial virus (hRSV) and human metapneumovirus (hMPV) infections has been shown to complement virus detection methods in epidemiologic studies. Enzyme immunoassays (EIAs) using cultured virus lysate antigens are often used to diagnose infection by demonstration of a ≥4-fold rises in antibody titer between acute and convalescent serum pairs. In this study, hRSV and hMPV nucleocapsid (recN) proteins were expressed in a baculovirus system and their performance compared with virus culture lysate antigen in EIAs using paired serum specimens collected from symptomatic children. The recN proteins were also used to develop a duplex assay based on the Luminex microbead-based suspension array technology, where diagnostic rises in antibody levels could be determined simultaneously at a single serum dilution. Antibody levels measured by the recN and viral lysate EIAs correlated moderately (hRSV, r(2)=0.72; hMPV, r(2)=0.76); the recN EIAs identified correctly 35 of 37 (94.6%) and 48 of 50 (96%) serum pairs showing diagnostic antibody rises by viral lysate EIAs. Purified recN proteins were then coupled to microbeads and serum pairs were tested at a single dilution on a Luminex MAGPIX(®) analyzer. The duplex recN assay identified correctly 33 of 39 (85%) and 41 of 47 (86.7%) serum pairs showing diagnostic rises to hRSV and hMPV, respectively. The recN assay permits simultaneous testing for acute hRSV and hMPV infections and offers a platform for expanded multiplexing of other respiratory virus assays.

    View details for DOI 10.1016/j.jviromet.2014.05.008

    View details for PubMedID 24859050

  • Outbreak of Hepatitis E in Urban Bangladesh Resulting in Maternal and Perinatal Mortality CLINICAL INFECTIOUS DISEASES Gurley, E. S., Hossain, M. J., Paul, R. C., Sazzad, H. M., Islam, M. S., Parveen, S., Faruque, L. I., Husain, M., Ara, K., Jahan, Y., Rahman, M., Luby, S. P. 2014; 59 (5): 658-665


    Hepatitis E virus (HEV) causes outbreaks of jaundice associated with maternal mortality. Four deaths among pregnant women with jaundice occurred in an urban community near Dhaka, Bangladesh, in late 2008 and were reported to authorities in January 2009. We investigated the etiology and risk factors for jaundice and death.Field workers identified suspected cases, defined as acute onset of yellow eyes or skin, through house-to-house visits. A subset of persons with suspected HEV was tested for immunoglobulin M (IgM) antibodies to HEV to confirm infection. We used logistic regression analysis to identify risk factors for HEV disease and for death. We estimated the increased risk of perinatal mortality associated with jaundice during pregnancy.We identified 4751 suspected HEV cases during August 2008-January 2009, including 17 deaths. IgM antibodies to HEV were identified in 56 of 73 (77%) case-patients tested who were neighbors of the case-patients who died. HEV disease was significantly associated with drinking municipally supplied water. Death among persons with HEV disease was significantly associated with being female and taking paracetamol (acetaminophen). Among women who were pregnant, miscarriage and perinatal mortality was 2.7 times higher (95% confidence interval, 1.2-6.1) in pregnancies complicated by jaundice.This outbreak of HEV was likely caused by sewage contamination of the municipal water system. Longer-term efforts to improve access to safe water and license HEV vaccines are needed. However, securing resources and support for intervention will rely on convincing data about the endemic burden of HEV disease, particularly its role in maternal and perinatal mortality.

    View details for DOI 10.1093/cid/ciu383

    View details for Web of Science ID 000342921100014

    View details for PubMedID 24855146

  • Dynamics of Japanese Encephalitis Virus Transmission among Pigs in Northwest Bangladesh and the Potential Impact of Pig Vaccination PLOS NEGLECTED TROPICAL DISEASES Khan, S. U., Salje, H., Hannan, A., Islam, M. A., Bhuyan, A. A., Islam, M. A., Rahman, M. Z., Nahar, N., Hossain, M. J., Luby, S. P., Gurley, E. S. 2014; 8 (9)


    Japanese encephalitis (JE) virus infection can cause severe disease in humans, resulting in death or permanent neurologic deficits among survivors. Studies indicate that the incidence of JE is high in northwestern Bangladesh. Pigs are amplifying hosts for JE virus (JEV) and a potentially important source of virus in the environment. The objectives of this study were to describe the transmission dynamics of JEV among pigs in northwestern Bangladesh and estimate the potential impact of vaccination to reduce incidence among pigs.We conducted a comprehensive census of pigs in three JE endemic districts and tested a sample of them for evidence of previous JEV infection. We built a compartmental model to describe JEV transmission dynamics in this region and to estimate the potential impact of pig vaccination. We identified 11,364 pigs in the study area. Previous JEV infection was identified in 30% of pigs with no spatial differences in the proportion of pigs that were seropositive across the study area. We estimated that JEV infects 20% of susceptible pigs each year and the basic reproductive number among pigs was 1.2. The model suggest that vaccinating 50% of pigs each year resulted in an estimated 82% reduction in annual incidence in pigs.The widespread distribution of historic JEV infection in pigs suggests they may play an important role in virus transmission in this area. Future studies are required to understand the contribution of pig infections to JE risk in humans and the potential impact of pig vaccination on human disease.

    View details for DOI 10.1371/journal.pntd.0003166

    View details for Web of Science ID 000342796600047

    View details for PubMedID 25255286

  • Nudging to use: Achieving safe water behaviors in Kenya and Bangladesh JOURNAL OF DEVELOPMENT ECONOMICS Luoto, J., Levine, D., Albert, J., Luby, S. 2014; 110: 13-21
  • Incidence of and Risk Factors for Hospital-Acquired Diarrhea in Three Tertiary Care Public Hospitals in Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Bhuiyan, M. U., Luby, S. P., Zaman, R. U., Rahman, M. W., Sharker, M. A., Hossain, M. J., Rasul, C. H., Ekram, A. R., Rahman, M., Sturm-Ramirez, K., Azziz-Baumgartner, E., Gurley, E. S. 2014; 91 (1): 165-172
  • Economic burden of influenza-associated hospitalizations and outpatient visits in Bangladesh during 2010 INFLUENZA AND OTHER RESPIRATORY VIRUSES Bhuiyan, M. U., Luby, S. P., Alamgir, N. I., Homaira, N., Mamun, A. A., Khan, J. A., Abedin, J., Sturm-Ramirez, K., Gurley, E. S., Zaman, R. U., Alamgir, A. S., Rahman, M., Widdowson, M., Azziz-Baumgartner, E. 2014; 8 (4): 406-413


    Understanding the costs of influenza-associated illness in Bangladesh may help health authorities assess the cost-effectiveness of influenza prevention programs. We estimated the annual economic burden of influenza-associated hospitalizations and outpatient visits in Bangladesh.From May through October 2010, investigators identified both outpatients and inpatients at four tertiary hospitals with laboratory-confirmed influenza infection through rRT-PCR. Research assistants visited case-patients' homes within 30 days of hospital visit/discharge and administered a structured questionnaire to capture direct medical costs (physician consultation, hospital bed, medicines and diagnostic tests), direct non-medical costs (food, lodging and travel) and indirect costs (case-patients' and caregivers' lost income). We used WHO-Choice estimates for routine healthcare service costs. We added direct, indirect and healthcare service costs to calculate cost-per-episode. We used median cost-per-episode, published influenza-associated outpatient and hospitalization rates and Bangladesh census data to estimate the annual economic burden of influenza-associated illnesses in 2010.We interviewed 132 outpatients and 41 hospitalized patients. The median cost of an influenza-associated outpatient visit was US$4.80 (IQR = 2.93-8.11) and an influenza-associated hospitalization was US$82.20 (IQR = 59.96-121.56). We estimated that influenza-associated outpatient visits resulted in US$108 million (95% CI: 76-147) in direct costs and US$59 million (95% CI: 37-91) in indirect costs; influenza-associated hospitalizations resulted in US$1.4 million (95% CI: 0.4-2.6) in direct costs and US$0.4 million (95% CI: 0.1-0.8) in indirect costs in 2010.In Bangladesh, influenza-associated illnesses caused an estimated US$169 million in economic loss in 2010, largely driven by frequent but low-cost outpatient visits.

    View details for DOI 10.1111/irv.12254

    View details for Web of Science ID 000337608700003

    View details for PubMedID 24750586

  • Identification and Epidemiology of a Rare HoBi-Like Pestivirus Strain in Bangladesh TRANSBOUNDARY AND EMERGING DISEASES Haider, N., Rahman, M. S., KHAN, S. U., Mikolon, A., Gurley, E. S., Osmani, M. G., Shanta, I. S., Paul, S. K., Macfarlane-Berry, L., Islam, A., Desmond, J., Epstein, J. H., Daszak, P., Azim, T., Luby, S. P., Zeidner, N., Rahman, M. Z. 2014; 61 (3): 193-198


    The genus pestivirus of the family flaviviridae consists of four recognized species: bovine viral diarrhoea virus 1 (BVDV-1), bovine viral diarrhoea virus 2 (BVDV-2), classical swine fever virus and border disease virus. A new putative pestivirus species tentatively named as either 'HoBi-like pestivirus' or BVDV-3 has recently been identified in Brazil, Italy and Thailand. Despite reports of serological evidence of BVDV in Bangladesh, the types of the virus circulating in cattle have not been identified. We conducted surveillance in cattle from May 2009 to August 2010 in three government veterinary hospitals to characterize BVDV in cattle of Bangladesh. We tested serum for BVDV using an antigen-capture ELISA. Of 638 cattle samples, 3% (16/638) tested positive for BVDV antigen. The ELISA-positive samples were selected for further molecular detection and characterization of BVDV. Molecular analysis of the partial 5' untranslated region (UTR) nucleotide sequences of BVDV-positive samples identified the rare HoBi-like pestivirus or BVDV-3 virus circulating in cattle of Bangladesh. The identification of this rare HoBi-like pestivirus or BVDV-3 strain in Bangladesh warrants further surveillance to evaluate its impact on livestock production.

    View details for DOI 10.1111/tbed.12218

    View details for Web of Science ID 000334298300001

    View details for PubMedID 24650238

  • Kala-azar in Pregnancy in Mymensingh, Bangladesh: A Social Autopsy. PLoS neglected tropical diseases Rahman, K. M., Olsen, A., Harley, D., Butler, C. D., Mondal, D., Luby, S. P., Sleigh, A. C. 2014; 8 (5)

    View details for DOI 10.1371/journal.pntd.0002710

    View details for PubMedID 24786280

  • Household Air Quality Risk Factors Associated with Childhood Pneumonia in Urban Dhaka, Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Ram, P. K., Dutt, D., Silk, B. J., Doshi, S., Rudra, C. B., Abedin, J., Goswami, D., Fry, A. M., Brooks, W. A., Luby, S. P., Cohen, A. L. 2014; 90 (5): 968-975


    To inform interventions to reduce the high burden of pneumonia in urban settings such as Kamalapur, Bangladesh, we evaluated household air quality risk factors for radiographically confirmed pneumonia in children. In 2009-2010, we recruited children < 5 years of age with pneumonia and controls from a population-based surveillance for respiratory and febrile illnesses. Piped natural gas was used by 85% of 331 case and 91% of 663 control households. Crowding, a tin roof in the living space, low socioeconomic status, and male sex of the child were risk factors for pneumonia. The living space in case households was 28% less likely than in control households to be cross-ventilated. Particulate matter concentrations were not significantly associated with pneumonia. With increasing urbanization and supply of improved cooking fuels to urban areas, the high burden of respiratory illnesses in urban populations such as Kamalapur may be reduced by decreasing crowding and improving ventilation in living spaces.

    View details for DOI 10.4269/ajtmh.13-0532

    View details for Web of Science ID 000335707600033

    View details for PubMedID 24664785

  • Toys and toilets: cross-sectional study using children's toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices TROPICAL MEDICINE & INTERNATIONAL HEALTH Vujcic, J., Ram, P. K., Hussain, F., Unicomb, L., Gope, P. S., Abedin, J., Mahmud, Z. H., Islam, M. S., Luby, S. P. 2014; 19 (5): 528-536


    To evaluate household faecal contamination using children's toys among 100 rural Bangladeshi households categorised as 'cleaner' (toilet that reliably separates faeces from the environment and no human faeces in/around living space) or 'less clean' (no toilet or toilet that does not reliably separate faeces from the environment and human faeces in/around living space).We distributed toy balls to each household and rinsed each study toy and a toy already owned by the household in 200 ml of Ringer's solution. We enumerated faecal coliforms and faecal streptococci from each rinse using membrane filtration methods.Study toys from 39 cleaner households had lower mean faecal coliform contamination than toys from 61 less clean households (2.4 log10 colony-forming units (CFU)/200 ml vs. 3.2 log10 CFU/200 ml, P = 0.03). However, wealth measures explained a portion of this relationship. Repeat measures were moderately variable [coefficient of variation (CV) = 6.5 between two toys in the household at the same time, CV = 37.6 between toys in the household at two different times 3-4 days apart]. Too few households owned a non-porous toy to compare groups without risk of bias.In rural Bangladesh, improved sanitation facilities and practices were associated with less environmental contamination. Whether this association is independent of household wealth and whether the difference in contamination improves child health merit further study. The variation found was typical for measures of environmental contamination, and requires large sample sizes to ascertain differences between groups with statistical significance.

    View details for DOI 10.1111/tmi.12292

    View details for Web of Science ID 000333984600006

    View details for PubMedID 24645919

  • Indoor Exposure to Particulate Matter and Age at First Acute Lower Respiratory Infection in a Low-Income Urban Community in Bangladesh AMERICAN JOURNAL OF EPIDEMIOLOGY Gurley, E. S., Salje, H., Homaira, N., Ram, P. K., Haque, R., Petri, W. A., Bresee, J., Moss, W. J., Luby, S. P., Breysse, P., Azziz-Baumgartner, E. 2014; 179 (8): 967-973


    The timing of a child's first acute lower respiratory infection (ALRI) is important, because the younger a child is when he or she experiences ALRI, the greater the risk of death. Indoor exposure to particulate matter less than or equal to 2.5 µm in diameter (PM2.5) has been associated with increased frequency of ALRI, but little is known about how it may affect the timing of a child's first ALRI. In this study, we aimed to estimate the association between a child's age at first ALRI and indoor exposure to PM2.5 in a low-income community in Dhaka, Bangladesh. We followed 257 children from birth through age 2 years to record their age at first ALRI. Between May 2009 and April 2010, we also measured indoor concentrations of PM2.5 in children's homes. We used generalized gamma distribution models to estimate the relative age at first ALRI associated with the mean number of hours in which PM2.5 concentrations exceeded 100 µg/m(3). Each hour in which PM2.5 levels exceeded 100 µg/m(3) was independently associated with a 12% decrease (95% confidence interval: 2, 21; P = 0.021) in age at first ALRI. Interventions to reduce indoor exposure to PM2.5 could increase the ages at which children experience their first ALRI in this urban community.

    View details for DOI 10.1093/aje/kwu002

    View details for Web of Science ID 000334075700005

    View details for PubMedID 24607596

  • Roosting behaviour and habitat selection of Pteropus giganteus reveal potential links to Nipah virus epidemiology JOURNAL OF APPLIED ECOLOGY Hahn, M. B., Epstein, J. H., Gurley, E. S., Islam, M. S., Luby, S. P., Daszak, P., Patz, J. A. 2014; 51 (2): 376-387
  • Impact of neighborhood biomass cooking patterns on episodic high indoor particulate matter concentrations in clean fuel homes in Dhaka, Bangladesh INDOOR AIR Salje, H., Gurley, E. S., Homaira, N., Ram, P. K., Haque, R., Petri, W., Moss, W. J., Luby, S. P., Breysse, P., Azziz-Baumgartner, E. 2014; 24 (2): 213-220


    Exposure to particulate matter (PM2.5 ) from the burning of biomass is associated with increased risk of respiratory disease. In Dhaka, Bangladesh, households that do not burn biomass often still experience high concentrations of PM2.5 , but the sources remain unexplained. We characterized the diurnal variation in the concentrations of PM2.5 in 257 households and compared the risk of experiencing high PM2.5 concentrations in biomass and non-biomass users. Indoor PM2.5 concentrations were estimated every minute over 24 h once a month from April 2009 through April 2010. We found that households that used gas or electricity experienced PM2.5 concentrations exceeding 1000 μg/m(3) for a mean of 35 min within a 24-h period compared with 66 min in biomass-burning households. In both households that used biomass and those that had no obvious source of particulate matter, the probability of PM2.5 exceeding 1000 μg/m(3) were highest during distinct morning, afternoon, and evening periods. In such densely populated settings, indoor pollution in clean fuel households may be determined by biomass used by neighbors, with the highest risk of exposure occurring during cooking periods. Community interventions to reduce biomass use may reduce exposure to high concentrations of PM2.5 in both biomass and non-biomass using households.

    View details for DOI 10.1111/ina.12065

    View details for Web of Science ID 000332773100011

    View details for PubMedID 24033488

  • Family caregivers in public tertiary care hospitals in Bangladesh: Risks and opportunities for infection control AMERICAN JOURNAL OF INFECTION CONTROL Islam, M. S., Luby, S. P., Sultana, R., Rimi, N. A., Zaman, R. U., Uddin, M., Nahar, N., Rahman, M., Hossain, M. J., Gurley, E. S. 2014; 42 (3): 305-310


    Family caregivers are integral to patient care in Bangladeshi public hospitals. This study explored family caregivers' activities and their perceptions and practices related to disease transmission and prevention in public hospitals.Trained qualitative researchers conducted a total of 48 hours of observation in 3 public tertiary care hospitals and 12 in-depth interviews with family caregivers.Family caregivers provided care 24 hours a day, including bedside nursing, cleaning care, and psychologic support. During observations, family members provided 2,065 episodes of care giving, 75% (1,544) of which involved close contact with patients. We observed family caregivers washing their hands with soap on only 4 occasions. The majority of respondents said diseases are transmitted through physical contact with surfaces and objects that have been contaminated with patient secretions and excretions, and avoiding contact with these contaminated objects would help prevent disease.Family caregivers are at risk for hospital-acquired infection from their repeated exposure to infectious agents combined with their inadequate hand hygiene and knowledge about disease transmission. Future research should explore potential strategies to improve family caregivers' knowledge about disease transmission and reduce family caregiver exposures, which may be accomplished by improving care provided by health care workers.

    View details for DOI 10.1016/j.ajic.2013.09.012

    View details for Web of Science ID 000332311500019

    View details for PubMedID 24406254

  • Investigating a crow die-off in January-February 2011 during the introduction of a new clade of highly pathogenic avian influenza virus H5N1 into Bangladesh ARCHIVES OF VIROLOGY Khan, S. U., Berman, L., Haider, N., Gerloff, N., Rahman, M. Z., Shu, B., Rahman, M., Dey, T. K., Davis, T. C., Das, B. C., Balish, A., Islam, A., Teifke, J. P., Zeidner, N., Lindstrom, S., Klimov, A., Donis, R. O., Luby, S. P., Shivaprasad, H. L., Mikolon, A. B. 2014; 159 (3): 509-518


    We investigated unusual crow mortality in Bangladesh during January-February 2011 at two sites. Crows of two species, Corvus splendens and C. macrorhynchos, were found sick and dead during the outbreaks. In selected crow roosts, morbidity was ~1 % and mortality was ~4 % during the investigation. Highly pathogenic avian influenza virus H5N1 clade was isolated from dead crows. All isolates were closely related to A/duck/India/02CA10/2011 (H5N1) with 99.8 % and A/crow/Bangladesh/11rs1984-15/2011 (H5N1) virus with 99 % nucleotide sequence identity in their HA genes. The phylogenetic cluster of Bangladesh viruses suggested a common ancestor with viruses found in poultry from India, Myanmar and Nepal. Histopathological changes and immunohistochemistry staining in brain, pancreas, liver, heart, kidney, bursa of Fabricius, rectum, and cloaca were consistent with influenza virus infection. Through our limited investigation in domesticated birds near the crow roosts, we did not identify any samples that tested positive for influenza virus A/H5N1. However, environmental samples collected from live-bird markets near an outbreak site during the month of the outbreaks tested very weakly positive for influenza virus A/H5N1 in clade rRT-PCR. Continuation of surveillance in wild and domestic birds may identify evolution of new avian influenza virus and associated public-health risks.

    View details for DOI 10.1007/s00705-013-1842-0

    View details for Web of Science ID 000332019500012

    View details for PubMedID 24081824

  • Poultry Slaughtering Practices in Rural Communities of Bangladesh and Risk of Avian Influenza Transmission: A Qualitative Study ECOHEALTH Rimi, N. A., Sultana, R., Ishtiak-Ahmed, K., Khan, S. U., Sharker, M. A., Zaman, R. U., Azziz-Baumgartner, E., Gurley, E. S., Nahar, N., Luby, S. P. 2014; 11 (1): 83-93


    Slaughtering sick poultry is a risk factor for human infection with highly pathogenic avian influenza and is a common practice in Bangladesh. This paper describes human exposures to poultry during slaughtering process and the customs and rituals influencing these practices in two Bangladeshi rural communities. In 2009, we conducted 30 observations to observe slaughtering practices and 110 in-depth and short interviews and 36 group discussions to explore reasons behind those practices. The villagers reported slaughtering 103 poultry, including 20 sick poultry during 2 months. During different stages of slaughtering, humans, the environment, healthy poultry, and other animals were exposed to poultry blood and body parts. Women performed most of the slaughtering tasks, including evisceration. Defeathering required the most time and involved several persons. During festivals, ceremonies, and rituals, many people gathered and participated in the slaughtering of poultry. Exposure to poultry slaughtering created numerous opportunities for potential avian influenza transmission. Strategies that can be further tested to determine if they reduce the risk of transmission include skinning the carcasses of sick poultry, using hot water for defeathering and cleaning, using a bucket to contain slaughtering blood and carcass, burying the offal and encouraging handwashing.

    View details for DOI 10.1007/s10393-013-0885-8

    View details for Web of Science ID 000337076000011

    View details for PubMedID 24306550

  • The Prevalence and Impact of Intimate Partner Violence on Maternal Distress in a Community of Low-Income Bangladeshi and Displaced Ethnic Bihari Mothers Dhaka, 2008-2009 SCANDINAVIAN JOURNAL OF IMMUNOLOGY Azziz-Baumgartner, E., Homaira, N., Hamadani, J. D., Tofail, F., Dahlberg, L. L., Haque, R., Luby, S. P., Naved, R. T. 2014; 79 (3): 59-73
  • Population-Based Incidence of Severe Acute Respiratory Virus Infections among Children Aged < 5 Years in Rural Bangladesh, June-October 2010 PLOS ONE Nasreen, S., Luby, S. P., Brooks, W. A., Homaira, N., Al Mamun, A., Bhuiyan, M. U., Rahman, M., Ahmed, D., Abedin, J., Rahman, M., Alamgir, A. S., Fry, A. M., Streatfield, P. K., Rahman, A., Bresee, J., Widdowson, M., Azziz-Baumgartner, E. 2014; 9 (2)


    Better understanding the etiology-specific incidence of severe acute respiratory infections (SARIs) in resource-poor, rural settings will help further develop and prioritize prevention strategies. To address this gap in knowledge, we conducted a longitudinal study to estimate the incidence of SARIs among children in rural Bangladesh.During June through October 2010, we followed children aged <5 years in 67 villages to identify those with cough, difficulty breathing, age-specific tachypnea and/or danger signs in the community or admitted to the local hospital. A study physician collected clinical information and obtained nasopharyngeal swabs from all SARI cases and blood for bacterial culture from those hospitalized. We tested swabs for respiratory syncytial virus (RSV), influenza viruses, human metapneumoviruses, adenoviruses and human parainfluenza viruses 1-3 (HPIV) by real-time reverse transcription polymerase chain reaction. We calculated virus-specific SARI incidence by dividing the number of new illnesses by the person-time each child contributed to the study.We followed 12,850 children for 279,029 person-weeks (pw) and identified 141 SARI cases; 76 (54%) at their homes and 65 (46%) at the hospital. RSV was associated with 7.9 SARI hospitalizations per 100,000 pw, HPIV3 2.2 hospitalizations/100,000 pw, and influenza 1.1 hospitalizations/100,000 pw. Among non-hospitalized SARI cases, RSV was associated with 10.8 illnesses/100,000 pw, HPIV3 1.8/100,000 pw, influenza 1.4/100,000 pw, and adenoviruses 0.4/100,000 pw.Respiratory viruses, particularly RSV, were commonly associated with SARI among children. It may be useful to explore the value of investing in prevention strategies, such as handwashing and respiratory hygiene, to reduce respiratory infections among young children in such settings.

    View details for DOI 10.1371/journal.pone.0089978

    View details for Web of Science ID 000332385900104

    View details for PubMedID 24587163

  • Infrastructure and Contamination of the Physical Environment in Three Bangladeshi Hospitals: Putting Infection Control into Context PLOS ONE Rimi, N. A., Sultana, R., Luby, S. P., Islam, M. S., Uddin, M., Hossain, M. J., Zaman, R. U., Nahar, N., Gurley, E. S. 2014; 9 (2)


    This paper describes the physical structure and environmental contamination in selected hospital wards in three government hospitals in Bangladesh.The qualitative research team conducted 48 hours of observation in six wards from three Bangladeshi tertiary hospitals in 2007. They recorded environmental contamination with body secretions and excretions and medical waste and observed ward occupant handwashing and use of personal protective equipment. They recorded number of persons, number of open doors and windows, and use of fans. They measured the ward area and informally observed waste disposal outside the wards. They conducted nine focus group discussions with doctors, nurses and support staff.A median of 3.7 persons were present per 10 m(2) of floor space in the wards. A median of 4.9 uncovered coughs or sneezes were recorded per 10 m(2) per hour per ward. Floors in the wards were soiled with saliva, spit, mucous, vomitus, feces and blood 125 times in 48 hours. Only two of the 12 patient handwashing stations had running water and none had soap. No disinfection was observed before or after using medical instruments. Used medical supplies were often discarded in open containers under the beds. Handwashing with soap was observed in only 32 of 3,373 handwashing opportunities noted during 48 hours. Mosquitoes and feral cats were commonly observed in the wards.The physical structure and environment of our study hospitals are conducive to the spread of infection to people in the wards. Low-cost interventions on hand hygiene and cleaning procedures for rooms and medical equipment should be developed and evaluated for their practicality and effectiveness.

    View details for DOI 10.1371/journal.pone.0089085

    View details for Web of Science ID 000331711900086

    View details for PubMedID 24586516

  • Efficacy of oseltamivir treatment started within 5 days of symptom onset to reduce influenza illness duration and virus shedding in an urban setting in Bangladesh: a randomised placebo-controlled trial LANCET INFECTIOUS DISEASES Fry, A. M., Goswami, D., Nahar, K., Sharmin, A. T., Rahman, M., Gubareva, L., Azim, T., Bresee, J., Luby, S. P., Brooks, W. A. 2014; 14 (2): 109-118


    Influenza causes substantial morbidity and mortality worldwide. Few data exist for the efficacy of neuraminidase inhibitors, which are the only readily available influenza treatment options, especially in low-income settings. We assessed the efficacy of treatment with the neuraminidase inhibitor oseltamivir to reduce patient illness and viral shedding in people with influenza, in whom treatment was started within 5 days of symptom onset, in an urban setting in Bangladesh.We undertook a double-blind, randomised, controlled trial between May, 2008, and December, 2010. Patients with a positive rapid influenza test identified by surveillance of households in Kamalapur, Bangladesh were randomly allocated on a 1:1 basis to receive oseltamivir or placebo twice daily for 5 days. Randomisation lists for individuals enrolled less than 48 h and 48 h or longer since illness onset were generated with permuted blocks of variable length between two and eight. Participants and study staff were masked to treatment group. Participants provided nasal wash specimens at enrolment and 2, 4, and 7 days later, and were visited daily to record symptoms. All specimens were tested for influenza with reverse-transcriptase PCR, and if the result was positive, we isolated the virus. The primary endpoints were duration of clinical illness and viral shedding in patients treated less than and more than 48 h since illness onset and the frequency of oseltamivir resistance during treatment. Analyses were intention to treat unless otherwise specified. This trial is registered with, number NCT00707941.Overall, 1190 people with a median age of 5 years (IQR 2-9) were enrolled: 794 (67%) less than 48 h since symptom onset and 396 (33%) 48 h or longer since symptom onset. 592 participants were assigned to placebo and 598 to oseltamivir. The median duration of symptoms was shorter in the oseltamivir group (3 days, IQR 1-5) than in the placebo group (4 days, 1-6; p=0.01). When stratified by timing of treatment initiation, in participants enrolled 48 h or longer since illness onset, the median duration of symptoms was similar in both groups (oseltamivir 3 days [IQR 2-5], placebo 3 days [1-5]; p=0.04). The median duration of symptoms was reduced by 1 day in the group given oseltamivir who were enrolled less than 48 h since symptom onset compared with those given placebo, but this difference was not significant. In those with all swab specimens (n=1134), oseltamivir significantly reduced virus isolation on days 2 (placebo 374 [66%] vs oseltamivir 321 [56%]; difference 15.2%, 95% CI 9.5-20.8, p=0.0004), 4 (241 [43%] vs 174 [30%]; difference 30.2%, 95% CI 24.6-35.8, p<0.0001), and 7 (68 [12%] vs 36 [6%]; difference 47.5%, 95% CI 44.2-50.8, p=0.0009). In participants enrolled 48 h or longer since illness onset, oseltamivir treatment significantly reduced virus isolation on days 2 and 4, but not day 7. In participants enrolled less than 48 h since illness onset, oseltamivir treatment significantly reduced virus isolation on days 2, 4, and 7. The emergency of resistance to oseltamivir during treatment was rare overall (<1%) and in influenza A H1N1pdm09 viruses (3.9%).Oseltamivir treatment resulted in a modest reduction in the duration of symptoms and virus shedding in people with uncomplicated influenza infections, even when treatment was started 48 h or longer after illness onset.Centers for Disease Control and Prevention (in agreement with the International Centre for Diarrhoeal Disease Research, Bangladesh).

    View details for DOI 10.1016/S1473-3099(13)70267-6

    View details for Web of Science ID 000330420400024

    View details for PubMedID 24268590

  • Multiple reassortment events among highly pathogenic avian influenza A(H5N1) viruses detected in Bangladesh VIROLOGY Gerloff, N. A., Khan, S. U., Balish, A., Shanta, I. S., Simpson, N., Berman, L., Haider, N., Poh, M. K., Islam, A., Gurley, E., Hasnat, M. A., Dey, T., Shu, B., Emery, S., Lindstrom, S., Haque, A., Klimov, A., Villanueva, J., Rahman, M., Azziz-Baumgartner, E., Rahman, M. Z., Luby, S. P., Zeidner, N., Donis, R. O., Sturm-Ramirez, K., Davis, C. T. 2014; 450: 297-307
  • The Prevalence and Impact of Intimate Partner Violence on Maternal Distress in a Community of Low-Income Bangladeshi and Displaced Ethnic Bihari Mothers: Dhaka, 2008-2009 VIOLENCE AGAINST WOMEN Azziz-Baumgartner, E., Homaira, N., Hamadani, J. D., Tofail, F., Dahlberg, L. L., Haque, R., Luby, S. P., Naved, R. T. 2014; 20 (1): 59-73


    Low-income, ethnic, and/or displaced mothers are frequently victimized; we explored the burden of intimate partner violence (IPV) among such women. Teams administered IPV and maternal distress questionnaires to quantify victimization after the birth of a child. Of 250 mothers reporting abuse, 133 (53%) reported their husband hitting; 111 (44%) kicking, dragging, or beating; 61 (24%) choking or burning; and 33 (13%) injuring them with a knife or gun (12 case-patients per 100 person-years). Women who experienced more forms of victimization reported more distress (p = .01). Mothers in this low-income community experienced severe victimization and distress.

    View details for DOI 10.1177/1077801213520579

    View details for Web of Science ID 000331690300005

    View details for PubMedID 24567536

  • Respiratory Syncytial Virus Circulation in Seven Countries With Global Disease Detection Regional Centers JOURNAL OF INFECTIOUS DISEASES Haynes, A. K., Manangan, A. P., Iwane, M. K., Sturm-Ramirez, K., Homaira, N., Brooks, W. A., Luby, S., Rahman, M., Klena, J. D., Zhang, Y., Yu, H., Zhan, F., Dueger, E., Mansour, A. M., Azazzy, N., Mccracken, J. P., Bryan, J. P., Lopez, M. R., Burton, D. C., Bigogo, G., Breiman, R. F., Feikin, D. R., Njenga, K., Montgomery, J., Cohen, A. L., Moyes, J., Pretorius, M., Cohen, C., Venter, M., Chittaganpitch, M., Thamthitiwat, S., Sawatwong, P., Baggett, H. C., Luber, G., Gerber, S. I. 2013; 208: S246-S254


    Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections in young children globally, with the highest burden in low- and middle-income countries where the association between RSV activity and climate remains unclear.Monthly laboratory-confirmed RSV cases and associations with climate data were assessed for respiratory surveillance sites in tropical and subtropical areas (Bangladesh, China, Egypt, Guatemala, Kenya, South Africa, and Thailand) during 2004-2012. Average monthly minimum and maximum temperatures, relative humidity, and precipitation were calculated using daily local weather data from the US National Climatic Data Center.RSV circulated with 1-2 epidemic periods each year in site areas. RSV seasonal timing and duration were generally consistent within country from year to year. Associations between RSV and weather varied across years and geographic locations. RSV usually peaked in climates with high annual precipitation (Bangladesh, Guatemala, and Thailand) during wet months, whereas RSV peaked during cooler months in moderately hot (China) and arid (Egypt) regions. In South Africa, RSV peaked in autumn, whereas no associations with seasonal weather trends were observed in Kenya.Further understanding of RSV seasonality in developing countries and various climate regions will be important to better understand the epidemiology of RSV and for timing the use of future RSV vaccines and immunoprophylaxis in low- and middle-income countries.

    View details for DOI 10.1093/infdis/jit515

    View details for Web of Science ID 000327544900012

    View details for PubMedID 24265484

  • Coverage and cost of a large oral cholera vaccination program in a high-risk cholera endemic urban population in Dhaka, Bangladesh VACCINE Khan, I. A., Saha, A., Chowdhury, F., Khan, A. I., Uddin, M. J., Begum, Y. A., Riaz, B. K., Islam, S., Ali, M., Luby, S. P., Clemens, J. D., Cravioto, A., Qadri, F. 2013; 31 (51): 6058-6064


    A feasibility study of an oral cholera vaccine was carried out to test strategies to reach high-risk populations in urban Mirpur, Dhaka, Bangladesh. The study was cluster randomized, with three arms: vaccine, vaccine plus safe water and hand washing practice, and no intervention. High risk people of age one year and above (except pregnant woman) from the two intervention arms received two doses of the oral cholera vaccine, Shanchol™. Vaccination was conducted between 17th February and 16th April 2011, with a minimum interval of fourteen days between two doses. Interpersonal communication preceded vaccination to raise awareness amongst the target population. The number of vaccine doses used, the population vaccinated, left-out, drop out, vaccine wastage and resources required were documented. Fixed outreach site vaccination strategy was adopted as the mode of vaccine delivery. Additionally, mobile vaccination sites and mop-up activities were carried out to reach the target communities. Of the 172,754 target population, 141,839 (82%) and 123,666 (72%) received complete first and second doses of the vaccine, respectively. Dropout rate from the first to the second dose was 13%. Two complete doses were received by 123,661 participants. Vaccine coverage in children was 81%. Coverage was significantly higher in females than in males (77% vs. 66%, P<0.001). Vaccine wastage for delivering the complete doses was 1.2%. The government provided cold-chain related support at no cost to the project. Costs for two doses of vaccine per-person were US$3.93, of which US$1.63 was spent on delivery. Cost for delivering a single dose was US$0.76. We observed no serious adverse events. Mass vaccination with oral cholera vaccine is feasible for reaching high risk endemic population through the existing national immunization delivery system employed by the government.

    View details for DOI 10.1016/j.vaccine.2013.10.021

    View details for Web of Science ID 000329010400005

    View details for PubMedID 24161413

  • Handwashing before Food Preparation and Child Feeding: A Missed Opportunity for Hygiene Promotion AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Nizame, F. A., Unicomb, L., Sanghvi, T., Roy, S., Nuruzzaman, M., Ghosh, P. K., Winch, P. J., Luby, S. P. 2013; 89 (6): 1179-1185


    Enteric diseases are often caused by poor hygiene and can contribute to stunting. From 50 randomly selected villages in Bangladesh, we collected quantitative and qualitative data on handwashing linked to child feeding to integrate handwashing promotion into a young child complementary feeding program. Most participants stated that the community knew the importance of handwashing with soap before food preparation and feeding a child, but had not developed the habit. We observed no handwashing with soap at these key times; sometimes hands were rinsed with water only. Most participants cited the unavailability of soap and water near the cooking place as a barrier to handwashing before food preparation. Most caregivers ranked nurturing messages as the best motivator to encourage handwashing with soap. An integrated intervention should include having soap and water available near the food preparation area and should use nurturing themes to encourage habitual handwashing with soap.

    View details for DOI 10.4269/ajtmh.13-0434

    View details for Web of Science ID 000328726100019

    View details for PubMedID 24080638

  • Isolation of Salmonella Virchow from a Fruit Bat (Pteropus giganteus) ECOHEALTH Islam, A., Mikolon, A., Mikoleit, M., Ahmed, D., Khan, S. U., Sharker, M. A., Hossain, M. J., Islam, A., Epstein, J. H., Zeidner, N., Luby, S. P. 2013; 10 (4): 348-351


    Detection of zoonotic pathogens carried by bats is important both for understanding disease ecology and for developing preventive measures. Pteropus fruit bats have been identified as potential carriers of Salmonella enterica serotype Typhi. A cross-sectional study was conducted to determine the prevalence of Salmonella Typhi and other Salmonella serotypes in Pteropus giganteus fruit bats in Bangladesh. Rectal swabs were collected from 302 bats and cultured for Salmonella species. The bats were trapped in three districts (Faridpur, Rajbari, and Cox's Bazar). Salmonella Typhi was not found but one juvenile female bat from Faridpur district was positive for Salmonella Virchow. Close associations between frugivorous bats, humans, and livestock in rural Bangladesh make it likely that the bat was infected by consuming contaminated water.

    View details for DOI 10.1007/s10393-013-0866-y

    View details for Web of Science ID 000332375100005

    View details for PubMedID 24136382

  • Outbreak of Mass Sociogenic Illness in a School Feeding Program in Northwest Bangladesh, 2010 PLOS ONE Haque, F., Kundu, S. K., Islam, M. S., Hasan, S. M., Khatun, A., Gope, P. S., Mahmud, Z. H., Alamgir, A. S., Islam, M. S., Rahman, M., Luby, S. P. 2013; 8 (11)


    In 2010, an acute illness outbreak was reported in school students eating high-energy biscuits supplied by the school feeding programme in northwest Bangladesh. We investigated this outbreak to describe the illness in terms of person, place and time, develop the timeline of events, and determine the cause and community perceptions regarding the outbreak.We defined case-patients as students from affected schools reporting any two symptoms including abdominal pain, heartburn, bitter taste, and headache after eating biscuits on the day of illness. We conducted in-depth interviews and group discussions with students, teachers, parents and community members to explore symptoms, exposures, and community perceptions. We conducted a questionnaire survey among case-patients to determine the symptoms and ascertain food items eaten 12 hours before illness onset, and microbiological and environmental investigations.Among 142 students seeking hospital care, 44 students from four schools qualified as case-patients. Of these, we surveyed 30 who had a mean age of 9 years; 70% (21/30) were females. Predominant symptoms included abdominal pain (93%), heartburn (90%), and bitter taste (57%). All students recovered within a few hours. No pathogenic Vibrio cholerae, Shigella or Salmonella spp. were isolated from collected stool samples. We found no rancid biscuits in schools and storage sites. The female index case perceived the unusually darker packet label as a "devil's deed" that made the biscuits poisonous. Many students, parents and community members reported concerns about rumors of students dying from biscuit poisoning.Rapid onset, followed by rapid recovery of symptoms; female preponderance; inconsistent physical, microbiological and environmental findings suggested mass sociogenic illness rather than a foodborne or toxic cause. Rumours of student deaths heightening community anxiety apparently propagated this outbreak. Sharing investigation results and reassuring students and parents through health communication campaigns could limit similar future outbreaks and help retain beneficiaries' trust on nutrition supplementation initiatives.

    View details for DOI 10.1371/journal.pone.0080420

    View details for Web of Science ID 000327143800145

    View details for PubMedID 24244685

  • Indoor exposure to particulate matter and the incidence of acute lower respiratory infections among children: A birth cohort study in urban Bangladesh INDOOR AIR Gurley, E. S., Homaira, N., Salje, H., Ram, P. K., Haque, R., Petri, W., Bresee, J., Moss, W. J., Breysse, P., Luby, S. P., Azziz-Baumgartner, E. 2013; 23 (5): 379-386


    Approximately half of all children under two years of age in Bangladesh suffer from an acute lower respiratory infection (ALRI) each year. Exposure to indoor biomass smoke has been consistently associated with an increased risk of ALRI in young children. Our aim was to estimate the effect of indoor exposure to particulate matter (PM2.5 ) on the incidence of ALRI among children in a low-income, urban community in Bangladesh. We followed 257 children through two years of age to determine their frequency of ALRI and measured the PM2.5 concentrations in their sleeping space. Poisson regression was used to estimate the association between ALRI and the number of hours per day that PM2.5 concentrations exceeded 100 μg/m(3) , adjusting for known confounders. Each hour that PM2.5 concentrations exceeded 100 μg/m(3) was associated with a 7% increase in incidence of ALRI among children aged 0-11 months (adjusted incidence rate ratio (IRR) 1.07, 95% CI 1.01-1.14), but not in children 12-23 months old (adjusted IRR 1.00, 95% CI 0.92-1.09). Results from this study suggest that reducing indoor PM2.5 exposure could decrease the frequency of ALRI among infants, the children at highest risk of death from these infections.

    View details for DOI 10.1111/ina.12038

    View details for Web of Science ID 000324385600004

    View details for PubMedID 23906055

  • Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH) BMC PUBLIC HEALTH Hulland, K. R., Leontsini, E., Dreibelbis, R., Unicomb, L., Afroz, A., Dutta, N. C., Nizame, F. A., Luby, S. P., Ram, P. K., Winch, P. J. 2013; 13


    In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations--a dedicated, convenient location where both soap and water are available for handwashing--are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour.We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs.Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials.A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework.

    View details for DOI 10.1186/1471-2458-13-877

    View details for Web of Science ID 000329279200002

    View details for PubMedID 24060247

  • Seroprevalence of Antibodies against Highly Pathogenic Avian Influenza A (H5N1) Virus among Poultry Workers in Bangladesh, 2009 PLOS ONE Nasreen, S., Khan, S. U., Azziz-Baumgartner, E., Hancock, K., Veguilla, V., Wang, D., Rahman, M., Alamgir, A. S., Sturm-Ramirez, K., Gurley, E. S., Luby, S. P., Katz, J. M., Uyeki, T. M. 2013; 8 (9)


    We conducted a cross-sectional study in 2009 to determine the seroprevalence and risk factors for highly pathogenic avian influenza A (H5N1) [HPAI H5N1] virus antibodies among poultry workers at farms and live bird markets with confirmed/suspected poultry outbreaks during 2009 in Bangladesh. We tested sera by microneutralization assay using A/Bangladesh/207095/2008 (H5N1; clade 2.2.2) virus with confirmation by horse red blood cell hemagglutination inhibition and H5-specific Western blot assays. We enrolled 212 workers from 87 farms and 210 workers from three live bird markets. One hundred and two farm workers (48%) culled poultry. One hundred and ninety-three farm workers (91%) and 178 market workers (85%) reported direct contact with poultry that died during a laboratory confirmed HPAI H5N1 poultry farm outbreak or market poultry die-offs from suspected HPAI H5N1. Despite exposure to sick poultry, no farm or market poultry workers were seropositive for HPAI H5N1 virus antibodies (95% confidence interval 0-1%).

    View details for DOI 10.1371/journal.pone.0073200

    View details for Web of Science ID 000324481600057

    View details for PubMedID 24039887

  • A Strategy To Estimate Unknown Viral Diversity in Mammals MBIO Anthony, S. J., Epstein, J. H., Murray, K. A., Navarrete-Macias, I., Zambrana-Torrelio, C. M., Solovyov, A., Ojeda-Flores, R., Arrigo, N. C., Islam, A., Khan, S. A., Hosseini, P., Bogich, T. L., Olival, K. J., Sanchez-Leon, M. D., Karesh, W. B., Goldstein, T., Luby, S. P., Morse, S. S., Mazet, J. A., Daszak, P., Lipkin, W. I. 2013; 4 (5)


    The majority of emerging zoonoses originate in wildlife, and many are caused by viruses. However, there are no rigorous estimates of total viral diversity (here termed "virodiversity") for any wildlife species, despite the utility of this to future surveillance and control of emerging zoonoses. In this case study, we repeatedly sampled a mammalian wildlife host known to harbor emerging zoonotic pathogens (the Indian Flying Fox, Pteropus giganteus) and used PCR with degenerate viral family-level primers to discover and analyze the occurrence patterns of 55 viruses from nine viral families. We then adapted statistical techniques used to estimate biodiversity in vertebrates and plants and estimated the total viral richness of these nine families in P. giganteus to be 58 viruses. Our analyses demonstrate proof-of-concept of a strategy for estimating viral richness and provide the first statistically supported estimate of the number of undiscovered viruses in a mammalian host. We used a simple extrapolation to estimate that there are a minimum of 320,000 mammalian viruses awaiting discovery within these nine families, assuming all species harbor a similar number of viruses, with minimal turnover between host species. We estimate the cost of discovering these viruses to be ~$6.3 billion (or ~$1.4 billion for 85% of the total diversity), which if annualized over a 10-year study time frame would represent a small fraction of the cost of many pandemic zoonoses.Recent years have seen a dramatic increase in viral discovery efforts. However, most lack rigorous systematic design, which limits our ability to understand viral diversity and its ecological drivers and reduces their value to public health intervention. Here, we present a new framework for the discovery of novel viruses in wildlife and use it to make the first-ever estimate of the number of viruses that exist in a mammalian host. As pathogens continue to emerge from wildlife, this estimate allows us to put preliminary bounds around the potential size of the total zoonotic pool and facilitates a better understanding of where best to allocate resources for the subsequent discovery of global viral diversity.

    View details for DOI 10.1128/mBio.00598-13

    View details for Web of Science ID 000326881800020

    View details for PubMedID 24003179

  • Piloting the use of indigenous methods to prevent Nipah virus infection by interrupting bats access to date palm sap in Bangladesh HEALTH PROMOTION INTERNATIONAL Nahar, N., Mondal, U. K., Sultana, R., Hossain, M. J., Khan, M. S., Gurley, E. S., Oliveras, E., Luby, S. P. 2013; 28 (3): 378-386


    People in Bangladesh frequently drink fresh date palm sap. Fruit bats (Pteropus giganteus) also drink raw sap and may contaminate the sap by shedding Nipah virus through saliva and urine. In a previous study we identified two indigenous methods to prevent bats accessing the sap, bamboo skirts and lime (calcium carbonate). We conducted a pilot study to assess the acceptability of these two methods among sap harvesters. We used interactive community meetings and group discussions to encourage all the sap harvesters (n = 12) from a village to use either bamboo skirts or lime smear that some of them (n = 4) prepared and applied. We measured the preparation and application time and calculated the cost of bamboo skirts. We conducted interviews after the use of each method. The sap harvesters found skirts effective in preventing bats from accessing sap. They were sceptical that lime would be effective as the lime was washed away by the sap flow. Preparation of the skirt took ∼105 min. The application of each method took ∼1 min. The cost of the bamboo skirt is minimal because bamboo is widely available and they made the skirts with pieces of used bamboo. The bamboo skirt method appeared practical and affordable to the sap harvesters. Further studies should explore its ability to prevent bats from accessing date palm sap and assess if its use produces more or better quality sap, which would provide further incentives to make it more acceptable for its regular use.

    View details for DOI 10.1093/heapro/das020

    View details for Web of Science ID 000322975000010

    View details for PubMedID 22669914

  • Household Environmental Conditions Are Associated with Enteropathy and Impaired Growth in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Lin, A., Arnold, B. F., Afreen, S., Goto, R., Huda, T. M., Haque, R., Raqib, R., Unicomb, L., Ahmed, T., Colford, J. M., Luby, S. P. 2013; 89 (1): 130-137
  • An improved tool for household faeces management in rural Bangladeshi communities TROPICAL MEDICINE & INTERNATIONAL HEALTH Sultana, R., Mondal, U. K., Rimi, N. A., Unicomb, L., Winch, P. J., Nahar, N., Luby, S. P. 2013; 18 (7): 854-860


    To explore child defecation and faeces management practices in rural Bangladesh with the aim to redesign and pilot a tool to facilitate removal and disposal of faeces.We conducted six group discussions, six short interviews and three observations of practices and designed the new tool. We piloted the new tool and elicited feedback through two in-depth interviews and two observations.Until three years of age, a child commonly defecates in the courtyard and occasionally inside the house. A heavy digging hoe was commonly used to remove child faeces. Mothers preferred a redesigned 'mini-hoe' and found it easier to use for removal and disposal of liquid faeces.Promoting modified local tools may contribute to improving environmental sanitation and health.

    View details for DOI 10.1111/tmi.12103

    View details for Web of Science ID 000320335400009

    View details for PubMedID 23557125

  • Aflatoxin contamination in food commodities in Bangladesh FOOD ADDITIVES & CONTAMINANTS PART B-SURVEILLANCE Roy, M., Harris, J., Afreen, S., Deak, E., Gade, L., Balajee, S. A., Park, B., Chiller, T., Luby, S. 2013; 6 (1): 17-23


    During September 2009, we performed a rapid cross-sectional study to investigate the extent of aflatoxin contamination among common Bangladeshi foods. We collected eight common human food commodities (rice, lentils, wheat flour, dates, betelnut, red chili powder, ginger and groundnuts) and poultry feed samples from two large markets in each of three cities in Bangladesh. We quantified aflatoxin levels from pooled subsamples using fluorescence high-performance liquid chromatography. Aflatoxin levels were highest in dates and groundnuts (maximum 623 and 423 ng/g), respectively. Samples of betelnut (mean 30.6 ng/g), lentils (mean 21.2 ng/g) and red chili powder (>20 ng/g) also had elevated levels. The mean aflatoxin level among poultry feed samples was 73.0 ng/g. Aflatoxin levels were above the US maximum regulatory levels of 20 ng/g in five of eight commonly ingested human food commodities tested.

    View details for DOI 10.1080/19393210.2012.720617

    View details for Web of Science ID 000327914400004

    View details for PubMedID 24786620

  • Seasonal concentrations and determinants of indoor particulate matter in a low-income community in Dhaka, Bangladesh ENVIRONMENTAL RESEARCH Gurley, E. S., Salje, H., Homaira, N., Ram, P. K., Haque, R., Petri, W. A., Bresee, J., Moss, W. J., Luby, S. P., Breysse, P., Azziz-Baumgartner, E. 2013; 121: 11-16


    Indoor exposure to particulate matter (PM) increases the risk of acute lower respiratory tract infections, which are the leading cause of death in young children in Bangladesh. Few studies, however, have measured children's exposures to indoor PM over time. The World Health Organization recommends that daily indoor concentrations of PM less than 2.5μm in diameter (PM(2.5)) not exceed 25μg/m(3). This study aimed to describe the seasonal variation and determinants of concentrations of indoor PM(2.5) in a low-income community in urban Dhaka, Bangladesh. PM(2.5) was measured in homes monthly during May 2009 to April 2010. We calculated the time-weighted average, 90th percentile PM(2.5) concentrations and the daily hours PM(2.5) exceeded 100μg/m(3). Linear regression models were used to estimate the associations between fuel use, ventilation, indoor smoking, and season to each metric describing indoor PM(2.5) concentrations. Time-weighted average PM(2.5) concentrations were 190μg/m(3) (95% CI 170-210). Sixteen percent of 258 households primarily used biomass fuels for cooking and PM(2.5) concentrations in these homes had average concentrations 75μg/m(3) (95% CI 56-124) greater than other homes. PM(2.5) concentrations were also associated with burning both biomass and kerosene, indoor smoking, and ventilation, and were more than twice as high during winter than during other seasons. Young children in this community are exposed to indoor PM(2.5) concentrations 7 times greater than those recommended by World Health Organization guidelines. Interventions to reduce biomass burning could result in a daily reduction of 75μg/m(3) (40%) in time-weighted average PM(2.5) concentrations.

    View details for DOI 10.1016/j.envres.2012.10.004

    View details for Web of Science ID 000315753700002

    View details for PubMedID 23127494

  • Nipah Virus Infection Outbreak with Nosocomial and Corpse-to-Human Transmission, Bangladesh EMERGING INFECTIOUS DISEASES Sazzad, H. M., Hossain, M. J., Gurley, E. S., Ameen, K. M., Parveen, S., Islam, M. S., Faruque, L. I., Podder, G., Banu, S. S., Lo, M. K., Rollin, P. E., Rota, P. A., Daszak, P., Rahman, M., Luby, S. P. 2013; 19 (2): 210-217


    Active Nipah virus encephalitis surveillance identified an encephalitis cluster and sporadic cases in Faridpur, Bangladesh, in January 2010. We identified 16 case-patients; 14 of these patients died. For 1 case-patient, the only known exposure was hugging a deceased patient with a probable case, while another case-patient's exposure involved preparing the same corpse for burial by removing oral secretions and anogenital excreta with a cloth and bare hands. Among 7 persons with confirmed sporadic cases, 6 died, including a physician who had physically examined encephalitis patients without gloves or a mask. Nipah virus-infected patients were more likely than community-based controls to report drinking raw date palm sap and to have had physical contact with an encephalitis patient (29% vs. 4%, matched odds ratio undefined). Efforts to prevent transmission should focus on reducing caregivers' exposure to infected patients' bodily secretions during care and traditional burial practices.

    View details for DOI 10.3201/eid1902.120971

    View details for Web of Science ID 000328172900004

    View details for PubMedID 23347678

  • Effect of recent diarrhoeal episodes on risk of pneumonia in children under the age of 5 years in Karachi, Pakistan INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Ashraf, S., Huque, M. H., Kenah, E., Agboatwalla, M., Luby, S. P. 2013; 42 (1): 194-200


    We assessed the association between the duration of diarrhoea and the risk ofpneumonia incidence among children <5 years of age.We analysed data from a cluster randomized controlled trial in Karachi, Pakistan, which assessed the effect of promoting hand washing with soap (antibacterial and plain) on child health. Field workers visited households with children <5 years of age weekly and asked primary caregivers if their child had diarrhoea, cough or difficulty breathing in the preceding week. We used the WHO clinical case definitions for diarrhoea and pneumonia.We used adjusted time-to-event analyses with cumulative diarrhoea prevalence over the previous 2 and 4 weeks as exposure and pneumonia as outcome. We calculated the attributable risk of pneumonia due to recent diarrhoea across the intervention groups.873 households with children <5 years were visited. Children had an increased risk of pneumonia for every additional day of diarrhoea in the 2 weeks (1.06, 95% CI: 1.03-1.09) and 4 weeks (1.04, 95% CI: 1.03-1.06) prior to the week of pneumonia onset. The attributable risk of pneumonia cases due to recent exposure to diarrhoea was 6%. A lower associated pneumonia risk following diarrhoea was found in the control group: (3%) compared with soap groups (6% in antibacterial soap, 9% in plain soap).Children <5 years of age are at an increased risk of pneumonia following recent diarrhoeal illness. Public health programmes that prevent diarrhoea may also reduce the burden of respiratory illnesses.

    View details for DOI 10.1093/ije/dys233

    View details for Web of Science ID 000316699300021

    View details for PubMedID 23378152

  • Ebola Virus Antibodies in Fruit Bats, Bangladesh EMERGING INFECTIOUS DISEASES Olival, K. J., Islam, A., Yu, M., Anthony, S. J., Epstein, J. H., Khan, S. A., Khan, S. U., Crameri, G., Wang, L., Lipkin, W. I., Luby, S. P., Daszak, P. 2013; 19 (2): 270-273


    To determine geographic range for Ebola virus, we tested 276 bats in Bangladesh. Five (3.5%) bats were positive for antibodies against Ebola Zaire and Reston viruses; no virus was detected by PCR. These bats might be a reservoir for Ebola or Ebola-like viruses, and extend the range of filoviruses to mainland Asia.

    View details for DOI 10.3201/eid1902.120524

    View details for Web of Science ID 000328172900014

    View details for PubMedID 23343532

  • Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ open Arnold, B. F., Null, C., Luby, S. P., Unicomb, L., Stewart, C. P., Dewey, K. G., Ahmed, T., Ashraf, S., Christensen, G., Clasen, T., Dentz, H. N., Fernald, L. C., Haque, R., Hubbard, A. E., Kariger, P., Leontsini, E., Lin, A., Njenga, S. M., Pickering, A. J., Ram, P. K., Tofail, F., Winch, P. J., Colford, J. M. 2013; 3 (8)


    Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap.WASH Benefits includes two cluster-randomised trials to assess improvements in water quality, sanitation, handwashing and child nutrition-alone and in combination-to rural households with pregnant women in Kenya and Bangladesh. Geographically matched clusters (groups of household compounds in Bangladesh and villages in Kenya) will be randomised to one of six intervention arms or control. Intervention arms include water quality, sanitation, handwashing, nutrition, combined water+sanitation+handwashing (WSH) and WSH+nutrition. The studies will enrol newborn children (N=5760 in Bangladesh and N=8000 in Kenya) and measure outcomes at 12 and 24 months after intervention delivery. Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea. Secondary outcomes include stunting prevalence, markers of environmental enteropathy and child development scores (verbal, motor and personal/social). We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests.Study protocols have been reviewed and approved by human subjects review boards at the University of California, Berkeley, Stanford University, the International Centre for Diarrheal Disease Research, Bangladesh, the Kenya Medical Research Institute, and Innovations for Poverty Action. Independent data safety monitoring boards in each country oversee the trials. This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California, Berkeley.Trial registration identifiers ( NCT01590095 (Bangladesh), NCT01704105 (Kenya).

    View details for DOI 10.1136/bmjopen-2013-003476

    View details for PubMedID 23996605

  • Exploring pig raising in Bangladesh: implications for public health interventions VETERINARIA ITALIANA Nahar, N., Uddin, M., Sarkar, R. A., Gurley, E. S., Khan, M. S., Hossain, M. J., Sultana, R., Luby, S. P. 2013; 49 (1): 7-17


    Pigs are intermediate hosts and potential reservoirs of a number of pathogens that can infect humans. The objectives of this manuscript are to understand pig raising patterns in Bangladesh, interactions between pigs and humans, social stigma and discrimination that pig raisers experience and to explore the implications of these findings for public health interventions. The study team conducted an exploratory qualitative study by interviewing backyard pig raisers and nomadic herders (n=34), observing daily interactions between pigs and humans (n=18) and drawing seasonal diagrams (n=6) with herders to understand the reasons for movement of nomadic herds. Pig raisers had regular close interaction with pigs. They often touched, caressed and fed their pigs which exposed them to pigs' saliva and feces. Herders took their pigs close to human settlements for scavenging. Other domestic animals and poultry shared food and sleeping and scavenging places with pigs. Since pigs are taboo in Islam, a majority of Muslims rejected pig raising and stigmatized pig raisers. This study identified several potential ways for pigs to transmit infectious agents to humans in Bangladesh. Poverty and stigmatization of pig raisers make it difficult to implement health interventions to reduce the risk of such transmissions. Interventions that offer social support to reduce stigma and highlight economic benefits of disease control might interest of pig raisers in accepting interventions targeting pig borne zoonoses.

    View details for Web of Science ID 000317957400002

    View details for PubMedID 23564585

  • Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ open Arnold, B. F., Null, C., Luby, S. P., Unicomb, L., Stewart, C. P., Dewey, K. G., Ahmed, T., Ashraf, S., Christensen, G., Clasen, T., Dentz, H. N., Fernald, L. C., Haque, R., Hubbard, A. E., Kariger, P., Leontsini, E., Lin, A., Njenga, S. M., Pickering, A. J., Ram, P. K., Tofail, F., Winch, P. J., Colford, J. M. 2013; 3 (8)

    View details for DOI 10.1136/bmjopen-2013-003476

    View details for PubMedID 23996605

  • Bronchiolitis outbreak caused by respiratory syncytial virus in southwest Bangladesh, 2010 INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES Haque, F., Husain, M. M., Ameen, K. M., Rahima, R., Hossain, M. J., Alamgir, A. S., Rahman, M., Rahman, M., Luby, S. P. 2012; 16 (12): E866-E871


    During July 2010, newspapers reported a respiratory disease outbreak in southwestern Bangladesh resulting in the admission of children to a secondary care hospital. We investigated this outbreak to determine the etiology and explore possible risk factors.The hospital's physician diagnosed children aged <2 years with cough, tachypnea or dyspnea, and expiratory wheeze as having acute bronchiolitis. We reviewed the hospital records and listed case patients admitted between 26 June and 26 July 2010. We surveyed the case patients and collected nasal and throat swabs to test for respiratory viruses.We identified 101 admitted acute bronchiolitis case patients. Fifty-nine (58%) of these were admitted between 16 and 20 July. Among the 29 case patients surveyed, the median age was 4 months and 65% were males. We identified respiratory syncytial virus (RSV) in 91% (21/23) of the samples, 43% of which had a dual viral infection. Most case patients (90%) were treated with broad-spectrum antibiotics. There were no reported deaths.The sudden increase in admitted acute bronchiolitis case patients, their median age, and identification of RSV in the majority of samples suggest an outbreak of RSV bronchiolitis. Research to identify strategies to prevent respiratory infections including RSV in low-income settings should be prioritized. Factors that perpetuate antibiotic use in managing this viral syndrome should also be explored.

    View details for DOI 10.1016/j.ijid.2012.07.016

    View details for Web of Science ID 000311223700007

    View details for PubMedID 22938872

  • Estimating the Burden of Maternal and Neonatal Deaths Associated With Jaundice in Bangladesh: Possible Role of Hepatitis E Infection AMERICAN JOURNAL OF PUBLIC HEALTH Gurley, E. S., Halder, A. K., Streatfield, P. K., Sazzad, H. M., Huda, T. M., Hossain, M. J., Luby, S. P. 2012; 102 (12): 2248-2254


    We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh.We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals.We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.

    View details for DOI 10.2105/AJPH.2012.300749

    View details for Web of Science ID 000311589100014

    View details for PubMedID 23078501

  • Seasonality, Timing, and Climate Drivers of Influenza Activity Worldwide JOURNAL OF INFECTIOUS DISEASES Baumgartner, E. A., Dao, C. N., Nasreen, S., Bhuiyan, M. U., Mah-e-Muneer, S., Al Mamun, A., Sharker, M. A., Zaman, R. U., Cheng, P., Klimov, A. I., Widdowson, M., Uyeki, T. M., Luby, S. P., Mounts, A., Bresee, J. 2012; 206 (6): 838-846


    Although influenza is a vaccine-preventable disease that annually causes substantial disease burden, data on virus activity in tropical countries are limited. We analyzed publicly available influenza data to better understand the global circulation of influenza viruses.We reviewed open-source, laboratory-confirmed influenza surveillance data. For each country, we abstracted data on the percentage of samples testing positive for influenza each epidemiologic week from the annual number of samples testing positive for influenza. The start of influenza season was defined as the first week when the proportion of samples that tested positive remained above the annual mean. We assessed the relationship between percentage of samples testing positive and mean monthly temperature with use of regression models.We identified data on laboratory-confirmed influenza virus infection from 85 countries. More than one influenza epidemic period per year was more common in tropical countries (41%) than in temperate countries (15%). Year-round activity (ie, influenza virus identified each week having ≥ 10 specimens submitted) occurred in 3 (7%) of 43 temperate, 1 (17%) of 6 subtropical, and 11 (37%) of 30 tropical countries with available data (P = .006). Percentage positivity was associated with low temperature (P = .001).Annual influenza epidemics occur in consistent temporal patterns depending on climate.

    View details for DOI 10.1093/infdis/jis467

    View details for Web of Science ID 000308233500007

    View details for PubMedID 22829641

  • A Randomized Controlled Trial of Interventions to Impede Date Palm Sap Contamination by Bats to Prevent Nipah Virus Transmission in Bangladesh PLOS ONE Khan, S. U., Gurley, E. S., Hossain, M. J., Nahar, N., Sharker, M. A., Luby, S. P. 2012; 7 (8)


    Drinking raw date palm sap is a risk factor for human Nipah virus (NiV) infection. Fruit bats, the natural reservoir of NiV, commonly contaminate raw sap with saliva by licking date palm's sap producing surface. We evaluated four types of physical barriers that may prevent bats from contacting sap.During 2009, we used a crossover design and randomly selected 20 date palm sap producing trees and observed each tree for 2 nights: one night with a bamboo skirt intervention applied and one night without the intervention. During 2010, we selected 120 trees and randomly assigned four types of interventions to 15 trees each: bamboo, dhoincha (local plant), jute stick and polythene skirts covering the shaved part, sap stream, tap and collection pot. We enrolled the remaining 60 trees as controls. We used motion sensor activated infrared cameras to examine bat contact with sap.During 2009 bats contacted date palm sap in 85% of observation nights when no intervention was used compared with 35% of nights when the intervention was used [p<0.001]. Bats were able to contact the sap when the skirt did not entirely cover the sap producing surface. Therefore, in 2010 we requested the sap harvesters to use larger skirts. During 2010 bats contacted date palm sap [2% vs. 83%, p<0.001] less frequently in trees protected with skirts compared to control trees. No bats contacted sap in trees with bamboo (p<0.001 compared to control), dhoincha skirt (p<0.001) or polythene covering (p<0.001), but bats did contact sap during one night (7%) with the jute stick skirt (p<0.001).Bamboo, dhoincha, jute stick and polythene skirts covering the sap producing areas of a tree effectively prevented bat-sap contact. Community interventions should promote applying these skirts to prevent occasional Nipah spillovers to human.

    View details for DOI 10.1371/journal.pone.0042689

    View details for Web of Science ID 000307331100056

    View details for PubMedID 22905160

  • The feasibility of identifying children with primary immunodeficiency disorders: Preparation for the polio post-eradication era in Bangladesh VACCINE Sazzad, H. M., Rainey, J. J., Mach, O., Sutter, R., Diordista, S., Kawser, C. A., Mobarak, R., Alam, D., Chowdhury, M. A., Hossain, M. J., Hasan, A. S., Luby, S. P. 2012; 30 (36): 5396-5400


    Persons with primary immunodeficiency disorders (PIDD) who receive oral poliovirus vaccine (OPV) or are household contacts of OPV recipients are at risk of excreting immunodeficiency-associated vaccine-derived polioviruses (iVDPVs). iVDPVs can be transmitted and cause paralytic polio. The objective of this study was to determine the feasibility of identifying infants and young children with PIDD in Bangladesh, and among those identified, to estimate the proportion excreting iVDPVs.Patients admitted at 5 referral and teaching hospitals from the hospital catchment area were screened for PIDD using a standardized clinical case definition. PIDD was confirmed using results of testing for age-specific quantitative immunoglobulins (QIGs) levels. Stool specimens were collected according to WHO guidelines from children with confirmed PIDD.During February-July 2009, 13 patients were identified who met the clinical case definition for PIDD; their median age was 1.4 years (range: 2 months to 10 years). Six (46%) of the patients had age-specific QIG results that confirmed PIDD. Stool specimens from four patients tested negative for polio vaccine viruses. All four had received OPV between 50 and 264 days prior to study recruitment.Identifying children with PIDD at referral and teaching hospitals in Bangladesh is feasible, but a larger number of patients is needed to estimate the risk for iVDPV excretion. The national polio eradication program should expand surveillance for PIDD case-patients and regularly test persons with PIDD for poliovirus excretion. These efforts will be essential for developing effective prevention and control strategies following OPV cessation, especially for densely populated and tropical countries like Bangladesh where even a minimal iVDPV risk could have significant public health consequences.

    View details for DOI 10.1016/j.vaccine.2012.06.017

    View details for Web of Science ID 000307698800016

    View details for PubMedID 22728220

  • Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh SOCIAL SCIENCE & MEDICINE Huda, T. M., Unicomb, L., Johnston, R. B., Halder, A. K., Sharker, M. A., Luby, S. P. 2012; 75 (4): 604-611


    Started in 2007, the Sanitation Hygiene Education and Water Supply in Bangladesh (SHEWA-B) project aims to improve the hygiene, sanitation and water supply for 20 million people in Bangladesh, and thus reduce disease among this population. This paper assesses the effectiveness of SHEWA-B on changing behaviors and reducing diarrhea and respiratory illness among children < 5 years of age. We assessed behaviors at baseline in 2007 and after 6 months and 18 months by conducting structured observation of handwashing behavior in 500 intervention and 500 control households. In addition we conducted spot checks of water and sanitation facilities in 850 intervention and 850 control households. We also collected monthly data on diarrhea and respiratory illness from 500 intervention and 500 control households from October 2007 to September 2009. Participants washed their hands with soap < 3% of the time around food related events in both intervention and control households at baseline and after 18 months. Washing both hands with soap or ash after cleaning a child's anus increased from 22% to 36%, and no access to a latrine decreased from 10% to 6.8% from baseline to 18 months. The prevalence of diarrhea and respiratory illness, among children <5 years of age were similar in intervention and control communities throughout the study. This large scale sanitation, hygiene and water improvement programme resulted in improvements in a few of its targeted behaviors, but these modest behavior changes have not yet resulted in a measurable reduction in childhood diarrhea and respiratory illness.

    View details for DOI 10.1016/j.socscimed.2011.10.042

    View details for Web of Science ID 000306890000003

    View details for PubMedID 22197292

  • Learning to Dislike Safe Water Products: Results from a Randomized Controlled Trial of the Effects of Direct and Peer Experience on Willingness to Pay ENVIRONMENTAL SCIENCE & TECHNOLOGY Luoto, J., Mahmud, M., Albert, J., Luby, S., Najnin, N., Unicomb, L., Levine, D. I. 2012; 46 (11): 6244-6251


    Low-cost point-of-use (POU) safe water products have the potential to reduce waterborne illness, but adoption by the global poor remains low. We performed an eight-month randomized trial of four low-cost household water treatment products in Dhaka, Bangladesh. Intervention households (n = 600) received repeated educational messages about the importance of drinking safe water along with consecutive two-month free trials with each of four POU products in random order. Households randomly assigned to the control group (n = 200) did not receive free products or repeated educational messages. Households' willingness to pay for these products was quite low on average (as measured by bids in an incentive-compatible real-money auction), although a modest share was willing to pay the actual or expected retail price for low-cost chlorine-based products. Furthermore, contrary to our hypotheses that both one's own personal experience and the influence of one's peers would increase consumers' willingness to pay, direct experience significantly decreased mean bids by 18-55% for three of the four products and had no discernible effect on the fourth. Neighbor experience also did not increase bids. Widespread dissemination of safe water products is unlikely until we better understand the preferences and aspirations of these at-risk populations.

    View details for DOI 10.1021/es2027967

    View details for Web of Science ID 000304783000079

    View details for PubMedID 22563851

  • Methodology and lessons-learned from the efficacy clinical trial of the pentavalent rotavirus vaccine in Bangladesh VACCINE Zaman, K., Yunus, M., El Arifeen, S., Azim, T., Faruque, A. S., Huq, E., Hossain, I., Luby, S. P., Victor, J. C., Dallas, M. J., Lewis, K. D., Rivers, S. B., Steele, A. D., Neuzil, K. M., Ciarlet, M., Sack, D. A. 2012; 30: A94-A100


    An efficacy clinical trial with pentavalent rotavirus vaccine (PRV), RotaTeq(®), was conducted at Matlab field site of ICDDR,B, Bangladesh from March 2007 to March 2009. The methodology, including operation logistics, and lessons-learned are described in this report. Vaccination was organized at 41 fixed-site clinics twice/month. A total of 1136 infants were randomized 1:1 to receive 3 doses of PRV/placebo at approximately 6-, 10-, and 14-weeks of age with routine vaccines of the Expanded Programme on Immunization (EPI) schedule. Twelve field-workers routinely visited study participants for safety and efficacy follow-up. The study was conducted following good clinical practices and maintaining cold-chain requirements. There were no temperature deviations of clinical vaccine supplies. Data entry was done using the source documents to a central database developed by the sponsor which was linked to web. Among enrolled infants, 1128 (99.3%) received 3 doses of PRV/placebo and efficacy follow-up was conducted for a median of 554 days. For the evaluation of immunogenicity, blood samples were collected from 150 participants predose 1 and from 147 (98%) of the same participants post dose 3. Stool samples were collected from 778 (99.9%) acute gastroenteritis episodes among children who reported to diarrhoea treatment centres. Thirty-nine serious adverse events, including 6 deaths, occurred among study participants. The efficacy of PRV against severe rotavirus gastroenteritis was 42.7% through the entire follow-up period; serum anti-rotavirus IgA response was 78.1%. Inclement weather, difficult transportation, and movement of study participants were some of the challenges identified. This is the first vaccine trial in rural Bangladesh with online data entry. The study was well accepted in the community and was completed successfully.

    View details for DOI 10.1016/j.vaccine.2011.07.117

    View details for Web of Science ID 000304850100014

    View details for PubMedID 22520143

  • Anthrax Outbreaks in Bangladesh, 2009-2010 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Chakraborty, A., Khan, S. U., Hasnat, M. A., Parveen, S., Islam, M. S., Mikolon, A., Chakraborty, R. K., Ahmed, B., Ara, K., Haider, N., Zaki, S. R., Hoffmaster, A. R., Rahman, M., Luby, S. P., Hossain, M. J. 2012; 86 (4): 703-710


    During August 2009-October 2010, a multidisciplinary team investigated 14 outbreaks of animal and human anthrax in Bangladesh to identify the etiology, pathway of transmission, and social, behavioral, and cultural factors that led to these outbreaks. The team identified 140 animal cases of anthrax and 273 human cases of cutaneous anthrax. Ninety one percent of persons in whom cutaneous anthrax developed had history of butchering sick animals, handling raw meat, contact with animal skin, or were present at slaughtering sites. Each year, Bacillus anthracis of identical genotypes were isolated from animal and human cases. Inadequate livestock vaccination coverage, lack of awareness of the risk of anthrax transmission from animal to humans, social norms and poverty contributed to these outbreaks. Addressing these challenges and adopting a joint animal and human health approach could contribute to detecting and preventing such outbreaks in the future.

    View details for DOI 10.4269/ajtmh.2012.11-0234

    View details for Web of Science ID 000302519700024

    View details for PubMedID 22492157

  • Pig illnesses and epidemics: a qualitative study on perceptions and practices of pig raisers in Bangladesh VETERINARIA ITALIANA Nahar, N., Uddin, M., Gurley, E. S., Khan, M. S., Hossain, M. J., Sultana, R., Luby, S. P. 2012; 48 (2): 157-165


    Zoonoses in swine are increasingly becoming a global public health concern. Understanding how livestock farmers perceive animal illnesses will help to develop locally acceptable and effective public health intervention strategies to control and manage zoonoses. The authors describe Bangladeshi pig raisers' perception of pig illnesses and their behaviour towards sick pigs. We collected qualitative data from August 2007 to September 2008. Included in our study are backyard pig raisers from three districts, namely: Faridpur, Chapainobabgonj and Tangail and nomadic herders from six districts, namely: Mymensingh, Tangail, Sherpur, Sirajgonj, Bogra and Pabna. We conducted in-depth interviews (n=34) and made observations of human interactions with pigs (n=18). Pig raisers reported several illnesses that caused their pigs to suffer and die. They had close contact with sick pigs whilst caring for them. They slaughtered sick pigs and consumed and sold the pork if they thought that the pig might die. They believed that pig illness could be transmitted among pigs but not between pigs and humans. The perception of pig raisers on pig illnesses and their behaviour towards sick pigs places them in close contact with potentially infectious pig secretions and excretions. Such exposure could favour zoonotic transmission of infectious diseases. A better surveillance system for pig diseases would provide an opportunity to identify the transmission of diseases, determine whether they pose a risk to humans, or whether they contribute to the emergence of diseases.

    View details for Web of Science ID 000305769100004

    View details for PubMedID 22718332

  • Influenza-associated mortality in 2009 in four sentinel sites in Bangladesh BULLETIN OF THE WORLD HEALTH ORGANIZATION Homaira, N., Luby, S. P., Alamgir, A. S., Islam, K., Paul, R., Abedin, J., Rahman, M., Azim, T., Podder, G., Sohel, B. M., Brooks, A., Fry, A. M., Widdowson, M., Bresee, J., Rahman, M., Azziz-Baumgartner, E. 2012; 90 (4): 272-278


    To estimate influenza-associated mortality in Bangladesh in 2009.In four hospitals in Bangladesh, respiratory samples were collected twice a month throughout 2009 from inpatients aged < 5 years with severe pneumonia and from older inpatients with severe acute respiratory infection. The samples were tested for influenza virus ribonucleic acid (RNA) using polymerase chain reaction. The deaths in 2009 in five randomly selected unions (the smallest administrative units in Bangladesh) in each hospital's catchment area were then investigated using formal records and informal group discussions. The deaths of those who had reportedly died within 14 days of suddenly developing fever with cough and/or a sore throat were assumed to be influenza-associated. The rate of such deaths in 2009 in each of the catchment areas was then estimated from the number of apparently influenza-associated deaths in the sampled unions, the proportion of the sampled inpatients in the local hospital who tested positive for influenza virus RNA, and the estimated number of residents of the sampled unions.Of the 2500 people known to have died in 2009 in all 20 study unions, 346 (14%) reportedly had fever with cough and/or sore throat within 14 days of their deaths. The estimated mean annual influenza-associated mortality in these unions was 11 per 100,000 population: 1.5, 4.0 and 125 deaths per 100,000 among those aged < 5, 5-59 and > 59 years, respectively.The highest burden of influenza-associated mortality in Bangladesh in 2009 was among the elderly.

    View details for DOI 10.2471/BLT.11.095653

    View details for Web of Science ID 000303273100017

    View details for PubMedID 22511823

  • Streptococcus pneumoniae Serotype-2 Childhood Meningitis in Bangladesh: A Newly Recognized Pneumococcal Infection Threat PLOS ONE Saha, S. K., Al Emran, H. M., Hossain, B., Darmstadt, G. L., Saha, S., Islam, M., Chowdhury, A. I., Foster, D., Naheed, A., El Arifeen, S., Baqui, A. H., Qazi, S. A., Luby, S. P., Breiman, R. F., Santosham, M., Black, R. E., Crook, D. W. 2012; 7 (3)


    Streptococcus pneumoniae is a leading cause of meningitis in countries where pneumococcal conjugate vaccines (PCV) targeting commonly occurring serotypes are not routinely used. However, effectiveness of PCV would be jeopardized by emergence of invasive pneumococcal diseases (IPD) caused by serotypes which are not included in PCV. Systematic hospital based surveillance in Bangladesh was established and progressively improved to determine the pathogens causing childhood sepsis and meningitis. This also provided the foundation for determining the spectrum of serotypes causing IPD. This article reports an unprecedented upsurge of serotype 2, an uncommon pneumococcal serotype, without any known intervention.Cases with suspected IPD had blood or cerebrospinal fluid (CSF) collected from the beginning of 2001 till 2009. Pneumococcal serotypes were determined by capsular swelling of isolates or PCR of culture-negative CSF specimens. Multicenter national surveillance, expanded from 2004, identified 45,437 patients with suspected bacteremia who were blood cultured and 10,618 suspected meningitis cases who had a lumber puncture. Pneumococcus accounted for 230 culture positive cases of meningitis in children <5 years. Serotype-2 was the leading cause of pneumococcal meningitis, accounting for 20.4% (45/221; 95% CI 15%-26%) of cases. Ninety eight percent (45/46) of these serotype-2 strains were isolated from meningitis cases, yielding the highest serotype-specific odds ratio for meningitis (29.6; 95% CI 3.4-256.3). The serotype-2 strains had three closely related pulsed field gel electrophoresis types.S. pneumoniae serotype-2 was found to possess an unusually high potential for causing meningitis and was the leading serotype-specific cause of childhood meningitis in Bangladesh over the past decade. Persisting disease occurrence or progressive spread would represent a major potential infection threat since serotype-2 is not included in PCVs currently licensed or under development.

    View details for DOI 10.1371/journal.pone.0032134

    View details for Web of Science ID 000305339100005

    View details for PubMedID 22479314

  • Incidence of Respiratory Virus-Associated Pneumonia in Urban Poor Young Children of Dhaka, Bangladesh, 2009-2011 PLOS ONE Homaira, N., Luby, S. P., Petri, W. A., Vainionpaa, R., Rahman, M., Hossain, K., Snider, C. B., Rahman, M., Alamgir, A. S., Zesmin, F., Alam, M., Gurley, E. S., Zaman, R. U., Azim, T., Erdman, D. D., Fry, A. M., Bresee, J., Widdowson, M., Haque, R., Azziz-Baumgartner, E. 2012; 7 (2)


    Pneumonia is the leading cause of childhood death in Bangladesh. We conducted a longitudinal study to estimate the incidence of virus-associated pneumonia in children aged <2 years in a low-income urban community in Dhaka, Bangladesh.We followed a cohort of children for two years. We collected nasal washes when children presented with respiratory symptoms. Study physicians diagnosed children with cough and age-specific tachypnea and positive lung findings as pneumonia case-patients. We tested respiratory samples for respiratory syncytial virus (RSV), rhinoviruses, human metapneumovirus (HMPV), influenza viruses, human parainfluenza viruses (HPIV 1, 2, 3), and adenoviruses using real-time reverse transcription polymerase chain reaction assays.Between April 2009-March 2011, we followed 515 children for 730 child-years. We identified a total of 378 pneumonia episodes, 77% of the episodes were associated with a respiratory viral pathogen. The overall incidence of pneumonia associated with a respiratory virus infection was 40/100 child-years. The annual incidence of pneumonia/100 child-years associated with a specific respiratory virus in children aged < 2 years was 12.5 for RSV, 6 for rhinoviruses, 6 for HMPV, 4 for influenza viruses, 3 for HPIV and 2 for adenoviruses.Young children in Dhaka are at high risk of childhood pneumonia and the majority of these episodes are associated with viral pathogens. Developing effective low-cost strategies for prevention are a high priority.

    View details for DOI 10.1371/journal.pone.0032056

    View details for Web of Science ID 000302875500068

    View details for PubMedID 22384139

  • Characterization of Nipah Virus from Outbreaks in Bangladesh, 2008-2010 EMERGING INFECTIOUS DISEASES Lo, M. K., Lowe, L., Hummel, K. B., Sazzad, H. M., Gurley, E. S., Hossain, M. J., Luby, S. P., Miller, D. M., Comer, J. A., Rollin, P. E., Bellini, W. J., Rota, P. A. 2012; 18 (2): 248-255


    Nipah virus (NiV) is a highly pathogenic paramyxovirus that causes fatal encephalitis in humans. The initial outbreak of NiV infection occurred in Malaysia and Singapore in 1998-1999; relatively small, sporadic outbreaks among humans have occurred in Bangladesh since 2001. We characterized the complete genomic sequences of identical NiV isolates from 2 patients in 2008 and partial genomic sequences of throat swab samples from 3 patients in 2010, all from Bangladesh. All sequences from patients in Bangladesh comprised a distinct genetic group. However, the detection of 3 genetically distinct sequences from patients in the districts of Faridpur and Gopalganj indicated multiple co-circulating lineages in a localized region over a short time (January-March 2010). Sequence comparisons between the open reading frames of all available NiV genes led us to propose a standardized protocol for genotyping NiV; this protcol provides a simple and accurate way to classify current and future NiV sequences.

    View details for DOI 10.3201/eid1802.111492

    View details for Web of Science ID 000300078600007

    View details for PubMedID 22304936

  • Bangladeshi backyard poultry raisers' perceptions and practices related to zoonotic transmission of avian influenza JOURNAL OF INFECTION IN DEVELOPING COUNTRIES Sultana, R., Rimi, N. A., Azad, S., Islam, M. S., Khan, M. S., Gurley, E. S., Nahar, N., Luby, S. P. 2012; 6 (2): 156-165


    Highly pathogenic avian influenza (H5N1) virus (known as "bird flu") is an important public health concern due to its potential to infect humans and cause a human pandemic. Bangladesh is a high-risk country for an influenza pandemic because of its dense human population, widespread backyard poultry raising, and endemic H5N1 infection in poultry. Understanding poultry raisers' perceived risks and identifying their risk exposures can help to develop interventions to reduce the risk of avian influenza transmission. This paper explores the perception of Bangladeshi backyard poultry raisers regarding poultry sickness and zoonotic disease transmission and relevant practices.We conducted a qualitative study using social mapping (n=2), in-depth interviews (n=40), household mapping (n=40) and observation (n=16), in two backyard poultry-raising communities.The poultry raisers recognized various signs of poultry illness but they did not distinguish among diseases using biomedical classifications. They perceived disease transmission from poultry to poultry, but not from poultry to humans. They usually kept sick poultry under the bed. If the poultry did not recover, they were slaughtered and consumed or sold. The poultry raisers had close contact with sick birds while handling and slaughtering poultry.The poultry raisers are unlikely to follow instructions from health authorities to prevent "bird flu" transmission because many of the instructions ask low-income producers to change their existing practices and require time, money, and financial loss. Villagers are more likely to comply with interventions that help to protect their flocks and address their financial interest.

    View details for Web of Science ID 000305908300009

    View details for PubMedID 22337845

  • Maternal and neonatal deaths associated with jaundice during pregnancy in Bangladesh: Using verbal autopsy data to estimate of the burden of endemic hepatitis E infection. Am J Public Health Gurley ES, Halder AK, Streatfield PK, Sazzad HMS, Huda MT, Hossain MJ, Luby SP 2012; 102 (12): 2248-54
  • Epidemiology of Henipavirus Disease in Humans HENIPAVIRUS: ECOLOGY, MOLECULAR VIROLOGY, AND PATHOGENESIS Luby, S. P., Gurley, E. S. 2012; 359: 25-40
  • Date Palm Sap Linked to Nipah Virus Outbreak in Bangladesh, 2008 VECTOR-BORNE AND ZOONOTIC DISEASES Rahman, M. A., Hossain, M. J., Sultana, S., Homaira, N., Khan, S. U., Rahman, M., Gurley, E. S., Rollin, P. E., Lo, M. K., Comer, J. A., Lowe, L., Rota, P. A., Ksiazek, T. G., Kenah, E., Sharker, Y., Luby, S. P. 2012; 12 (1): 65-72


    We investigated a cluster of patients with encephalitis in the Manikgonj and Rajbari Districts of Bangladesh in February 2008 to determine the etiology and risk factors for disease.We classified persons as confirmed Nipah cases by the presence of immunoglobulin M antibodies against Nipah virus (NiV), or by the presence of NiV RNA or by isolation of NiV from cerebrospinal fluid or throat swabs who had onset of symptoms between February 6 and March 10, 2008. We classified persons as probable cases if they reported fever with convulsions or altered mental status, who resided in the outbreak areas during that period, and who died before serum samples were collected. For the case-control study, we compared both confirmed and probable Nipah case-patients to controls, who were free from illness during the reference period. We used motion-sensor-infrared cameras to observe bat's contact of date palm sap.We identified four confirmed and six probable case-patients, nine (90%) of whom died. The median age of the cases was 10 years; eight were males. The outbreak occurred simultaneously in two communities that were 44 km apart and separated by a river. Drinking raw date palm sap 2-12 days before illness onset was the only risk factor most strongly associated with the illness (adjusted odds ratio 25, 95% confidence intervals 3.3-∞, p<0.001). Case-patients reported no history of physical contact with bats, though community members often reported seeing bats. Infrared camera photographs showed that Pteropus bats frequently visited date palm trees in those communities where sap was collected for human consumption.This is the second Nipah outbreak in Bangladesh where date palm sap has been implicated as the vehicle of transmission. Fresh date palm sap should not be drunk, unless effective steps have been taken to prevent bat access to the sap during collection.

    View details for DOI 10.1089/vbz.2011.0656

    View details for Web of Science ID 000299112800011

    View details for PubMedID 21923274

  • Incidence of influenza-like illness and severe acute respiratory infection during three influenza seasons in Bangladesh, 2008-2010 BULLETIN OF THE WORLD HEALTH ORGANIZATION Azziz-Baumgartner, E., Alamgir, A. S., Rahman, M., Homaira, N., Sohel, B. M., Sharker, M. A., Zaman, R. U., Dee, J., Gurley, E. S., Al Mamun, A., Mah-e-Muneer, S., Fry, A. M., Widdowson, M., Bresee, J., Lindstrom, S., Azim, T., Brooks, A., Podder, G., Hossain, M. J., Rahman, M., Luby, S. P. 2012; 90 (1): 12-19


    To determine how much influenza contributes to severe acute respiratory illness (SARI), a leading cause of death in children, among people of all ages in Bangladesh.Physicians obtained nasal and throat swabs to test for influenza virus from patients who were hospitalized within 7 days of the onset of severe acute respiratory infection (SARI) or who consulted as outpatients for influenza-like illness (ILI). A community health care utilization survey was conducted to determine the proportion of hospital catchment area residents who sought care at study hospitals and calculate the incidence of influenza using this denominator.The estimated incidence of SARI associated with influenza in children < 5 years old was 6.7 (95% confidence interval, CI: 0-18.3); 4.4 (95% CI: 0-13.4) and 6.5 per 1000 person-years (95% CI: 0-8.3/1000) during the 2008, 2009 and 2010 influenza seasons, respectively. The incidence of SARI in people aged ≥ 5 years was 1.1 (95% CI: 0.4-2.0) and 1.3 (95% CI: 0.5-2.2) per 10,000 person-years during 2009 and 2010, respectively. The incidence of medically attended, laboratory-confirmed seasonal influenza in outpatients with ILI was 10 (95% CI: 8-14), 6.6 (95% CI: 5-9) and 17 per 100 person-years (95% CI: 13-22) during the 2008, 2009 and 2010 influenza seasons, respectively.Influenza-like illness is a frequent cause of consultation in the outpatient setting in Bangladesh. Children aged less than  5 years are hospitalized for influenza in greater proportions than children in other age groups.

    View details for DOI 10.2471/BLT.11.090209

    View details for Web of Science ID 000299913600018

    View details for PubMedID 22271960

  • Early Detection of Pandemic (H1N1) 2009, Bangladesh EMERGING INFECTIOUS DISEASES Azziz-Baumgartner, E., Rahman, M., Al Mamun, A., Haider, M. S., Zaman, R. U., Karmakar, P. C., Nasreen, S., Mah-e-Muneer, S., Homaira, N., Goswami, D. R., Ahmed, B., Husain, M. M., Jamil, K. M., Khatun, S., Ahmed, M., Chakraborty, A., Fry, A., Widdowson, M., Bresee, J., Azim, T., Alamgir, A. S., Brooks, A., Hossain, M. J., Klimov, A., Rahman, M., Luby, S. P. 2012; 18 (1): 146-149


    To explore Bangladesh's ability to detect novel influenza, we examined a series of laboratory-confirmed pandemic (H1N1) 2009 cases. During June-July 2009, event-based surveillance identified 30 case-patients (57% travelers); starting July 29, sentinel sites identified 252 case-patients (1% travelers). Surveillance facilitated response weeks before the spread of pandemic (H1N1) 2009 infection to the general population.

    View details for DOI 10.3201/eid1801.101996

    View details for Web of Science ID 000298973000029

    View details for PubMedID 22257637

  • Hospital-Based Prevalence of Malaria and Dengue in Febrile Patients in Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Faruque, L. I., Zaman, R. U., Alamgir, A. S., Gurley, E. S., Haque, R., Rahman, M., Luby, S. P. 2012; 86 (1): 58-64


    We conducted a nationwide study at six tertiary hospitals from December 2008 through November 2009 to investigate etiologies of febrile illnesses in Bangladesh. Febrile patients meeting a clinical case definition were enrolled from inpatient and outpatient medicine and pediatric units. We assessed 720 febrile patients over 12 months; 69 (9.6%) were positive for IgM antibodies against dengue virus by enzyme-linked immunosorbent assay, and four malaria patients (0.56%) were confirmed with immuno-chromatography and microscopic slide tests. We identified dengue cases throughout the year from rural (49%) and urban areas (51%). We followed-up 55 accessible dengue-infected patients two months after their initial enrollment: 45 (82%) patients had fully recovered, 9 (16%) reported ongoing jaundice, fever and/or joint pain, and one died. Dengue infection is widespread across Bangladesh, but malaria is sufficiently uncommon that it should not be assumed as the cause of fever without laboratory confirmation.

    View details for DOI 10.4269/ajtmh.2012.11-0190

    View details for Web of Science ID 000299065200016

    View details for PubMedID 22232452

  • Epidemiology of henipavirus disease in humans. Current topics in microbiology and immunology Luby, S. P., Gurley, E. S. 2012; 359: 25-40


    All seven recognized human cases of Hendra virus (HeV) infection have occurred in Queensland, Australia. Recognized human infections have all resulted from a HeV infected horse that was unusually efficient in transmitting the virus and a person with a high exposure to infectious secretions. In the large outbreak in Malaysia where Nipah virus (NiV) was first identified, most human infections resulted from close contact with NiV infected pigs. Outbreak investigations in Bangladesh have identified drinking raw date palm sap as the most common pathway of NiV transmission from Pteropus bats to people, but person-to-person transmission of NiV has been repeatedly identified in Bangladesh and India. Although henipaviruses are not easily transmitted to people, these newly recognized, high mortality agents warrant continued scientific attention.

    View details for DOI 10.1007/82_2012_207

    View details for PubMedID 22752412

  • Understanding community perceptions, social norms and current practice related to respiratory infection in Bangladesh during 2009: a qualitative formative study BMC PUBLIC HEALTH Nizame, F. A., Nasreen, S., Unicomb, L., Southern, D., Gurley, E. S., Arman, S., Kadir, M. A., Azziz-Baumgartner, E., Luby, S. P., Winch, P. J. 2011; 11


    Respiratory infections are the leading cause of childhood deaths in Bangladesh. Promoting respiratory hygiene may reduce infection transmission. This formative research explored community perceptions about respiratory infections.We conducted 34 in-depth interviews and 16 focus group discussions with community members and school children to explore respiratory hygiene related perceptions, practices, and social norms in an urban and a rural setting. We conducted unstructured observations on respiratory hygiene practices in public markets.Informants were not familiar with the term "respiratory infection"; most named diseases that had no relation to respiratory dysfunction. Informants reported that their community identified a number of 'good behaviors' related to respiratory hygiene, but they also noted, and we observed, that very few people practiced these. All informants cited hot/cold weather changes or using cold water as causes for catching cold. They associated transmission of respiratory infections with close contact with a sick person's breath, cough droplets, or spit; sharing a sick person's utensils and food. Informants suggested that avoiding such contact was the most effective method to prevent respiratory infection. Although informants perceived that handwashing after coughing or sneezing might prevent illness, they felt this was not typically feasible or practical.Community perceptions of respiratory infections include both concerns with imbalances between hot and cold, and with person-to-person transmission. Many people were aware of measures that could prevent respiratory infection, but did not practice them. Interventions that leverage community understanding of person-to-person transmission and that encourage the practice of their identified 'good behaviors' related to respiratory hygiene may reduce respiratory disease transmission.

    View details for DOI 10.1186/1471-2458-11-901

    View details for Web of Science ID 000300283500001

    View details for PubMedID 22136080

  • Epidemiological methods in diarrhoea studies-an update INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Schmidt, W., Arnold, B. F., Boisson, S., Genser, B., Luby, S. P., Barreto, M. L., Clasen, T., Cairncross, S. 2011; 40 (6): 1678-1692


    Diarrhoea remains a leading cause of morbidity and mortality but is difficult to measure in epidemiological studies. Challenges include the diagnosis based on self-reported symptoms, the logistical burden of intensive surveillance and the variability of diarrhoea in space, time and person.We review current practices in sampling procedures to measure diarrhoea, and provide guidance for diarrhoea measurement across a range of study goals. Using 14 available data sets, we estimated typical design effects for clustering at household and village/ neighbourhood level, and measured the impact of adjusting for baseline variables on the precision of intervention effect estimates.Incidence is the preferred outcome measure in aetiological studies, health services research and vaccine trials. Repeated prevalence measurements (longitudinal prevalence) are appropriate in high-mortality settings where malnutrition is common, although many repeat measures are rarely useful. Period prevalence is an inadequate outcome if an intervention affects illness duration. Adjusting point estimates for age or diarrhoea at baseline in randomized trials has little effect on the precision of estimates. Design effects in trials randomized at household level are usually <2 (range 1.0–3.2). Design effects for larger clusters (e.g. villages or neighbourhoods) vary greatly among different settings and study designs (range 0.1–25.8).Using appropriate sampling strategies and outcome measures can improve the efficiency, validity and comparability of diarrhoea studies. Allocating large clusters in cluster randomized trials is compromized by unpredictable design effects and should be carried out only if the research question requires it.

    View details for DOI 10.1093/ije/dyr152

    View details for Web of Science ID 000297868500029

    View details for PubMedID 22268237

  • Using Child Health Outcomes to Identify Effective Measures of Handwashing AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Halder, A. K., Huda, T. M., Unicomb, L., Johnston, R. B. 2011; 85 (5): 882-892


    We assessed which practical handwashing indicators were independently associated with reduced child diarrhea or respiratory disease. Fieldworkers collected 33 indicators of handwashing at baseline in 498 households in 50 villages in rural Bangladesh. Community monitors visited households monthly and asked standard questions about diarrhea and symptoms of respiratory illness among children under 5 years of age. In multivariate analysis, three handwashing indicators were independently associated with less child diarrhea-mothers reporting usually washing hands with soap before feeding a child, mothers using soap when asked to show how they usually washed their hands after defecation, and children having visibly clean finger pads. Two indicators were independently associated with fewer respiratory infections-mothers allowing their hands to air dry after the handwashing demonstration and the presence of water where the respondents usually wash hands after defecation. These rapid handwashing indicators should be considered for inclusion in handwashing assessments.

    View details for DOI 10.4269/ajtmh.2011.11-0142

    View details for Web of Science ID 000296661900017

    View details for PubMedID 22049043

  • Lethal Factor Toxemia and Anti-Protective Antigen Antibody Activity in Naturally Acquired Cutaneous Anthrax JOURNAL OF INFECTIOUS DISEASES Boyer, A. E., Quinn, C. P., Beesley, C. A., Gallegos-Candela, M., Marston, C. K., Cronin, L. X., Lins, R. C., Stoddard, R. A., Li, H., Schiffer, J., Hossain, M. J., Chakraborty, A., Rahman, M., Luby, S. P., Shieh, W., Zaki, S., Barr, J. R., Hoffmaster, A. R. 2011; 204 (9): 1321-1327


    Cutaneous anthrax outbreaks occurred in Bangladesh from August to October 2009. As part of the epidemiological response and to confirm anthrax diagnoses, serum samples were collected from suspected case patients with observed cutaneous lesions. Anthrax lethal factor (LF), anti-protective antigen (anti-PA) immunoglobulin G (IgG), and anthrax lethal toxin neutralization activity (TNA) levels were determined in acute and convalescent serum of 26 case patients with suspected cutaneous anthrax from the first and largest of these outbreaks. LF (0.005-1.264 ng/mL) was detected in acute serum from 18 of 26 individuals. Anti-PA IgG and TNA were detected in sera from the same 18 individuals and ranged from 10.0 to 679.5 μg/mL and 27 to 593 units, respectively. Seroconversion to serum anti-PA and TNA was found only in case patients with measurable toxemia. This is the first report of quantitative analysis of serum LF in cutaneous anthrax and the first to associate acute stage toxemia with subsequent antitoxin antibody responses.

    View details for DOI 10.1093/infdis/jir543

    View details for Web of Science ID 000295509300005

    View details for PubMedID 21908727

  • What Point-of-Use Water Treatment Products Do Consumers Use? Evidence from a Randomized Controlled Trial among the Urban Poor in Bangladesh PLOS ONE Luoto, J., Najnin, N., Mahmud, M., Albert, J., Islam, M. S., Luby, S., Unicomb, L., Levine, D. I. 2011; 6 (10)


    There is evidence that household point-of-use (POU) water treatment products can reduce the enormous burden of water-borne illness. Nevertheless, adoption among the global poor is very low, and little evidence exists on why.We gave 600 households in poor communities in Dhaka, Bangladesh randomly-ordered two-month free trials of four water treatment products: dilute liquid chlorine (sodium hypochlorite solution, marketed locally as Water Guard), sodium dichloroisocyanurate tablets (branded as Aquatabs), a combined flocculant-disinfectant powdered mixture (the PUR Purifier of Water), and a silver-coated ceramic siphon filter. Consumers also received education on the dangers of untreated drinking water. We measured which products consumers used with self-reports, observation (for the filter), and chlorine tests (for the other products). We also measured drinking water's contamination with E. coli (compared to 200 control households).Households reported highest usage of the filter, although no product had even 30% usage. E. coli concentrations in stored drinking water were generally lowest when households had Water Guard. Households that self-reported product usage had large reductions in E. coli concentrations with any product as compared to controls.Traditional arguments for the low adoption of POU products focus on affordability, consumers' lack of information about germs and the dangers of unsafe water, and specific products not meshing with a household's preferences. In this study we provided free trials, repeated informational messages explaining the dangers of untreated water, and a variety of product designs. The low usage of all products despite such efforts makes clear that important barriers exist beyond cost, information, and variation among these four product designs. Without a better understanding of the choices and aspirations of the target end-users, household-based water treatment is unlikely to reduce morbidity and mortality substantially in urban Bangladesh and similar populations.

    View details for DOI 10.1371/journal.pone.0026132

    View details for Web of Science ID 000296510800020

    View details for PubMedID 22028817

  • Economic Consequences of Post Kala-Azar Dermal Leishmaniasis in a Rural Bangladeshi Community AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Ozaki, M., Islam, S., Rahman, K. M., Rahman, A., Luby, S. P., Bern, C. 2011; 85 (3): 528-534


    Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis. Bangladesh national treatment guidelines during the study period called for 120 intramuscular injections of sodium antimony gluconate (SAG). We assessed care-seeking behavior, diagnosis and treatment costs, and coping strategies among 134 PKDL patients; 56 (42%) patients had been treated with SAG, and 78 (58%) remained untreated. The median direct cost per patient treated was US$367 (interquartile range [IQR] = 90-284), more than two times the estimated per capita annual income for the study population. The most common coping strategy was to take a loan; the median amount borrowed was US$98 (IQR = 71-150), with a median interest of US$32 (IQR = 16-95). Households lost a median of 123 work-days per patient treated. The current regimen for PKDL imposes a significant financial burden, reinforcing the link between poverty and visceral leishmaniasis. More practical shorter-course regimens for PKDL are urgently needed to achieve national and regional visceral leishmaniasis elimination goals.

    View details for DOI 10.4269/ajtmh.2011.10-0683

    View details for Web of Science ID 000294581400026

    View details for PubMedID 21896817

  • Social Ecological Analysis of an Outbreak of Pufferfish Egg Poisoning in a Coastal Area of Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Islam, M. S., Luby, S. P., Rahman, M., Parveen, S., Homaira, N., Begum, N. H., Khan, A. K., Sultana, R., Akhter, S., Gurley, E. S. 2011; 85 (3): 498-503


    Recurrent outbreaks of marine pufferfish poisoning in Bangladesh highlight the need to understand the context in which the outbreaks occurred. In a recent outbreak investigation, a multidisciplinary team conducted a mixed-method study to identify the demography and clinical manifestation of the victims and to explore different uses of pufferfish, and local buying, selling, and processing practices. The outbreak primarily affected a low income household where an elderly woman collected and cooked pufferfish egg curry. Nine persons consumed the curry, and symptoms developed in 6 (67%) of these persons. Symptoms included vomiting, diarrhea, paresis, and tingling sensation; 2 (22%) persons died. The unstable income of the affected family, food crisis, and the public disposal of unsafe pufferfish byproducts all contributed to the outbreak. A multi-level intervention should be developed and disseminated with the participation of target communities to discourage unsafe discarding of pufferfish scraps and to improve the community knowledge about the risk of consuming pufferfish.

    View details for DOI 10.4269/ajtmh.2011.10-0629

    View details for Web of Science ID 000294581400020

    View details for PubMedID 21896811

  • A Novel Low-Cost Approach to Estimate the Incidence of Japanese Encephalitis in the Catchment Area of Three Hospitals in Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Paul, R. C., Rahman, M., Gurley, E. S., Hossain, M. J., Diorditsa, S., Hasan, A. S., Banu, S. S., Alamgir, A. S., Rahman, M. A., Sandhu, H., Fischer, M., Luby, S. P. 2011; 85 (2): 379-385


    Acute meningoencephalitis syndrome surveillance was initiated in three medical college hospitals in Bangladesh in October 2007 to identify Japanese encephalitis (JE) cases. We estimated the population-based incidence of JE in the three hospitals' catchment areas by adjusting the hospital-based crude incidence of JE by the proportion of catchment area meningoencephalitis cases who were admitted to surveillance hospitals. Instead of a traditional house-to-house survey, which is expensive for a disease with low frequency, we attempted a novel approach to identify meningoencephalitis cases in the hospital catchment area through social networks among the community residents. The estimated JE incidence was 2.7/100,000 population in Rajshahi (95% confidence interval [CI] = 1.8-4.9), 1.4 in Khulna (95% CI = 0.9-4.1), and 0.6 in Chittagong (95% CI = 0.4-0.9). Bangladesh should consider a pilot project to introduce JE vaccine in high-incidence areas.

    View details for DOI 10.4269/ajtmh.2011.10-0706

    View details for Web of Science ID 000293613000031

    View details for PubMedID 21813862

  • Family and community concerns about post-mortem needle biopsies in a Muslim society BMC MEDICAL ETHICS Gurley, E. S., Parveen, S., Islam, M. S., Hossain, M. J., Nahar, N., Homaira, N., Sultana, R., Sejvar, J. J., Rahman, M., Luby, S. P. 2011; 12


    Post-mortem needle biopsies have been used in resource-poor settings to determine cause of death and there is interest in using them in Bangladesh. However, we did not know how families and communities would perceive this procedure or how they would decide whether or not to consent to a post-mortem needle biopsy. The goal of this study was to better understand family and community concerns and decision-making about post-mortem needle biopsies in this low-income, predominantly Muslim country in order to design an informed consent process.We conducted 16 group discussions with family members of persons who died during an outbreak of Nipah virus illness during 2004-2008 and 11 key informant interviews with their community and religious leaders. Qualitative researchers first described the post-mortem needle biopsy procedure and asked participants whether they would have agreed to this procedure during the outbreak. Researchers probed participants about the circumstances under which the procedure would be acceptable, if any, their concerns about the procedure, and how they would decide whether or not to consent to the procedure.Overall, most participants agreed that post-mortem needle biopsies would be acceptable in some situations, particularly if they benefitted society. This procedure was deemed more acceptable than full autopsy because it would not require major delays in burial or remove organs, and did not require cutting or stitching of the body. It could be performed before the ritual bathing of the body in either the community or hospital setting. However, before consent would be granted for such a procedure, the research team must gain the trust of the family and community which could be difficult. Although consent may only be provided by the guardians of the body, decisions about consent for the procedure would involve extended family and community and religious leaders.The possible acceptability of this procedure during outbreaks represents an important opportunity to better characterize cause of death in Bangladesh which could lead to improved public health interventions to prevent these deaths. Obstacles for research teams will include engaging all major stakeholders in decision-making and quickly building a trusting relationship with the family and community, which will be difficult given the short window of time prior to the ritual bathing of the body.

    View details for DOI 10.1186/1472-6939-12-10

    View details for Web of Science ID 000292831500001

    View details for PubMedID 21668979

  • The Effect of Handwashing at Recommended Times with Water Alone and With Soap on Child Diarrhea in Rural Bangladesh: An Observational Study PLOS MEDICINE Luby, S. P., Halder, A. K., Huda, T., Unicomb, L., Johnston, R. B. 2011; 8 (6)


    Standard public health interventions to improve hand hygiene in communities with high levels of child mortality encourage community residents to wash their hands with soap at five separate key times, a recommendation that would require mothers living in impoverished households to typically wash hands with soap more than ten times per day. We analyzed data from households that received no intervention in a large prospective project evaluation to assess the relationship between observed handwashing behavior and subsequent diarrhea.Fieldworkers conducted a 5-hour structured observation and a cross-sectional survey in 347 households from 50 villages across rural Bangladesh in 2007. For the subsequent 2 years, a trained community resident visited each of the enrolled households every month and collected information on the occurrence of diarrhea in the preceding 48 hours among household residents under the age of 5 years. Compared with children living in households where persons prepared food without washing their hands, children living in households where the food preparer washed at least one hand with water only (odds ratio [OR]=0.78; 95% confidence interval [CI]=0.57-1.05), washed both hands with water only (OR=0.67; 95% CI=0.51-0.89), or washed at least one hand with soap (OR=0.30; 95% CI=0.19-0.47) had less diarrhea. In households where residents washed at least one hand with soap after defecation, children had less diarrhea (OR=0.45; 95% CI=0.26-0.77). There was no significant association between handwashing with or without soap before feeding a child, before eating, or after cleaning a child's anus who defecated and subsequent child diarrhea.These observations suggest that handwashing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and that handwashing with water alone can significantly reduce childhood diarrhea.

    View details for DOI 10.1371/journal.pmed.1001052

    View details for Web of Science ID 000292136800015

    View details for PubMedID 21738452

  • Variability in Hand Contamination Based on Serial Measurements: Implications for Assessment of Hand-Cleansing Behavior and Disease Risk AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Ram, P. K., Jahid, I., Halder, A. K., Nygren, B., Islam, M. S., Granger, S. P., Molyneaux, J. W., Luby, S. P. 2011; 84 (4): 510-516


    Measuring hand contamination at critical times, such as eating, can be challenging. We examined whether hand contamination measured at random, such as on arrival (initial), predicts contamination at critical times. Mothers of young children in Bangladesh rinsed both hands in 200 mL of Ringer's solution. We compared results of serial samples with respect to fecal coliform counts. Among 39 mothers, the geometric mean of fecal coliforms was 307 colony-forming units (cfu)/100 mL at initial collection and 3,001 cfu/100 mL during critical times (P = 0.0006). There was no correlation between initial and critical time fecal coliform counts (R = 0.13, P = 0.43). The mean difference between initial and critical time counts was 3.5 (standard deviation = 1.4) on the log base-10 scale. Contamination of the same subjects' hands varied substantially within a few hours. Because hand contamination measured at random cannot reliably predict hand contamination at times of potential pathogen transmission, single random hand rinses are not valid proxy measures for handwashing behavior.

    View details for DOI 10.4269/ajtmh.2011.10-0299

    View details for Web of Science ID 000289023600002

    View details for PubMedID 21460002

  • The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: An observational study. PLoS Med Luby SP, Halder AK, Huda T, Tronchet C, Unicomb L, Johnston RB. 2011; 8 (6): e1001052
  • A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh TROPICAL MEDICINE & INTERNATIONAL HEALTH Luby, S. P., Kadir, M. A., Sharker, M. A., Yeasmin, F., Unicomb, L., Islam, M. S. 2010; 15 (12): 1508-1516


    To pilot two intensive hand hygiene promotion interventions, one using soap and one using a waterless hand sanitizer, in low-income housing compounds in Dhaka, Bangladesh and assess subsequent changes in handwashing behaviour and hand microbiology.Fieldworkers randomized 30 housing compounds: 10 received handwashing promotion with free soap, 10 received handwashing promotion with free waterless hand sanitizer and 10 were non-intervention controls. Fieldworkers assessed handwashing behaviour by structured observation and collected hand rinse specimens.At baseline, compound residents washed their hands with soap 26% of the time after defecation and 30% after cleaning a child's anus but <1% at other times. Compared with baseline, residents of soap intervention compounds were much more likely to wash their hands with soap after faecal contact (85-91%), before preparing food (26%) and before eating (26%). Compounds that received waterless hand sanitizer cleansed their hands more commonly than control compounds that used soap (10.4%vs. 2.3%), but less commonly than soap intervention compounds used soap (25%). Post-intervention hand rinse samples from soap and sanitizer compounds had lower concentrations of faecal indicator bacteria compared with baseline and control compounds.Waterless hand sanitizer was readily adopted by this low-income community and reduced hand contamination but did not improve the frequency of handwashing compared with soap. Future deployments of waterless hand sanitizers may improve hand hygiene more effectively by targeting settings where soap and water is unavailable.

    View details for DOI 10.1111/j.1365-3156.2010.02648.x

    View details for Web of Science ID 000284374600014

    View details for PubMedID 20958896

  • Use of Infrared Camera to Understand Bats' Access to Date Palm Sap: Implications for Preventing Nipah Virus Transmission ECOHEALTH Khan, M. S., Hossain, J., Gurley, E. S., Nahar, N., Sultana, R., Luby, S. P. 2010; 7 (4): 517-525


    Pteropus bats are commonly infected with Nipah virus, but show no signs of illness. Human Nipah outbreaks in Bangladesh coincide with the date palm sap harvesting season. In epidemiologic studies, drinking raw date palm sap is a risk factor for human Nipah infection. We conducted a study to evaluate bats' access to date palm sap. We mounted infrared cameras that silently captured images upon detection of motion on date palm trees from 5:00 pm to 6:00 am. Additionally, we placed two locally used preventative techniques, bamboo skirts and lime (CaCO₃) smeared on date palm trees to assess their effectiveness in preventing bats access to sap. Out of 20 camera-nights of observations, 14 identified 132 visits of bats around the tree, 91 to the shaved surface of the tree where the sap flow originates, 4 at the stream of sap moving toward the collection pot, and no bats at the tap or on the collection pots; the remaining 6 camera-nights recorded no visits. Of the preventative techniques, the bamboo skirt placed for four camera-nights prevented bats access to sap. This study confirmed that bats commonly visited date palm trees and physically contacted the sap collected for human consumption. This is further evidence that date palm sap is an important link between Nipah virus in bats and Nipah virus in humans. Efforts that prevent bat access to the shaved surface and the sap stream of the tree could reduce Nipah spillovers to the human population.

    View details for DOI 10.1007/s10393-010-0366-2

    View details for Web of Science ID 000294563300010

    View details for PubMedID 21207105

  • Nipah virus outbreak with person-to-person transmission in a district of Bangladesh, 2007 EPIDEMIOLOGY AND INFECTION Homaira, N., Rahman, M., Hossain, M. J., Epstein, J. H., Sultana, R., Khan, M. S., Podder, G., Nahar, K., Ahmed, B., Gurley, E. S., Daszak, P., Lipkin, W. I., ROLLIN, P. E., Comer, J. A., Ksiazek, T. G., Luby, S. P. 2010; 138 (11): 1630-1636


    In February 2007 an outbreak of Nipah virus (NiV) encephalitis in Thakurgaon District of northwest Bangladesh affected seven people, three of whom died. All subsequent cases developed illness 7-14 days after close physical contact with the index case while he was ill. Cases were more likely than controls to have been in the same room (100% vs. 9.5%, OR undefined, P<0.001) and to have touched him (83% vs. 0%, OR undefined, P<0.001). Although the source of infection for the index case was not identified, 50% of Pteropus bats sampled from near the outbreak area 1 month after the outbreak had antibodies to NiV confirming the presence of the virus in the area. The outbreak was spread by person-to-person transmission. Risk of NiV infection in family caregivers highlights the need for infection control practices to limit transmission of potentially infectious body secretions.

    View details for DOI 10.1017/S0950268810000695

    View details for Web of Science ID 000282196000013

    View details for PubMedID 20380769

  • Cluster of Nipah Virus Infection, Kushtia District, Bangladesh, 2007 PLOS ONE Homaira, N., Rahman, M., Hossain, M. J., Nahar, N., Khan, R., Rahman, M., Podder, G., Nahar, K., Khan, D., Gurley, E. S., Rollin, P. E., Comer, J. A., Ksiazek, T. G., Luby, S. P. 2010; 5 (10)


    In March 2007, we investigated a cluster of Nipah encephalitis to identify risk factors for Nipah infection in Bangladesh.We defined confirmed Nipah cases by the presence of IgM and IgG antibodies against Nipah virus in serum. Case-patients, who resided in the same village during the outbreak period but died before serum could be collected, were classified as probable cases.We identified three confirmed and five probable Nipah cases. There was a single index case. Five of the secondary cases came in close physical contact to the index case when she was ill. Case-patients were more likely to have physical contact with the index case (71% cases versus 0% controls, p = <0.001). The index case, on her third day of illness, and all the subsequent cases attended the same religious gathering. For three probable cases including the index case, we could not identify any known risk factors for Nipah infection such as physical contact with Nipah case-patients, consumption of raw date palm juice, or contact with sick animals or fruit bats.Though person-to-person transmission remains an important mode of transmission for Nipah infection, we could not confirm the source of infection for three of the probable Nipah case-patients. Continued surveillance and outbreak investigations will help better understand the transmission of Nipah virus and develop preventive strategies.

    View details for DOI 10.1371/journal.pone.0013570

    View details for Web of Science ID 000283293800027

    View details for PubMedID 21042407

  • Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh BMC PUBLIC HEALTH Halder, A. K., Tronchet, C., Akhter, S., Bhuiya, A., Johnston, R., Luby, S. P. 2010; 10


    We analyzed data from the baseline assessment of a large intervention project to describe typical handwashing practices in rural Bangladesh, and compare measures of hand cleanliness with household characteristics.We randomly selected 100 villages from 36 districts in rural Bangladesh. Field workers identified 17 eligible households per village using systematic sampling. Field workers conducted 5-hour structured observations in 1000 households, and a cross-sectional assessment in 1692 households that included spot checks, an evaluation of hand cleanliness and a request that residents demonstrate their usual handwashing practices after defecation.Although 47% of caregivers reported and 51% demonstrated washing both hands with soap after defecation, in structured observation, only 33% of caregivers and 14% of all persons observed washed both hands with soap after defecation. Less than 1% used soap and water for handwashing before eating and/or feeding a child. More commonly people washed their hands only with water, 23% after defecation and 5% before eating. Spot checks during the cross sectional survey classified 930 caregivers (55%) and 453 children (28%) as having clean appearing hands. In multivariate analysis economic status and water available at handwashing locations were significantly associated with hand cleanliness among both caregivers and children.A minority of rural Bangladeshi residents washed both hands with soap at key handwashing times, though rinsing hands with only water was more common. To realize the health benefits of handwashing, efforts to improve handwashing in these communities should target adding soap to current hand rinsing practices.

    View details for DOI 10.1186/1471-2458-10-545

    View details for Web of Science ID 000282239900003

    View details for PubMedID 20828412

  • Burden of typhoid and paratyphoid fever in a densely populated urban community, Dhaka, Bangladesh INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES Naheed, A., Ram, P. K., Brooks, W. A., Hossain, M. A., Parsons, M. B., Talukder, K. A., Mintz, E., Luby, S., Breiman, R. F. 2010; 14: E93-E99


    We conducted blood culture surveillance to estimate the incidence of typhoid and paratyphoid fever among urban slum residents in Dhaka, Bangladesh.Between January 7, 2003 and January 6, 2004, participants were visited weekly to detect febrile illnesses. Blood cultures were obtained at the clinic from patients with fever (≥38°C). Salmonella isolates were assayed for antimicrobial susceptibility.Forty Salmonella Typhi and eight Salmonella Paratyphi A were isolated from 961 blood cultures. The incidence of typhoid fever was 2.0 episodes/1000 person-years, with a higher incidence in children aged<5 years (10.5/1000 person-years) than in older persons (0.9/1000 person-years) (relative risk=12, 95% confidence interval (CI) 6.3-22.6). The incidence of paratyphoid fever was 0.4/1000 person-years without variation by age group. Sixteen S. Typhi isolates were multidrug-resistant (MDR). All S. Paratyphi isolates were pan-susceptible. The duration of fever among patients with an MDR S. Typhi infection was longer than among patients with non-MDR S. Typhi (16±8 vs. 11±4 days, p=0.02) and S. Paratyphi (10±2 days, p=0.04) infections.Typhoid fever is more common than paratyphoid fever in the urban Bangladeshi slum; children<5 years old have the highest incidence. Multidrug resistance is common in S. Typhi isolates and is associated with prolonged illness. Strategies for typhoid fever prevention in children aged<5 years in Bangladesh, including immunization, are needed.

    View details for DOI 10.1016/j.ijid.2009.11.023

    View details for Web of Science ID 000282643000020

    View details for PubMedID 20236850

  • Multiple Outbreaks of Puffer Fish Intoxication in Bangladesh, 2008 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Homaira, N., Rahman, M., Luby, S. P., Rahman, M., Haider, M. S., Faruque, L. I., Khan, D., Parveen, S., Gurley, E. S. 2010; 83 (2): 440-444


    During April and June 2008, we investigated three outbreaks of marine puffer fish intoxication in three districts of Bangladesh (Narshingdi, Natore, and Dhaka). We also explored trade of marine puffer fish in Cox's Bazaar, a coastal area of the country. We identified 95 people who had consumed puffer fish; 63 (66%) developed toxicity characterized by tingling sensation in the body, perioral numbness, dizziness, and weakness, 14 of them died. All three outbreaks were caused by consumption of large (0.2-1.5 kg) marine puffer fish, sold in communities where people were unfamiliar with the marine variety of the fish and its toxicity. Coastal fishermen reported that some local businessmen distributed the fresh fish to non-coastal parts of the country, where people were unfamiliar with the larger variety, to make a quick profit. Lack of knowledge about marine puffer toxicity contributed to the outbreaks. Health communication campaigns will enhance people's knowledge and may prevent future outbreaks.

    View details for DOI 10.4269/ajtmh.2010.10-0168

    View details for Web of Science ID 000280694300040

    View details for PubMedID 20682896

  • A low-cost approach to measure the burden of vaccine preventable diseases in urban areas VACCINE Luby, S. P., Halder, A. K., Saha, S. K., Naheed, A., Sazzad, H. M., Akhter, S., Gurley, E. S., Brooks, W. A., El-Arifeen, S., Najnin, N., Nazneen, A., Breiman, R. F. 2010; 28 (31): 4903-4912


    We piloted a low-cost approach to measure the disease burden of Streptococcus pneumoniae, Hib and Salmonella Typhi by leveraging the existing infrastructure of high performing microbiology laboratories at two large paediatric hospitals in Dhaka Bangladesh, and assessing the hospital utilization of the catchment population of these hospitals for different syndromes. S. Typhi was the most common bacterium identified in culture and accounted for an estimated 211 hospitalizations per 100,000 children <5 years of age per year. Meningitis due to S. pneumoniae was the most common cause of mortality accounting for 8.0 deaths per 100,000 children <5 years of age per year. This low-cost approach can provide data to support vaccine introduction and the health impact of newly introduced vaccines.

    View details for DOI 10.1016/j.vaccine.2010.05.040

    View details for Web of Science ID 000280659600009

    View details for PubMedID 20653079

  • Identification of GBV-D, a Novel GB-like Flavivirus from Old World Frugivorous Bats (Pteropus giganteus) in Bangladesh PLOS PATHOGENS Epstein, J. H., Quan, P., Briese, T., Street, C., Jabado, O., Conlan, S., Khan, S. A., Verdugo, D., Hossain, M. J., Hutchison, S. K., Egholm, M., Luby, S. P., Daszak, P., Lipkin, W. I. 2010; 6 (7)


    Bats are reservoirs for a wide range of zoonotic agents including lyssa-, henipah-, SARS-like corona-, Marburg-, Ebola-, and astroviruses. In an effort to survey for the presence of other infectious agents, known and unknown, we screened sera from 16 Pteropus giganteus bats from Faridpur, Bangladesh, using high-throughput pyrosequencing. Sequence analyses indicated the presence of a previously undescribed virus that has approximately 50% identity at the amino acid level to GB virus A and C (GBV-A and -C). Viral nucleic acid was present in 5 of 98 sera (5%) from a single colony of free-ranging bats. Infection was not associated with evidence of hepatitis or hepatic dysfunction. Phylogenetic analysis indicates that this first GBV-like flavivirus reported in bats constitutes a distinct species within the Flaviviridae family and is ancestral to the GBV-A and -C virus clades.

    View details for DOI 10.1371/journal.ppat.1000972

    View details for Web of Science ID 000280527000007

    View details for PubMedID 20617167

  • Short Report: Leptospirosis as a Cause of Fever in Urban Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Kendall, E. A., LaRocque, R. C., Bui, D. M., Galloway, R., Ari, M. D., Goswami, D., Breiman, R. F., Luby, S., Brooks, W. A. 2010; 82 (6): 1127-1130
  • Prevalent high-risk respiratory hygiene practices in urban and rural Bangladesh TROPICAL MEDICINE & INTERNATIONAL HEALTH Nasreen, S., Azziz-Baumgartner, E., Gurley, E. S., Winch, P. J., Unicomb, L., Sharker, M. A., Southern, D., Luby, S. P. 2010; 15 (6): 762-771


    To identify existing respiratory hygiene risk practices, and guide the development of interventions for improving respiratory hygiene.We selected a convenience sample of 80 households and 20 schools in two densely populated communities in Bangladesh, one urban and one rural. We observed and recorded respiratory hygiene events with potential to spread viruses such as coughing, sneezing, spitting and nasal cleaning using a standardized assessment tool.In 907 (81%) of 1122 observed events, households' participants coughed or sneezed into the air (i.e. uncovered), 119 (11%) into their hands and 83 (7%) into their clothing. Twenty-two per cent of women covered their coughs and sneezes compared to 13% of men (OR 2.6, 95% CI 1.6-4.3). Twenty-seven per cent of persons living in households with a reported monthly income of >72.6 US$ covered their coughs or sneezes compared to 13% of persons living in households with lower income (OR 3.2, 95% CI 1.6-6.2). In 956 (85%) of 1126 events, school participants coughed or sneezed into the air and 142 (13%) into their hands. Twenty-seven per cent of coughs/sneezes in rural schools were covered compared to 10% of coughs/sneezes in urban schools (OR 2.3, 95% CI 1.5-3.6). Hand washing was never observed after participants coughed or sneezed into their hands.There is an urgent need to develop culturally appropriate, cost-effective and scalable interventions to improve respiratory hygiene practices and to assess their effectiveness in reducing respiratory pathogen transmission.

    View details for DOI 10.1111/j.1365-3156.2010.02531.x

    View details for Web of Science ID 000277529100014

    View details for PubMedID 20374564

  • Rates of Hospital-Acquired Respiratory Illness in Bangladeshi Tertiary Care Hospitals: Results from a Low-Cost Pilot Surveillance Strategy CLINICAL INFECTIOUS DISEASES Gurley, E. S., Zaman, R. U., Sultana, R., Bell, M., Fry, A. M., Srinivasan, A., Rahman, M., Rahman, M. W., Hossain, M. J., Luby, S. P. 2010; 50 (8): 1084-1090


    Patients hospitalized in resource-poor health care settings are at increased risk for hospital-acquired respiratory infections due to inadequate infrastructure.From 1 April 2007 through 31 March 2008, we used a low-cost surveillance strategy to identify new onset of respiratory symptoms in patients hospitalized for >72 h and in health care workers in medicine and pediatric wards at 3 public tertiary care hospitals in Bangladesh.During 46,273 patient-days of observation, we recorded 136 episodes of hospital-acquired respiratory disease, representing 1.7% of all patient hospital admissions; rates by ward ranged from 0.8 to 15.8 cases per 1000 patient-days at risk. We identified 22 clusters of respiratory disease, 3 of which included both patients and health care workers. Of 226 of heath care workers who worked on our surveillance wards, 61 (27%) experienced a respiratory illness during the study period. The cost of surveillance was US$43 per month per ward plus 30 min per day in data collection.Patients on these study wards frequently experienced hospital-acquired respiratory infections, including 1 in every 20 patients hospitalized for >72 h on 1 ward. The surveillance method was useful in calculating rates of hospital-acquired respiratory illness and could be used to enhance capacity to quickly detect outbreaks of respiratory disease in health care facilities where systems for outbreak detection are currently limited and to test interventions to reduce transmission of respiratory pathogens in resource-poor settings.

    View details for DOI 10.1086/651265

    View details for Web of Science ID 000275645900002

    View details for PubMedID 20210642

  • Fatal Outbreak from Consuming Xanthium strumarium Seedlings during Time of Food Scarcity in Northeastern Bangladesh PLOS ONE Gurley, E. S., Rahman, M., Hossain, M. J., Nahar, N., Faiz, M. A., Islam, N., Sultana, R., Khatun, S., Uddin, M. Z., Haider, M. S., Islam, M. S., Ahmed, B., Rahman, M. W., Mondal, U. K., Luby, S. P. 2010; 5 (3)


    An outbreak characterized by vomiting and rapid progression to unconsciousness and death was reported in Sylhet Distrct in northeastern Bangladesh following destructive monsoon floods in November 2007.We identified cases presenting to local hospitals and described their clinical signs and symptoms. We interviewed patients and their families to collect illness histories and generate hypotheses about exposures associated with disease. An epidemiological study was conducted in two outbreak villages to investigate risk factors for developing illness. 76 patients were identified from 9 villages; 25% (19/76) died. Common presenting symptoms included vomiting, elevated liver enzymes, and altered mental status. In-depth interviews with 33 cases revealed that 31 (94%) had consumed ghagra shak, an uncultivated plant, in the hours before illness onset. Ghagra shak was consumed as a main meal by villagers due to inaccessibility of other foods following destructive monsoon flooding and rises in global food prices. Persons who ate this plant were 34.2 times more likely (95% CI 10.2 to 115.8, p-value<0.000) than others to develop vomiting and unconsciousness during the outbreak in our multivariate model. Ghagra shak is the local name for Xanthium strumarium, or common cocklebur.The consumption of Xanthium strumarium seedlings in large quantities, due to inaccessibility of other foods, caused this outbreak. The toxic chemical in the plant, carboxyatratyloside, has been previously described and eating X. strumarium seeds and seedlings has been associated with fatalities in humans and livestock. Unless people are able to meet their nutritional requirements with safe foods, they will continue to be at risk for poor health outcomes beyond undernutrition.

    View details for DOI 10.1371/journal.pone.0009756

    View details for Web of Science ID 000276456300007

    View details for PubMedID 20305785

  • Influenza is a Major Contributor to Childhood Pneumonia in a Tropical Developing Country PEDIATRIC INFECTIOUS DISEASE JOURNAL Brooks, W. A., Goswami, D., Rahman, M., Nahar, K., Fry, A. M., Balish, A., Iftekharuddin, N., Azim, T., Xu, X., Klimov, A., Bresee, J., Bridges, C., Luby, S. 2010; 29 (3): 216-221


    Pneumonia is the leading cause of child mortality worldwide. The role of influenza in childhood pneumonia in tropical developing countries is poorly understood. We undertook population-based surveillance among low-income urban preschool children to determine its role in childhood pneumonia.Longitudinal prospective active surveillance was conducted among randomly selected households in a poor urban area of Dhaka. Nasopharyngeal washes were collected from 1 in 5 children for influenza culture isolation. Clinical data were collected at clinical presentation and through the illness course.From April 1, 2004 through December 31, 2007, 12,062 children presented in clinic with eligible febrile and respiratory illnesses, from whom 321 influenza isolates were obtained from 2370 nasopharyngeal washes (13.5%), representing 16,043 child-years of observation (adjusted influenza incidence 102 episodes/1000 child-years). There were 8198 pneumonia episodes during the period (pneumonia incidence 511 episodes/1000 child-years). Ninety influenza-positive children (28%) developed pneumonia during their illness. Among influenza culture-positive children, those with pneumonia were younger than those without (23.4 vs. 29.7 months, ANOVA: P < 0.001). Pneumonia was more commonly associated with Influenza A (H3N2) than either A (H1N1) or B infections (age-adjusted relative odds (RO) 2.98, [95% CI: 1.56, 5.71] and 2.75, [95% CI: 1.52, 4.98], respectively). Influenza was associated with 10% all childhood pneumonia.Influenza is a major contributor to childhood pneumonia both through high influenza infection incidence and high pneumonia prevalence among infected children. Its contribution to early childhood pneumonia appears under-appreciated in high pneumonia-endemic tropical settings. Influenza vaccine trials against childhood pneumonia are warranted.

    View details for DOI 10.1097/INF.0b013e3181bc23fd

    View details for Web of Science ID 000275136000005

    View details for PubMedID 20190613

  • Hospital-Based Surveillance for Japanese Encephalitis at Four Sites in Bangladesh, 2003-2005 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Hossain, M. J., Gurley, E. S., Montgomery, S., Petersen, L., Sejvar, J., Fischer, M., Panella, A., Powers, A. M., Nahar, N., Uddin, A. K., Rahman, M. E., Ekram, A. R., Luby, S. P., Breiman, R. F. 2010; 82 (2): 344-349


    We investigated the epidemiology and etiology of encephalitis at four tertiary hospitals in Bangladesh during 2003-2005. Patients who met a clinical case definition for acute encephalitis and had cerebrospinal fluid (CSF) pleocytosis were eligible for enrollment; a standardized sampling pattern was used to enroll eligible patients. Recent Japanese encephalitis virus (JEV) infection was defined by presence of IgM antibodies against JEV in CSF or serum. Twenty (4%) of 492 cases had laboratory evidence of recent JEV infection; two died. All JE cases occurred during May-December, and cases were identified among all age groups. All cases resided in rural areas. Fifteen patients were re-assessed 4-6 weeks after hospitalization; 5 (33%) patients had physical disabilities and 7 (47%) reported cognitive difficulties. Infection with JEV is clearly an etiology of encephalitis in Bangladesh. Population-based studies to quantify burden of disease could assess options for targeted immunization programs.

    View details for DOI 10.4269/ajtmh.2010.09-0125

    View details for Web of Science ID 000274263300028

    View details for PubMedID 20134015

  • Increasing Incidence of Post-Kala-Azar Dermal Leishmaniasis in a Population-Based Study in Bangladesh CLINICAL INFECTIOUS DISEASES Rahman, K. M., Islam, S., Rahman, M. W., Kenah, E., Galive, C. M., Zahid, M. M., Maguire, J., Rahman, M., Haque, R., Luby, S. P., Bern, C. 2010; 50 (1): 73-76


    Post-kala-azar dermal leishmaniasis (PKDL) occurs after kala-azar treatment and acts as a durable infection reservoir. On the basis of active case finding among 22,699 respondents, 813 (3.6%) had had kala-azar since 2002, of whom 79 (9.7%) developed PKDL. Eight additional patients with PKDL had no history of kala-azar. Annual kala-azar incidence peaked at 85 cases per 10,000 person-years in 2004 and fell to 46 cases per 10,000 person-years in 2007, but PKDL incidence rose from 1 case per 10,000 person-years in 2002-2004 to 21 cases per 10,000 person-years in 2007. The rising PKDL incidence threatens the regional visceral leishmaniasis elimination initiative and underscores the urgent need for more effective PKDL diagnosis and treatment.

    View details for DOI 10.1086/648727

    View details for Web of Science ID 000273296500012

    View details for PubMedID 19951168

  • Date Palm Sap Collection: Exploring Opportunities to Prevent Nipah Transmission ECOHEALTH Nahar, N., Sultana, R., Gurley, E. S., Hossain, M. J., Luby, S. P. 2010; 7 (2): 196-203


    Nipah virus (NiV) infection is a seasonal disease in Bangladesh that coincides with the date palm sap collection season. Raw date palm sap is a delicacy to drink in Bengali culture. If fruit bats that are infected with NiV gain access to the sap for drinking, they might occasionally contaminate the sap through saliva and urine. In February 2007, we conducted a qualitative study in six villages, interviewing 27 date palm sap collectors (gachhis) within the geographical area where NiV outbreaks have occurred since 2001. Gachhis reported that bats pose a challenge to successful collection of quality sap, because bats drink and defecate into the sap which markedly reduces its value. They know some methods to prevent access by bats and other pests but do not use them consistently, because of lack of time and resources. Further studies to explore the effectiveness of these methods and to motivate gachhis to invest their time and money to use them could reduce the risk of human Nipah infection in Bangladesh.

    View details for DOI 10.1007/s10393-010-0320-3

    View details for Web of Science ID 000285911700005

    View details for PubMedID 20617362

  • Influenza in Outpatient ILI Case-Patients in National Hospital-Based Surveillance, Bangladesh, 2007-2008 PLOS ONE Zaman, R. U., Alamgir, A. S., Rahman, M., Azziz-Baumgartner, E., Gurley, E. S., Sharker, M. A., Brooks, W. A., Azim, T., Fry, A. M., Lindstrom, S., Gubareva, L. V., Xu, X., Garten, R. J., Hossain, M. J., Khan, S. U., Faruque, L. I., Ameer, S. S., Klimov, A. I., Rahman, M., Luby, S. P. 2009; 4 (12)


    Recent population-based estimates in a Dhaka low-income community suggest that influenza was prevalent among children. To explore the epidemiology and seasonality of influenza throughout the country and among all age groups, we established nationally representative hospital-based surveillance necessary to guide influenza prevention and control efforts.We conducted influenza-like illness and severe acute respiratory illness sentinel surveillance in 12 hospitals across Bangladesh during May 2007-December 2008. We collected specimens from 3,699 patients, 385 (10%) which were influenza positive by real time RT-PCR. Among the sample-positive patients, 192 (51%) were type A and 188 (49%) were type B. Hemagglutinin subtyping of type A viruses detected 137 (71%) A/H1 and 55 (29%) A/H3, but no A/H5 or other novel influenza strains. The frequency of influenza cases was highest among children aged under 5 years (44%), while the proportions of laboratory confirmed cases was highest among participants aged 11-15 (18%). We applied kriging, a geo-statistical technique, to explore the spatial and temporal spread of influenza and found that, during 2008, influenza was first identified in large port cities and then gradually spread to other parts of the country. We identified a distinct influenza peak during the rainy season (May-September).Our surveillance data confirms that influenza is prevalent throughout Bangladesh, affecting a wide range of ages and causing considerable morbidity and hospital care. A unimodal influenza seasonality may allow Bangladesh to time annual influenza prevention messages and vaccination campaigns to reduce the national influenza burden. To scale-up such national interventions, we need to quantify the national rates of influenza and the economic burden associated with this disease through further studies.

    View details for DOI 10.1371/journal.pone.0008452

    View details for Web of Science ID 000273105200003

    View details for PubMedID 20041114

  • Causes of Early Childhood Deaths in Urban Dhaka, Bangladesh PLOS ONE Halder, A. K., Gurley, E. S., Naheed, A., Saha, S. K., Brooks, W. A., El Arifeen, S., Sazzad, H. M., Kenah, E., Luby, S. P. 2009; 4 (12)


    Data on causes of early childhood death from low-income urban areas are limited. The nationally representative Bangladesh Demographic and Health Survey 2007 estimates 65 children died per 1,000 live births. We investigated rates and causes of under-five deaths in an urban community near two large pediatric hospitals in Dhaka, Bangladesh and evaluated the impact of different recall periods. We conducted a survey in 2006 for 6971 households and a follow up survey in 2007 among eligible remaining households or replacement households. The initial survey collected information for all children under five years old who died in the previous year; the follow up survey on child deaths in the preceding five years. We compared mortality rates based on 1-year recall to the 4 years preceding the most recent 1 year. The initial survey identified 58 deaths among children <5 years in the preceding year. The follow up survey identified a mean 53 deaths per year in the preceding five years (SD+/-7.3). Under-five mortality rate was 34 and neonatal mortality was 15 per thousand live births during 2006-2007. The leading cause of under-five death was respiratory infections (22%). The mortality rates among children under 4 years old for the two time periods (most recent 1-year recall and the 4 years preceding the most recent 1 year) were similar (36 versus 32). The child mortality in urban Dhaka was substantially lower than the national rate. Mortality rates were not affected by recall periods between 1 and 5 years.

    View details for DOI 10.1371/journal.pone.0008145

    View details for Web of Science ID 000272829000006

    View details for PubMedID 19997507

  • Transmission of Human Infection with Nipah Virus CLINICAL INFECTIOUS DISEASES Luby, S. P., Gurley, E. S., Hossain, M. J. 2009; 49 (11): 1743-1748


    Nipah virus (NiV) is a paramyxovirus whose reservoir host is fruit bats of the genus Pteropus. Occasionally the virus is introduced into human populations and causes severe illness characterized by encephalitis or respiratory disease. The first outbreak of NiV was recognized in Malaysia, but 8 outbreaks have been reported from Bangladesh since 2001. The primary pathways of transmission from bats to people in Bangladesh are through contamination of raw date palm sap by bats with subsequent consumption by humans and through infection of domestic animals (cattle, pigs, and goats), presumably from consumption of food contaminated with bat saliva or urine with subsequent transmission to people. Approximately one-half of recognized Nipah case patients in Bangladesh developed their disease following person-to-person transmission of the virus. Efforts to prevent transmission should focus on decreasing bat access to date palm sap and reducing family members' and friends' exposure to infected patients' saliva.

    View details for DOI 10.1086/647951

    View details for Web of Science ID 000271505200021

    View details for PubMedID 19886791

  • Surveillance of rotavirus in a rural diarrhoea treatment centre in Bangladesh, 2000-2006 VACCINE Zaman, K., Yunus, M., Faruque, A. S., El Arifeen, S., Hossain, I., Azim, T., Rahman, M., Podder, G., Roy, E., Luby, S., Sack, D. A. 2009; 27: F31-F34


    Rotavirus was detected in 33% of 4519 children less than 5 years of age admitted with diarrhoea to treatment centres at Matlab in rural Bangladesh from 2000 to 2006. Highest rotavirus detection rates were in children aged 6-11 months with 56% being less than 1 year old. The peak seasonal detection was in July-September and December-February. The population-based incidence rates of rotavirus ranged from 10.8 to 19.6/1000 children less than 5 years of age. G1 serotype predominated between June 2002-May 2005 and June 2005-May 2006 the predominant type was G2 (41%) followed by G1 (22%) and G9 (22%). Rotavirus is an important cause of childhood diarrhoea in rural Bangladesh and this burden may be reduced with a rotavirus vaccination programme.

    View details for DOI 10.1016/j.vaccine.2009.08.063

    View details for Web of Science ID 000273415000007

    View details for PubMedID 19931715

  • Household Characteristics Associated with Handwashing with Soap in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Halder, A. K., Tronchet, C., Akhter, S., Bhuiya, A., Johnston, R. B. 2009; 81 (5): 882-887


    Handwashing with soap prevents diarrhea and respiratory disease, but it is rarely practiced in high-need settings. Among 100 randomly selected villages in rural Bangladesh, field workers enrolled 10 households per village and observed and recorded household activities for 5 hours. Field workers observed 761 handwashing opportunities among household members in 527 households who had just defecated or who cleaned a child's anus who had defecated. In the final multivariate analysis, having water available at the place to wash hands after toileting (odds ratio = 2.2, 95% confidence interval 1.3, 4.0) and having soap available at the place to wash hands after toileting (odds ratio = 2.1, 95% confidence interval 1.3, 3.4) were associated with washing both hands with soap after fecal contact. Interventions that improve the presence of water and soap at the designated place to wash hands would be expected to improve handwashing behavior and health.

    View details for DOI 10.4269/ajtmh.2009.09-0031

    View details for Web of Science ID 000271956500026

    View details for PubMedID 19861626

  • Etiologies of Bacterial Meningitis in Bangladesh: Results from a Hospital-Based Study AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Gurley, E. S., Hossain, M. J., Montgomery, S. P., Petersen, L. R., Sejvar, J. J., Mayer, L. W., Whitney, A., Dull, P., Nahar, N., Uddin, A. K., Rahman, M. E., Ekram, A. R., Luby, S. R., Breiman, R. F. 2009; 81 (3): 475-483


    We conducted a study at four hospitals from June 2003 to July 2005 to investigate the etiologies of bacterial meningitis in Bangladesh. A total of 2,609 patients met the clinical case definition, and 766 had cerebrospinal fluid tested by at least one of the following methods: latex agglutination, 16S rRNA gene sequencing, or real-time polymerase chain reaction for Neisseria meningitidis A and C, Streptococcus pneumoniae, and Haemophilus influenzae type b (Hib); culture results were noted from patient records. In total, 189 patients (24%) of those tested, representing all age groups, were diagnosed with bacterial meningitis; 136 (18%) had meningococcal, 23 (3%) had pneumococcal, and 25 (3%) had Hib infection. Twenty percent of patients with Hib meningitis (5/25) were > 15 years old. Case-fatality ratios were 10% for N. meningitidis, 22% for S. pneumoniae, and 24% for Hib. Bacterial meningitis from vaccine-preventable pathogens causes significant morbidity and mortality in Bangladesh in adults and children.

    View details for Web of Science ID 000269290900022

    View details for PubMedID 19706918

  • Recurrent Zoonotic Transmission of Nipah Virus into Humans, Bangladesh, 2001-2007 EMERGING INFECTIOUS DISEASES Luby, S. P., Hossain, M. J., Gurley, E. S., Ahmed, B., Banu, S., Khan, S. U., Homaira, N., Rota, P. A., Rollin, P. E., Comer, J. A., Kenah, E., Ksiazek, T. G., Rahman, M. 2009; 15 (8): 1229-1235


    Human Nipah outbreaks recur in a specific region and time of year in Bangladesh. Fruit bats are the reservoir host for Nipah virus. We identified 23 introductions of Nipah virus into human populations in central and northwestern Bangladesh from 2001 through 2007. Ten introductions affected multiple persons (median 10). Illness onset occurred from December through May but not every year. We identified 122 cases of human Nipah infection. The mean age of case-patients was 27 years; 87 (71%) died. In 62 (51%) Nipah virus-infected patients, illness developed 5-15 days after close contact with another Nipah case-patient. Nine (7%) Nipah case-patients transmitted virus to others. Nipah case-patients who had difficulty breathing were more likely than those without respiratory difficulty to transmit Nipah (12% vs. 0%, p = 0.03). Although a small minority of infected patients transmit Nipah virus, more than half of identified cases result from person-to-person transmission. Interventions to prevent virus transmission from bats to humans and from person to person are needed.

    View details for DOI 10.3201/eid1508.081237

    View details for Web of Science ID 000268819100011

    View details for PubMedID 19751584

  • Difficulties in Maintaining Improved Handwashing Behavior, Karachi, Pakistan AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Agboatwalla, M., Bowen, A., Kenah, E., Sharker, Y., Hoekstra, R. M. 2009; 81 (1): 140-145


    In an earlier study in Karachi, Pakistan, households that received free soap and handwashing promotion for 9 months reported 53% less diarrhea than controls. Eighteen months after the intervention ended, these households were enrolled in a follow-up study to assess sustainability of handwashing behavior. Upon re-enrollment, mothers in households originally assigned to the intervention were 1.5 times more likely to have a place with soap and water to wash hands (79% versus 53%, P = 0.001) and when asked to wash hands were 2.2 times more likely to rub their hands together at least three times (50% versus 23%, P = 0.002) compared with controls. In the ensuing 14 months, former intervention households reported a similar proportion of person-days with diarrhea (1.59% versus 1.88%, P = 0.66) as controls. Although intervention households showed better handwashing technique after 2 years without intervention, their soap purchases and diarrhea experience was not significantly different from controls.

    View details for Web of Science ID 000267526500024

    View details for PubMedID 19556579

  • Invasive Pneumococcal Disease among Children in Rural Bangladesh: Results from a Population-Based Surveillance CLINICAL INFECTIOUS DISEASES Arifeen, S. E., Saha, S. K., Rahman, S., Rahman, K. M., Rahman, S. M., Bari, S., Naheed, A., Mannan, I., Seraji, M. H., Ahmed, N. U., Hassan, M. S., Huda, N., Siddik, A. U., Quasem, I., Islam, M., Fatima, K., Al-Emran, H., Brooks, W. A., Baqui, A. H., Breiman, R. F., Sack, D., Luby, S. P. 2009; 48: S103-S113


    Streptococcus pneumoniae infection is recognized as a global priority public health problem, and conjugate vaccines have been shown to prevent vaccine-type invasive pneumococcal disease (IPD) in children. However, better estimates of the disease burden and reliable population-based data on serotype composition are needed for vaccine development and implementation in developing countries.We initiated a population-based surveillance in the rural Bangladesh community of Mirzapur, covering a population of approximately 144,000. Village health care workers made weekly visits to approximately 12,000 children 1-59 months of age in the study area. Children with reported fever, cough, or difficulty breathing were assessed by the village health care workers using a clinical algorithm and were referred to the hospital if required. Children from the study area who were seen in the hospital underwent clinical examination and laboratory testing if they met standardized case definitions. IPD was confirmed by blood and/or cerebrospinal fluid culture results. Isolates were identified, tested for susceptibility to antibiotics, and serotyped in accordance with standard laboratory methods. We present here the results from the first 3 years of the surveillance (July 2004-June 2007).Village health care workers identified 5020 cases of possible severe pneumonia and/or very severe disease (165 cases per 1000 child-years)and 9411 cases of possible pneumonia (310 cases per 1000 child-years) as well as 2029 cases of suspected meningitis and/or very severe disease (67 cases per 1000 child-years) and 8967 cases of high fever and/or possible bacteremia (295 cases per 1000 child-years). Pneumonia was the single most common form of illness observed among 2596 hospitalizations (found in 977 [38%] of cases). We recovered 26 S. pneumoniae isolates (25 isolates from 6925 blood cultures and 1 isolate from 41 cerebrospinal fluid cultures), which gave an overall IPD incidence of 86 cases per 100,000 child-years. Invasive pneumococcal infection was common during infancy (with infants accounting for 23 of the 26 cases), and 50% of the total isolates were obtained from nonhospitalized patients who received a diagnosis of upper respiratory tract infection and fever. The most prevalent pneumococcal serotypes were serotypes 1, 5, 14, 18C, 19A, and 38. Ten of the 26 isolates were completely resistant to trimethoprim-sulfamethoxazole, and another 10 isolates had intermediate resistance.IPD contributes substantially to childhood morbidity in rural Bangladesh. S. pneumoniae can cause invasive but nonsevere disease in children, and IPD incidence can be seriously under reported if such cases are overlooked. The emerging high resistance to trimethoprim-sulfamethoxazole should be addressed. Data on serotype distribution would help to guide appropriate pneumococcal conjugate vaccine formulation.

    View details for DOI 10.1086/596543

    View details for Web of Science ID 000263061800010

    View details for PubMedID 19191605

  • Use of Multiple Surveillance Modalities to Assess the Epidemiology of Streptococcus pneumoniae Infection in Bangladesh CLINICAL INFECTIOUS DISEASES Luby, S. P., Brooks, W. A., Saha, S. K., El-Arifeen, S., Naheed, A., Sack, D., Breiman, R. F. 2009; 48: S97-S102


    Measuring the broad impact of pneumococcal disease requires multiple surveillance modalities. Four major data sources elucidate the burden of pneumococcal disease in Bangladesh. The Bangladesh Demographic and Health Survey has identified pneumonia as the leading cause of childhood death. By extrapolation of mortality rates in the survey to the Bangladesh population, it has been estimated that approximately 90,000 children >1 month and <5 years of age die of pneumonia every year in Bangladesh. Through hospital-based surveillance, a wide range of pneumococcal serotypes leading to hospitalization and pneumonia have been identified as a leading cause of pediatric hospitalization. Urban community-based surveillance has demonstrated that invasive pneumococcal disease (IPD) is common in the community. Rural community-based surveillance has demonstrated that serious IPD is common in rural areas. Together, these data provide a strong scientific case for the importance of pneumococcal disease prevention to child health in Bangladesh and, therefore, the potential benefit of an effective vaccine.

    View details for DOI 10.1086/596487

    View details for Web of Science ID 000263061800009

    View details for PubMedID 19191625

  • Successful co-administration of a human rotavirus and oral poliovirus vaccines in Bangladeshi infants in a 2-dose schedule at 12 and 16 weeks of age VACCINE Zaman, K., Sack, D. A., Yunus, M., Arifeen, S. E., Podder, G., Azim, T., Luby, S., Breiman, R. F., Neuzil, K., Datta, S. K., DELEM, A., Suryakiran, P. V., Bock, H. L. 2009; 27 (9): 1333-1339


    Co-administration of oral live-attenuated human rotavirus vaccine RIX4414 (Rotarix) and oral polio vaccine (OPV) was assessed. Healthy infants were randomised to receive 2-doses of either: RIX4414 or placebo co-administered with OPV (12 and 16 weeks of age); or RIX4414 or placebo given 15 days after OPV. After vaccination, 56.5-66.7% of RIX4414 and 18.6% of placebo recipients had seroconverted for rotavirus IgA. No significant differences between RIX4414 groups with or without OPV co-administration were observed. No statistically significant differences were observed between groups for polio seroprotection rates. RIX4414 vaccine was immunogenic when co-administered with OPV and did not interfere with OPV seroprotection rates.

    View details for DOI 10.1016/j.vaccine.2008.12.059

    View details for Web of Science ID 000264430400008

    View details for PubMedID 19162114

  • Flocculant-disinfectant point-of-use water treatment for reducing arsenic exposure in rural Bangladesh INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH Norton, D. M., Rahman, M., Shane, A. L., Hossain, Z., Kulick, R. M., Bhuiyan, M. I., Wahed, M. A., Yunus, M., Islam, M. S., Breiman, R. F., Henderson, A., Keswick, B. H., Luby, S. P. 2009; 19 (1): 17-29


    We introduced flocculant-disinfectant water treatment for 12 weeks in 103 households in Bangladesh to assess if drinking water would be chemically and microbiologically improved and the body burden of arsenic reduced. The median concentration of arsenic in tubewell water decreased by 88% after introduction of the flocculant-disinfectant from 136 microg/l at baseline to 16 (p < 0.001). The median concentration of total urinary arsenic decreased 42% from 385 microg/g creatinine at baseline to 225 microg/g creatinine after intervention (p < 0.001). Among 206 post-intervention drinking water samples that were reportedly treated on the date the sample was collected, 99 (48%) lacked residual free chlorine and 100 (49%) were contaminated with thermotolerant coliforms. The flocculant-disinfectant markedly reduced arsenic in drinking water, but treated drinking water was frequently contaminated with fecal organisms. The lesser reduction in urinary arsenic compared to water arsenic and the health consequences of this reduction require further research.

    View details for DOI 10.1080/09603120802272219

    View details for Web of Science ID 000263715700002

    View details for PubMedID 19241244

  • Identification of Serotype in Culture Negative Pneumococcal Meningitis Using Sequential Multiplex PCR: Implication for Surveillance and Vaccine Design PLOS ONE Saha, S. K., Darmstadt, G. L., Baqui, A. H., Hossain, B., Islam, M., Foster, D., Al-Emran, H., Naheed, A., El Arifeen, S., Luby, S. P., Santosham, M., Crook, D. 2008; 3 (10)


    PCR-based serotyping of Streptococcus pneumoniae has been proposed as a simpler approach than conventional methods, but has not been applied to strains in Asia where serotypes are diverse and different from other part of the world. Furthermore, PCR has not been used to determine serotype distribution in culture-negative meningitis cases.Thirty six serotype-specific primers, 7 newly designed and 29 previously published, were arranged in 7 multiplex PCR sets, each in new hierarchies designed for overall serotype distribution in Bangladesh, and specifically for meningitis and non-meningitis isolates. Culture-negative CSF specimens were then tested directly for serotype-specific sequences using the meningitis-specific set of primers. PCR-based serotyping of 367 strains of 56 known serotypes showed 100% concordance with quellung reaction test. The first 7 multiplex reactions revealed the serotype of 40% of all, and 31% and 48% non-meningitis and meningitis isolates, respectively. By redesigning the multiplex scheme specifically for non-meningitis or meningitis, the quellung reaction of 43% and 48% of respective isolates could be identified. Direct examination of 127 culture-negative CSF specimens, using the meningitis-specific set of primers, yielded serotype for 51 additional cases.This PCR approach, could improve ascertainment of pneumococcal serotype distributions, especially for meningitis in settings with high prior use of antibiotics.

    View details for DOI 10.1371/journal.pone.0003576

    View details for Web of Science ID 000265131700003

    View details for PubMedID 18974887

  • Tubewell water quality and predictors of contamination in three flood-prone areas in Bangladesh JOURNAL OF APPLIED MICROBIOLOGY Luby, S. P., Gupta, S. K., Sheikh, M. A., Johnston, R. B., Ram, P. K., Islam, M. S. 2008; 105 (4): 1002-1008


    To measure enteric bacterial contamination of tubewells in three flood prone areas in Bangladesh and the relationship of bacteriological contamination with tubewell sanitary inspection scores.Microbiologists selected 207 tubewells in three flood prone districts, assessed physical characteristics of the tubewells and collected a single water sample from each tubewell. Tubewell water samples were contaminated with total coliforms (41%, n = 85), thermotolerant coliforms (29%, n = 60) and Escherichia coli (13%, n = 27). Among contaminated wells, the median CFU of contamination per 100 ml was 8 (interquartile range, 2-30) total coliforms, 5 (interquartile range, 2-23) thermotolerant coliforms and 6 (interquartile range, 1-30) E. coli. There was no significant association between tubewell contamination with E. coli, thermotolerant coliforms or total coliforms and a poor sanitary inspection score, though a history of inundation was associated with contamination with both E. coli and thermotolerant coliforms.Tubewells in flood-prone regions of Bangladesh were commonly contaminated with low levels of faecal organisms, contamination that could not be predicted by examining the tubewell's external characteristics.The forms currently used for sanitary inspection do not identify the most important causes of drinking water contamination in these communities.

    View details for DOI 10.1111/j.1365-2672.2008.03826.x

    View details for Web of Science ID 000259270500008

    View details for PubMedID 18422953

  • Infectious diseases and vaccine sciences: Strategic directions JOURNAL OF HEALTH POPULATION AND NUTRITION Luby, S. P., Brooks, W. A., Zaman, K., Hossain, S., Ahmed, T. 2008; 26 (3): 295-310


    Despite substantial progress, infectious diseases remain important causes of ill-health and premature deaths in Bangladesh. Bangladesh has experienced a > 90% reduction in the incidence of deaths due to childhood diarrhoea over the last 25 years. Further reductions can be achieved through the introduction of effective vaccines against rotavirus and improvements in home hygiene, quality of drinking-water, and clinical case management, including appropriate use of oral rehydration solution and zinc. Pneumonia is now the leading cause of childhood deaths in Bangladesh, and the pneumonia-specific child mortality is largely unchanged over the last 25 years. Reductions in mortality due to pneumonia can be achieved through the introduction of protein conjugate vaccines against Haemophilus influenza type b and Streptococcus pneumoniae, improvements in case management, including efforts to prevent delays in providing appropriate treatment, and the wider use of zinc. Tuberculosis is responsible for an estimated 70,000 deaths each year in Bangladesh. Although services for directly-observed therapy have expanded markedly, improved case finding and involvement of private practitioners will be important to reduce the burden of disease.

    View details for Web of Science ID 000259552300006

    View details for PubMedID 18831226

  • Clinical value of Tubex (TM) and Typhidot (R) rapid diagnostic tests for typhoid fever in an urban community clinic in Bangladesh DIAGNOSTIC MICROBIOLOGY AND INFECTIOUS DISEASE Naheed, A., Ram, P. K., Brooks, W. A., Mintz, E. D., Hossain, M. A., Parsons, M. M., Luby, S. P., Breiman, R. F. 2008; 61 (4): 381-386


    Tubex and Typhidot, rapid tests for typhoid fever, performed well in evaluations conducted in hospital settings among patients with culture-confirmed typhoid fever. We evaluated these tests in a community clinic in Bangladesh. Blood samples were obtained from 867 febrile patients for culture, Typhidot and Tubex tests. Considering the 43 blood culture-confirmed cases of typhoid fever as typhoid positive and the 24 other confirmed bacteremia cases as typhoid negative, Tubex was 60% sensitive and 58% specific, with 90% positive and 58% negative predictive values (NPVs); Typhidot was 67% sensitive and 54% specific, with 85% positive and 81% NPVs. When blood culture-negative patients and other bacteremia cases together were considered typhoid negative, positive predictive values were only 14% for Tubex and 13% for Typhidot, increasing to only 38% and 20% when restricted to patients with > or = 7 days of fever. We conclude that the value of Tubex and Typhidot tests for typhoid fever diagnosis in a community clinic in urban Bangladesh is low.

    View details for DOI 10.1016/j.diagmicrobio.2008.03.018

    View details for Web of Science ID 000258219100003

    View details for PubMedID 18501549

  • The chulli water purifier: Acceptability and effectiveness of an innovative strategy for household water treatment in Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Gupta, S. K., Islam, M. S., Johnston, R., Ram, P. K., Luby, S. P. 2008; 78 (6): 979-984


    To evaluate the effectiveness of the chulli water purifier, a new household water treatment strategy in Bangladesh that relies on passing water through a stove, we interviewed persons who had this water purifier. From households using it regularly, we tested untreated water, sand-filtered water without heat pasteurization, sand-filtered and heat pasteurized water, and household stored, treated water. Reasons for discontinuing use among 80 of 101 persons included mechanical problems (49%), inconvenience (35%), and high cost (10%). Only four households were regularly using the purifier. Three (19%) of 16 heat-treated samples were positive for Escherichia coli. The median log reduction from source water was > 5. Nine (56%) stored water samples were positive for E. coli, indicating recontamination. Poor durability, inconvenience, high cost, and post-treatment contamination limit the usefulness of the purifier. These issues, which are relevant for other household water treatment strategies, should be resolved before further implementation.

    View details for Web of Science ID 000256504500025

    View details for PubMedID 18541780

  • Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh TROPICAL MEDICINE & INTERNATIONAL HEALTH Luby, S. P., Halder, A. K. 2008; 13 (6): 835-844


    To explore the relationship of easy to collect handwashing indicators with socioeconomic status and reported respiratory disease among children <5 years of age.We added several handwashing indicators to a population-based, cross-sectional study of respiratory illness in Dhaka, Bangladesh. We constructed a wealth index using 12 household characteristics analysed with principal component analysis to assess socioeconomic status.Of 6970 households, 92% had a bar of body soap, 41% had a place with water to wash hands inside the house, and 40% had soap present at the most convenient place to wash hands. Handwashing indicators were more common among households with higher socioeconomic status. Within each wealth quintile a place to wash hands within the household was strongly associated with the presence of soap at the handwashing location (odds ratios 13-70). In general estimated equation models that controlled for socioeconomic status, the presence of a place inside the house with water to wash hands was the only handwashing indicator significantly associated with a child in the household who reported cough or difficulty breathing in the preceding 7 days (adjusted odds ratio 0.95, 95% confidence interval 0.93-0.98, P < 0.001).Handwashing indicators were strongly influenced by socio-economic status and so would not be an independent measure of handwashing behaviour. Handwashing promotion efforts in urban Dhaka that include specific efforts to provide handwashing facilities inside the house are more likely to improve handwashing behaviour than interventions that ignore this component.

    View details for DOI 10.1111/j.1365-3156.2008.02074.x

    View details for Web of Science ID 000255836600012

    View details for PubMedID 18363587

  • Usefulness of the hydrogen sulfide test for assessment of water quality in Bangladesh JOURNAL OF APPLIED MICROBIOLOGY Gupta, S. K., Sheikh, M. A., Islam, M. S., Rahman, K. S., Jahan, N., Rahman, M. M., Hoekstra, R. M., Johnston, R., Ram, P. K., Luby, S. 2008; 104 (2): 388-395


    To evaluate the usefulness of the hydrogen sulfide (H(2)S) test for assessing water quality in Bangladesh.We tested 382 water samples from a variety of sources using locally produced H(2)S test kits and laboratory-based membrane filtration for the detection of Escherichia coli. Compared with membrane filtration, H(2)S tests, when incubated for 24 h, had both a sensitivity and positive predictive value (PPV) of <40% when analysis was restricted to water samples with E. coli levels below 100 colony forming units (CFU) per 100 ml. In contrast, for E. coli levels from 1000 to 9999 CFU per 100 ml, sensitivity was 94% and PPV 88%; specificity was 97% and negative predictive value was 99%.The hydrogen sulfide test, when incubated at 24 h, is a promising alternative for assessing water quality where E. coli levels may be high. An improved understanding of the incremental impact of contamination level on health is needed to better determine its usefulness.The hydrogen sulfide test is inexpensive, easy to use and portable. Its use may allow rapid assessment of water quality in situations where cost or logistics prevent use of other testing methods, such as in remote areas or during flood and other natural disasters.

    View details for DOI 10.1111/j.1365-2672.2007.03562.x

    View details for Web of Science ID 000252496100007

    View details for PubMedID 17922823

  • Deaths from rotavirus disease in Bangladeshi children - Estimates from hospital-based surveillance PEDIATRIC INFECTIOUS DISEASE JOURNAL Tanaka, G., Faruque, A. S., Luby, S. P., Malek, M. A., Glass, R. I., Parashar, U. D. 2007; 26 (11): 1014-1018


    To assess the potential health benefits of introducing new rotavirus (RV) vaccines, we estimated mortality from RV gastroenteritis in Bangladeshi children <5 years of age.We examined data from ongoing diarrhea surveillance in a systematic 2% sample (4% until 1995) of patients visiting the International Centre for Diarrheal Disease Research, Bangladesh, Dhaka Hospital during 1993-2004 and all patients visiting the rural Matlab Hospital during 2000-2004. To estimate deaths from RV, we multiplied the proportion of diarrhea visits attributable to RV with 2004 estimates of diarrhea deaths in Bangladeshi children.At Dhaka Hospital, RV was detected in 33% of 18,300 children with diarrhea. The proportion of diarrhea attributable to RV nearly doubled during 2002-2004 compared with 1993-1995 (42% versus 22%, P < 0.001). At Matlab Hospital, RV was detected in 35% of 4597 children with diarrhea. At both sites, most RV cases were among children age 3-24 months and the number of cases peaked during the cool and dry months from December through February. Of the 325,600 deaths among children <5 years that occur each year, we estimated 5600 to 9400 (2-3%) were attributable to RV. Thus, between 1 in 390 and 1 in 660 children born in Bangladesh each year die of RV infection by age 5.These data clearly demonstrate the tremendous health burden of RV gastroenteritis. The increasing proportion of severe diarrhea cases underscores the need for specific interventions against RV, such as vaccines, to further reduce diarrhea mortality and morbidity.

    View details for DOI 10.1097/INF.0b013e318125721c

    View details for Web of Science ID 000250818300007

    View details for PubMedID 17984808

  • Person-to-person transmission of Nipah virus in a Bangladeshi community EMERGING INFECTIOUS DISEASES Gurley, E. S., Montgomery, J. M., Hossain, M. J., Bell, M., Azad, A. K., Islam, M. R., Molla, M. A., Carroll, D. S., Ksiazek, T. G., Rota, P. A., Lowe, L., Comer, J. A., Rollin, P., Czub, M., Grolla, A., Feldmann, H., Luby, S. P., Woodward, J. L., Breiman, R. F. 2007; 13 (7): 1031-1037


    An encephalitis outbreak was investigated in Faridpur District, Bangladesh, in April-May 2004 to determine the cause of the outbreak and risk factors for disease. Biologic specimens were tested for Nipah virus. Surfaces were evaluated for Nipah virus contamination by using reverse transcription-PCR (RT-PCR). Thirty-six cases of Nipah virus illness were identified; 75% of case-patients died. Multiple peaks of illness occurred, and 33 case-patients had close contact with another Nipah virus patient before their illness. Results from a case-control study showed that contact with 1 patient carried the highest risk for infection (odds ratio 6.7, 95% confidence interval 2.9-16.8, p < 0.001). RT-PCR testing of environmental samples confirmed Nipah virus contamination of hospital surfaces. This investigation provides evidence for person-to-person transmission of Nipah virus. Capacity for person-to-person transmission increases the potential for wider spread of this highly lethal pathogen and highlights the need for infection control strategies for resource-poor settings.

    View details for Web of Science ID 000247758200010

    View details for PubMedID 18214175

  • Risk factors for typhoid fever in a slum in Dhaka, Bangladesh EPIDEMIOLOGY AND INFECTION Ram, P. K., Naheed, A., Brooks, W. A., Hossain, M. A., Mintz, E. D., Breiman, R. F., Luby, S. P. 2007; 135 (3): 458-465


    We systematically investigated risk factors for typhoid fever in Kamalapur, a poor urban area of Bangladesh, to inform targeted public health measures for its control. We interviewed patients with typhoid fever and two age-matched controls per case about exposures during the 14 days before the onset of illness. The municipal water supply was used by all 41 cases and 81of 82 controls. In multivariate analysis, drinking unboiled water at home was a significant risk factor [adjusted odds ratio (aOR) 12.1, 95% CI 2.2-65.6]. Twenty-three (56%) cases and 21 (26%) controls reported that water from the primary source was foul-smelling (aOR 7.4, 95% CI 2.1-25.4). Eating papaya was associated with illness (aOR 5.2, 95% CI 1.2-22.2). Using a latrine for defecation was significantly protective (aOR 0.1, 95% CI 0.02-0.9). Improved chlorination of the municipal water supply or disinfecting drinking water at the household level may dramatically reduce the risk of typhoid fever in Kamalapur. The protective effect of using latrines, particularly among young children, should be investigated further.

    View details for DOI 10.1017/S0950268806007114

    View details for Web of Science ID 000246221000012

    View details for PubMedID 16893490

  • Foodborne transmission of Nipah virus, Bangladesh EMERGING INFECTIOUS DISEASES Luby, S. P., Rahman, M., Hossain, M. J., Blum, L. S., Husain, M. M., Gurley, E., Khan, R., Ahmed, B., Rahman, S., Nahar, N., Kenah, E., Comer, J. A., Ksiazek, T. G. 2006; 12 (12): 1888-1894


    We investigated an outbreak of encephalitis in Tangail District, Bangladesh. We defined case-patients as persons from the outbreak area in whom fever developed with new onset of seizures or altered mental status from December 15, 2004, through January 31, 2005. Twelve persons met the definition; 11 (92%) died. Serum specimens were available from 3; 2 had immunoglobulin M antibodies against Nipah virus by capture enzyme immunoassay. We enrolled 11 case-patients and 33 neighborhood controls in a case-control study. The only exposure significantly associated with illness was drinking raw date palm sap (64% among case-patients vs. 18% among controls, odds ratio [OR] 7.9, p = 0.01). Fruit bats (Pteropus giganteus) are a nuisance to date palm sap collectors because the bats drink from the clay pots used to collect the sap at night. This investigation suggests that Nipah virus was transmitted from P. giganteus to persons through drinking fresh date palm sap.

    View details for Web of Science ID 000242301900013

    View details for PubMedID 17326940

  • Diarrheal epidemics in Dhaka, Bangladesh, during three consecutive floods: 1988, 1998, and 2004 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Schwartz, B. S., Harris, J. B., Khan, A. I., Larocque, R. C., Sack, D. A., Malek, M. A., Faruque, A. S., Qadri, F., Calderwood, S. B., Luby, S. P., Ryan, E. T. 2006; 74 (6): 1067-1073


    We examined demographic, microbiologic, and clinical data from patients presenting during 1988, 1998, and 2004 flood-associated diarrheal epidemics at a diarrhea treatment hospital in Dhaka, Bangladesh. Compared with non-flood periods, individuals presenting during flood-associated epidemics were older, more severely dehydrated, and of lower socioeconomic status. During flood-associated epidemics, Vibrio cholerae was the most commonly identified cause of diarrhea, and the only diarrheal pathogen whose incidence proportionally increased in each epidemic compared with seasonally matched periods. Rotavirus was the second most frequently identified flood-associated pathogen, although the proportion of cases caused by rotavirus infection decreased during floods compared with matched periods. Other causes of diarrhea did not proportionally change, although more patients per day presented with enterotoxigenic Escherichia coli, Shigella, and Salmonella species-associated diarrhea during floods compared with matched periods. Our findings suggest that cholera is the predominant cause of flood-associated diarrheal epidemics in Dhaka, but that other organisms spread by the fecal-oral route also contribute.

    View details for Web of Science ID 000238200900024

    View details for PubMedID 16760521

  • No evidence for prolonged excretion of polioviruses in persons with residual paralytic poliomyelitis in Ethiopia, Pakistan and Guatemala BIOLOGICALS Khan, A. J., Gebreselassie, H., Asturias, E. J., Agboatwalla, M., Teklehaimanot, R., Luby, S. P., Bayene, B., Chezzi, C., Asghar, H., Moatter, T., Torres, O. R., Kew, O., Winkelstein, J., Halsey, N. A. 2006; 34 (2): 113-116


    Persons who have developed acute flaccid paralysis following infection with wild-type polioviruses or vaccine-associated paralytic poliomyelitis usually excrete polioviruses for only a few weeks. However, some patients with paralytic poliomyelitis have had prolonged excretion of polioviruses for periods of up to 10 years after onset of disease. Most prolonged excretors have been identified in industrialized countries. We studied 348 patients 2-28 years old in Ethiopia, Pakistan and Guatemala with residual paralytic poliomyelitis to determine if they had IgA or IgG deficiency or persistent poliomyelitis excretion at least 1 year after onset of disease. None of the 348 affected individuals had IgG deficiency or persistent poliovirus excretion. One child had borderline low serum IgA concentration. Since we did not study children under 2 years of age, persons born with IgG deficiency disorders may have died in developing countries where replacement immunoglobulin therapy is not readily available. Nevertheless, persistent poliovirus excretion among persons 2 years of age and older with residual paralytic poliomyelitis is uncommon in developing countries.

    View details for DOI 10.1016/j.biologicals.2006.03.004

    View details for Web of Science ID 000238304800008

    View details for PubMedID 16682222

  • Chlorine spot treatment of flooded tube wells, an efficacy trial JOURNAL OF APPLIED MICROBIOLOGY Luby, S., Islam, M. S., Johnston, R. 2006; 100 (5): 1154-1158


    To evaluate the water quality of recently flooded tube wells in Bangladesh and the effect of spot chlorination on improving bacteriological quality.The study team identified and tested water samples from 127 tube wells that were flooded within the preceding 4 weeks. Twenty-six of the tube wells with the highest concentration of thermotolerant coliform bacteria were randomly assigned to spot chlorination vs control. On initial screening, water samples from 56 recently inundated tube wells (44%) were contaminated with thermotolerant coliforms. Among the 13 wells randomized to chlorination, there was no change in the proportion of water samples that had no detectable thermotolerant coliform bacteria immediately before chlorine treatment (n = 4, 23%) and 60 min following chlorine treatment (n = 4, 23%). Similarly, there was no difference in the proportion of water samples that had no detectable thermotolerant coliforms between chlorine spot treated and control tube wells 7-18 days later (31 vs 23%P = 0.66).Spot chlorine treatment of inundated tube wells in Bangladesh three to 6 weeks after the flooding did not improve drinking water quality.Unless modified methods improve effectiveness, resources should not be spent promoting spot chlorination of flooded tube wells.

    View details for DOI 10.1111/j.1365-2672.2006.02940.x

    View details for Web of Science ID 000237626800027

    View details for PubMedID 16630017

  • Toxoplasma gondii infection in rural Guatemalan children AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Jones, J. L., Lopez, B., Mury, M. A., Wilson, M., Klein, R., Luby, S., Maguire, J. H. 2005; 72 (3): 295-300


    To determine the prevalence and risk factors for Toxoplasma gondii infection in Guatemalan children, in 1999 and 2003 we surveyed caretakers and serologically tested children in the San Juan Sacatepequez area using Platelia Toxo IgG TMB enzyme immunoassay kits. In 1999, of 532 children six months to two years old, 66 (12.4%) were antibody positive. In 2003, in 500 children 3-10 years old antibody prevalence increased from 24% to 43% at age five years then leveled off. By multivariate analysis, drinking well water (relative risk [RR] = 1.78, 95% confidence limit [CL] = 1.00, 3.17, P = 0.05) and not cleaning up cat feces (RR = 2.06, 95% CL = 1.00, 4.28, P = 0.05) increased the risk of T. gondii seropositivity. Most T. gondii infections in children from these villages occurred by age five, but half were still not infected by adolescence. Therefore, it is important to educate girls entering child-bearing age about the risks of acute T. gondii infection and the local risk factors for infection.

    View details for Web of Science ID 000227752100014

    View details for PubMedID 15772325

  • Hypertension and its determinants among adults in high mountain villages of the Northern Areas of Pakistan JOURNAL OF HUMAN HYPERTENSION Shah, S. M., Luby, S., Rahbar, M., Khan, A. W., MCCORMICK, J. B. 2001; 15 (2): 107-112


    We studied the prevalence and determinants of hypertension among adults in mountainous rural villages in the Ghizar district Northern Areas of Pakistan, an area that recently has undergone substantial economic development. We selected a stratified random sample of 4203 adults (age > 18 years) from 16 villages in Punial Valley of Ghizar district where the number of study subjects from each village was proportionate to the size of the village. We obtained blood pressure (BP) records by taking the mean of the second and third BP measurement, using a standard mercury sphygmomanometer, and assessed risk factors for hypertension in the study subjects. The mean +/- s.d. blood pressures (mm Hg) were 125 +/- 19 systolic and 80 +/- 12 diastolic in men and 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The mm Hg, or systolic BP > or = 140 mm Hg or currently taking antihypertensive medication) was 15%, increasing from 4% in the 18-29 year age group to 36% among persons 60 years of age or older. The age-standardised prevalence of hypertension was 14% (12.5% among men and 14% among women). There was no significant difference in prevalence of hypertension in males, and in females. Multivariate analysis revealed that age, and higher body mass index (overweight and obesity) were independently associated with higher prevalence of hypertension. People with hypertension were more likely to have a first-degree relative with physician-diagnosed hypertension (OR = 1.90, 95% CI 1.49, 2). Hypertension is a significant health problem in rural northern Pakistan. The primary health care programme in the Northern Areas of Pakistan needs to address this problem, especially identifying people at risk.

    View details for Web of Science ID 000167349300006

    View details for PubMedID 11317189