Stephen Luby

All Publications

• Food safety policy enforcement and associated actions reduce turmeric lead chromate adulteration across Bangladesh. Environmental research Forsyth, J. E., Baker, M., Nurunnahar, S., Islam, S., Islam, M. S., Islam, T., Plambeck, E., Winch, P. J., Mistree, D., Luby, S. P., Rahman, M. 2023: 116328

  Abstract

  Turmeric adulterated with lead chromate pigment has been previously identified as a primary source of lead exposure in Bangladesh. This study assesses the impact of a multi-faceted intervention between 2017 and 2021 to reduce lead-tainted turmeric in Bangladesh. The intervention involved: i) disseminating findings from scientific studies via news media that identified turmeric as a source of lead poisoning, ii) educating consumers and businesspeople about the risks of lead chromate in turmeric via public notices and face-to-face meetings, and iii) collaborating with the Bangladesh Food Safety Authority to utilize a rapid lead detection technology to enforce policy disallowing turmeric adulteration. Before and after the intervention, evidence of lead chromate turmeric adulteration was assessed at the nation's largest turmeric wholesale market and at turmeric polishing mills across the country. Blood lead levels of workers at two mills were also assessed. Forty-seven interviews were conducted with consumers, businesspeople, and government officials to assess changes in supply, demand, and regulatory capacity. The proportion of market turmeric samples containing detectable lead decreased from 47% pre-intervention in 2019 to 0% in 2021 (n = 631, p < 0.0001). The proportion of mills with direct evidence of lead chromate adulteration (pigment on-site) decreased from 30% pre-intervention in 2017 to 0% in 2021 (n = 33, p < 0.0001). Blood lead levels dropped a median of 30% (IQR: 21-43%), while the 90th percentile dropped 49% from 18.2 μg/dL to 9.2 μg/dL 16 months after the intervention (n = 15, p = 0.033). Media attention, credible information, rapid lead detection tools and swift government action to enforce penalties all contributed to the intervention's success. Subsequent efforts should evaluate if this is an example of an effective intervention that can be replicated to reduce lead chromate adulteration of spices globally.

  View details for DOI 10.1016/j.envres.2023.116328

  View details for PubMedID 37286126

• Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh SCIENCE Abaluck, J., Kwong, L. H., Styczynski, A., Haque, A., Kabir, M., Bates-Jefferys, E., Crawford, E., Benjamin-Chung, J., Raihan, S., Rahman, S., Benhachmi, S., Bintee, N., Winch, P. J., Hossain, M., Reza, H., Jaber, A., Momen, S., Rahman, A., Banti, F., Huq, T., Luby, S. P., Mobarak, A. 2022; 375 (6577): 160-+

  View details for DOI 10.1126/science.abi9069

  View details for Web of Science ID 000742401600026

• Assessing the feasibility of Nipah vaccine efficacy trials based on previous outbreaks in Bangladesh. Vaccine Nikolay, B., Ribeiro Dos Santos, G., Lipsitch, M., Rahman, M., Luby, S. P., Salje, H., Gurley, E. S., Cauchemez, S. 2021

  Abstract

  BACKGROUND: Nipah virus (NiV) is an emerging, bat-borne pathogen that can be transmitted from person-to-person. Vaccines are currently being developed for NiV, and studies have been funded to evaluate their safety and immunogenicity. An important unanswered question is whether it will be possible to evaluate the efficacy of vaccine candidates in phase III clinical trials in a context where spillovers from the zoonotic reservoir are infrequent and associated with small outbreaks. The objective of this study was to investigate the feasibility of conducting a phase III vaccine trial in Bangladesh, the only country regularly reporting NiV cases.METHODS: We used simulations based on previously observed NiV cases from Bangladesh, an assumed vaccine efficacy of 90% and other NiV vaccine target characteristics, to compare three vaccination study designs: (i) cluster randomized ring vaccination, (ii) cluster randomized mass vaccination, and (iii) an observational case-control study design.RESULTS: The simulations showed that, assuming a ramp-up period of 10days and a mean hospitalization delay of 4days,a cluster-randomized ring vaccination trial would require 516years and over 163,000 vaccine doses to run a ring vaccination trial under current epidemic conditions. A cluster-randomized mass vaccination trial in the two most affected districts would take 43years and 1.83 million vaccine doses. An observational case-control design in these two districts would require seven years and 2.5 million vaccine doses.DISCUSSION: Without a change in the epidemiology of NiV, ring vaccination or mass vaccination trials are unlikely to be completed within a reasonable time window. In this light, the remaining options are: (i) not conducting a phase III trial until the epidemiology of NiV changes, (ii) identifying alternative ways to licensure such as observational studies or controlled studies in animals such as in the US Food and Drug Administration's (FDA) Animal Rule.

  View details for DOI 10.1016/j.vaccine.2021.08.027

  View details for PubMedID 34426025

• Scalable deep learning to identify brick kilns and aid regulatory capacity. Proceedings of the National Academy of Sciences of the United States of America Lee, J., Brooks, N. R., Tajwar, F., Burke, M., Ermon, S., Lobell, D. B., Biswas, D., Luby, S. P. 2021; 118 (17)

  Abstract

  Improving compliance with environmental regulations is critical for promoting clean environments and healthy populations. In South Asia, brick manufacturing is a major source of pollution but is dominated by small-scale, informal producers who are difficult to monitor and regulate-a common challenge in low-income settings. We demonstrate a low-cost, scalable approach for locating brick kilns in high-resolution satellite imagery from Bangladesh. Our approach identifies kilns with 94.2% accuracy and 88.7% precision and extracts the precise GPS coordinates of every brick kiln across Bangladesh. Using these estimates, we show that at least 12% of the population of Bangladesh (>18 million people) live within 1 km of a kiln and that 77% and 9% of kilns are (illegally) within 1 km of schools and health facilities, respectively. Finally, we show how kilns contribute up to 20.4 mug/[Formula: see text] of [Formula: see text] (particulate matter of a diameter less than 2.5 mum) in Dhaka when the wind blows from an unfavorable direction. We document inaccuracies and potential bias with respect to local regulations in the government data. Our approach demonstrates how machine learning and Earth observation can be combined to better understand the extent and implications of regulatory compliance in informal industry.

  View details for DOI 10.1073/pnas.2018863118

  View details for PubMedID 33888583

• Monitoring of diverse enteric pathogens across environmental and host reservoirs with TaqMan array cards and standard qPCR: a methodological comparison study. The Lancet. Planetary health Lappan, R. n., Henry, R. n., Chown, S. L., Luby, S. P., Higginson, E. E., Bata, L. n., Jirapanjawat, T. n., Schang, C. n., Openshaw, J. J., O'Toole, J. n., Lin, A. n., Tela, A. n., Turagabeci, A. n., Wong, T. H., French, M. A., Brown, R. R., Leder, K. n., Greening, C. n., McCarthy, D. n. 2021; 5 (5): e297–e308

  Abstract

  Multiple bacteria, viruses, protists, and helminths cause enteric infections that greatly impact human health and wellbeing. These enteropathogens are transmited via several pathways through human, animal, and environmental reservoirs. Individual qPCR assays have been extensively used to detect enteropathogens within these types of samples, whereas the TaqMan array card (TAC), which allows simultaneous detection of multiple enteropathogens, has only previously been validated in human clinical samples.In this methodological comparison study, we compared the performance of a custom 48-singleplex TAC relative to standard qPCR. We established the sensitivity and specificity of each method for the detection of eight enteric targets, by using spiked samples with varying levels of PCR inhibition. We then tested the prevalence and abundance of pathogens in wastewater from Melbourne (Australia), and human, animal, and environmental samples from informal settlements in Suva, Fiji using both TAC and qPCR.Both methods exhibited similarly h specificity (TAC 100%, qPCR 94%), sensitivity (TAC 92%, qPCR 100%), and quantitation accuracy (TAC 91%, qPCR 99%) in non-inhibited sample matrices with spiked gene fragments. PCR inhibitors substantially affected detection via TAC, though this issue was alleviated by ten-fold sample dilution. Among samples from informal settlements, the two techniques performed similarly for detection (89% agreement) and quantitation (R2 0·82) for the eight enteropathogen targets. The TAC additionally included 38 other enteric targets, enabling detection of diverse faecal pathogens and extensive environmental contamination that would be prohibitively labour intensive to assay by standard qPCR.The two techniques produced similar results across diverse sample types, with qPCR prioritising greater sensitivity and quantitation accuracy, and TAC trading small reductions in these for a cost-effective larger enteropathogen panel enabling a greater number of enteric pathogens to be analysed concurrently, which is beneficial given the abundance and variety of enteric pathogens in environments such as urban informal settlements. The ability to monitor multiple enteric pathogens across diverse reservoirs could allow better resolution of pathogen exposure pathways, and the design and monitoring of interventions to reduce pathogen load.Wellcome Trust Our Planet, Our Health programme.

  View details for DOI 10.1016/S2542-5196(21)00051-6

  View details for PubMedID 33964239

• Associations between ambient fine particulate matter and child respiratory infection: The role of particulate matter source composition in Dhaka, Bangladesh. Environmental pollution (Barking, Essex : 1987) Sherris, A. R., Begum, B. A., Baiocchi, M., Goswami, D., Hopke, P. K., Brooks, W. A., Luby, S. P. 2021; 290: 118073

  Abstract

  Air pollution in the form of fine particulate matter (PM2.5) has been linked to adverse respiratory outcomes in children. However, the magnitude of this association in South Asia and sources of PM2.5 that drive adverse health effects are largely unknown. This study evaluates associations between short-term variation in ambient PM2.5 and incidence of pneumonia and upper respiratory infections among children in Dhaka, Bangladesh. We also perform an exploratory analysis of the PM2.5 source composition that is most strongly associated with health endpoints. We leveraged data from health surveillance of children less than five years of age between 2005 and 2014 in Kamalapur, Bangladesh, including daily physician-confirmed diagnoses of pneumonia and upper respiratory infection. Twice-weekly source-apportioned ambient PM2.5 measurements were obtained for the same period, and Poisson regression adjusted for time-varying covariates was used to estimate lagged associations between ambient PM2.5 and respiratory infection. We use complementary matching and stratification approaches to evaluate whether these associations vary across PM2.5 source composition. Total PM2.5 mass was associated with a modest increase in incidence of pneumonia, with a peak effect size two days after exposure (rate ratio = 1.032; 95% confidence interval = 1.008-1.056). We did not identify a significant association between PM2.5 and upper respiratory infection. Stratified and matching analyses suggested this association was stronger among days when ambient PM2.5 had a higher mass percent associated with brick kiln and fugitive lead emissions.: This study suggests that elevated ambient PM2.5 contributes to increased incidence of child pneumonia in urban Dhaka, and that this relationship varies among days with different source composition of PM2.5.

  View details for DOI 10.1016/j.envpol.2021.118073

  View details for PubMedID 34496331

• Sources of Blood Lead Exposure in Rural Bangladesh ENVIRONMENTAL SCIENCE & TECHNOLOGY Forsyth, J. E., Weaver, K. L., Maher, K., Islam, M., Raqib, R., Rahman, M., Fendorf, S., Luby, S. P. 2019; 53 (19): 11429–36

  Abstract

  Lead (Pb) exposure is a major public health problem worldwide. Although high levels of Pb in blood in Bangladesh have been documented, the dominant Pb sources contributing to human exposure in rural Bangladesh have not been determined. Here, we first obtained blood from pregnant women from three rural Bangladeshi districts who were previously assessed by a case-control and sampling study, and we then conducted semistructured in-depth interviews to understand Pb exposure behavior and finally collected samples of the suspected Pb sources. We measured the Pb isotopic composition of both potential Pb sources and 45 blood samples in order to understand which of three sources predominate: (1) food from Pb-soldered cans, (2) turmeric, or (3) geophagous materials (clay, soil, or ash). The Pb isotope ratios of the three sources are distinct (p = 0.0001) and blood isotope ratios are most similar to turmeric. Elevated lead and chromium (Cr) concentrations in turmeric and a yellow pigment used in turmeric processing are consistent with reported consumption behavior that indicated turmeric as a primary contributor to blood Pb. The Pb isotopic composition analyses combined with a case-control and sampling approach provides evidence that turmeric adulterated with the yellow Pb-bearing pigment is the main Pb exposure source in these districts and illustrates the need to assess drivers and practices of turmeric adulteration, as well as the prevalence of adulteration across South Asia.

  View details for DOI 10.1021/acs.est.9b00744

  View details for Web of Science ID 000488993500041

  View details for PubMedID 31525910

• Effect of in-line drinking water chlorination at the point of collection on child diarrhoea in urban Bangladesh: a double-blind, cluster-randomised controlled trial LANCET GLOBAL HEALTH Pickering, A. J., Crider, Y., Sultana, S., Swarthout, J., Goddard, F. B., Islam, S., Sen, S., Ayyagari, R., Luby, S. P. 2019; 7 (9): E1247–E1256

  View details for Web of Science ID 000480291600028

• Turmeric means "yellow" in Bengali: Lead chromate pigments added to turmeric threaten public health across Bangladesh. Environmental research Forsyth, J. E., Nurunnahar, S. n., Islam, S. S., Baker, M. n., Yeasmin, D. n., Islam, M. S., Rahman, M. n., Fendorf, S. n., Ardoin, N. M., Winch, P. J., Luby, S. P. 2019; 179 (Pt A): 108722

  Abstract

  Adulteration is a growing food safety concern worldwide. Previous studies have implicated turmeric as a source of lead (Pb) exposure due to the addition of lead chromate (PbCrO4), a yellow pigment used to enhance brightness. We aimed to assess the practice of adding yellow pigments to turmeric and producer- consumer- and regulatory-factors affecting this practice across the supply chain in Bangladesh. We identified and visited the nine major turmeric-producing districts of Bangladesh as well as two districts with minimal turmeric production. In each district, we conducted semi-structured interviews and informal observations with individuals involved in the production, consumption, and regulation of turmeric. We explored perceptions of and preferences for turmeric quality. We collected samples of yellow pigments and turmeric from the most-frequented wholesale and retail markets. We collected samples of turmeric, pigments, dust, and soil from turmeric polishing mills to assess evidence of adulteration. Interviews were analyzed through an inductive, thematic coding process, with attention focused on perceptions of and preferences for turmeric quality. Samples were analyzed for Pb and chromium (Cr) concentrations via inductively coupled plasma mass spectrometry and x-ray fluorescence. In total, we interviewed 152 individuals from across the supply chain and collected 524 samples of turmeric, pigments, dust, and soil (Table S3, Table S4). Turmeric Pb and Cr concentrations were highest in Dhaka and Munshiganj districts, with maximum turmeric powder Pb concentrations of 1152 μg/g, compared to 690 μg/g in the 9 major turmeric-producing districts. We found evidence of PbCrO4-based yellow pigment adulteration in 7 of the 9 major turmeric-producing districts. Soil samples from polishing mills contained a maximum of 4257 μg/g Pb and yellow pigments contained 2-10% Pb by weight with an average Pb:Cr molar ratio of 1.3. Turmeric wholesalers reported that the practice of adding yellow pigments to dried turmeric root during polishing began more than 30 years ago and continues today, primarily driven by consumer preferences for colorful yellow curries. Farmers stated that merchants are able to sell otherwise poor-quality roots and increase their profits by asking polishers to adulterate with yellow pigments. Adulterating turmeric with lead chromate poses significant risks to human health and development. The results from this study indicate that PbCrO4 is being added to turmeric by polishers, who are unaware of its neurotoxic effects, in order to satisfy wholesalers who are driven by consumer demand for yellow roots. We recommend immediate intervention that engages turmeric producers and consumers to address this public health crisis and ensure a future with Pb-free turmeric.

  View details for DOI 10.1016/j.envres.2019.108722

  View details for PubMedID 31550596

• 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

  View details for DOI 10.3201/eid2204.151747

  View details for Web of Science ID 000372688500011

• 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)

  Abstract

  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 Bangladesh.ClinicalTrials.gov NCT01350063.

  View details for DOI 10.1371/journal.pone.0121907

  View details for Web of Science ID 000352133600126

  View details for PubMedID 25816342

  View details for PubMedCentralID PMC4376788

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC4348460

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3919225

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

• 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
• Implementing a group-based multi-component early child development intervention through the government health system in rural Bangladesh: A feasibility study. The International journal of health planning and management Rahman, M., Jahir, T., Akter, F., Yeasmin, F., Pitchik, H. O., Hasan, R., Das, J. B., Grant, H. X., Hossain, K., Sultana, J., Huda, T. M., Shoab, A., Khan, R., Tofail, F., Luby, S. P., Fernald, L. C., Rashid, J., Ashrafee, S., Leontsini, E., Winch, P. J. 2023

  Abstract

  Children in low- and middle-income countries face an increased risk of impaired cognitive development due to contaminated environments, poor nutrition, and inadequate responsive stimulation from caregivers. Implementing multi-component, community-level interventions may reduce these risks; however, there is little evidence supporting implementation of these interventions at scale. We assessed the feasibility of implementing a group-based intervention that included responsive stimulation, maternal and child nutrition, water and sanitation, and childhood lead exposure prevention through the government health system in Chatmohar, Bangladesh. After implementation, we conducted 17 in-depth interviews with frontline health service providers and 12 key informant interviews with their supervisors and managers to explore the facilitators and difficulties implementing such a complex programme within the health system. Factors facilitating implementation included: high quality training and skill level of providers, support from community members, family, and supervisors, positive relationships between providers and participants, and provision of children's toys and books free of cost. Difficulties included increased workload of the providers, complicated group-based yet stage-specific delivery where providers had to manage a large group of mother-child dyads representing many different child age-groups at once, and logistics difficulties in providing toys and books through a centralised health system process. Key informants made suggestions to ensure effective government-level scale-up including engaging relevant NGOs as partners, identifying feasible ways to make toys available, and offering providers meaningful even if non-monetary rewards. These findings can be used to shape the design and delivery of multi-component child development interventions to be delivered through the health system.

  View details for DOI 10.1002/hpm.3647

  View details for PubMedID 37132061

• Human Exposure to Bats, Rodents and Monkeys in Bangladesh. EcoHealth Shanta, I. S., Luby, S. P., Hossain, K., Heffelfinger, J. D., Kilpatrick, A. M., Haider, N., Rahman, T., Chakma, S., Ahmed, S. S., Sharker, Y., Pulliam, J. R., Kennedy, E. D., Gurley, E. S. 2023

  Abstract

  Bats, rodents and monkeys are reservoirs for emerging zoonotic infections. We sought to describe the frequency of human exposure to these animals and the seasonal and geographic variation of these exposures in Bangladesh. During 2013-2016, we conducted a cross-sectional survey in a nationally representative sample of 10,002 households from 1001 randomly selected communities. We interviewed household members about exposures to bats, rodents and monkeys, including a key human-bat interface-raw date palm sap consumption. Respondents reported observing rodents (90%), bats (52%) and monkeys (2%) in or around their households, although fewer reported direct contact. The presence of monkeys around the household was reported more often in Sylhet division (7%) compared to other divisions. Households in Khulna (17%) and Rajshahi (13%) were more likely to report drinking date palm sap than in other divisions (1.5-5.6%). Date palm sap was mostly consumed during winter with higher frequencies in January (16%) and February (12%) than in other months (0-5.6%). There was a decreasing trend in drinking sap over the three years. Overall, we observed substantial geographic and seasonal patterns in human exposure to animals that could be sources of zoonotic disease. These findings could facilitate targeting emerging zoonoses surveillance, research and prevention efforts to areas and seasons with the highest levels of exposure.

  View details for DOI 10.1007/s10393-023-01628-9

  View details for PubMedID 37099204

• The lasting influence of Ebola: a qualitative study of community-level behaviors, trust, and perceptions three years after the 2014-16 Ebola epidemic in Liberia. BMC public health Arthur, R. F., Horng, L. M., Tandanpolie, A. F., Gilstad, J. R., Tantum, L. K., Luby, S. P. 2023; 23 (1): 682

  Abstract

  The majority of disease transmission during the 2014-16 West Africa Ebola epidemic was driven by community-based behaviors that proved difficult to change in a social paradigm of misinformation, denial, and deep-seated distrust of government representatives and institutions. In Liberia, perceptions and beliefs about Ebola during and since the epidemic can provide insights useful to public health strategies aimed at improving community preparedness. In this 2018 study, we conducted nine focus groups with Liberians from three communities who experienced Ebola differently, to evaluate behaviors, attitudes, and trust during and after the epidemic. Focus group participants reported that some behaviors adopted during Ebola have persisted (e.g. handwashing and caretaking practices), while others have reverted (e.g. physical proximity and funeral customs); and reported ongoing distrust of the government and denial of the Ebola epidemic. These findings suggest that a lack of trust in the biomedical paradigm and government health institutions persists in Liberia. Future public health information campaigns may benefit from community engagement addressed at understanding beliefs and sources of trust and mistrust in the community to effect behavior change and improve community-level epidemic preparedness.

  View details for DOI 10.1186/s12889-023-15559-1

  View details for PubMedID 37046227

  View details for PubMedCentralID 6886773

• Programmatic Effectiveness of a Pediatric Typhoid Conjugate Vaccine Campaign in Navi Mumbai, India. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Hoffman, S. A., LeBoa, C., Date, K., Haldar, P., Harvey, P., Shimpi, R., An, Q., Zhang, C., Jayaprasad, N., Horng, L., Fagerli, K., Borhade, P., Chakraborty, D., Bahl, S., Katkar, A., Kunwar, A., Yewale, V., Andrews, J. R., Bhatnagar, P., Dutta, S., Luby, S. P. 2023

  Abstract

  The WHO recommends vaccines for prevention and control of typhoid fever, especially where antimicrobial-resistant typhoid circulates. In 2018 the Navi Mumbai Municipal Corporation (NMMC), implemented a TCV campaign. The campaign targeted all children aged 9-months through 14-years within NMMC boundaries (∼320,000 children) over 2 vaccination phases. The phase 1 campaign occurred from July 14-August 25, 2018 (71% coverage, ∼113,420 children). We evaluated the phase 1 campaign's programmatic effectiveness in reducing typhoid cases at the community level.We established prospective, blood culture-based surveillance at 6 hospitals in Navi Mumbai, offering blood cultures to children presenting with fever ≥ 3 days. We employed a cluster-randomized (by administrative boundary) test-negative design to estimate the effectiveness of the vaccination campaign on pediatric typhoid cases. We matched test-positive, culture-confirmed typhoid cases with up to 3 test-negative, culture-negative controls by age and date of blood culture and assessed community vaccine campaign phase as an exposure using conditional logistic regression.Between September 1, 2018-March 31, 2021, we identified 81 typhoid cases and matched these with 238 controls. Cases were 0.44 times as likely to live in vaccine campaign communities (programmatic effectiveness, 56%, 95%CI: 25%-74%, p=0.002). Cases ≥ 5-years-old were 0.37 times as likely (95% CI: 0.19-0.70; p-value = 0.002) and cases during the first year of surveillance were 0.30 times as likely (95% CI: 0.14-0.64; p-value = 0.002) to live in vaccine campaign communities.Our findings support the use of TCV mass vaccination campaigns as effective population-based tools to combat typhoid fever.

  View details for DOI 10.1093/cid/ciad132

  View details for PubMedID 36947143

• Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation. International journal of hygiene and environmental health Islam, M., Rahman, M., Kafi, M. A., Unicomb, L., Rahman, M., Mertens, A., Benjamin-Chung, J., Arnold, B. F., Colford, J. M., Luby, S. P., Ercumen, A. 2023; 250: 114149

  Abstract

  BACKGROUND: Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh.METHODS: We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics.RESULTS: The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p<0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p<0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion.CONCLUSION: Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.

  View details for DOI 10.1016/j.ijheh.2023.114149

  View details for PubMedID 36913791

• Concurrent validity of the Ages and Stages Questionnaire Inventory and the Bayley Scales of Infantand Toddler Development in rural Bangladesh. BMC pediatrics Pitchik, H. O., Tofail, F., Akter, F., Shoab, A. K., Sultana, J., Huda, T. M., Rahman, M., Winch, P. J., Luby, S. P., Fernald, L. C. 2023; 23 (1): 93

  Abstract

  BACKGROUND: Reliable and valid measurement of early child development are necessary for the design of effective interventions, programs, and policies to improve early child outcomes. One widely used measure in low- and middle-income countries (LMICs) is the Bayley Scales of Infant and Toddler Development III (Bayley-III). Alternatively, the Bangladeshi-adapted Ages and Stages Questionnaire Inventory (ASQ:I) can be administered more quickly, inexpensively, and with less training than the Bayley-III. We aimed to assess the concurrent validity of the Bangladeshi-adapted ASQ:I with the Bayley-III in children 4-27months old in rural Bangladesh.METHODS: The sample was a sub-sample (n=244) of endline participants from an evaluation of an early child development intervention (July-August 2018). We assessed concurrent validity between internally age-standardized domain-specific and total scores using Pearson correlations both overall and stratified by age and intervention status. We also assessed correlations between scores and variables theoretically related to child development including maternal education and stimulation in the home.RESULTS: The overall correlation between ASQ:I and Bayley-III total scores was moderate (r=0.42 95%CI: 0.30-0.53), with no systematic differences by intervention status. Overall, concurrent validity was highest for the gross motor domain (r=0.51, 0.40-0.60), and lowest for the fine motor domain (r=0.20, 0.04-0.33). Total ASQ:I and Bayley-III scores were positively correlated with child stimulation and maternal education.CONCLUSION: The Bangladeshi-adapted ASQ:I is a low-cost tool that can be feasibly administered in rural Bangladesh, is moderately correlated with the Bayley-III, and can be used to measure child development when human, time, or financial resources are constrained.

  View details for DOI 10.1186/s12887-022-03800-6

  View details for PubMedID 36859070

• Effects of water, sanitation, and hygiene interventions on detection of enteropathogens and host-specific faecal markers in the environment: a systematic review and individual participant data meta-analysis. The Lancet. Planetary health Mertens, A., Arnold, B. F., Benjamin-Chung, J., Boehm, A. B., Brown, J., Capone, D., Clasen, T., Fuhrmeister, E., Grembi, J. A., Holcomb, D., Knee, J., Kwong, L. H., Lin, A., Luby, S. P., Nala, R., Nelson, K., Njenga, S. M., Null, C., Pickering, A. J., Rahman, M., Reese, H. E., Steinbaum, L., Stewart, J., Thilakaratne, R., Cumming, O., Colford, J. M., Ercumen, A. 2023; 7 (3): e197-e208

  Abstract

  Water, sanitation, and hygiene (WASH) improvements are promoted to reduce diarrhoea in low-income countries. However, trials from the past 5 years have found mixed effects of household-level and community-level WASH interventions on child health. Measuring pathogens and host-specific faecal markers in the environment can help investigate causal pathways between WASH and health by quantifying whether and by how much interventions reduce environmental exposure to enteric pathogens and faecal contamination from human and different animal sources. We aimed to assess the effects of WASH interventions on enteropathogens and microbial source tracking (MST) markers in environmental samples.We did a systematic review and individual participant data meta-analysis, which included searches from Jan 1, 2000, to Jan 5, 2023, from PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus, of prospective studies with water, sanitation, or hygiene interventions and concurrent control group that measured pathogens or MST markers in environmental samples and measured child anthropometry, diarrhoea, or pathogen-specific infections. We used covariate-adjusted regression models with robust standard errors to estimate study-specific intervention effects and pooled effect estimates across studies using random-effects models.Few trials have measured the effect of sanitation interventions on pathogens and MST markers in the environment and they mostly focused on onsite sanitation. We extracted individual participant data on nine environmental assessments from five eligible trials. Environmental sampling included drinking water, hand rinses, soil, and flies. Interventions were consistently associated with reduced pathogen detection in the environment but effect estimates in most individual studies could not be distinguished from chance. Pooled across studies, we found a small reduction in the prevalence of any pathogen in any sample type (pooled prevalence ratio [PR] 0·94 [95% CI 0·90-0·99]). Interventions had no effect on the prevalence of MST markers from humans (pooled PR 1·00 [95% CI 0·88-1·13]) or animals (pooled PR 1·00 [95% CI 0·97-1·03]).The small effect of these sanitation interventions on pathogen detection and absence of effects on human or animal faecal markers are consistent with the small or null health effects previously reported in these trials. Our findings suggest that the basic sanitation interventions implemented in these studies did not contain human waste and did not adequately reduce exposure to enteropathogens in the environment.Bill and Melinda Gates Foundation and the UK Foreign and Commonwealth Development Office.

  View details for DOI 10.1016/S2542-5196(23)00028-1

  View details for PubMedID 36889861

• Nipah Virus Exposure in Domestic and Peridomestic Animals Living in Human Outbreak Sites, Bangladesh, 2013-2015 EMERGING INFECTIOUS DISEASES Islam, A., Cannon, D. L., Rahman, M., Khan, S., Epstein, J. H., Daszak, P., Luby, S. P., Montgomery, J. M., Klena, J. D., Gurley, E. S. 2023; 29 (2): 393-396

  Abstract

  Spillovers of Nipah virus (NiV) from Pteropus bats to humans occurs frequently in Bangladesh, but the risk for spillover into other animals is poorly understood. We detected NiV antibodies in cattle, dogs, and cats from 6 sites where spillover human NiV infection cases occurred during 2013-2015.

  View details for DOI 10.3201/eid2902.221379

  View details for Web of Science ID 000930068100019

  View details for PubMedID 36692447

  View details for PubMedCentralID PMC9881791

• Engaging boys in menstrual hygiene management (MHM) interventions in Bangladeshi schools: a pilot study to assess acceptability and feasibility JOURNAL OF WATER SANITATION AND HYGIENE FOR DEVELOPMENT Khan, R., Sarker, S., Sultana, F., Ul Alam, M., Mahfuz, M., Nuruzzaman, M., Robi, R., Al Masud, A., Khan, S., Hunter, E. C., Unicomb, L., Rahman, M., Luby, S. P., Winch, P. J. 2023

  View details for DOI 10.2166/washdev.2023.153

  View details for Web of Science ID 000918111000001

• Paratype: a genotyping tool for Salmonella Paratyphi A reveals its global genomic diversity. Nature communications Tanmoy, A. M., Hooda, Y., Sajib, M. S., da Silva, K. E., Iqbal, J., Qamar, F. N., Luby, S. P., Dougan, G., Dyson, Z. A., Baker, S., Garrett, D. O., Andrews, J. R., Saha, S. K., Saha, S. 2022; 13 (1): 7912

  Abstract

  Salmonella Paratyphi A, the primary etiology of paratyphoid, is estimated to cause 3.4 million infections annually, worldwide. With rising antimicrobial resistance and no licensed vaccines, genomic surveillance is key to track and monitor transmission, but there is currently no reliable genotyping framework for this pathogen. Here, we sequence 817 isolates from South Asia and add 562 publicly available genomes to build a global database representing 37 countries, covering 1917-2019. We develop a single nucleotide polymorphism-based genotyping scheme, Paratype, that segregates Salmonella Paratyphi A population into three primary and nine secondary clades, and 18 genotypes. Each genotype is assigned a unique allele definition located on an essential gene. Using Paratype, we identify spatiotemporal genomic variation and antimicrobial resistance markers. We release Paratype as an open-access tool that can use raw read files from both Illumina and Nanopore platforms, and thus can assist surveillance studies tracking Salmonella Paratyphi A across the globe.

  View details for DOI 10.1038/s41467-022-35587-6

  View details for PubMedID 36564386

• Measuring Water Quantity Used for Personal and Domestic Hygiene and Determinants of Water Use in a Low-Income Urban Community. International journal of environmental research and public health Sultana, R., Nahar, N., Luby, S. P., Swarna, S. T., Gurley, E. S., Tamason, C. C., Khan, S., Rimi, N. A., Kabir, H., Saifullah, M. K., Howlader, S. R., Jensen, P. K. 2022; 19 (23)

  Abstract

  There is a paucity of recent research on direct water quantity measurement for personal and domestic hygiene. We aimed to measure the water quantity used for personal and domestic hygiene and to explore the reasons and determinants for variation of water usage. We conducted this study from September 2014 to June 2016 in a low-income urban community in Dhaka. In 12 households, the team conducted a day-long bimonthly ethnographic observation for one year to measure the volume of water used per activity per person. They conducted 28 in-depth interviews to explore the reasons for changes of water usage. Participants used a median of 75 L (61-100) of water per capita per day (LCPD) and of this 75 LCPD they used a median of 39 LCPD (26-58) for personal hygiene. Women used less water than men. Individual and social norms, beliefs, and weather determinants determined personal hygiene. Water availability determined domestic hygiene (e.g., washing dishes, toilets and bathrooms). This study helps to elucidate a range of determinants of water usage of the participants from the participants' perspective. The quantity of water used for domestic and personal hygiene and its relationship to fecal-oral transmitted disease can be explored in future research.

  View details for DOI 10.3390/ijerph192315656

  View details for PubMedID 36497732

  View details for PubMedCentralID PMC9737866

• Assessing Analytical Methods for the Rapid Detection of Lead Adulteration in the Global Spice Market. Environmental science & technology Lopez, A. M., Nicolini, C. M., Aeppli, M., Luby, S. P., Fendorf, S., Forsyth, J. E. 2022

  Abstract

  Lead adulteration of spices, primarily via Pb chromate compounds, has been documented globally as a growing public health concern. Currently, Pb detection in spices relies primarily on expensive and time-consuming laboratory analyses. Advancing rapid Pb detection methods, inclusive of their accuracy and precision, would improve field assessments by food safety inspectors, stakeholders, and the public in the hope of reducing Pb exposure risks at its source. Here, we present two field procedures for Pb detection: portable X-ray fluorescence analysis (pXRF) and a simple colorimetric test. We assess their efficacy to detect Pb and its chemical form in seven spice types, including powders, spice-salt mixtures, and dried roots, compared to the proven laboratory technique, inductively coupled plasma mass spectrometry (ICP-MS). Lead concentrations measured using pXRF and ICP-MS were within 5% of each other for spice powders and 24% for dried roots. By pXRF, spice samples were analyzed within collection plastic bags without preparation, resulting in a detection limit of 2 mg Pb/kg for spice powders, which is comparable to national food standards. The colorimetric test utilized here targets hexavalent chromium, making the method selective to Pb chromate adulteration assuming that this is its dominant source in spices. Color development, and thus detection, was observed when Pb concentrations exceeded approximately 5-70 mg/kg in dried turmeric roots and 1000 mg/kg in spice powders; however, it was ineffective for the spice-salt mixture. We show that pXRF analysis and a colorimetric assay provide information that may improve field decisions about Pb adulteration in a range of spice types, helping to minimize Pb exposure.

  View details for DOI 10.1021/acs.est.2c03241

  View details for PubMedID 36343212

• Drinking Water Chlorination Impact on Fecal Carriage of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae in Bangladeshi Children in a Double-Blind, Cluster-Randomized Controlled Trial. Environmental health perspectives Montealegre, M. C., Greenwood, E. E., Teichmann, L., Nadimpalli, M. L., Caduff, L., Swarthout, J. M., Nydegger, T., Sultana, S., Islam, M. A., Lanza, V. F., Luby, S. P., Pickering, A. J., Julian, T. R. 2022; 130 (11): 117702

  View details for DOI 10.1289/EHP11359

  View details for PubMedID 36416733

• Co-administration of Oral Cholera Vaccine with Oral Polio Vaccine among Bangladeshi Young Children: A Randomized Controlled Open Label Trial to Assess Interference. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Islam, M. T., Date, K., Khan, A. I., Bhuiyan, T. R., Khan, Z. H., Ahmed, S., Hossain, M., Khaton, F., Zaman, K., McMillan, N. A., Anand, A., An, Q., Zhang, C., Weldon, W. C., Yu, A., Luby, S., Qadri, F. 2022

  Abstract

  BACKGROUND: Cholera remains a public health threat for low- and middle-income countries, particularly in Asia and Africa. ShancholTM, an inactivated oral cholera vaccine (OCV) is currently in use globally. OCV and oral poliovirus vaccines (OPV) could be administered concomitantly but the immunogenicity and safety of coadministration among children aged 1-3 years is unknown.METHOD: We undertook an open-label, randomized, controlled, inequality trial in Dhaka city, Bangladesh. Healthy children aged 1-3 years were randomly assigned to one of the three groups: bivalent OPV (bOPV)-alone, OCV-alone, or combined bOPV+OCV and received vaccines on the day of enrollment and 28 days later. Blood samples were collected on the day of enrollment, day 28, and day 56. Serum poliovirus neutralizing antibodies and vibriocidal antibodies against V. cholerae O1 were assessed using microneutralization assays.RESULTS: A total of 579 children aged 1‒3 years were recruited, 193 children per group. More than 90% of the children completed visits at day 56. Few adverse events following immunization were recorded and were equivalent among study arms. On day 28, 60% (90% Confidence interval, 53%-67%) and 54% (46%-61%) of participants with co-administration of bOPV+OCV responded to polioviruses type 1 and 3 respectively, compared to 55% (47%-62%) and 46% (38%-53%) in the bOPV-only group. Additionally, >50% of participants showed a ≥4-fold increase in vibriocidal antibody titre responses on day 28, comparable to the responses observed in OCV-only arm.CONCLUSIONS: Co-administration of bOPV and OCV is safe and effective in children aged 1-3 years and can be cost-beneficial.

  View details for DOI 10.1093/cid/ciac782

  View details for PubMedID 36136760

• The effect of a large-scale water, sanitation and hygiene intervention in Bangladesh on knowledge, behaviour and health: Findings from an endline programme evaluation TROPICAL MEDICINE & INTERNATIONAL HEALTH Aluri, K., Halder, A. K., Islam, M., Benjamin-Chung, J., Alam, M., Shoab, A., Rahman, M., Unicomb, L., Luby, S. P. 2022

  Abstract

  The Sanitation, Hygiene Education and Water Supply in Bangladesh Programme (SHEWA-B) was a 5-year intervention aiming to improve water, sanitation and hygiene (WASH) practices among 20 million rural residents through community hygiene promoters. This analysis evaluates the impact of SHEWA-B on knowledge, behaviour and childhood diarrhoea outcomes.The evaluation included repeated cross-sectional surveys and health surveillance in matched cohorts in intervention and control clusters. Cross-sectional surveys and structured observations at baseline, midline, and endline assessed the availability of WASH technology, caregiver knowledge and behaviour. Fieldworkers collected monthly health data in a subset of control and intervention households to determine the prevalence of diarrhoea.Of 5091 households surveyed, participants residing in intervention clusters showed minimal improvements in knowledge, reported behaviour, or use of WASH technology compared to the control clusters. During structured observations, intervention households increased more than control households at handwashing before preparing food and after cleaning a baby's anus when comparing endline to baseline, but these changes were not seen when comparing endline to the midline. The prevalence of childhood diarrhoea remained similar in both groups before (10.2% in intervention, 10.0% in control) and after (8.8% in intervention, 11.7% in control) midline changes were made to improve the intervention. Intervention clusters showed no improvement in diarrhoea over time compared to control clusters.SHEWA-B's community-based WASH promotion did not yield the intended impact on knowledge, behaviour or health. Greater priority should be given to approaches that have demonstrated effectiveness. Including rigorous evaluations would broaden the evidence base to support and improve large-scale programmes.

  View details for DOI 10.1111/tmi.13813

  View details for Web of Science ID 000852794600001

  View details for PubMedID 36096154

• Influence of community-level sanitation coverage and population density on environmental fecal contamination and child health in a longitudinal cohort in rural Bangladesh. International journal of hygiene and environmental health Contreras, J. D., Islam, M., Mertens, A., Pickering, A. J., Kwong, L. H., Arnold, B. F., Benjamin-Chung, J., Hubbard, A. E., Alam, M., Sen, D., Islam, S., Rahman, M., Unicomb, L., Luby, S. P., Colford, J. M., Ercumen, A. 2022; 245: 114031

  Abstract

  BACKGROUND: Household-level sanitation interventions have had limited effects on child health or environmental contamination, potentially due to low community coverage. Higher community-level coverage with safely managed sanitation can reduce opportunities for disease transmission.METHODS: We estimated associations between community sanitation coverage, environmental fecal contamination, and child health among 360 compounds in the control arm of the WASH Benefits trial in rural Bangladesh (NCT01590095). In each compound, we enumerated E. coli in environmental samples and recorded the 7-day prevalence of caregiver-reported diarrheal disease and acute respiratory infections (ARI) in children under five. We observed indicators of latrine access and quality among all neighboring compounds within 100m of study compounds. We defined community coverage as the proportion of neighboring compounds with (1) at least one latrine, and (2) exclusively hygienic latrines (improved facility observed to safely contain feces), within both 50m and 100m of study compounds. We assessed effect modification by population density and season.RESULTS: Adjusted for confounders, study compounds surrounded by 100% coverage of at least one latrine per compound within 50m had slightly lower log10E. coli counts in stored water (Deltalog=-0.13, 95% CI -0.26, -0.01), child hand rinses (Deltalog=-0.13, 95% CI -0.24, -0.02), and caregiver hand rinses (Deltalog=-0.16, 95% CI -0.29, -0.03) and marginally lower prevalence of diarrheal disease (prevalence ratio [PR]=0.82, 95% CI 0.64, 1.04) and ARI (PR=0.84, 95% CI 0.69, 1.03) compared to compounds surrounded by <100% coverage. Effects were similar but less pronounced at 100m. At higher population densities, community latrine coverage was associated with larger reductions in E. coli on child and caregiver hands and prevalence of diarrheal disease. Coverage with exclusively hygienic latrines was not associated with any outcome.CONCLUSION: Higher community sanitation coverage was associated with reduced fecal contamination and improved child health, with stronger effects at highly local scales (50m) and at high population densities. Our findings indicate that the relationship between community sanitation coverage, environmental contamination, and child health varies by definition of coverage, distance, and population density. This work highlights significant uncertainty around how to best measure sanitation coverage and the expected health effects of increasing sanitation coverage using a specific metric. Better understanding of community-level sanitation access is needed to inform policy for implementing sanitation systems that effectively protect community health.

  View details for DOI 10.1016/j.ijheh.2022.114031

  View details for PubMedID 36058111

• Preventive small-quantity lipid-based nutrient supplements reduce severe wasting and severe stunting among young children: an individual participant data meta-analysis of randomized controlled trials. The American journal of clinical nutrition Dewey, K. G., Arnold, C. D., Wessells, K. R., Prado, E. L., Abbeddou, S., Adu-Afarwuah, S., Ali, H., Arnold, B. F., Ashorn, P., Ashorn, U., Ashraf, S., Becquey, E., Brown, K. H., Christian, P., Colford, J. M., Dulience, S. J., Fernald, L. C., Galasso, E., Hallamaa, L., Hess, S. Y., Humphrey, J. H., Huybregts, L., Iannottie, L. L., Jannat, K., Lartey, A., Port, A. L., Leroy, J. L., Luby, S. P., Maleta, K., Matias, S. L., Mbuya, M. N., Mridha, M. K., Nkhoma, M., Null, C., Paul, R. R., Okronipa, H., Ouédraogo, J. B., Pickering, A. J., Prendergast, A. J., Ruel, M., Shaikh, S., Weber, A. M., Wolff, P., Zongrone, A., Stewart, C. P. 2022

  Abstract

  Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNS) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting.We aimed to identify the effect of SQ-LNS on prevalence of severe wasting (weight-for-length z-score < -3) and severe stunting (length-for-age z-score < -3).We conducted a two-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNS provided to children 6 to 24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS vs. control and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.SQ-LNS provision led to a relative reduction of 31% in severe wasting (Prevalence Ratio, PR 0.69 (0.55, 0.86), n=34,373) and 17% in severe stunting (PR 0.83 (95% CI: 0.78, 0.90), n=36,795) at endline. Results were similar in most of the sensitivity analyses but somewhat attenuated when comparisons using passive control arms were excluded: PR 0.74 (0.57, 0.96), n=26,327 for severe wasting and PR 0.88 (0.81, 0.95), n=28,742 for severe stunting. Study-level characteristics generally did not significantly modify the effects of SQ-LNS, but results suggested greater effects of SQ-LNS in sites with greater burdens of wasting or stunting, or with poorer water quality or sanitation.Including SQ-LNS in preventive interventions to promote healthy child growth and development is likely to reduce rates of severe wasting and stunting. Registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

  View details for DOI 10.1093/ajcn/nqac232

  View details for PubMedID 36045000

• The Effect of Particulate Matter Exposure During Pregnancy on Pregnancy and Child Health Outcomes in South Asia: Protocol for an Instrumental Variable Analysis. JMIR research protocols Reitzug, F., Luby, S. P., Pullabhotla, H. K., Geldsetzer, P. 2022; 11 (8): e35249

  Abstract

  BACKGROUND: Determining the longer-term health effects of air pollution has been difficult owing to the multitude of potential confounding variables in the relationship between air pollution and health. Air pollution in many areas of South Asia is seasonal, with large spikes in particulate matter (PM) concentration occurring in the winter months. This study exploits this seasonal variation in PM concentration through a natural experiment.OBJECTIVE: This project aims to determine the causal effect of PM exposure during pregnancy on pregnancy and child health outcomes.METHODS: We will use an instrumental variable (IV) design whereby the estimated month of conception is our instrument for exposure to PM with a diameter less than 2.5 mum (PM2.5) during pregnancy. We will assess the plausibility of our assumption that timing of conception is exogenous with regard to our outcomes of interest and will adjust for date of monsoon onset to control for confounding variables related to harvest timing. Our outcomes are 1) birth weight, 2) pregnancy termination resulting in miscarriage, abortion, or still birth, 3) neonatal death, 4) infant death, and 5) child death. We will use data from the Demographic and Health Surveys (DHS) conducted in relevant regions of Bangladesh, India, Nepal, and Pakistan, along with monthly gridded data on PM2.5 concentration (0.1°*0.1° spatial resolution), precipitation data (0.5°*0.5° resolution), temperature data (0.5°*0.5°), and agricultural land use data (0.1°*0.1° resolution).RESULTS: Data access to relevant DHSs was granted on June 6, 2021 for India, Nepal, Bangladesh, August 24, 2021 for Pakistan, and June 19 2022 for the latest DHS from India.CONCLUSIONS: If the assumptions for a causal interpretation of our instrumental variable analysis are met, this analysis will provide important causal evidence on the maternal and child health effects of PM2.5 exposure during pregnancy. This evidence is important to inform personal behavior and interventions, such as the adoption of indoor air filtration during pregnancy as well as environmental and health policy.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35249.

  View details for DOI 10.2196/35249

  View details for PubMedID 35947440

• Evaluation of an on-site sanitation intervention against childhood diarrhea and acute respiratory infection 1 to 3.5 years after implementation: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh. PLoS medicine Contreras, J. D., Islam, M., Mertens, A., Pickering, A. J., Arnold, B. F., Benjamin-Chung, J., Hubbard, A. E., Rahman, M., Unicomb, L., Luby, S. P., Colford, J. M., Ercumen, A. 2022; 19 (8): e1004041

  Abstract

  BACKGROUND: Diarrhea and acute respiratory infection (ARI) are leading causes of death in children. The WASH Benefits Bangladesh trial implemented a multicomponent sanitation intervention that led to a 39% reduction in the prevalence of diarrhea among children and a 25% reduction for ARI, measured 1 to 2 years after intervention implementation. We measured longer-term intervention effects on these outcomes between 1 to 3.5 years after intervention implementation, including periods with differing intensity of behavioral promotion.METHODS AND FINDINGS: WASH Benefits Bangladesh was a cluster-randomized controlled trial of water, sanitation, hygiene, and nutrition interventions (NCT01590095). The sanitation intervention included provision of or upgrades to improved latrines, sani-scoops for feces removal, children's potties, and in-person behavioral promotion. Promotion was intensive up to 2 years after intervention initiation, decreased in intensity between years 2 to 3, and stopped after 3 years. Access to and reported use of latrines was high in both arms, and latrine quality was significantly improved by the intervention, while use of child feces management tools was low. We enrolled a random subset of households from the sanitation and control arms into a longitudinal substudy, which measured child health with quarterly visits between 1 to 3.5 years after intervention implementation. The study period therefore included approximately 1 year of high-intensity promotion, 1 year of low-intensity promotion, and 6 months with no promotion. We assessed intervention effects on diarrhea and ARI prevalence among children <5 years through intention-to-treat analysis using generalized linear models with robust standard errors. Masking was not possible during data collection, but data analysis was masked. We enrolled 720 households (360 per arm) from the parent trial and made 9,800 child observations between June 2014 and December 2016. Over the entire study period, diarrheal prevalence was lower among children in the sanitation arm (11.9%) compared to the control arm (14.5%) (prevalence ratio [PR] = 0.81, 95% CI 0.66, 1.00, p = 0.05; prevalence difference [PD] = -0.027, 95% CI -0.053, 0, p = 0.05). ARI prevalence did not differ between sanitation (21.3%) and control (22.7%) arms (PR = 0.93, 95% CI 0.82, 1.05, p = 0.23; PD = -0.016, 95% CI -0.043, 0.010, p = 0.23). There were no significant differences in intervention effects between periods with high-intensity versus low-intensity/no promotion. Study limitations include use of caregiver-reported symptoms to define health outcomes and limited data collected after promotion ceased.CONCLUSIONS: The observed effect of the WASH Benefits Bangladesh sanitation intervention on diarrhea in children appeared to be sustained for at least 3.5 years after implementation, including 1.5 years after heavy promotion ceased. Existing latrine access was high in the study setting, suggesting that improving on-site latrine quality can deliver health benefits when latrine use practices are in place. Further work is needed to understand how latrine adoption can be achieved and sustained in settings with low existing access and how sanitation programs can adopt transformative approaches of excreta management, including safe disposal of child and animal feces, to generate a hygienic home environment.TRIAL REGISTRATION: ClinicalTrials.gov; NCT01590095; https://clinicaltrials.gov/ct2/show/NCT01590095.

  View details for DOI 10.1371/journal.pmed.1004041

  View details for PubMedID 35939520

• Vertical outbreak of COVID-19 in high-rise buildings: the role of sewer stacks and prevention measures. Current opinion in environmental science & health Guo, Y., Li, X., Luby, S., Jiang, G. 2022: 100379

  Abstract

  COVID-19 outbreaks in high-rise buildings suggested the transmission route of fecal-aerosol-inhalation due to the involvement of viral aerosols in sewer stacks. The vertical transmission is likely due to the failure of water traps that allow viral aerosols to spread through sewer stacks. This process can be further facilitated by chimney effect in vent stack, extract ventilation in bathrooms, or wind-induced air pressure fluctuations. To eliminate the risk of such vertical disease spread, installation of protective devices is highly encouraged in high-rise buildings. Although the mechanism of vertical pathogen spread through drainage pipeline has been illustrated by tracer gas or microbial experiments and numerical modeling, more research is needed to support the update of regulatory and design standards for sewerage facilities.

  View details for DOI 10.1016/j.coesh.2022.100379

  View details for PubMedID 35856009

• Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project. The Lancet. Global health Garrett, D. O., Longley, A. T., Aiemjoy, K., Yousafzai, M. T., Hemlock, C., Yu, A. T., Vaidya, K., Tamrakar, D., Saha, S., Bogoch, I. I., Date, K., Saha, S., Islam, M. S., Sayeed, K. M., Bern, C., Shakoor, S., Dehraj, I. F., Mehmood, J., Sajib, M. S., Islam, M., Thobani, R. S., Hotwani, A., Rahman, N., Irfan, S., Naga, S. R., Memon, A. M., Pradhan, S., Iqbal, K., Shrestha, R., Rahman, H., Hasan, M. M., Qazi, S. H., Kazi, A. M., Saddal, N. S., Jamal, R., Hunzai, M. J., Hossain, T., Marks, F., Carter, A. S., Seidman, J. C., Qamar, F. N., Saha, S. K., Andrews, J. R., Luby, S. P. 2022; 10 (7): e978-e988

  Abstract

  Precise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. We established the Surveillance for Enteric Fever in Asia Project (SEAP) to inform these strategies.From September, 2016, to September, 2019, we conducted prospective clinical surveillance for Salmonella enterica serotype Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C at health facilities in predetermined catchment areas in Dhaka, Bangladesh; Kathmandu and Kavrepalanchok, Nepal; and Karachi, Pakistan. Patients eligible for inclusion were outpatients with 3 or more consecutive days of fever in the last 7 days; inpatients with suspected or confirmed enteric fever; patients with blood culture-confirmed enteric fever from the hospital laboratories not captured by inpatient or outpatient enrolment and cases from the laboratory network; and patients with non-traumatic ileal perforation under surgical care. We used a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of health-care use. Blood cultures were performed for enrolled patients. We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking. We additionally calculated incidence of hospitalisation due to typhoid and paratyphoid.A total of 34 747 patients were enrolled across 23 facilitates (six tertiary hospitals, surgical wards of two additional hospitals, and 15 laboratory network sites) during the study period. Of the 34 303 blood cultures performed on enrolled patients, 8705 (26%) were positive for typhoidal Salmonella. Adjusted incidence rates of enteric fever considered patients in the six tertiary hospitals. Adjusted incidence of S Typhi, expressed per 100 000 person-years, was 913 (95% CI 765-1095) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (230-480) in Kathmandu and 268 (202-362) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 176 (144-216) and 103 (85-126). The adjusted incidence rates of paratyphoid (of which all included cases were due to S Paratyphi A) were 128 (107-154) in Bangladesh, 46 (34-62) and 81 (56-118) in the Nepal sites, and 23 (19-29) and 1 (1-1) in the Pakistan sites. Adjusted incidence of hospitalisation was high across sites, and overall, 2804 (32%) of 8705 patients with blood culture-confirmed enteric fever were hospitalised.Across diverse communities in three south Asian countries, adjusted incidence exceeded the threshold for "high burden" of enteric fever (100 per 100 000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines.Bill & Melinda Gates Foundation.

  View details for DOI 10.1016/S2214-109X(22)00119-X

  View details for PubMedID 35714648

• Nipah Virus Detection at Bat Roosts after Spillover Events, Bangladesh, 2012-2019 EMERGING INFECTIOUS DISEASES McKee, C. D., Islam, A., Rahman, M., Khan, S., Rahman, M., Satter, S. M., Islam, A., Yinda, C., Epstein, J. H., Daszak, P., Munster, V. J., Hudson, P. J., Plowright, R. K., Luby, S. P., Gurley, E. S. 2022; 28 (7): 1384-1392

  Abstract

  Knowledge of the dynamics and genetic diversity of Nipah virus circulating in bats and at the human-animal interface is limited by current sampling efforts, which produce few detections of viral RNA. We report a series of investigations at Pteropus medius bat roosts identified near the locations of human Nipah cases in Bangladesh during 2012-2019. Pooled bat urine was collected from 23 roosts; 7 roosts (30%) had >1 sample in which Nipah RNA was detected from the first visit. In subsequent visits to these 7 roosts, RNA was detected in bat urine up to 52 days after the presumed exposure of the human case-patient, although the probability of detection declined rapidly with time. These results suggest that rapidly deployed investigations of Nipah virus shedding from bat roosts near human cases could increase the success of viral sequencing compared with background surveillance and could enhance understanding of Nipah virus ecology and evolution.

  View details for DOI 10.3201/eid2807.212614

  View details for Web of Science ID 000830154100009

  View details for PubMedID 35731130

  View details for PubMedCentralID PMC9239894

• Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project LANCET GLOBAL HEALTH Garrett, D. O., Longley, A. T., Aiemjoy, K., Yousafzai, M. T., Hemlock, C., Yu, A. T., Vaidya, K., Tamrakar, D., Saha, S., Bogoch, I. I., Date, K., Saha, S., Islam, M., Sayeed, K., Bern, C., Shakoor, S., Dehraj, I. F., Mehmood, J., Sajib, M. S., Islam, M., Thobani, R. S., Hotwani, A., Rahman, N., Irfan, S., Naga, S. R., Memon, A. M., Pradhan, S., Iqbal, K., Shrestha, R., Rahman, H., Hasan, M., Qazi, S. H., Kazi, A. M., Saddal, N. S., Jamal, R., Hunzai, M. J., Hossain, T., Marks, F., Carter, A. S., Seidman, J. C., Qamar, F. N., Saha, S. K., Andrews, J. R., Luby, S. P. 2022; 10 (7): E978-E988

  View details for Web of Science ID 000835720300024

• Estimating typhoid incidence from community-based serosurveys: a multicohort study. The Lancet. Microbe Aiemjoy, K., Seidman, J. C., Saha, S., Munira, S. J., Islam Sajib, M. S., Sium, S. M., Sarkar, A., Alam, N., Zahan, F. N., Kabir, M. S., Tamrakar, D., Vaidya, K., Shrestha, R., Shakya, J., Katuwal, N., Shrestha, S., Yousafzai, M. T., Iqbal, J., Dehraj, I. F., Ladak, Y., Maria, N., Adnan, M., Pervaiz, S., Carter, A. S., Longley, A. T., Fraser, C., Ryan, E. T., Nodoushani, A., Fasano, A., Leonard, M. M., Kenyon, V., Bogoch, I. I., Jeon, H. J., Haselbeck, A., Park, S. E., Zellweger, R. M., Marks, F., Owusu-Dabo, E., Adu-Sarkodie, Y., Owusu, M., Teunis, P., Luby, S. P., Garrett, D. O., Qamar, F. N., Saha, S. K., Charles, R. C., Andrews, J. R. 2022

  Abstract

  The incidence of enteric fever, an invasive bacterial infection caused by typhoidal Salmonellae (Salmonella enterica serovars Typhi and Paratyphi), is largely unknown in regions without blood culture surveillance. The aim of this study was to evaluate whether new diagnostic serological markers for typhoidal Salmonella can reliably estimate population-level incidence.We collected longitudinal blood samples from patients with blood culture-confirmed enteric fever enrolled from surveillance studies in Bangladesh, Nepal, Pakistan, and Ghana between 2016 and 2021 and conducted cross-sectional serosurveys in the catchment areas of each surveillance site. We used ELISAs to measure quantitative IgA and IgG antibody responses to hemolysin E and S Typhi lipopolysaccharide. We used Bayesian hierarchical models to fit two-phase power-function decay models to the longitudinal antibody responses among enteric fever cases and used the joint distributions of the peak antibody titres and decay rate to estimate population-level incidence rates from cross-sectional serosurveys.The longitudinal antibody kinetics for all antigen-isotypes were similar across countries and did not vary by clinical severity. The seroincidence of typhoidal Salmonella infection among children younger than 5 years ranged between 58·5 per 100 person-years (95% CI 42·1-81·4) in Dhaka, Bangladesh, to 6·6 per 100 person-years (4·3-9·9) in Kavrepalanchok, Nepal, and followed the same rank order as clinical incidence estimates.The approach described here has the potential to expand the geographical scope of typhoidal Salmonella surveillance and generate incidence estimates that are comparable across geographical regions and time.Bill & Melinda Gates Foundation.For the Nepali, Bengali and Urdu translations of the abstract see Supplementary Materials section.

  View details for DOI 10.1016/S2666-5247(22)00114-8

  View details for PubMedID 35750069

• Prevalence of Sugar-Sweetened Food Consumption in Rural Bangladeshi Children Aged 6-24 Months. The Journal of nutrition Salem, M. K., Pitchik, H. O., Sultana, J., Rahman, M., Jannat, K. K., Luby, S. P., Mridha, M. K., Winch, P. J., Fernald, L. C. 2022

  Abstract

  BACKGROUND: While the prevalence of undernutrition in children has decreased in many low- and middle-income countries since the 1990s, overweightand obesity have increased. Frequent consumption of sugar-sweetened food might have contributed to this change, although very little is known about sugar-sweetened food consumption in early life.OBJECTIVE: The objective of this study was to explore the association between individual, household and maternal factors, and the primary outcome, prevalence of sugar-sweetened food consumption in 6-24-month-old children in Bangladesh.METHODS: Multistage sampling was used to select households with children 6-24 months in rural Chatmohar, sub-district of Bangladesh (n=1635). Research assistants conducted a 24-hour qualitative dietary recall questionnaire with the enrolled child's primary caregiver to measure maternal and child dietary patterns. We examined factors associated with the prevalence of child sugar-sweetened food consumption with multivariate logistic regression models. We conducted tests of heterogeneity to explore differential associations between child sugar-sweetened food consumption prevalence and household income by maternal nutrition knowledge and wealth.RESULTS: Primary caregivers reported that 62% of toddlers had consumed sugar-sweetened food in the past 24 hours. Higher prevalence of child sugar-sweetened food consumption was associated both with a higher dietary diversity score (OR: 1.19, 95% CI: 1.09, 1.29) and with a higher prevalence of maternal sugar-sweetened food consumption (OR: 2.54, 95% CI: 1.97, 3.28). At higher levels of maternal nutrition knowledge and wealth, more household income was associated with lower prevalence of child sugar-sweetened food consumption.CONCLUSIONS: Almost two-thirds of 6-24-month-old children in rural Chatmohar, Bangladesh had consumed sugar-sweetened food in the last day. This is a high and concerning prevalence and the associated factors identified in this study should be investigated further to identify potential areas of intervention to decrease the prevalence of child sugar consumption in Bangladesh.

  View details for DOI 10.1093/jn/nxac119

  View details for PubMedID 35709397

• Evaluation of a menstrual hygiene intervention in urban and rural schools in Bangladesh: a pilot study. BMC public health Alam, M., Sultana, F., Hunter, E. C., Winch, P. J., Unicomb, L., Sarker, S., Mahfuz, M. T., Al-Masud, A., Rahman, M., Luby, S. P. 2022; 22 (1): 1100

  Abstract

  Girls' menstrual experiences impact their social and educational participation, physical and psychological health. We conducted a pilot study to assess the acceptability and feasibility of a multi-component intervention intended to support menstruating girls; improve menstrual care knowledge, practices, and comfort; and increase school attendance.We conducted a pre/post evaluation of a 6-month pilot intervention in four schools (2 urban, 2 rural) in Dhaka, Bangladesh. We selected 527 schoolgirls (grades 5 to 10; aged 10 to 17years) for a baseline survey and 528 girls at endline. The intervention included: 1) Menstrual Hygiene Management (MHM) packs- reusable cloth pads, underwear, carry bags and menstrual cycle tracking calendars, 2) education curriculum- pictorial flipcharts, puberty related-booklets, and teachers' training to deliver puberty and MHM sessions, 3) maintenance- improvements to school sanitation, provision of disposable pads in the school office, provision of chute disposal systems for disposable pads, and gender committees to promote a gender-friendly school environment and maintenance of intervention facilities. We estimated intervention uptake and intervention effect by calculating prevalence differences and 95% confidence intervals using fixed-effects logistic regression.The intervention uptake was more than 85% for most indicators; 100% reported receiving puberty education, 85% received MHM packs, and 92% received booklets. Reusable cloth pads uptake was 34% by endline compared with 0% at baseline. Knowledge about menstrual physiology and knowledge of recommended menstrual management practices significantly improved from baseline to endline. Reported improvements included more frequent changing of menstrual materials (4.2 times/day at endline vs. 3.4 times/day at baseline), increased use of recommended disposal methods (prevalence difference (PD): 8%; 95% Confidence Interval: 1, 14), and fewer staining incidents (PD: -12%; 95% CI: -22, -1). More girls reported being satisfied with their menstrual materials (59% at endline vs. 46% at baseline, p<0.005) and thought school facilities were adequate for menstrual management at endline compared to baseline (54% vs. 8%, p<0.001). At endline, 64% girls disagreed/strongly disagreed that they felt anxious at school due to menstruation, compared to 33% at baseline (p<0.001). Sixty-five percent girls disagreed/strongly disagreed about feeling distracted or trouble concentrating in class at endline, compared to 41% at baseline (p<0.001). Self-reported absences decreased slightly (PD: -8%; 95% CI: -14, -2).Uptake of cloth pads, improved maintenance and disposal of menstrual materials, and reduced anxiety at school suggest acceptability and feasibility of the intervention aiming to create a supportive school environment.

  View details for DOI 10.1186/s12889-022-13478-1

  View details for PubMedID 35655267

• Drinking water chlorination has minor effects on the intestinal flora and resistomes of Bangladeshi children. Nature microbiology Nadimpalli, M. L., Lanza, V. F., Montealegre, M. C., Sultana, S., Fuhrmeister, E. R., Worby, C. J., Teichmann, L., Caduff, L., Swarthout, J. M., Crider, Y. S., Earl, A. M., Brown, J., Luby, S. P., Islam, M. A., Julian, T. R., Pickering, A. J. 2022

  Abstract

  Healthy development of the gut microbiome provides long-term health benefits. Children raised in countries with high infectious disease burdens are frequently exposed to diarrhoeal pathogens and antibiotics, which perturb gut microbiome assembly. A recent cluster-randomized trial leveraging >4,000 child observations in Dhaka, Bangladesh, found that automated water chlorination of shared taps effectively reduced child diarrhoea and antibiotic use. In this substudy, we leveraged stool samples collected from 130 children 1 year after chlorine doser installation to examine differences between treatment and control children's gut microbiota. Water chlorination was associated with increased abundance of several bacterial genera previously linked to improved gut health; however, we observed no effects on the overall richness or diversity of taxa. Several clinically relevant antibiotic resistance genes were relatively more abundant in the gut microbiome of treatment children, possibly due to increases in Enterobacteriaceae. While further studies on the long-term health impacts of drinking chlorinated water would be valuable, we conclude that access to chlorinated water did not substantially impact child gut microbiome development in this setting, supporting the use of chlorination to increase global access to safe drinking water.

  View details for DOI 10.1038/s41564-022-01101-3

  View details for PubMedID 35422497

• SARS-CoV-2 shedding sources in wastewater and implications for wastewater-based epidemiology. Journal of hazardous materials Li, X., Kulandaivelu, J., Guo, Y., Zhang, S., Shi, J., O'Brien, J., Arora, S., Kumar, M., Sherchan, S. P., Honda, R., Jackson, G., Luby, S. P., Jiang, G. 2022; 432: 128667

  Abstract

  Wastewater-based epidemiology (WBE) approach for COVID-19 surveillance is largely based on the assumption of SARS-CoV-2 RNA shedding into sewers by infected individuals. Recent studies found that SARS-CoV-2 RNA concentration in wastewater (CRNA) could not be accounted by the fecal shedding alone. This study aimed to determine potential major shedding sources based on literature data of CRNA, along with the COVID-19 prevalence in the catchment area through a systematic literature review. Theoretical CRNA under a certain prevalence was estimated using Monte Carlo simulations, with eight scenarios accommodating feces alone, and both feces and sputum as shedding sources. With feces alone, none of the WBE data was in the confidence interval of theoretical CRNA estimated with the mean feces shedding magnitude and probability, and 63% of CRNA in WBE reports were higher than the maximum theoretical concentration. With both sputum and feces, 91% of the WBE data were below the simulated maximum CRNA in wastewater. The inclusion of sputum as a major shedding source led to more comparable theoretical CRNA to the literature WBE data. Sputum discharging behavior of patients also resulted in great fluctuations of CRNA under a certain prevalence. Thus, sputum is a potential critical shedding source for COVID-19 WBE surveillance.

  View details for DOI 10.1016/j.jhazmat.2022.128667

  View details for PubMedID 35339834

• Community trust of government and non-governmental organizations during the 2014-16 Ebola epidemic in Liberia. PLoS neglected tropical diseases Arthur, R. F., Horng, L. M., Bolay, F. K., Tandanpolie, A., Gilstad, J. R., Tantum, L. K., Luby, S. P. 1800; 16 (1): e0010083

  Abstract

  The West African Ebola Virus Disease epidemic of 2014-16 cost more than 11,000 lives. Interventions targeting key behaviors to curb transmission, such as safe funeral practices and reporting and isolating the ill, were initially unsuccessful in a climate of fear, mistrust, and denial. Building trust was eventually recognized as essential to epidemic response and prioritized, and trust was seen to improve toward the end of the epidemic as incidence fell. However, little is understood about how and why trust changed during Ebola, what factors were most influential to community trust, and how different institutions might have been perceived under different levels of exposure to the outbreak. In this large-N household survey conducted in Liberia in 2018, we measured self-reported trust over time retrospectively in three different communities with different exposures to Ebola. We found trust was consistently higher for non-governmental organizations than for the government of Liberia across all time periods. Trust reportedly decreased significantly from the start to the peak of the epidemic in the study site of highest Ebola incidence. This finding, in combination with a negative association found between knowing someone infected and trust of both iNGOs and the government, indicates the experience of Ebola may have itself caused a decline of trust in the community. These results suggest that national governments should aim to establish trust when engaging communities to change behavior during epidemics. Further research on the relationship between trust and epidemics may serve to improve epidemic response efficacy and behavior uptake.

  View details for DOI 10.1371/journal.pntd.0010083

  View details for PubMedID 35085236

• Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh. Science (New York, N.Y.) Abaluck, J., Kwong, L. H., Styczynski, A., Haque, A., Kabir, M. A., Bates-Jefferys, E., Crawford, E., Benjamin-Chung, J., Raihan, S., Rahman, S., Benhachmi, S., Bintee, N. Z., Winch, P. J., Hossain, M., Reza, H. M., Jaber, A. A., Momen, S. G., Rahman, A., Banti, F. L., Huq, T. S., Luby, S. P., Mobarak, A. M. 2021: eabi9069

  Abstract

  [Figure: see text].

  View details for PubMedID 34855513

• Pilot of a Low-Cost Elementary School Handwashing Intervention in Bangladesh: Acceptability, Feasibility, and Potential for Sustainability. The American journal of tropical medicine and hygiene Sultana, F., Unicomb, L., Rahman, M., Ali, S., Southern, D. L., Yeasmin, D., Sarkar, R. A., Das, K. K., Nizame, F. A., Winch, P. J., Luby, S. P. 2021

  Abstract

  Schoolchildren frequently transmit respiratory and gastrointestinal infections because of dense person-to-person contact in schools. We piloted a low-cost handwashing intervention among elementary schoolchildren in Bangladesh. We trained teachers to lead behavior change communication sessions using flipcharts to encourage students' handwashing before eating, after defecating, and after cleaning school toilets; provided handwashing stations (reservoirs with taps and stool + basin + soapy water solution [mix of 30 gm detergent with 1.5 L water] + pump top bottle with steel holder); and formed hygiene committees for maintenance and covering the recurrent cost of detergent. We evaluated intervention acceptability, feasibility, and potential for sustainability at 1 and 14 months after the intervention. At baseline, of 300 before eating events, no one washed hands with soap, and 99.7% (299) did not wash hands at all as soap was unavailable. Out of 269 after toileting events, 0.7% (2) washed hands with soap, and 88% (237) did not wash hands. After 4 weeks of the intervention, 45% (87/195 before eating events), 83% (155/186 after toileting events), and 100% (15/15 after cleaning toilet events) washed both hands with soapy water as children found it accessible, low cost, and child friendly. After 14 months, 9.4% (55/586 before eating events) and 37% (172/465 after toileting events) washed both hands with soapy water for health benefits. The intervention was acceptable and feasible; it overcame limited access to soap and water and was affordable as schools covered the recurrent costs of detergent. Further research should explore long-term habit adoption and impact on health and attendance.

  View details for DOI 10.4269/ajtmh.20-1335

  View details for PubMedID 34844216

• Displacing fishmeal with protein derived from stranded methane NATURE SUSTAINABILITY El Abbadi, S. H., Sherwin, E. D., Brandt, A. R., Luby, S. P., Criddle, C. S. 2021

  View details for DOI 10.1038/s41893-021-00796-2

  View details for Web of Science ID 000721454400003

• LONGITUDINAL EFFECTS OF A SANITATION INTERVENTION ON ENVIRONMENTAL FECAL CONTAMINATION IN A CLUSTER-RANDOMIZED CONTROLLED TRIAL IN RURAL BANGLADESH Contreras, J. D., Islam, M., Mertens, A., Pickering, A. J., Kwong, L. H., Arnold, B. F., Benjamin-Chung, J., Hubbard, A. E., Alam, M., Sen, D., Islam, S., Rahman, M., Unicomb, L., Luby, S. P., Colford, J. M., Ercumen, A. AMER SOC TROP MED & HYGIENE. 2021: 287-288

  View details for Web of Science ID 000778105602587

• EFFECTS OF DRINKING WATER, SANITATION, HANDWASHING, AND NUTRITIONAL INTERVENTIONS ON IMMUNE STATUS IN YOUNG CHILDREN: A CLUSTER-RANDOMIZED CONTROLLED TRIAL IN RURAL BANGLADESH Lin, A., Mertens, A. N., Tan, S., Rahman, M., Hester, L., Kim, L., Arnold, B. F., Karim, M., Shahriar, S., Ali, S., Shoab, A. K., Hossen, M., Mutsuddi, P., Famida, S. L., Akther, S., Rahman, M., Unicomb, L., Butzin-Dozier, Z., Hemlock, C., Hubbard, A. E., Stewart, C. P., Fernald, L. C., Colford, J. M., Luby, S. P., Dhabhar, F. S. AMER SOC TROP MED & HYGIENE. 2021: 287

  View details for Web of Science ID 000778105602586

• Formative Research to Design a Child-Friendly Latrine in Bangladesh. International journal of environmental research and public health Huda, T. M., Jahir, T., Sarker, S., Yeasmin, F., Masud, A. A., Sultana, J., Das, J. B., Nizame, F. A., Leontsini, E., Shoab, A. K., Kwong, L. H., Rahman, M., Luby, S. P., Winch, P. J. 2021; 18 (21)

  Abstract

  In low- and middle-income countries, most latrines are not accessible to young children. We explored how to modify existing pit latrines to make them child friendly. We conducted four focus group discussions with mothers to explore barriers to child latrine use. We then enrolled 20 households with a child aged 3-7 years old to test six enabling technologies developed based on the identified barriers. Two to three weeks after installing the selected enabling technologies in each household, researchers conducted 19 in-depth interviews with caregivers to explore the technologies' acceptance and feasibility. Common barriers included the discomfort of squatting on a large pan, fear of darkness, and fear of a slippery floor. Of the potential solutions, a ring to stabilize the child while squatting in the latrine was preferred by children and was affordable and available. A wooden board with a smaller hole than the usual pan reduced fears of falling and helped eliminate discomfort but was inconvenient to handle and clean. A transparent fiberglass roof tile was affordable, available, increased visibility, and kept the latrine floor dry. In conclusion, the fiberglass roof tile and stability ring were two affordable and locally available technologies that facilitated latrine use by children aged 3-7 years.

  View details for DOI 10.3390/ijerph182111092

  View details for PubMedID 34769612

• Seasonality of Date Palm Sap Feeding Behavior by Bats in Bangladesh. EcoHealth Islam, A., McKee, C., Ghosh, P. K., Abedin, J., Epstein, J. H., Daszak, P., Luby, S. P., Khan, S. U., Gurley, E. S. 2021

  Abstract

  Pteropus bats are the natural reservoir for Nipah virus, and in Bangladesh, it is transmitted to people through consumption of raw or fermented date palm sap. Our objective was to understand seasonal patterns of bat feeding on date palm sap at a location where sap is collected year-round. Seven nights each month over three years, we mounted infrared cameras in four trees to observe bats' feeding behavior at date palm trees harvested for fermented sap production. We described the frequency of bat visits, duration of bat visits, and duration of bat-sap contact by month and by year. We captured 42,873 bat visits during 256 camera-nights of observation, of which 3% were Pteropus and 94% were non-Pteropus bats. Though the frequency of Pteropus bat visits to each tree/night was much lower than non-Pteropus bat visits, Pteropus bats stayed in contact with sap longer than non-Pteropus bats. Frequency of bat visits was higher during winter compared to other seasons, which may arise as a consequence of limited availability of food sources during this period or may be related to seasonal characteristics of the sap. Seasonal alignment of sap consumption by humans and bats may have consequences for viral spillover into humans.

  View details for DOI 10.1007/s10393-021-01561-9

  View details for PubMedID 34609649

• Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials. The American journal of clinical nutrition Dewey, K. G., Wessells, K. R., Arnold, C. D., Prado, E. L., Abbeddou, S., Adu-Afarwuah, S., Ali, H., Arnold, B. F., Ashorn, P., Ashorn, U., Ashraf, S., Becquey, E., Bendabenda, J., Brown, K. H., Christian, P., Colford, J. M., Dulience, S. J., Fernald, L. C., Galasso, E., Hallamaa, L., Hess, S. Y., Humphrey, J. H., Huybregts, L., Iannotti, L. L., Jannat, K., Lartey, A., Le Port, A., Leroy, J. L., Luby, S. P., Maleta, K., Matias, S. L., Mbuya, M. N., Mridha, M. K., Nkhoma, M., Null, C., Paul, R. R., Okronipa, H., Ouedraogo, J., Pickering, A. J., Prendergast, A. J., Ruel, M., Shaikh, S., Weber, A. M., Wolff, P., Zongrone, A., Stewart, C. P. 2021

  Abstract

  BACKGROUND: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design.OBJECTIVES: We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes.METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n=37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.RESULTS: SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation.CONCLUSIONS: The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

  View details for DOI 10.1093/ajcn/nqab278

  View details for PubMedID 34590672

• Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers. The American journal of clinical nutrition Prado, E. L., Arnold, C. D., Wessells, K. R., Stewart, C. P., Abbeddou, S., Adu-Afarwuah, S., Arnold, B. F., Ashorn, U., Ashorn, P., Becquey, E., Brown, K. H., Chandna, J., Christian, P., Dentz, H. N., Dulience, S. J., Fernald, L. C., Galasso, E., Hallamaa, L., Hess, S. Y., Huybregts, L., Iannotti, L. L., Jimenez, E. Y., Kohl, P., Lartey, A., Le Port, A., Luby, S. P., Maleta, K., Matchado, A., Matias, S. L., Mridha, M. K., Ntozini, R., Null, C., Ocansey, M. E., Parvez, S. M., Phuka, J., Pickering, A. J., Prendergast, A. J., Shamim, A. A., Siddiqui, Z., Tofail, F., Weber, A. M., Wu, L. S., Dewey, K. G. 2021

  Abstract

  BACKGROUND: Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development.OBJECTIVES: We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects.METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n=30,024).RESULTS: In 11-13 intervention against control group comparisons (n=23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11).CONCLUSIONS: Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

  View details for DOI 10.1093/ajcn/nqab277

  View details for PubMedID 34590116

• Effective Demand for In-Line Chlorination Bundled with Rental Housing in Dhaka, Bangladesh. Environmental science & technology Smith, D. W., Sultana, S., Crider, Y. S., Islam, S. A., Swarthout, J. M., Goddard, F. G., Rabbani, A., Luby, S. P., Pickering, A. J., Davis, J. 2021

  Abstract

  Delivering safe water in cities of lower- and middle-income countries remains elusive even where there is a piped supply. Passive, in-line chlorination upstream of the point of water collection reduces child diarrhea without the behavior change required for point-of-use water treatment products or manual chlorine dispensers. We conducted a price experiment to measure effective demand (willingness and ability to pay) for an in-line chlorination service using tablet chlorinators among 196 landlords of rental housing properties in Dhaka, Bangladesh. We offered a 12-month subscription using Becker-DeGroot-Marschak auctions with real money payments. The service consistently delivered chlorinated water and satisfied tenants. Landlords' effective demand for in-line chlorination was similar to or greater than that for point-of-use treatment products and manual chlorine dispensers previously documented among Dhaka households. Over the service period, landlords renting to low-income households had lower effective demand than those renting to middle-income households despite similar initial rates of payment across both groups. Making in-line chlorination financially viable for the lowest-income consumers would likely require service cost reductions, subsidies, or both. Our findings suggest that even revealed preference experiments may overestimate the effective demand needed to sustain water supply improvements, especially in low-income populations, if they only measure demand once.

  View details for DOI 10.1021/acs.est.1c01308

  View details for PubMedID 34498866

• Telomere length is associated with growth in children in rural Bangladesh. eLife Lin, A., Mertens, A. N., Arnold, B. F., Tan, S., Lin, J., Stewart, C. P., Hubbard, A. E., Ali, S., Benjamin-Chung, J., Shoab, A. K., Rahman, M. Z., Famida, S. L., Hossen, M. S., Mutsuddi, P., Akther, S., Rahman, M., Unicomb, L., Naved, R. T., Mamun, M. M., Parvin, K., Dhabhar, F. S., Kariger, P., Fernald, L. C., Luby, S. P., Colford, J. M. 2021; 10

  Abstract

  Background: Previously, we demonstrated that a water, sanitation, handwashing, and nutritional intervention improved linear growth and was unexpectedly associated with shortened childhood telomere length (TL) (Lin et al., 2017). Here, we assessed the association between TL and growth.Methods: We measured relative TL in whole blood from 713 children. We reported differences between the 10th percentile and 90th percentile of TL or change in TL distribution using generalized additive models, adjusted for potential confounders.Results: In cross-sectional analyses, long TL was associated with a higher length-for-age Z score at age 1 year (0.23 SD adjusted difference in length-for-age Z score (95% CI 0.05, 0.42; FDR-corrected p-value = 0.01)). TL was not associated with other outcomes.Conclusions: Consistent with the metabolic telomere attrition hypothesis, our previous trial findings support an adaptive role for telomere attrition, whereby active TL regulation is employed as a strategy to address 'emergency states' with increased energy requirements such as rapid growth during the first year of life. Although short periods of active telomere attrition may be essential to promote growth, this study suggests that a longer overall initial TL setting in the first two years of life could signal increased resilience against future telomere erosion events and healthy growth trajectories.Funding: Funded by the Bill and Melinda Gates Foundation.

  View details for DOI 10.7554/eLife.60389

  View details for PubMedID 34494545

• Telomere length is associated with growth in children in rural Bangladesh ELIFE Lin, A., Mertens, A. N., Arnold, B. F., Tan, S., Lin, J., Stewart, C. P., Hubbard, A. E., Ali, S., Benjamin-Chung, J., Shoab, A. K., Rahman, M., Famida, S. L., Hossen, M., Mutsuddi, P., Akther, S., Rahman, M., Unicomb, L., Naved, R., Al Mamun, M., Parvin, K., Dhabhar, F. S., Kariger, P., Fernald, L. H., Luby, S. P., Colford, J. M. 2021; 10

  View details for DOI 10.7554/eLife.60389.sa2

  View details for Web of Science ID 000705933300001

• Effects of the COVID-19 pandemic on caregiver mental health and the child caregiving environment in a low-resource, rural context. Child development Pitchik, H. O., Tofail, F., Akter, F., Sultana, J., Shoab, A., Huda, T. M., Forsyth, J. E., Kaushal, N., Jahir, T., Yeasmin, F., Khan, R., Das, J. B., Khobair Hossain, M., Hasan, M. R., Rahman, M., Winch, P. J., Luby, S. P., Fernald, L. C. 2021

  Abstract

  Early child development has been influenced directly and indirectly by the COVID-19 pandemic, and these effects are exacerbated in contexts of poverty. This study estimates effects of the pandemic and subsequent population lockdowns on mental health, caregiving practices, and freedom of movement among female caregivers of children 6-27months (50% female), in rural Bangladesh. A cohort (N=517) was assessed before and during the pandemic (May-June, 2019 and July-September, 2020). Caregivers who experienced more food insecurity and financial loss during the pandemic reported larger increases in depressive symptoms (0.26 SD, 95% CI 0.08-0.44; 0.21 SD, 0.04-0.40) compared to less affected caregivers. Stimulating caregiving and freedom of movement results were inconsistent. Increases in depressive symptoms during the pandemic may have consequences for child development.

  View details for DOI 10.1111/cdev.13651

  View details for PubMedID 34490612

• Barriers and Opportunities for Sustainable Hand Hygiene Interventions in Rural Liberian Hospitals. International journal of environmental research and public health Tantum, L. K., Gilstad, J. R., Bolay, F. K., Horng, L. M., Simpson, A. D., Letizia, A. G., Styczynski, A. R., Luby, S. P., Arthur, R. F. 2021; 18 (16)

  Abstract

  Hand hygiene is central to hospital infection control. During the 2014-2016 West Africa Ebola virus disease epidemic in Liberia, gaps in hand hygiene infrastructure and health worker training contributed to hospital-based Ebola transmission. Hand hygiene interventions were undertaken post-Ebola, but many improvements were not sustainable. This study characterizes barriers to, and facilitators of, hand hygiene in rural Liberian hospitals and evaluates readiness for sustainable, locally derived interventions to improve hand hygiene. Research enumerators collected data at all hospitals in Bong and Lofa counties, Liberia, in the period March-May 2020. Enumerators performed standardized spot checks of hand hygiene infrastructure and supplies, structured observations of hand hygiene behavior, and semi-structured key informant interviews for thematic analysis. During spot checks, hospital staff reported that handwashing container water was always available in 89% (n = 42) of hospital wards, piped running water in 23% (n = 11), and soap in 62% (n = 29). Enumerators observed 5% of wall-mounted hand sanitizer dispensers (n = 8) and 95% of pocket-size dispensers (n = 53) to be working. In interviews, hospital staff described willingness to purchase personal hand sanitizer dispensers when hospital-provided supplies were unavailable. Low-cost, sustainable interventions should address supply and infrastructure-related obstacles to hospital hand hygiene improvement.

  View details for DOI 10.3390/ijerph18168588

  View details for PubMedID 34444337

• Success Factors for Community Health Workers in Implementing an Integrated Group-Based Child Development Intervention in Rural Bangladesh. International journal of environmental research and public health Jahir, T., Winch, P. J., Leontsini, E., Hwang, S. T., Yeasmin, F., Hossain, K., Das, J. B., Amin, R., Nurul Huda, T. M., Sultana, J., Khan, R., Akter, F., Shoab, A., Hasan, R., Pitchik, H. O., Tofail, F., Fernald, L. C., Luby, S. P., Rahman, M. 2021; 18 (15)

  Abstract

  Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs' training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children's attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.

  View details for DOI 10.3390/ijerph18157891

  View details for PubMedID 34360185

• Early diagnosis of kala-azar in Bangladesh: Findings from a population based mixed methods research informing the post-elimination era. Parasitology international Rahman, K. M., Olsen, A., Harley, D., Samarawickrema, I. V., Butler, C. D., Zahid, K., Sumon, S. A., Mondal, D., Luby, S. P., Sleigh, A. C. 2021: 102421

  Abstract

  BACKGROUND: Global annual reports of visceral leishmaniasis or kala-azar ("black fever") reduced from 200,000 cases in 2012 to 23,804 in 2015. India, Bangladesh and Nepal reported 80% of the global cases in 2012, but 39% in 2015. We sought to identify major amenable barriers to early diagnosis of kala-azar in peripheral areas of Mymensingh district, an area of Bangladesh that was highly endemic for kala-azar.METHODS: We conducted sequential exploratory mixed methods research. Qualitative data were first derived from in-depth interviews and focus group discussions among 29 patients diagnosed with kala-azar, their families, and neighbours. Preliminary results from qualitative analysis were used to design a structured questionnaire, which was administered to collect data on the processes leading to the diagnosis of kala-azar from 102 patients. Qualitative and quantitative data were integrated consistent with the chronology for kala-azar patients seeking care. The study was conducted from September 2011 to May 2012 in Fulbaria and Gaffargaon sub-districts of Mymensingh.RESULTS: The median delay from fever onset to confirmatory diagnosis of kala-azar was 60 days, with 38% of the cases diagnosed within 30 days. Public health facilities and Gaffargaon sub-district achieved high proportions of early diagnosis. Individual barriers to early diagnosis were low awareness of symptoms and treatment facilities, poverty, and traditional beliefs. Other factors were the remoteness of health care centres, wet season transport difficulty, mis-diagnosis as typhoid, limited availability of rK-39 testing at the community level, and the inclusion of splenomegaly in the case definition.CONCLUSIONS: Targeted community awareness campaigns appropriate for underprivileged communities will increase care seeking and consequently diagnosis. Improved diagnostic guidelines and a strong referral chain for kala-azar will accelerate diagnosis. These steps will contribute significantly to the National Kala-azar Elimination Program of Bangladesh, especially during the post-elimination era.

  View details for DOI 10.1016/j.parint.2021.102421

  View details for PubMedID 34280530

• Uncertainties in estimating SARS-CoV-2 prevalence by wastewater-based epidemiology. Chemical engineering journal (Lausanne, Switzerland : 1996) Li, X., Zhang, S., Shi, J., Luby, S. P., Jiang, G. 2021; 415: 129039

  Abstract

  Wastewater-based epidemiology (WBE) is a promising approach for estimating population-wide COVID-19 prevalence through detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in wastewater. However, various methodological challenges associated with WBE would affect the accuracy of prevalence estimation. To date, the overall uncertainty of WBE and the impact of each step on the prevalence estimation are largely unknown. This study divided the WBE approach into five steps (i.e., virus shedding; in-sewer transportation; sampling and storage; analysis of SARS-CoV-2 RNA concentration in wastewater; back-estimation) and further summarized and quantified the uncertainties associated with each step through a systematic review. Although the shedding of SARS-CoV-2 RNA varied greatly between COVID-19 positive patients, with more than 10 infected persons in the catchment area, the uncertainty caused by the excretion rate became limited for the prevalence estimation. Using a high-frequency flow-proportional sampling and estimating the prevalence through actual water usage data significantly reduced the overall uncertainties to around 20-40% (relative standard deviation, RSD). And under such a scenario, the analytical uncertainty of SARS-CoV-2 RNA in wastewater was the dominant factor. This highlights the importance of using surrogate viruses as internal or external standards during the wastewater analysis, and the need for further improvement on analytical approaches to minimize the analytical uncertainty. This study supports the application of WBE as a complementary surveillance strategy for monitoring COVID-19 prevalence and provides methodological improvements and suggestions to enhance the reliability for future studies.

  View details for DOI 10.1016/j.cej.2021.129039

  View details for PubMedID 33642938

• Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study. PLoS neglected tropical diseases Sultana, R., Luby, S. P., Gurley, E. S., Rimi, N. A., Swarna, S. T., Khan, J. A., Nahar, N., Ghosh, P. K., Howlader, S. R., Kabir, H., Khan, S., Jensen, P. K. 2021; 15 (6): e0009439

  Abstract

  The illness cost borne by households, known as out-of-pocket expenditure, was 74% of the total health expenditure in Bangladesh in 2017. Calculating economic burden of diarrhea of low-income urban community is important to identify potential cost savings strategies and prioritize policy decision to improve the quality of life of this population. This study aimed to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 17, 2015 to July 26, 2016. We used the World Health Organization (WHO) definition of three or more loose stool in 24 hours to enroll patients and enrolled 106 severe patients and 158 non-severe patients from Tongi General Hospital, local pharmacy and study community. The team enrolled patients between the first to third day of the illness (≤ 72 hours) and continued daily follow-up by phone until recovery. We considered direct and indirect costs to calculate cost-per-episode. We applied the published incidence rate to estimate the annual cost of diarrhea. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 [95% CI: 24.55, 30.23] (2,147 BDT), 17% of the average monthly income of the households. The average cost of illness for patient with non-severe diarrhea was US$ 6.36 [95% CI: 5.19, 7.55] (499 BDT), 4% of the average monthly income of households. A single diarrheal episode substantially affects financial condition of low-income urban community residents: a severe episode can cost almost equivalent to 4.35 days (17%) and a non-severe episode can cost almost equivalent to 1 day (4%) of household's income. Preventing diarrhea preserves health and supports financial livelihoods.

  View details for DOI 10.1371/journal.pntd.0009439

  View details for PubMedID 34115764

• A planetary health model for reducing exposure to faecal contamination in urban informal settlements: Baseline findings from Makassar, Indonesia. Environment international French, M. A., Fiona Barker, S., Taruc, R. R., Ansariadi, A., Duffy, G. A., Saifuddaolah, M., Zulkifli Agussalim, A., Awaluddin, F., Zainal, Z., Wardani, J., Faber, P. A., Fleming, G., Ramsay, E. E., Henry, R., Lin, A., O'Toole, J., Openshaw, J., Sweeney, R., Sinharoy, S. S., Kolotelo, P., Jovanovic, D., Schang, C., Higginson, E. E., Prescott, M. F., Burge, K., Davis, B., Ramirez-Lovering, D., Reidpath, D., Greening, C., Allotey, P., Simpson, J. A., Forbes, A., Chown, S. L., McCarthy, D., Johnston, D., Wong, T., Brown, R., Clasen, T., Luby, S., Leder, K., RISE consortium 2021; 155: 106679

  Abstract

  BACKGROUND: The intense interactions between people, animals and environmental systems in urban informal settlements compromise human and environmental health. Inadequate water and sanitation services, compounded by exposure to flooding and climate change risks, expose inhabitants to environmental contamination causing poor health and wellbeing and degrading ecosystems. However, the exact nature and full scope of risks and exposure pathways between human health and the environment in informal settlements are uncertain. Existing models are limited to microbiological linkages related to faecal-oral exposures at the individual level, and do not account for a broader range of human-environmental variables and interactions that affect population health and wellbeing.METHODS: We undertook a 12-month health and environmental assessment in 12 flood-prone informal settlements in Makassar, Indonesia. We obtained caregiver-reported health data, anthropometric measurements, stool and blood samples from children<5years, and health and wellbeing data for children 5-14years and adult respondents. We collected environmental data including temperature, mosquito and rat species abundance, and water and sediment samples. Demographic, built environment and household asset data were also collected. We combined our data with existing literature to generate a novel planetary health model of health and environment in informal settlements.RESULTS: Across the 12 settlements, 593 households and 2764 participants were enrolled. Two-thirds (64·1%) of all houses (26·3-82·7% per settlement) had formal land tenure documentation. Cough, fever and diarrhoea in the week prior to the survey were reported among an average of 34.3%, 26.9% and 9.7% of children aged<5years, respectively; although proportions varied over time, prevalence among these youngest children was consistently higher than among children 5-14years or adult respondents. Among children<5years, 44·3% experienced stunting, 41·1% underweight, 12.4% wasting, and 26.5% were anaemic. There was self- or carer-reported poor mental health among 16.6% of children aged 5-14years and 13.9% of adult respondents. Rates of potential risky exposures from swimming in waterways, eating uncooked produce, and eating soil or dirt were high, as were exposures to flooding and livestock. Just over one third of households (35.3%) had access to municipal water, and contamination of well water with E. coli and nitrogen species was common. Most (79·5%) houses had an in-house toilet, but no houses were connected to a piped sewer network or safe, properly constructed septic tank. Median monthly settlement outdoor temperatures ranged from 26·2°C to 29.3°C, and were on average, 1·1°C warmer inside houses than outside. Mosquito density varied over time, with Culex quinquefasciatus accounting for 94·7% of species. Framed by a planetary health lens, our model includes four thematic domains: (1) the physical/built environment; (2) the ecological environment; (3) human health; and (4) socio-economic wellbeing, and is structured at individual, household, settlement, and city/beyond spatial scales.CONCLUSIONS: Our planetary health model includes key risk factors and faecal-oral exposure pathways but extends beyond conventional microbiological faecal-oral enteropathogen exposure pathways to comprehensively account for a wider range of variables affecting health in urban informal settlements. It includes broader ecological interconnections and planetary health-related variables at the household, settlement and city levels. It proposes a composite framework of markers to assess water and sanitation challenges and flood risks in urban informal settlements for optimal design and monitoring of interventions.

  View details for DOI 10.1016/j.envint.2021.106679

  View details for PubMedID 34126296

• Data-driven estimation of COVID-19 community prevalence through wastewater-based epidemiology. The Science of the total environment Li, X., Kulandaivelu, J., Zhang, S., Shi, J., Sivakumar, M., Mueller, J., Luby, S., Ahmed, W., Coin, L., Jiang, G. 2021; 789: 147947

  Abstract

  Wastewater-based epidemiology (WBE) has been regarded as a potential tool for the prevalence estimation of coronavirus disease 2019 (COVID-19) in the community. However, the application of the conventional back-estimation approach is currently limited due to the methodological challenges and various uncertainties. This study systematically performed meta-analysis for WBE datasets and investigated the use of data-driven models for the COVID-19 community prevalence in lieu of the conventional WBE back-estimation approach. Three different data-driven models, i.e. multiple linear regression (MLR), artificial neural network (ANN), and adaptive neuro fuzzy inference system (ANFIS) were applied to the multi-national WBE dataset. To evaluate the robustness of these models, predictions for sixteen scenarios with partial inputs were compared against the actual prevalence reports from clinical testing. The performance of models was further validated using unseen data (data sets not included for establishing the model) from different stages of the COVID-19 outbreak. Generally, ANN and ANFIS models showed better accuracy and robustness over MLR models. Air and wastewater temperature played a critical role in the prevalence estimation by data-driven models, especially MLR models. With unseen datasets, ANN model reasonably estimated the prevalence of COVID-19 (cumulative cases) at the initial phase and forecasted the upcoming new cases in 2-4 days at the post-peak phase of the COVID-19 outbreak. This study provided essential information about the feasibility and accuracy of data-driven estimation of COVID-19 prevalence through the WBE approach.

  View details for DOI 10.1016/j.scitotenv.2021.147947

  View details for PubMedID 34051491

• Making the invisible visible: developing and evaluating an intervention to raise awareness and reduce lead exposure among children and their caregivers in rural Bangladesh. Environmental research Jahir, T., Pitchik, H. O., Rahman, M., Sultana, J., Shoab, A. K., Nurul Huda, T. M., Byrd, K. A., Islam, M. S., Yeasmin, F., Baker, M., Yeasmin, D., Nurunnahar, S., Luby, S. P., Winch, P. J., Forsyth, J. E. 2021: 111292

  Abstract

  Lead exposure is harmful at any time in life, but pre-natal and early childhood exposures are particularly detrimental to cognitive development. In Bangladesh, multiple household-level lead exposures pose risks, including turmeric adulterated with lead chromate and food storage in lead-soldered cans. We developed and evaluated an intervention to reduce lead exposure among children and their caregivers in rural Bangladesh. We conducted formative research to inform theory-based behavioral recommendations. Lead exposure was one of several topics covered in the multi-component intervention focused on early child development. Community health workers (CHWs) delivered the lead component of the intervention during group sessions with pregnant women and mother-child dyads (<15 months old) in a cluster-randomized trial. We administered household surveys at baseline (control n=301; intervention n=320) and 9 months later at endline (control n=279; intervention n=239) and calculated adjusted risk and mean differences for primary outcomes. We conducted two qualitative assessments, one after 3 months and a second after 9 months, to examine the feasibility and benefits of the intervention. At endline, the prevalence of lead awareness was 52 percentage points higher in the intervention arm compared to the control (adjusted risk difference: 0.52 [95% CI 0.46 to 0.61]). Safe turmeric consumption and food storage practices were more common in the intervention versus control arm at endline, with adjusted risk differences of 0.22 [0.10 to 0.32] and 0.13 [0.00 to 0.19], respectively. Semi-structured interviews conducted with a subset of participants after the intervention revealed that the perceived benefit of reducing lead exposure was high because of the long-term negative impacts that lead can have on child cognitive development. The study demonstrates that a group-based CHW-led intervention can effectively raise awareness about and motivate lead exposure prevention behaviors in rural Bangladesh. Future efforts should combine similar awareness-raising efforts with longer-term regulatory and structural changes to systematically and sustainably reduce lead exposure.

  View details for DOI 10.1016/j.envres.2021.111292

  View details for PubMedID 33971132

• Monitoring of diverse enteric pathogens across environmental and host reservoirs with TaqMan array cards and standard qPCR: a methodological comparison study LANCET PLANETARY HEALTH Lappan, R., Henry, R., Chown, S. L., Luby, S. P., Higginson, E. E., Bata, L., Jirapanjawat, T., Schang, C., Openshaw, J. J., O'Toole, J., Lin, A., Tela, A., Turagabeci, A., Wong, T. F., French, M. A., Brown, R. R., Leder, K., Greening, C., McCarthy, D. 2021; 5 (5): E297-E308

  View details for Web of Science ID 000648653900013

• Nitrate in Drinking Water during Pregnancy and Spontaneous Preterm Birth: A Retrospective Within-Mother Analysis in California. Environmental health perspectives Sherris, A. R., Baiocchi, M., Fendorf, S., Luby, S. P., Yang, W., Shaw, G. M. 2021; 129 (5): 57001

  Abstract

  BACKGROUND: Nitrate is a widespread groundwater contaminant and a leading cause of drinking water quality violations in California. Associations between nitrate exposure and select adverse birth outcomes have been suggested, but few studies have examined gestational exposures to nitrate and risk of preterm birth (before 37 wk gestation).OBJECTIVE: We investigated the association between elevated nitrate in drinking water and spontaneous preterm birth through a within-mother retrospective cohort study of births in California.METHODS: We acquired over 6 million birth certificate records linked with Office of Statewide Health Planning and Development hospital discharge data for California births from 2000-2011. We used public water system monitoring records to estimate nitrate concentrations in drinking water for each woman's residence during gestation. After exclusions, we constructed a sample of 1,443,318 consecutive sibling births in order to conduct a within-mother analysis. We used separate conditional logistic regression models to estimate the odds of preterm birth at 20-31 and 32-36 wk, respectively, among women whose nitrate exposure changed between consecutive pregnancies.RESULTS: Spontaneous preterm birth at 20-31 wk was increased in association with tap water nitrate concentrations during pregnancy of 5 to <10mg/L [odds ratio (OR)=1.47; 95% confidence interval (CI): 1.29, 1.67] and ≥10mg/L (OR=2.52; 95% CI: 1.49, 4.26) compared with <5mg/L (as nitrogen). Corresponding estimates for spontaneous preterm birth at 32-36 wk were positive but close to the null for 5 to <10mg/L nitrate (OR=1.08; 95% CI: 1.02, 1.15) and for ≥10mg/L nitrate (OR=1.05; 95% CI: 0.85, 1.31) vs. <5mg/L nitrate. Our findings were similar in several secondary and sensitivity analyses, including in a conventional individual-level design.DISCUSSION: The results suggest that nitrate in drinking water is associated with increased odds of spontaneous preterm birth. Notably, we estimated modestly increased odds associated with tap water nitrate concentrations of 5 to <10mg/L (below the federal drinking water standard of 10mg/L) relative to <5mg/L. https://doi.org/10.1289/EHP8205.

  View details for DOI 10.1289/EHP8205

  View details for PubMedID 33949893

• The Lived Experiences of Community Health Workers Serving in a Large-Scale Water, Sanitation, and Hygiene Intervention Trial in Rural Bangladesh. International journal of environmental research and public health Rahman, M., Jahir, T., Yeasmin, F., Begum, F., Mobashara, M., Hossain, K., Khan, R., Hossain, R., Nizame, F. A., Jain, A., Leontsini, E., Unicomb, L., Luby, S. P., Winch, P. J. 2021; 18 (7)

  Abstract

  Community health workers (CHWs) are key to implementing community-based health interventions and quality can be enhanced by better understanding their lived experiences. The WASH Benefits, Bangladesh trial engaged 540 female CHWs to promote varying health intervention packages. We report on factors influencing their lived experiences during the trial, to aid future recruitment, training and retention of CHWs. Nine focus groups and 18 in-depth interviews were conducted with CHWs. Focus groups and interviews were transcribed and thematic content analysis performed to summarize the results. All CHWs described experiencing positive working conditions and many benefits both socially and financially; these contributed to their retention and job satisfaction. Their honorarium was commonly applied towards their children's education and invested for income generation. CHWs gained self-confidence as women, to move unaccompanied in the community and speak in public. They earned respect from the community and their family members who helped them manage their family obligations during work and were viewed as a resource for advice on health and social issues. Many participated in family decision-making from which they were previously excluded. Health programs should foster a positive experience among their CHWs to aid the recruitment, retention and development of this important human resource.

  View details for DOI 10.3390/ijerph18073389

  View details for PubMedID 33805884

• A holistic approach to promoting early child development: a cluster randomised trial of a group-based, multicomponent intervention in rural Bangladesh. BMJ global health Pitchik, H. O., Tofail, F., Rahman, M., Akter, F., Sultana, J., Shoab, A. K., Huda, T. M., Jahir, T., Amin, M. R., Hossain, M. K., Das, J. B., Chung, E. O., Byrd, K. A., Yeasmin, F., Kwong, L. H., Forsyth, J. E., Mridha, M. K., Winch, P. J., Luby, S. P., Fernald, L. C. 2021; 6 (3)

  Abstract

  INTRODUCTION: In low- and middle-income countries, children experience multiple risks for delayed development. We evaluated a multicomponent, group-based early child development intervention including behavioural recommendations on responsive stimulation, nutrition, water, sanitation, hygiene, mental health and lead exposure prevention.METHODS: We conducted a 9-month, parallel, multiarm, cluster-randomised controlled trial in 31 rural villages in Kishoreganj District, Bangladesh. Villages were randomly allocated to: group sessions ('group'); alternating groups and home visits ('combined'); or a passive control arm. Sessions were delivered fortnightly by trained community members. The primary outcome was child stimulation (Family Care Indicators); the secondary outcome was child development (Ages and Stages Questionnaire Inventory, ASQi). Other outcomes included dietary diversity, latrine status, use of a child potty, handwashing infrastructure, caregiver mental health and knowledge of lead. Analyses were intention to treat. Data collectors were independent from implementers.RESULTS: In July-August 2017, 621 pregnant women and primary caregivers of children<15 months were enrolled (group n=160, combined n=160, control n=301). At endline, immediately following intervention completion (July-August 2018), 574 participants were assessed (group n=144, combined n=149, control n=281). Primary caregivers in both intervention arms participated in more play activities than control caregivers (age-adjusted means: group 4.22, 95% CI 3.97 to 4.47; combined 4.77, 4.60 to 4.96; control 3.24, 3.05 to 3.39), and provided a larger variety of play materials (age-adjusted means: group 3.63, 3.31 to 3.96; combined 3.81, 3.62 to 3.99; control 2.48, 2.34 to 2.59). Compared with the control arm, children in the group arm had higher total ASQi scores (adjusted mean difference in standardised scores: 0.39, 0.15 to 0.64), while in the combined arm scores were not significantly different from the control (0.25, -0.07 to 0.54).CONCLUSION: Our findings suggest that group-based, multicomponent interventions can be effective at improving child development outcomes in rural Bangladesh, and that they have the potential to be delivered at scale.TRIAL REGISTRATION NUMBER: The trial is registered in ISRCTN (ISRCTN16001234).

  View details for DOI 10.1136/bmjgh-2020-004307

  View details for PubMedID 33727278

• Household finished flooring and soil-transmitted helminth and Giardia infections among children in rural Bangladesh and Kenya: a prospective cohort study LANCET GLOBAL HEALTH Benjamin-Chung, J., Crider, Y. S., Mertens, A., Ercumen, A., Pickering, A. J., Lin, A., Steinbaum, L., Swarthout, J., Rahman, M., Parvez, S. M., Haque, R., Njenga, S. M., Kihara, J., Null, C., Luby, S. P., Colford, J. M., Arnold, B. F. 2021; 9 (3): E301–E308

  View details for Web of Science ID 000621377000027

• Evaluation of Vaccine Safety After the First Public Sector Introduction of Typhoid Conjugate Vaccine-Navi Mumbai, India, 2018. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Longley, A. T., Date, K., Luby, S. P., Bhatnagar, P., Bentsi-Enchill, A. D., Goyal, V., Shimpi, R., Katkar, A., Yewale, V., Jayaprasad, N., Horng, L., Kunwar, A., Harvey, P., Haldar, P., Dutta, S., Gidudu, J. 2021

  Abstract

  BACKGROUND: In December 2017, the World Health Organization (WHO) prequalified the first typhoid conjugate vaccine (TCV) (Typbar-TCV). While no safety concerns were identified in pre- and post-licensure studies, WHO's Global Advisory Committee on Vaccine Safety recommended robust safety evaluation with large-scale TCV introductions. During July-August 2018, the Navi Mumbai Municipal Corporation (NMMC) launched the world's first public sector TCV introduction. Per administrative reports, 113,420 children 9 months-14 years old received TCV.METHODS: We evaluated adverse events following immunization (AEFI) using passive and active surveillance via 1) reports from the passive NMMC AEFI surveillance system, 2) telephone interviews with 5% of caregivers of vaccine recipients 48 hours and 7 days post-vaccination, and 3) chart abstraction for adverse events of special interest (AESI) among patients admitted to 5 hospitals using the Brighton Collaboration criteria followed by ascertainment of vaccination status.RESULTS: We identified 222/113,420 (0.2%) AEFI through the NMMC AEFI surveillance system: 211 (0.19%) minor, 2 (0.002%) severe, and 9 (0.008%) serious. At 48 hours post-vaccination, 1,852/5,605 (33%) caregivers reported one or more AEFI, including injection site pain (n=1,452, 26%), swelling (n=419, 7.5%), and fever (n=416, 7.4%). Of the 4,728 interviews completed at 7 days post-vaccination, the most reported AEFI included fever (n=200, 4%), pain (n=52, 1%), and headache (n=42, 1%). Among 525 hospitalized children diagnosed with an AESI, 60 were vaccinated; no AESI were causally associated with TCV.CONCLUSIONS: No unexpected safety signals were identified with TCV introduction. This provides further reassurance for the large-scale use of Typbar-TCV among children 9 months-14 years old.

  View details for DOI 10.1093/cid/ciab059

  View details for PubMedID 33502453

• The Ecology of Nipah Virus in Bangladesh: A Nexus of Land-Use Change and Opportunistic Feeding Behavior in Bats. Viruses McKee, C. D., Islam, A., Luby, S. P., Salje, H., Hudson, P. J., Plowright, R. K., Gurley, E. S. 2021; 13 (2)

  Abstract

  Nipah virus is a bat-borne paramyxovirus that produces yearly outbreaks of fatal encephalitis in Bangladesh. Understanding the ecological conditions that lead to spillover from bats to humans can assist in designing effective interventions. To investigate the current and historical processes that drive Nipah spillover in Bangladesh, we analyzed the relationship among spillover events and climatic conditions, the spatial distribution and size of Pteropus medius roosts, and patterns of land-use change in Bangladesh over the last 300 years. We found that 53% of annual variation in winter spillovers is explained by winter temperature, which may affect bat behavior, physiology, and human risk behaviors. We infer from changes in forest cover that a progressive shift in bat roosting behavior occurred over hundreds of years, producing the current system where a majority of P. medius populations are small (median of 150 bats), occupy roost sites for 10 years or more, live in areas of high human population density, and opportunistically feed on cultivated food resources-conditions that promote viral spillover. Without interventions, continuing anthropogenic pressure on bat populations similar to what has occurred in Bangladesh could result in more regular spillovers of other bat viruses, including Hendra and Ebola viruses.

  View details for DOI 10.3390/v13020169

  View details for PubMedID 33498685

• Could Alcohol-Based Hand Sanitizer Be an Option for Hand Hygiene for Households in Rural Bangladesh? The American journal of tropical medicine and hygiene Yeasmin, D., Dutta, N. C., Nizame, F. A., Rahman, M. J., Ashraf, S., Ram, P. K., Leontsini, E., Rahman, M., Winch, P. J., Luby, S. P., Unicomb, L. 2021

  Abstract

  In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.

  View details for DOI 10.4269/ajtmh.20-0755

  View details for PubMedID 33534756

• Exploration of Attendance, Active Participation, and Behavior Change in a Group-Based Responsive Stimulation, Maternal and Child Health, and Nutrition Intervention. The American journal of tropical medicine and hygiene Yeasmin, F., Winch, P. J., Hwang, S. T., Leontsini, E., Jahir, T., Das, J. B., Amin, M. R., Hossain, M. K., Huda, T. M., Akter, F., Shoab, A. K., Tofail, F., Mridha, M. K., Sultana, J., Pitchik, H., Fernald, L. C., Luby, S. P., Rahman, M. 2021

  Abstract

  Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant's attendance were identified, and the resulting intervention shows promise for future implementation at scale.

  View details for DOI 10.4269/ajtmh.20-0991

  View details for PubMedID 33534769

• Study design, rationale and methods of the Revitalising Informal Settlements and their Environments (RISE) study: a cluster randomised controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in Indonesia and Fiji. BMJ open Leder, K., Openshaw, J. J., Allotey, P., Ansariadi, A., Barker, S. F., Burge, K., Clasen, T. F., Chown, S. L., Duffy, G. A., Faber, P. A., Fleming, G., Forbes, A. B., French, M., Greening, C., Henry, R., Higginson, E., Johnston, D. W., Lappan, R., Lin, A., Luby, S. P., McCarthy, D., O'Toole, J. E., Ramirez-Lovering, D., Reidpath, D. D., Simpson, J. A., Sinharoy, S. S., Sweeney, R., Taruc, R. R., Tela, A., Turagabeci, A. R., Wardani, J., Wong, T., Brown, R., RISE Consortium, Awaluddin, F., Batagol, B., Bata, L., Bulachi, D., Cahan, B., Davis, B., El-Sioufi, M., Jovanovic, D., Prescott, M. F., Ramsay, E., Rogersh, B., Saifuddaolah, M., Schang, C., Tseng, C., Vamosi, R., Vilsoni, S., Vakarewa, I., Zulkifli, A. 2021; 11 (1): e042850

  Abstract

  INTRODUCTION: Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries.METHODS AND ANALYSIS: RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being.ETHICS: Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University.TRIAL REGISTRATION NUMBER: ACTRN12618000633280; Pre-results.

  View details for DOI 10.1136/bmjopen-2020-042850

  View details for PubMedID 33419917

• Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh. International journal for equity in health Parvez, S. M., Rahman, M. J., Azad, R., Rahman, M., Unicomb, L., Ashraf, S., Mondol, M. H., Jahan, F., Winch, P. J., Luby, S. P. 2021; 20 (1): 16

  Abstract

  BACKGROUND: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.METHODS: The current analysis selected 4 indicators from the WASH Benefits trial- presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.RESULTS: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (-4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, -25% (-35, -15) Q2: -34% (-44, -23%)] than the wealthiest household [Q5 DID: -1% (-11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%).CONCLUSION: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program.TRIAL REGISTRATION: WASH Benefits Bangladesh: ClinicalTrials.gov , identifier: NCT01590095 . Date of registration: April 30, 2012 'Retrospectively registered'.

  View details for DOI 10.1186/s12939-020-01353-7

  View details for PubMedID 33407549

• Child lead exposure near abandoned lead acid battery recycling sites in a residential community in Bangladesh: risk factors and the impact of soil remediation on blood lead levels. Environmental research Amin Chowdhury, K. I., Nurunnahar, S. n., Kabir, M. L., Islam, M. T., Baker, M. n., Islam, M. S., Rahman, M. n., Hasan, M. A., Sikder, A. n., Kwong, L. H., Binkhorst, G. K., Nash, E. n., Keith, J. n., McCartor, A. n., Luby, S. P., Forsyth, J. E. 2021: 110689

  Abstract

  Lead is a potent neurotoxin that is particularly detrimental to children's cognitive development. Batteries account for at least 80% of global lead use and unsafe battery recycling is a major contributor to childhood lead poisoning. Our objectives were to assess the intensity and nature of child lead exposure at abandoned, informal used lead acid battery (ULAB) recycling sites in Kathgora, Savar, Bangladesh, as well as to assess the feasibility and effectiveness of a soil remediation effort to reduce exposure. ULAB recycling operations were abandoned in 2016 due to complaints from residents, but the lead contamination remained in the soil after operations ceased. We measured soil and blood lead levels (BLLs) among 69 children living within 200 meters of the ULAB recycling site once before, and twice after (7 and 14 months after), a multi-part remediation intervention involving soil capping, household cleaning, and awareness-raising activities. Due to attrition, the sample size of children decreased from 69 to 47 children at the 7-month post-intervention assessment and further to 25 children at 14 months. We conducted non-parametric tests to assess changes in soil lead levels and BLLs. We conducted baseline surveys, as well as semi-structured interviews and observations with residents throughout the study period to characterize exposure behaviors and the community perceptions. We conducted bivariate and multivariate regression analyses of exposure characteristics to determine the strongest predictors of baseline child BLLs. Prior to remediation, median soil lead concentrations were 1,400 mg/kg, with a maximum of 119,000 mg/kg and dropped to a median of 55 mg/kg after remediation (p<0.0001). Among the 47 children with both baseline and post-intervention time 1 measurements, BLLs dropped from a median of 21.3 μg/dL to 17.0 μg/dL at 7 months (p<0.0001). Among the 25 children with all three measurements, BLLs dropped from a median of 22.6 μg/dL to 14.8 μg/dL after 14 months (p<0.0001). At baseline, distance from a child's residence to the nearest abandoned ULAB site was the strongest predictor of BLLs and baseline BLLs were 31% higher for children living within 50 meters from the sites compared to those living further away (n=69, p=0.028). Women and children spent time in the contaminated site daily and relied on it for their livelihoods and for recreation. Overall, this study highlights the intensity of lead exposure associated with the ULAB recycling industry. Additionally, we document the feasibility and effectiveness of a multi-part remediation intervention at a contaminated site embedded within a residential community; substantially reducing child BLLs and soil lead concentrations.

  View details for DOI 10.1016/j.envres.2020.110689

  View details for PubMedID 33412099

• Longitudinal Effects of a Sanitation Intervention on Environmental Fecal Contamination in a Cluster-Randomized Controlled Trial in Rural Bangladesh. Environmental science & technology Contreras, J. D., Islam, M., Mertens, A., Pickering, A. J., Kwong, L. H., Arnold, B. F., Benjamin-Chung, J., Hubbard, A. E., Alam, M., Sen, D., Islam, S., Rahman, M., Unicomb, L., Luby, S. P., Colford, J. M., Ercumen, A. 2021

  Abstract

  Household latrine access generally is not associated with reduced fecal contamination in the environment, but its long-term effectiveness has not been measured. We conducted an environmental assessment nested within the WASH Benefits Bangladesh randomized controlled trial (NCT01590095). We quantified E. coli and fecal coliforms in samples of stored drinking water, child hands, mother hands, soil, and food among a random sample of households from the sanitation and control arms of the trial. Samples were collected during eight quarterly visits approximately 1-3.5 years after intervention initiation. Overall, there were no substantial differences in environmental fecal contamination between households enrolled in the sanitation and control arms. Statistically significant reductions were found in stored water and child hands after pooling across sampling rounds, but the effects were small and not consistent across rounds. In addition, we assessed potential effect modification of intervention effects by follow-up time, season, wealth, community-level latrine density and coverage, population density, and domestic animal ownership. While the intervention had statistically significant effects within some subgroups, there were no consistent patterns of effect modification. Our findings support a growing consensus that on-site latrines are insufficient to prevent fecal contamination in the rural household environment.

  View details for DOI 10.1021/acs.est.1c01114

  View details for PubMedID 34086447

• Analytical performance comparison of four SARS-CoV-2 RT-qPCR primer-probe sets for wastewater samples. The Science of the total environment Zhang, S., Li, X., Shi, J., Sivakumar, M., Luby, S., O'Brien, J., Jiang, G. 2021: 150572

  Abstract

  Current studies have confirmed the feasibility of SARS-CoV-2 RNA detection by RT-qPCR assays in wastewater samples as an effective surveillance tool of COVID-19 prevalence in a community. Analytical performance of various RT-qPCR assays has been compared against wastewater samples based on the positive ratio. However, there is no systematic comparison work has been conducted for both analytical sensitivity and quantitative reliability against wastewater, which are essential factors for WBE. In this study, the detection performance of four RT-qPCR primer-probe sets, including CCDC-N, CDC-N1, N-Sarbeco, and E-Sarbeco, was systematically evaluated with pure synthetized plasmids, spiked wastewater mocks and raw wastewater samples. In addition to confirm RT-qPCR results, Nanopore sequencing was employed to delineate at molecular level for the analytical sensitivity and reproducibility of those primer-probe sets. CCDC-N showed high sensitivity and the broadest linearity range for wastewater samples. It was thus recommended to be the most efficient tool in the quantitative analysis of SARS-CoV-2 in wastewater. CDC-N1 had the highest sensitivity for real wastewater and thus would be suitable for the screening of wastewater for the presence of SARS-CoV-2. When applying the primer-probe sets to wastewater samples collected from different Australian catchments, the augment of SARS-CoV-2 RNA in wastewater reflected the increase of active clinical cases within those communities.

  View details for DOI 10.1016/j.scitotenv.2021.150572

  View details for PubMedID 34582851

• Teachers' perspective on implementation of menstrual hygiene management and puberty education in a pilot study in Bangladeshi schools. Global health action Mahfuz, M. T., Sultana, F., Hunter, E. C., Jahan, F., Akand, F., Khan, S., Mobashhara, M., Rahman, M., Alam, M., Unicomb, L., Luby, S. P., Winch, P. J. 2021; 14 (1): 1955492

  Abstract

  OBJECTIVE: To assess the perspectives of Bangladeshi teachers on the feasibility of delivery and potential for long-term sustainability of puberty and menstruation education in urban and rural schools.METHOD: We developed a multi-module puberty and menstrual hygiene management education curriculum that teachers piloted for six months in four urban and rural government and private schools in Bangladesh. We conducted monthly assessments during piloting, discussion for manual revision and four group discussions with 20 participating teachers to understand perceived benefits, barriers, and sustainability of puberty and menstruation education among school children.RESULTS: Teachers acknowledged the importance of school-based puberty and menstruation education to improve students' perception and preparedness. They found that the training and instructors' manual they received were useful tools for effectively communicating with students. Teachers noted school and community pressure to de-emphasize educational content not included on nationally standardized examinations, and insufficient time and pre-service training for teaching sensitive topics served as barriers to implementing the pilot curriculum.CONCLUSION: Pressure from school authorities and community may hinder the successful long-term delivery of school-based puberty and menstruation education programs that are external to the national curriculum. Our findings indicate that feasibly and sustainably improving education on these topics in Bangladeshi classrooms should be achieved through 1) revision of the current national curriculum to incorporate more comprehensive puberty and menstruation information including its physiology, management, and social context, 2) adequate training and support for teachers to deliver the content, and 3) incorporation of puberty and menstruation content into students' national examinations which may better ensure teachers are given the tools and opportunity to prioritize teaching this content.

  View details for DOI 10.1080/16549716.2021.1955492

  View details for PubMedID 34338160

• Effect of sanitation improvements on soil-transmitted helminth eggs in courtyard soil from rural Bangladesh: Evidence from a cluster-randomized controlled trial. PLoS neglected tropical diseases Kwong, L. H., Sen, D., Islam, S., Shahriar, S., Benjamin-Chung, J., Arnold, B. F., Hubbard, A., Parvez, S. M., Islam, M., Unicomb, L., Rahman, M., Nelson, K., Colford, J. M., Luby, S. P., Ercumen, A. 2021; 15 (7): e0008815

  Abstract

  Improved sanitation has been hypothesized to reduce soil-transmitted helminth (STH) infections by reducing the prevalence and concentration of STH eggs/larvae in soil. We evaluated the effect of a randomized sanitation program (providing households with an improved dual-pit latrine, tools for child/animal feces management, and behavioral messaging) on reducing the prevalence and concentration of STH eggs in soil from household courtyards. We collected soil samples from 1405 households enrolled in the sanitation intervention (n = 419) and control (n = 914) groups of a cluster-randomized controlled trial (WASH Benefits) in rural Bangladesh approximately 2 years after the initiation of the interventions. We analyzed samples for Ascaris lumbricoides, Trichuris trichiura, and hookworm eggs by microscopy. We estimated prevalence ratios (PR) and egg count ratio (ECR) to compare the prevalence of STH eggs and arithmetic and geometric mean egg counts for STH eggs per gram of soil in the sanitation and control arms. Among intervention households, latrines achieved high and sustained user uptake by adults while child open defecation remained common and most households did not dispose of child feces hygienically. In courtyard soil from control households, the prevalence of any STH eggs was 75.7% and the prevalence of any larvated STH eggs was 67.3%. A. lumbricoides was detected in 63.0% of control samples and T. trichiura in 55.7% of control samples; hookworm was not detected in any sample. In the control arm, the arithmetic mean egg count for any STH was 3.96 eggs/dry gram, while the geometric mean was 1.58 eggs/dry gram. There was no difference between the intervention and control groups in the prevalence of any STH eggs (PR = 0.98 (95% CI: 0.91, 1.05)) or mean egg counts (ECR = 0.08 (95% CI: -0.10, 0.26) for geometric mean and 0.07 (95% CI: -0.22, 0.37) for arithmetic mean). Adjusted models gave similar results. A compound-level sanitation intervention that provided improved latrines and tools for disposal of child and animal feces did not have an impact on STH eggs in soil. In order to effectively reduce the prevalence and concentration of STH eggs in the environment, sustained, widespread use of sanitation strategies to isolate and hygienically dispose of child and animal feces may need to complement traditional strategies for containment of adult human feces. Trial Registration: NCT01590095.

  View details for DOI 10.1371/journal.pntd.0008815

  View details for PubMedID 34319986

• Effectiveness of Mass Media Campaigns to Improve Handwashing-Related Behavior, Knowledge, and Practices in Rural Bangladesh. The American journal of tropical medicine and hygiene Islam, M. n., Benjamin-Chung, J. n., Sultana, S. n., Unicomb, L. n., Alam, M. n., Rahman, M. n., Ercumen, A. n., Luby, S. P. 2021

  Abstract

  Water, sanitation, and handwashing interventions that use intensive interpersonal communication improve targeted behaviors, but are expensive at scale. Mass media is an alternative that could reach more people at lower cost but has rarely been rigorously evaluated. We assessed the effectiveness of a mass media campaign in improving handwashing knowledge and practices in rural Bangladesh. We conducted a cross-sectional assessment before the campaign among 8,947 households and again after 4 months of the campaign among 8,400 different households in the same areas. Trained enumerators conducted spot checks of water, sanitation, and hygiene facilities, and recorded reported knowledge and practices. We compared these outcomes after versus before the campaign using generalized linear models with robust standard errors. After the media campaign, caregivers were more likely to recall ≥ 3 messages regarding handwashing (prevalence ratio [PR] = 1.44, 1.34-1.55), sanitation (PR = 1.45, 1.35-1.55), and safe water (PR = 1.17, 1.08-1.26). After the campaign, the prevalence of using soap and water during handwashing demonstrations was higher among caregivers (PR = 1.15, 1.12-1.19) and children (PR = 1.31, 1.22-1.41). Hands were more commonly observed to be visibly clean among caregivers (PR = 1.14, 1.07-1.20) and children (PR = 1.13, 1.05-1.21). Soap and water was more commonly observed in handwashing stations near latrines (PR = 1.12, 1.06-1.19) and in cooking/eating places (PR = 1.09, 1.01-1.18). Our findings indicate improved handwashing knowledge and behaviors following a mass media campaign. This promising approach can be deployed to improve water, sanitation, and hygiene practices at scale and should be evaluated in other contexts.

  View details for DOI 10.4269/ajtmh.20-1154

  View details for PubMedID 33534770

• Household finished flooring and soil-transmitted helminth and Giardia infections among children in rural Bangladesh and Kenya: a prospective cohort study. The Lancet. Global health Benjamin-Chung, J. n., Crider, Y. S., Mertens, A. n., Ercumen, A. n., Pickering, A. J., Lin, A. n., Steinbaum, L. n., Swarthout, J. n., Rahman, M. n., Parvez, S. M., Haque, R. n., Njenga, S. M., Kihara, J. n., Null, C. n., Luby, S. P., Colford, J. M., Arnold, B. F. 2021; 9 (3): e301–e308

  Abstract

  Soil-transmitted helminths and Giardia duodenalis are responsible for a large burden of disease globally. In low-resource settings, household finished floors (eg, concrete floors) might reduce transmission of soil-transmitted helminths and G duodenalis.In a prospective cohort of children nested within two randomised trials in rural Bangladesh and Kenya, we estimated associations between household finished flooring and soil-transmitted helminths and G duodenalis prevalence. In 2015-16, we collected stool samples from children aged 2-16 years in rural Bangladesh and Kenya. We detected soil-transmitted helminth infection using quantitative PCR (qPCR; Bangladesh n=2800; Kenya n=3094), and G duodenalis using qPCR in Bangladesh (n=6894) and ELISA in Kenya (n=8899). We estimated adjusted prevalence ratios (aPRs) using log-linear models adjusted for potential confounders.7187 (92·2%) of 7795 children in Bangladesh and 9077 (93·7%) of 9686 children in Kenya provided stool specimens that were analysed by qPCR. At enrolment, 691 (10%) households in Bangladesh and 471 (5%) households in Kenya had finished floors. In both countries, household finished flooring was associated with lower Ascaris lumbricoides prevalence (Bangladesh aPR 0·33, 95% CI 0·14-0·78; Kenya 0·62, 0·39-0·98) and any soil-transmitted helminths (Bangladesh 0·73, 0·52-1·01; Kenya 0·57, 0·37-0·88). Household finished floors were also associated with lower Necator americanus prevalence in Bangladesh (0·52, 0·29-0·94) and G duodenalis prevalence in both countries (Bangladesh 0·78, 0·64-0·95; Kenya 0·82, 0·70-0·97).In low-resource settings, living in households with finished floors over a 2-year period was associated with lower prevalence of G duodenalis and some soil-transmitted helminths in children.Bill & Melinda Gates Foundation and Task Force for Global Health.

  View details for DOI 10.1016/S2214-109X(20)30523-4

  View details for PubMedID 33607029

• An Association between Rainy Days with Clinical Dengue Fever in Dhaka, Bangladesh: Findings from a Hospital Based Study. International journal of environmental research and public health Rahman, K. M., Sharker, Y., Rumi, R. A., Khan, M. I., Shomik, M. S., Rahman, M. W., Billah, S. M., Rahman, M., Streatfield, P. K., Harley, D., Luby, S. P. 2020; 17 (24)

  Abstract

  BACKGROUND: Dengue, a febrile illness, is caused by a Flavivirus transmitted by Aedes aegypti and Aedes albopictus mosquitoes. Climate influences the ecology of the vectors. We aimed to identify the influence of climatic variability on the occurrence of clinical dengue requiring hospitalization in Zone-5, a high incidence area of Dhaka City Corporation (DCC), Bangladesh.METHODS AND FINDINGS: We retrospectively identified clinical dengue cases hospitalized from Zone-5 of DCC between 2005 and 2009. We extracted records of the four major catchment hospitals of the study area. The Bangladesh Meteorological Department (BMD) provided data on temperature, rainfall, and humidity of DCC for the study period. We used autoregressive integrated moving average (ARIMA) models for the number of monthly dengue hospitalizations. We also modeled all the climatic variables using Poisson regression. During our study period, dengue occurred throughout the year in Zone-5 of DCC. The median number of hospitalized dengue cases was 9 per month. Dengue incidence increased sharply from June, and reached its peak in August. One additional rainy day per month increased dengue cases in the succeeding month by 6% (RR = 1.06, 95% CI: 1.04-1.09).CONCLUSIONS: Dengue is transmitted throughout the year in Zone-5 of DCC, with seasonal variation in incidence. The number of rainy days per month is significantly associated with dengue incidence in the subsequent month. Our study suggests the initiation of campaigns in DCC for controlling dengue and other Aedes mosquito borne diseases, including Chikunguniya from the month of May each year. BMD rainfall data may be used to determine campaign timing.

  View details for DOI 10.3390/ijerph17249506

  View details for PubMedID 33353025

• Introducing Typhoid Conjugate Vaccine in South Asia: Lessons From the Surveillance for Enteric Fever in Asia Project. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Carter, A. S., Luby, S. P., Garrett, D. O. 2020; 71 (Supplement_3): S191–S195

  Abstract

  Enteric fever remains a public health concern in communities lacking sanitation infrastructure to separate sewage from drinking water. To bridge the gap until large-scale civil-engineering projects are implemented in high-burden countries, typhoid conjugate vaccine presents a promising disease-prevention technology. A new typhoid conjugate vaccine was prequalified by the World Health Organization in 2017 and is beginning to be introduced in countries around the world. To help inform vaccine introduction, the Surveillance for Enteric Fever in Asia Project (SEAP) conducts prospective enteric fever surveillance in Bangladesh, Nepal, and Pakistan. This supplement presents findings from Phase II of the study (2016-2019) on burden of disease, clinical presentation, the growing spread of drug-resistant strains, and policy and economic ramifications. These findings are delivered to support policymakers in their deliberations on strategies to introduce typhoid conjugate vaccine as a preventive tool against enteric fever.

  View details for DOI 10.1093/cid/ciaa1296

  View details for PubMedID 33258930

• Addressing Climate Change and Its Effects on Human Health: A Call to Action for Medical Schools. Academic medicine : journal of the Association of American Medical Colleges Goshua, A., Gomez, J., Erny, B., Burke, M., Luby, S., Sokolow, S., LaBeaud, A. D., Auerbach, P., Gisondi, M. A., Nadeau, K. 2020

  Abstract

  Human health is increasingly threatened by rapid and widespread changes in the environment and climate, including rising temperatures, air and water pollution, disease vector migration, floods, and droughts. In the United States, many medical schools, the American Medical Association, and the National Academy of Sciences have published calls for physicians and physicians-in-training to develop a basic knowledge of the science of climate change and an awareness of the associated health risks. The authors--all medical students and educators--argue for the expeditious redesign of medical school curricula to teach students to recognize, diagnose, and treat the many health conditions exacerbated by climate change as well as understanding public health issues. In this Invited Commentary, the authors briefly review the health impacts of climate change, examine current climate change course offerings and proposals, and describe the rationale for promptly and comprehensively including climate science education in medical school curricula. Efforts in training physicians now will benefit those physicians' communities, whose health will be impacted by a period of remarkable climate change. The bottom line is that the health effects of climate reality cannot be ignored, and people everywhere must adapt as quickly as possible.

  View details for DOI 10.1097/ACM.0000000000003861

  View details for PubMedID 33239537

• Planetary health approaches for dry cities: water quality and heat mitigation BMJ-BRITISH MEDICAL JOURNAL Wong, T. F., Tapper, N. J., Luby, S. P. 2020; 371

  View details for DOI 10.1136/bmj.m4313

  View details for Web of Science ID 000591526200011

• Nipah virus dynamics in bats and implications for spillover to humans. Proceedings of the National Academy of Sciences of the United States of America Epstein, J. H., Anthony, S. J., Islam, A., Kilpatrick, A. M., Ali Khan, S., Balkey, M. D., Ross, N., Smith, I., Zambrana-Torrelio, C., Tao, Y., Islam, A., Quan, P. L., Olival, K. J., Khan, M. S., Gurley, E. S., Hossein, M. J., Field, H. E., Fielder, M. D., Briese, T., Rahman, M., Broder, C. C., Crameri, G., Wang, L., Luby, S. P., Lipkin, W. I., Daszak, P. 2020

  Abstract

  Nipah virus (NiV) is an emerging bat-borne zoonotic virus that causes near-annual outbreaks of fatal encephalitis in South Asia-one of the most populous regions on Earth. In Bangladesh, infection occurs when people drink date-palm sap contaminated with bat excreta. Outbreaks are sporadic, and the influence of viral dynamics in bats on their temporal and spatial distribution is poorly understood. We analyzed data on host ecology, molecular epidemiology, serological dynamics, and viral genetics to characterize spatiotemporal patterns of NiV dynamics in its wildlife reservoir, Pteropus medius bats, in Bangladesh. We found that NiV transmission occurred throughout the country and throughout the year. Model results indicated that local transmission dynamics were modulated by density-dependent transmission, acquired immunity that is lost over time, and recrudescence. Increased transmission followed multiyear periods of declining seroprevalence due to bat-population turnover and individual loss of humoral immunity. Individual bats had smaller host ranges than other Pteropus species (spp.), although movement data and the discovery of a Malaysia-clade NiV strain in eastern Bangladesh suggest connectivity with bats east of Bangladesh. These data suggest that discrete multiannual local epizootics in bat populations contribute to the sporadic nature of NiV outbreaks in South Asia. At the same time, the broad spatial and temporal extent of NiV transmission, including the recent outbreak in Kerala, India, highlights the continued risk of spillover to humans wherever they may interact with pteropid bats and the importance of limiting opportunities for spillover throughout Pteropus's range.

  View details for DOI 10.1073/pnas.2000429117

  View details for PubMedID 33139552

• Ingestion of Fecal Bacteria along Multiple Pathways by Young Children in Rural Bangladesh Participating in a Cluster-Randomized Trial of Water, Sanitation, and Hygiene Interventions (WASH Benefits). Environmental science & technology Kwong, L. H., Ercumen, A., Pickering, A. J., Arsenault, J. E., Islam, M., Parvez, S. M., Unicomb, L., Rahman, M., Davis, J., Luby, S. P. 2020

  Abstract

  Quantifying the contribution of individual exposure pathways to a child's total ingestion of fecal matter could help prioritize interventions to reduce environmental enteropathy and diarrhea. This study used data on fecal contamination of drinking water, food, soil, hands, and objects and second-by-second data on children's contacts with these environmental reservoirs in rural Bangladesh to assess the relative contribution of different pathways to children's ingestion of fecal indicator bacteria and if ingestion decreased with the water, sanitation, and hygiene interventions implemented in the WASH Benefits Trial. Our model estimated that rural Bangladeshi children <36 months old consume 3.6-4.9 log10 most probable number E. coli/day. Among children <6 months, placing objects in the mouth accounted for 60% of E. coli ingested. For children 6-35 months old, mouthing their own hands, direct soil ingestion, and ingestion of contaminated food were the primary pathways of E. coli ingestion. The amount of E. coli ingested by children and the predominant pathways of E. coli ingestion were unchanged by the water, sanitation, and hygiene interventions. These results highlight contaminated soil, children's hands, food, and objects as primary pathways of E. coli ingestion and emphasize the value of intervening along these pathways.

  View details for DOI 10.1021/acs.est.0c02606

  View details for PubMedID 33078615

• Waterless Hand Cleansing with Chlorhexidine during the Neonatal Period by Mothers and Other Household Members: Findings from a Randomized Controlled Trial. The American journal of tropical medicine and hygiene Ram, P. K., Begum, F., Crabtree-Ide, C., Uddin, M. R., Weaver, A. M., Dostogir Harun, M. G., Allen, J. V., Kumar, S., Nasreen, S., Luby, S. P., El Arifeen, S. 2020

  Abstract

  Observational data suggest maternal handwashing with soap prevents neonatal mortality. We tested the impact of a chlorhexidine-based waterless hand cleansing promotion on the behavior of mothers and other household members. In rural Bangladesh in 2014, we randomized consenting pregnant women to chlorhexidine provision and hand cleansing promotion or standard practices. We compared hand cleansing with chlorhexidine or handwashing with soap before baby care, among mothers and household members in the two groups, and measured chlorhexidine use in the intervention arm. Chlorhexidine was observed in the baby's sleep space in 97% of 130 intervention homes, versus soap in 59% of 128 control homes. Hand cleansing before baby care was observed 5.6 times more frequently among mothers in the intervention arm than in the controls (95% CI = 4.0-7.7). Hand cleansing was significantly more frequently observed in the intervention arm among women other than the mother (RR = 10.9) and girls (RR = 37.0). Men and boys in the intervention arm cleansed hands before 29% and 44% of baby care events, respectively, compared with 0% in the control arm. The median number of grams consumed during the neonatal period was 176 (IQR = 95-305 g), about 7.8 g/day (IQR = 4.2-13.8 g). Promotion of waterless chlorhexidine increased hand cleansing behavior among mothers and other household members. Discrepancy between observed use and measured chlorhexidine consumption suggested courtesy bias in structured observations. A waterless hand cleanser may represent one component of the multimodal strategies to prevent neonatal infections in low-resource settings.

  View details for DOI 10.4269/ajtmh.19-0773

  View details for PubMedID 32959761

• Piloting an acceptable and feasible menstrual hygiene products disposal system in urban and rural schools in Bangladesh. BMC public health Jahan, F., Nuruzzaman, M., Sultana, F., Mahfuz, M. T., Rahman, M., Akhand, F., Luby, S. P., Unicomb, L., Winch, P. J. 2020; 20 (1): 1366

  Abstract

  BACKGROUND: Access to washroom facilities and a place to dispose of menstrual waste are prerequisites for optimal menstrual hygiene management in schools. Like other low- and middle-income countries, Bangladeshi schools lack facilities for girls to change and dispose of their menstrual absorbents. We explored existing systems for disposing of menstrual absorbent wastes in urban and rural schools of Bangladesh and assessed the feasibility and acceptability of alternative disposal options.METHODS: We explored how girls dispose of their menstrual products, identified girls' preferences and choices for a disposal system and piloted four disposal options in four different schools. We then implemented one preferred option in four additional schools. We explored girls', teachers', and janitors' perspectives and evaluated the acceptability, feasibility, and potential for sustainability of the piloted disposal system.RESULTS: Barriers to optimal menstrual hygiene management included lack of functional toilets and private locations for changing menstrual products, and limited options for disposal. Girls, teachers, and janitors preferred and ranked the chute disposal system as their first choice, because it has large capacity (765L), is relatively durable, requires less maintenance, and will take longer time to fill. During implementation of the chute disposal system in four schools, girls, teachers, and janitors reported positive changes in toilet cleanliness and menstrual products disposal resulting from the intervention.CONCLUSIONS: The chute disposal system for menstrual products is a durable option that does not require frequent emptying or regular maintenance, and is accepted by schoolgirls and janitors alike, and can improve conditions for menstrual hygiene management in schools. However, regular supervision, motivation of girls to correctly dispose of their products, and a long-term maintenance and management plan for the system are necessary.

  View details for DOI 10.1186/s12889-020-09413-x

  View details for PubMedID 32894120

• Past Sodium Intake, Contemporary Sodium Intake, and Cardiometabolic Health in Southwest Coastal Bangladesh. Journal of the American Heart Association Naser, A. M., Rahman, M., Unicomb, L., Doza, S., Selim, S., Chaity, M., Luby, S. P., Anand, S., Staimez, L., Clasen, T. F., Gujral, U. P., Gribble, M. O., Narayan, K. M. 2020: e014978

  Abstract

  Background We compared the relationship of past and contemporary sodium (Na) intake with cardiometabolic biomarkers. Methods and Results A total of 1191 participants' data from a randomized controlled trial in coastal Bangladesh were analyzed. Participants provided 24-hour urine Na (24UNa) data for 5 monthly visits. Their fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein, blood pressure, and 24-hour urine protein were measured at the fifth visit. Participants' mean 24UNa over the first 4 visits was the past Na, and 24UNa of the fifth visit was the contemporary Na intake. We estimated the prevalence ratios of elevated cardiometabolic biomarkers and metabolic syndrome across 24UNa tertiles by multilevel logistic regression using participant-, household-, and community-level random intercepts. Models were adjusted for age, sex, body mass index, smoking, physical activity, alcohol consumption, sleep hours, religion, and household wealth. Compared with participants in tertile 1 of past urine Na, those in tertile 3 had 1.46 (95% CI, 1.08-1.99) times higher prevalence of prediabetes or diabetes mellitus, 5.49 (95% CI, 2.73-11.01) times higher prevalence of large waist circumference, and 1.60 (95% CI, 1.04-2.46) times higher prevalence of metabolic syndrome. Compared with participants in tertile 1 of contemporary urine Na, those in tertile 3 had 1.93 (95% CI, 1.24-3.00) times higher prevalence of prediabetes or diabetes mellitus, 3.14 (95% CI, 1.45-6.83) times higher prevalence of proteinuria, and 2.23 (95% CI, 1.34-3.71) times higher prevalence of large waist circumference. Conclusions Both past and contemporary Na intakes were associated with higher cardiometabolic disease risk.

  View details for DOI 10.1161/JAHA.119.014978

  View details for PubMedID 32875927

• Effect of water, sanitation, handwashing and nutrition interventions on enteropathogens in children 14 months old: a cluster-randomized controlled trial in rural Bangladesh. The Journal of infectious diseases Grembi, J. A., Lin, A., Karim, M. A., Islam, M. O., Miah, R., Arnold, B. F., McQuade, E. T., Ali, S., Rahman, M. Z., Hussain, Z., Shoab, A. K., Famida, S. L., Hossen, M. S., Mutsuddi, P., Rahman, M., Unicomb, L., Haque, R., Taniuchi, M., Liu, J., Platts-Mills, J. A., Holmes, S. P., Stewart, C. P., Benjamin-Chung, J., Colford, J. M., Houpt, E. R., Luby, S. P. 2020

  Abstract

  BACKGROUND: We evaluated the impact of low-cost water, sanitation, handwashing (WSH) and child nutrition interventions on enteropathogen carriage in the WASH Benefits cluster-randomized controlled trial in rural Bangladesh.METHODS: We analyzed 1411 routine fecal samples from children 14±2 months old in the WSH (n = 369), nutrition counseling plus lipid-based nutrient supplement (n = 353), nutrition plus WSH (n = 360), and control (n = 329) arms for 34 enteropathogens using quantitative PCR. Outcomes included the number of co-occurring pathogens; cumulative quantity of four stunting-associated pathogens; and prevalence and quantity of individual pathogens. Masked analysis was by intention-to-treat.RESULTS: 326 (99.1%) control children had one or more enteropathogens detected (mean 3.8±1.8). Children receiving WSH interventions had lower prevalence and quantity of individual viruses than controls (prevalence difference for norovirus: -11% [95% confidence interval [CI], -5 to -17%]; sapovirus: -9% [95%CI, -3 to -15%]; and adenovirus 40/41: -9% [95%CI, -2 to - 15%]). There was no difference in bacteria, parasites, or cumulative quantity of stunting-associated pathogens between controls and any intervention arm.CONCLUSIONS: WSH interventions were associated with fewer enteric viruses in children aged 14 months. Different strategies are needed to reduce enteric bacteria and parasites at this critical young age.

  View details for DOI 10.1093/infdis/jiaa549

  View details for PubMedID 32861214

• Adaptation and Integration of Psychosocial Stimulation, Maternal Mental Health and Nutritional Interventions for Pregnant and Lactating Women in Rural Bangladesh. International journal of environmental research and public health Akter, F., Rahman, M., Pitchik, H. O., Winch, P. J., Fernald, L. C., Nurul Huda, T. M., Jahir, T., Amin, R., Das, J. B., Hossain, K., Shoab, A. K., Khan, R., Yeasmin, F., Sultana, J., Luby, S. P., Tofail, F. 2020; 17 (17)

  Abstract

  Supporting caregivers' mental wellbeing and ability to provide psychosocial stimulation may promote early childhood development. This paper describes the systematic approach of developing an integrated stimulation intervention, identifying the feasibility and challenges faced throughout the period. We developed an integrated curriculum by culturally adapting three interventions (Reach Up, Thinking Healthy, and general nutrition advice) and piloted this curriculum (Mar-April 2017) in courtyard groups sessions and individual home visits with pregnant women (n = 11) and lactating mothers (of children <24 months) (n = 29). We conducted qualitative interviews with the participants (n = 8) and the community health workers who delivered the intervention (n = 2). Most participants reported willingness to attend the sessions if extended for 1 year, and recommended additional visual cues and interactive role-play activities to make the sessions more engaging. Participants and community health workers found it difficult to understand the concept of "unhealthy thoughts" in the curriculum. This component was then revised to include a simplified behavior-focused story. Community health workers reported difficulty balancing the required content of the integrated curriculum but were able to manage after the contents were reduced. The revised intervention is likely feasible to deliver to a group of pregnant and lactating mothers in a low-resource setting.

  View details for DOI 10.3390/ijerph17176233

  View details for PubMedID 32867253

• Assessing the Feasibility of Typhoid Elimination. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Stanaway, J. D., Atuhebwe, P. L., Luby, S. P., Crump, J. A. 2020; 71 (Supplement_2): S179–S184

  Abstract

  In 1993, the International Task Force on Disease Eradication classified the political will for typhoid eradication as "none." Here we revisit the Task Force's assessment in light of developments in typhoid vaccines and increasing antimicrobial resistance in Salmonella Typhi that have served to increase interest in typhoid elimination. Considering the requisite biological and technical factors for elimination, effective interventions exist for typhoid, and humans are the organism's only known reservoir. Improvements in water supply, sanitation, hygiene, and food safety are critical for robust long-term typhoid control, and the recent Strategic Advisory Group of Experts on Immunization recommendation and World Health Organization prequalification should make typhoid conjugate vaccine more accessible and affordable in low-income countries, which will allow the vaccine to offer a critical bridge to quickly reduce burden. While these developments are encouraging, all current typhoid diagnostics are inadequate, having either poor performance characteristics, limited scalability, or both. No clear solution exists, and this should be viewed as a critical challenge to any elimination effort. Moreover, asymptomatic carriers and limited data and surveillance remain major challenges, and countries considering elimination campaigns will need to develop strategies to identify high-risk populations and to monitor progress over time. Finally, policymakers must be realistic in planning, learn from the planning failures of previous elimination and eradication efforts, and expect unforeseeable shocks and setbacks. In the end, if we assume neither unanticipated breakthroughs in typhoid control nor any chaotic shocks, history suggests that we should expect typhoid elimination to take decades.

  View details for DOI 10.1093/cid/ciaa585

  View details for PubMedID 32725226

• Decision Making and Implementation of the First Public Sector Introduction of Typhoid Conjugate Vaccine-Navi Mumbai, India, 2018. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Date, K., Shimpi, R., Luby, S., N, R., Haldar, P., Katkar, A., Wannemuehler, K., Mogasale, V., Pallas, S., Song, D., Kunwar, A., Loharikar, A., Yewale, V., Ahmed, D., Horng, L., Wilhelm, E., Bahl, S., Harvey, P., Dutta, S., Bhatnagar, P. 2020; 71 (Supplement_2): S172–S178

  Abstract

  BACKGROUND: Typhoid fever prevention and control efforts are critical in an era of rising antimicrobial resistance among typhoid pathogens. India remains one of the highest typhoid disease burden countries, although a highly efficacious typhoid conjugate vaccine (TCV), prequalified by the World Health Organization in 2017, has been available since 2013. In 2018, the Navi Mumbai Municipal Corporation (NMMC) introduced TCV into its immunization program, targeting children aged 9 months to 14 years in 11 of 22 areas (Phase 1 campaign). We describe the decision making, implementation, and delivery costing to inform TCV use in other settings.METHODS: We collected information on the decision making and campaign implementation in addition to administrative coverage from NMMC and partners. We then used a microcosting approach from the local government (NMMC) perspective, using a new Microsoft Excel-based tool to estimate the financial and economic vaccination campaign costs.RESULTS: The planning and implementation of the campaign were led by NMMC with support from multiple partners. A fixed-post campaign was conducted during weekends and public holidays in July-August 2018 which achieved an administrative vaccination coverage of 71% (ranging from 46% in high-income to 92% in low-income areas). Not including vaccine and vaccination supplies, the average financial cost and economic cost per dose of TCV delivery were $0.45 and $1.42, respectively.CONCLUSION: The first public sector TCV campaign was successfully implemented by NMMC, with high administrative coverage in slums and low-income areas. Delivery cost estimates provide important inputs to evaluate the cost-effectiveness and affordability of TCV vaccination through public sector preventive campaigns.

  View details for DOI 10.1093/cid/ciaa597

  View details for PubMedID 32725235

• Hospital-based surveillance for Japanese encephalitis in Bangladesh, 2007-2016: Implications for introduction of immunization. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases Paul, K. K., Sazzad, H. M., Rahman, M., Sultana, S., Hossain, M. J., Ledermann, J. P., Burns, P., Friedman, M. S., Flora, M. S., Fischer, M., Hills, S., Luby, S. P., Gurley, E. S. 2020

  Abstract

  BACKGROUND: Japanese encephalitis (JE) virus is recognized as a major cause of encephalitis in Bangladesh. The World Health Organization (WHO) recommends human immunization as the most effective means to control JE. Several WHO-prequalified vaccines are available to prevent JE but no vaccination program has been implemented in Bangladesh.METHODS: We conducted hospital-based surveillance for acute meningitis-encephalitis syndrome (AMES) to describe JE epidemiology and help inform policy decisions about possible immunization strategies for Bangladesh.RESULTS: During 2007-2016, a total of 6,543 AMES patients were identified at four tertiary hospitals. Of the 6,525 patients tested, 548 (8%) were classified as JE cases. These 548 patients resided in 36 (56%) out of 64 districts of Bangladesh, with the highest proportion of JE cases among AMES patients (12% and 7%) presenting at two hospitals in the northwestern part of the country. The median age of JE cases was 30 years, and 193 (35%) were aged ≤15 years. The majority of JE cases (80%) were identified from July through November.CONCLUSIONS: Surveillance results suggest that JE continues to be an important cause of meningo-encephalitis in Bangladesh. Immunization strategies including JE vaccine introduction into the routine childhood immunization program or mass vaccination in certain age groups or geographic areas need to be examined, taking into consideration the cost-effectiveness ratio of the approach and potential for decreasing disease burden.

  View details for DOI 10.1016/j.ijid.2020.07.026

  View details for PubMedID 32721530

• Landlords' and Compound Managers' Role in Improving and Sustaining Shared Latrines in Three Dhaka City Slums WATER Yeasmin, F., Rahman, M., Luby, S. P., Das, J., Begum, F., Saxton, R. E., Nizame, F. A., Hwang, S. T., Mahbub-Ul Alam, Hossain, M., Yeasmin, D., Unicomb, L., Winch, P. J. 2020; 12 (7)

  View details for DOI 10.3390/w12072073

  View details for Web of Science ID 000558145600001

• Associations of drinking rainwater with macro-mineral intake and cardiometabolic health: a pooled cohort analysis in Bangladesh, 2016-2019 NPJ CLEAN WATER Naser, A., Rahman, M., Unicomb, L., Parvez, S., Islam, S., Doza, S., Khan, G., Ahmed, K., Anand, S., Luby, S. P., Shamsudduha, M., Gribble, M. O., Narayan, K., Clasen, T. F. 2020; 3 (1)

  View details for DOI 10.1038/s41545-020-0067-5

  View details for Web of Science ID 000528385700001

• Associations of drinking rainwater with macro-mineral intake and cardiometabolic health: a pooled cohort analysis in Bangladesh, 2016-2019. NPJ clean water Naser, A. M., Rahman, M., Unicomb, L., Parvez, S. M., Islam, S., Doza, S., Khan, G. K., Ahmed, K. M., Anand, S., Luby, S. P., Shamsudduha, M., Gribble, M. O., Venkat Narayan, K. M., Clasen, T. F. 2020; 3: 20

  Abstract

  This study explores the associations of drinking rainwater with mineral intake and cardiometabolic health in the Bangladeshi population. We pooled 10030 person-visit data on drinking water sources, blood pressure (BP) and 24-h urine minerals. Fasting blood glucose (FBG) was measured in 3724 person-visits, and lipids in 1118 person-visits. We measured concentrations of sodium (Na), potassium (K), calcium (Ca) and magnesium (Mg) in 253 rainwater, 935 groundwater and 130 pond water samples. We used multilevel linear or gamma regression models with participant-, household- and community-level random intercepts to estimate the associations of rainwater consumption with urine minerals and cardiometabolic biomarkers. Rainwater samples had the lowest concentrations of Na, K, Ca and Mg. Rainwater drinkers had lower urine minerals than coastal groundwater drinkers: -13.42 (95% CI: -18.27, -8.57) mmol Na/24 h, -2.00 (95% CI: -3.16, -0.85) mmol K/24 h and -0.57 (95% CI: -1.02, -0.16) mmol Mg/24 h. The ratio of median 24-hour urinary Ca for rainwater versus coastal groundwater drinkers was 0.72 (95% CI: 0.64, 0.80). Rainwater drinkers had 2.15 (95% CI: 1.02, 3.27) mm Hg higher systolic BP, 1.82 (95% CI: 1.19, 2.54) mm Hg higher diastolic BP, 0.59 (95% CI: 0.17, 1.01) mmol/L higher FBG and -2.02 (95% CI: -5.85, 0.81) mg/dl change in high-density lipoprotein cholesterol compared with the coastal groundwater drinkers. Drinking rainwater was associated with worse cardiometabolic health measures, which may be due to the lower intake of salubrious Ca, Mg and K.

  View details for DOI 10.1038/s41545-020-0067-5

  View details for PubMedID 33777415

  View details for PubMedCentralID PMC7610435

• Changing contact patterns over disease progression: Nipah virus as a case study. The Journal of infectious diseases Lee, K. H., Nikolay, B., Sazzad, H. M., Hossain, M. J., Khan, A. K., Rahman, M., Satter, S. M., Nichol, S. T., Klena, J. D., Pulliam, J. R., Kilpatrick, A. M., Sultana, S., Afroj, S., Daszak, P., Luby, S., Cauchemez, S., Salje, H., Gurley, E. 2020

  Abstract

  Contact patterns play a key role in disease transmission, and variation in contacts during the course of illness can influence transmission, particularly when accompanied by changes in host infectiousness. We used surveys among 1,642 contacts of 94 Nipah case-patients in Bangladesh to determine how contact patterns (physical and with bodily fluids) changed as disease progressed in severity. The number of contacts increased with severity and, for case-patients who died, peaked on the day of death. Given transmission has only been observed among fatal Nipah cases, our findings suggest changes in contact patterns during illness contribute to risk of infection.

  View details for DOI 10.1093/infdis/jiaa091

  View details for PubMedID 32115627

• Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Environmental Enteric Dysfunction in Young Children: A Cluster-randomized, Controlled Trial in Rural Bangladesh CLINICAL INFECTIOUS DISEASES Lin, A., Ali, S., Arnold, B. F., Rahman, M., Alauddin, M., Grembi, J., Mertens, A. N., Famida, S. L., Akther, S., Hossen, M., Mutsuddi, P., Shoab, A. K., Hussain, Z., Rahman, M., Unicomb, L., Ashraf, S., Naser, A., Parvez, S. M., Ercumen, A., Benjamin-Chung, J., Haque, R., Ahmed, T., Hossain, M., Choudhury, N., Jannat, K., Alauddin, S. T., Minchala, S. G., Cekovic, R., Hubbard, A. E., Stewart, C. P., Dewey, K. G., Colford, J. M., Luby, S. P. 2020; 70 (5): 738–47

  View details for DOI 10.1093/cid/ciz291

  View details for Web of Science ID 000520551800008

• Effect of Improved Water Quality, Sanitation, Hygiene and Nutrition Interventions on Respiratory Illness in Young Children in Rural Bangladesh: A Multi-Arm Cluster-Randomized Controlled Trial. The American journal of tropical medicine and hygiene Ashraf, S., Unicomb, L., Rahman, M., Winch, P. J., Arnold, B. F., Benjamin Chung, J., Ram, P. K., Colford, J. M., Luby, S. P. 2020

  Abstract

  Acute respiratory infections (ARIs) cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (S); 3) handwashing promotion (H); 4) combined water, sanitation, and handwashing (WSH); 5) nutrition intervention including lipid-based nutrient supplements; 6) combined WSH plus nutrition (WSHN); or 7) no intervention (control). Masking of participants was not possible. Acute respiratory infection was defined as caregiver-reported persistent cough, panting, wheezing, or difficulty breathing in the past 7 days among index children, those born to enrolled women. We assessed outcomes at 12 and 24 months of intervention using intention to treat. Compared with children in the control group (ARI prevalence, P: 8.9%), caregivers of index children reported significantly lower ARI in the water (P: 6.3%, prevalence ratio (PR): 0.71; 95% CI: 0.53, 0.96), sanitation (P: 6.4%, PR: 0.75, 95% CI: 0.58, 0.96), handwashing (P: 6.4%, PR: 0.68, 95% CI: 0.50, 0.93), and the combined WSH+N arms (P: 5.9%, PR: 0.67, 95% CI: 0.50, 0.90). Those in the nutrition (P: 7.4%, PR: 0.84, 95% CI: 0.63, 1.10) or the WSH arm (P: 8.9%, PR: 0.99, 95% CI: 0.76, 1.28) reported similar ARI prevalence compared with control children. Single targeted water, sanitation, and hygiene interventions reduced reported respiratory illness in young children. There was no apparent respiratory health benefit from combining WASH interventions.

  View details for DOI 10.4269/ajtmh.19-0769

  View details for PubMedID 32100681

• Hepatitis E as a cause of adult hospitalization in Bangladesh: Results from an acute jaundice surveillance study in six tertiary hospitals, 2014-2017. PLoS neglected tropical diseases Paul, R. C., Nazneen, A., Banik, K. C., Sumon, S. A., Paul, K. K., Akram, A., Uzzaman, M. S., Iqbal, T., Tejada-Strop, A., Kamili, S., Luby, S. P., Gidding, H. F., Hayen, A., Gurley, E. S. 2020; 14 (1): e0007586

  Abstract

  In the absence of reliable data on the burden of hepatitis E virus (HEV) in high endemic countries, we established a hospital-based acute jaundice surveillance program in six tertiary hospitals in Bangladesh to estimate the burden of HEV infection among hospitalized acute jaundice patients aged ≥14 years, identify seasonal and geographic patterns in the prevalence of hepatitis E, and examine factors associated with death. We collected blood specimens from enrolled acute jaundice patients, defined as new onset of either yellow eyes or skin during the past three months of hospital admission, and tested for immunoglobulin M (IgM) antibodies against HEV, HBV and HAV. The enrolled patients were followed up three months after hospital discharge to assess their survival status; pregnant women were followed up three months after their delivery to assess pregnancy outcomes. From December'2014 to September'2017, 1925 patients with acute jaundice were enrolled; 661 (34%) had acute hepatitis E, 48 (8%) had hepatitis A, and 293 (15%) had acute hepatitis B infection. Case fatality among hepatitis E patients was 5% (28/589). Most of the hepatitis E cases were males (74%; 486/661), but case fatality was higher among females-12% (8/68) among pregnant and 8% (7/91) among non-pregnant women. Half of the patients who died with acute hepatitis E had co-infection with HAV or HBV. Of the 62 HEV infected mothers who were alive until the delivery, 9 (15%) had miscarriage/stillbirth, and of those children who were born alive, 19% (10/53) died, all within one week of birth. This study confirms that hepatitis E is the leading cause of acute jaundice, leads to hospitalizations in all regions in Bangladesh, occurs throughout the year, and is associated with considerable morbidity and mortality. Effective control measures should be taken to reduce the risk of HEV infections including improvements in water quality, sanitation and hygiene practices and the introduction of HEV vaccine to high-risk groups.

  View details for DOI 10.1371/journal.pntd.0007586

  View details for PubMedID 31961861

• Age-related changes to environmental exposure: variation in the frequency that young children place hands and objects in their mouths JOURNAL OF EXPOSURE SCIENCE AND ENVIRONMENTAL EPIDEMIOLOGY Kwong, L. H., Ercumen, A., Pickering, A. J., Unicomb, L., Davis, J., Luby, S. P. 2020; 30 (1): 205–16

  View details for DOI 10.1038/s41370-019-0115-8

  View details for Web of Science ID 000503057800017

• Child defecation and feces management practices in rural Bangladesh: Associations with fecal contamination, observed hand cleanliness and child diarrhea. PloS one Islam, M. n., Rahman, M. n., Unicomb, L. n., Kafi, M. A., Rahman, M. n., Alam, M. n., Sen, D. n., Islam, S. n., Pickering, A. J., Hubbard, A. E., Luby, S. P., Arnold, B. F., Colford, J. M., Ercumen, A. n. 2020; 15 (7): e0236163

  Abstract

  Child open defecation is common in low-income countries and can lead to fecal exposure in the domestic environment. We assessed associations between child feces management practices vs. measures of contamination and child diarrhea among households with children <5 years in rural Bangladesh. We visited 360 households quarterly and recorded caregiver-reported diarrhea prevalence, and defecation and feces disposal practices for children <5 years. We examined caregiver and child hands for visible dirt and enumerated E. coli in child and caregiver hand rinse and stored drinking water samples. Safe child defecation (in latrine/potty) and safe feces disposal (in latrine) was reported by 21% and 23% of households, respectively. Controlling for potential confounders, households reporting unsafe child defecation had higher E. coli prevalence on child hands (prevalence ratio [PR] = 1.12, 1.04-1.20) and in stored water (PR = 1.12,1.03-1.21). Similarly, households reporting unsafe feces disposal had higher E. coli prevalence on child hands (PR = 1.11, 1.02-1.21) and in stored water (PR = 1.10, 1.03-1.18). Effects on E. coli levels were similar. Children in households with unsafe defecation and feces disposal had higher diarrhea prevalence but the associations were not statistically significant. Our findings suggest that unsafe child feces management may present a source of fecal exposure for young children.

  View details for DOI 10.1371/journal.pone.0236163

  View details for PubMedID 32687513

• Comparison of multi-parallel qPCR and double-slide Kato-Katz for detection of soil-transmitted helminth infection among children in rural Bangladesh. PLoS neglected tropical diseases Benjamin-Chung, J. n., Pilotte, N. n., Ercumen, A. n., Grant, J. R., Maasch, J. R., Gonzalez, A. M., Ester, A. C., Arnold, B. F., Rahman, M. n., Haque, R. n., Hubbard, A. E., Luby, S. P., Williams, S. A., Colford, J. M. 2020; 14 (4): e0008087

  Abstract

  There is growing interest in local elimination of soil-transmitted helminth (STH) infection in endemic settings. In such settings, highly sensitive diagnostics are needed to detect STH infection. We compared double-slide Kato-Katz, the most commonly used copromicroscopic detection method, to multi-parallel quantitative polymerase chain reaction (qPCR) in 2,799 stool samples from children aged 2-12 years in a setting in rural Bangladesh with predominantly low STH infection intensity. We estimated the sensitivity and specificity of each diagnostic using Bayesian latent class analysis. Compared to double-slide Kato-Katz, STH prevalence using qPCR was almost 3-fold higher for hookworm species and nearly 2-fold higher for Trichuris trichiura. Ascaris lumbricoides prevalence was lower using qPCR, and 26% of samples classified as A. lumbricoides positive by Kato-Katz were negative by qPCR. Amplicon sequencing of the 18S rDNA from 10 samples confirmed that A. lumbricoides was absent in samples classified as positive by Kato-Katz and negative by qPCR. The sensitivity of Kato-Katz was 49% for A. lumbricoides, 32% for hookworm, and 52% for T. trichiura; the sensitivity of qPCR was 79% for A. lumbricoides, 93% for hookworm, and 90% for T. trichiura. Specificity was ≥ 97% for both tests for all STH except for Kato-Katz for A. lumbricoides (specificity = 68%). There were moderate negative, monotonic correlations between qPCR cycle quantification values and eggs per gram quantified by Kato-Katz. While it is widely assumed that double-slide Kato-Katz has few false positives, our results indicate otherwise and highlight inherent limitations of the Kato-Katz technique. qPCR had higher sensitivity than Kato-Katz in this low intensity infection setting.

  View details for DOI 10.1371/journal.pntd.0008087

  View details for PubMedID 32330127

• High-Throughput Multiparallel Enteropathogen Detection via Nano-Liter qPCR. Frontiers in cellular and infection microbiology Grembi, J. A., Mayer-Blackwell, K. n., Luby, S. P., Spormann, A. M. 2020; 10: 351

  Abstract

  Quantitative molecular diagnostic methods can effectively detect pathogen-specific nucleic acid sequences, but costs associated with multi-pathogen panels hinder their widespread use in research trials. Nano-liter qPCR (nL-qPCR) is a miniaturized tool for quantification of multiple targets in large numbers of samples based on assay parallelization on a single chip, with potentially significant cost-savings due to rapid throughput and reduced reagent volumes. We evaluated a suite of novel and published assays to detect 17 enteric pathogens using a commercially available nL-qPCR technology. Amplification efficiencies ranged from 88 to 98% (mean 91%) and were reproducible across four operators at two separate facilities. When applied to fecal material, assays were sensitive and selective (99.8% of DNA amplified were genes from the target organism). Due to nanofluidic volumes, detection limits were 1-2 orders of magnitude less sensitive for nL-qPCR than an enteric TaqMan Array Card (TAC). However, higher detection limits do not hinder detection of diarrhea-causing pathogen concentrations. Compared to TAC, nL-qPCR displayed 99% (95% CI 0.98, 0.99) negative percent agreement and 62% (95% CI 0.59, 0.65) overall positive percent agreement for presence of pathogens across diarrheal and non-diarrheal fecal samples. Positive percent agreement was 89% among samples with concentrations above the nL-qPCR detection limits. nL-qPCR assays showed an underestimation bias of 0.34 log10 copies/gram of stool [IQR -0.40, -0.28] compared with TAC. With 12 times higher throughput for a sixth of the per-sample cost of the enteric TAC, the nL-qPCR chip is a viable alternative for enteropathogen quantification for studies where other technologies are cost-prohibitive.

  View details for DOI 10.3389/fcimb.2020.00351

  View details for PubMedID 32766166

  View details for PubMedCentralID PMC7381150

• A Framework to Monitor Changes in Transmission and Epidemiology of Emerging Pathogens: Lessons From Nipah Virus. The Journal of infectious diseases Nikolay, B. n., Salje, H. n., Khan, A. K., Sazzad, H. M., Satter, S. M., Rahman, M. n., Doan, S. n., Knust, B. n., Flora, M. S., Luby, S. P., Cauchemez, S. n., Gurley, E. S. 2020; 221 (Supplement_4): S363–S369

  Abstract

  It is of uttermost importance that the global health community develops the surveillance capability to effectively monitor emerging zoonotic pathogens that constitute a major and evolving threat for human health. In this study, we propose a comprehensive framework to measure changes in (1) spillover risk, (2) interhuman transmission, and (3) morbidity/mortality associated with infections based on 6 epidemiological key indicators derived from routine surveillance. We demonstrate the indicators' value for the retrospective or real-time assessment of changes in transmission and epidemiological characteristics using data collected through a long-standing, systematic, hospital-based surveillance system for Nipah virus in Bangladesh. We show that although interhuman transmission and morbidity/mortality indicators were stable, the number and geographic extent of spillovers varied significantly over time. This combination of systematic surveillance and active tracking of transmission and epidemiological indicators should be applied to other high-risk emerging pathogens to prevent public health emergencies.

  View details for DOI 10.1093/infdis/jiaa074

  View details for PubMedID 32392322

• Measuring Environmental Exposure to Enteric Pathogens in Low-Income Settings: Review and Recommendations of an Interdisciplinary Working Group. Environmental science & technology Goddard, F. G., Ban, R. n., Barr, D. B., Brown, J. n., Cannon, J. n., Colford, J. M., Eisenberg, J. N., Ercumen, A. n., Petach, H. n., Freeman, M. C., Levy, K. n., Luby, S. P., Moe, C. n., Pickering, A. J., Sarnat, J. A., Stewart, J. n., Thomas, E. n., Taniuchi, M. n., Clasen, T. n. 2020

  Abstract

  Infections with enteric pathogens impose a heavy disease burden, especially among young children in low-income countries. Recent findings from randomized controlled trials of water, sanitation, and hygiene interventions have raised questions about current methods for assessing environmental exposure to enteric pathogens. Approaches for estimating sources and doses of exposure suffer from a number of shortcomings, including reliance on imperfect indicators of fecal contamination instead of actual pathogens and estimating exposure indirectly from imprecise measurements of pathogens in the environment and human interaction therewith. These shortcomings limit the potential for effective surveillance of exposures, identification of important sources and modes of transmission, and evaluation of the effectiveness of interventions. In this review, we summarize current and emerging approaches used to characterize enteric pathogen hazards in different environmental media as well as human interaction with those media (external measures of exposure), and review methods that measure human infection with enteric pathogens as a proxy for past exposure (internal measures of exposure). We draw from lessons learned in other areas of environmental health to highlight how external and internal measures of exposure can be used to more comprehensively assess exposure. We conclude by recommending strategies for advancing enteric pathogen exposure assessments.

  View details for DOI 10.1021/acs.est.0c02421

  View details for PubMedID 32813503

• Snack food consumption among Bangladeshi children, supplementary data from a large RCT. Maternal & child nutrition Jannat, K. n., Luby, S. P., Unicomb, L. n., Rahman, M. n., Winch, P. J., Hossain, M. I., Stewart, C. P. 2020: e12994

  Abstract

  Childhood obesity has been associated with consumption of energy-dense foods such as caloric beverages and fast foods. Many low- and middle-income countries like Bangladesh are now experiencing a rising problem of noncommunicable diseases along with the long-standing problem of stunting and undernutrition. WASH Benefits Bangladesh was a large community-based cluster randomized controlled trial conducted in rural Bangladesh. Study clusters were randomized into seven arms: single nutrition (N); water (W); sanitation (S); hygiene (H); combined water, sanitation, and hygiene (WSH); WSH and nutrition (N + WSH); and a double sized control (C). Nutrition intervention messages included four promotional components: maternal nutrition, breastfeeding, complementary feeding, and lipid-based nutrient supplements. The World Health Organization infant food frequency questionnaire (24-hr recall and 7-day recall) was administered at Year 1 and Year 2 of intervention. The likelihood of any snack food consumption was significantly lower (odds ratio 0.37: 95% confidence interval [0.28, 0.49]) in the nutrition intervention arms compared to the control arm in Year 2 follow-up. In addition, in the water intervention arm, fewer children (about 50% less) consumed soft drinks, but not the other sugar-sweetened beverages, compared with control in Year 2. There were no other differences between groups. Simple messages about balanced diet and feeding family foods were effective in lowering commercially produced snack food consumption of the young children in low-income rural communities of Bangladesh. Provision of safe water apparently encouraged mothers to reduce offering unhealthy beverages to the young children.

  View details for DOI 10.1111/mcn.12994

  View details for PubMedID 32196968

• Effect of Sanitation Improvements on Pathogens and Microbial Source Tracking Markers in the Rural Bangladeshi Household Environment. Environmental science & technology Fuhrmeister, E. R., Ercumen, A. n., Pickering, A. J., Jeanis, K. M., Crider, Y. n., Ahmed, M. n., Brown, S. n., Alam, M. n., Sen, D. n., Islam, S. n., Kabir, M. H., Islam, M. n., Rahman, M. n., Kwong, L. H., Arnold, B. F., Luby, S. P., Colford, J. M., Nelson, K. L. 2020

  Abstract

  Diarrheal illnesses from enteric pathogens are a leading cause of death in children under five in low- and middle-income countries (LMICs). Sanitation is one way to reduce the spread of enteric pathogens in the environment; however, few studies have investigated the effectiveness of sanitation in rural LMICs in reducing pathogens in the environment. In this study, we measured the impact of a sanitation intervention (dual-pit latrines, sani-scoops, child potties delivered as part of a randomized control trial, WASH Benefits) in rural Bangladeshi household compounds by assessing prevalence ratios, differences, and changes in the concentration of pathogen genes and host-specific fecal markers. We found no difference in the prevalence of pathogenic Escherichia coli, norovirus, or Giardia genes in the domestic environment in the sanitation and control arms. The prevalence of the human fecal marker was lower on child hands and the concentration of animal fecal marker was lower on mother hands in the sanitation arm in adjusted models, but these associations were not significant after correcting for multiple comparisons. In the subset of households with ≥10 individuals per compound, the prevalence of enterotoxigenic E. coli genes on child hands was lower in the sanitation arm. Incomplete removal of child and animal feces or the compound (versus community-wide) scale of intervention could explain the limited impacts of improved sanitation.

  View details for DOI 10.1021/acs.est.9b04835

  View details for PubMedID 32167305

• Methods for Model Calibration under High Uncertainty: Modeling Cholera in Bangladesh. Medical decision making : an international journal of the Society for Medical Decision Making Ryckman, T. n., Luby, S. n., Owens, D. K., Bendavid, E. n., Goldhaber-Fiebert, J. D. 2020: 272989X20938683

  Abstract

  Background. Published data on a disease do not always correspond directly to the parameters needed to simulate natural history. Several calibration methods have been applied to computer-based disease models to extract needed parameters that make a model's output consistent with available data. Objective. To assess 3 calibration methods and evaluate their performance in a real-world application. Methods. We calibrated a model of cholera natural history in Bangladesh, where a lack of active surveillance biases available data. We built a cohort state-transition cholera natural history model that includes case hospitalization to reflect the passive surveillance data-generating process. We applied 3 calibration techniques: incremental mixture importance sampling, sampling importance resampling, and random search with rejection sampling. We adapted these techniques to the context of wide prior uncertainty and many degrees of freedom. We evaluated the resulting posterior parameter distributions using a range of metrics and compared predicted cholera burden estimates. Results. All 3 calibration techniques produced posterior distributions with a higher likelihood and better fit to calibration targets as compared with prior distributions. Incremental mixture importance sampling resulted in the highest likelihood and largest number of unique parameter sets to better inform joint parameter uncertainty. Compared with naïve uncalibrated parameter sets, calibrated models of cholera in Bangladesh project substantially more cases, many of which are not detected by passive surveillance, and fewer deaths. Limitations. Calibration cannot completely overcome poor data quality, which can leave some parameters less well informed than others. Calibration techniques may perform differently under different circumstances. Conclusions. Incremental mixture importance sampling, when adapted to the context of high uncertainty, performs well. By accounting for biases in data, calibration can improve model projections of disease burden.

  View details for DOI 10.1177/0272989X20938683

  View details for PubMedID 32639859

• Burden of Ileal Perforations Among Surgical Patients Admitted in Tertiary Care Hospitals of Three Asian countries: Surveillance of Enteric Fever in Asia Project (SEAP), September 2016-September 2019. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Qazi, S. H., Yousafzai, M. T., Saddal, N. S., Dehraj, I. F., Thobani, R. S., Akhtar, A. n., Syed, J. R., Kazi, A. M., Hotwani, A. n., Rahman, N. n., Mehmood, J. n., Andrews, J. R., Luby, S. P., Garrett, D. O., Qamar, F. N. 2020; 71 (Supplement_3): S232–S238

  Abstract

  Typhoid fever is caused by Salmonella enterica subspecies enterica serovar Typhi (S. Typhi) and can lead to systemic illness and complications. We aimed to characterize typhoid-related ileal perforation in the context of the population-based Surveillance of Enteric Fever in Asia Project (SEAP) in Bangladesh, Nepal and Pakistan.Between September 2016 and September 2019, all cases of nontraumatic ileal perforation with a clinical diagnosis of typhoid were enrolled from 4 tertiary care hospitals in Karachi, 2 pediatric hospitals in Bangladesh, and 2 hospitals in Nepal. Sociodemographic data were collected from patients or their caregivers, and clinical and outcome data were retrieved from medical records. Tissue samples were collected for histopathology and blood cultures where available.Of the 249 enrolled cases, 2 from Bangladesh, 5 from Nepal and 242 from Pakistan. In Pakistan, most of the cases were in the 0-15 (117/242; 48%) and 16-30 (89/242; 37%) age groups. In all countries, males were most affected: Pakistan 74.9% (180/242), Nepal 80% (4/5), and Bangladesh 100% (2/2). Blood culture was done on 76 cases; 8 (11%) were positive for S. Typhi, and all were extensively drug resistant (XDR) S. Typhi. Tissue cultures was done on 86 patients; 3 (3%) were positive for S. Typhi, and all were XDR S. Typhi, out of 86 samples tested for histopathology 4 (5%) revealed ileal perforation with necrosis. Culture or histopathology confirmed total 15 (11%) enteric fever cases with ileal perforation are similar to the clinically diagnosed cases. There were 16/242 (7%) deaths from Pakistan. Cases of ileal perforation who survived were more likely to have sought care before visiting the sentinel hospital (P = .009), visited any hospital for treatment (P = .013) compared to those who survived.Although surveillance differed substantially by country, one reason for the higher number of ileal perforation cases in Pakistan could be the circulation of XDR strain of S. Typhi in Karachi.

  View details for DOI 10.1093/cid/ciaa1309

  View details for PubMedID 33258928

• Illness Severity and Outcomes Among Enteric Fever Cases From Bangladesh, Nepal, and Pakistan: Data From the Surveillance for Enteric Fever in Asia Project, 2016-2019. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Longley, A. T., Hemlock, C. n., Date, K. n., Luby, S. P., Andrews, J. R., Saha, S. K., Bogoch, I. I., Yousafzai, M. T., Garrett, D. O., Qamar, F. N. 2020; 71 (Supplement_3): S222–S231

  Abstract

  Enteric fever can lead to prolonged hospital stays, clinical complications, and death. The Surveillance for Enteric Fever in Asia Project (SEAP), a prospective surveillance study, characterized the burden of enteric fever, including illness severity, in selected settings in Bangladesh, Nepal, and Pakistan. We assessed disease severity, including hospitalization, clinical complications, and death among SEAP participants.We analyzed clinical and laboratory data from blood culture-confirmed enteric fever cases enrolled in SEAP hospitals and associated network laboratories from September 2016 to September 2019. We used hospitalization and duration of hospital stay as proxies for severity. We conducted a follow-up interview 6 weeks after enrollment to ascertain final outcomes.Of the 8705 blood culture-confirmed enteric fever cases enrolled, we identified 6 deaths (case-fatality ratio, .07%; 95% CI, .01-.13%), 2 from Nepal, 4 from Pakistan, and none from Bangladesh. Overall, 1.7% (90/5205) of patients recruited from SEAP hospitals experienced a clinical complication (Bangladesh, 0.6% [18/3032]; Nepal, 2.3% [12/531]; Pakistan, 3.7% [60/1642]). The most identified complications were hepatitis (n = 36), septic shock (n = 22), and pulmonary complications/pneumonia (n = 13). Across countries, 32% (2804/8669) of patients with hospitalization data available were hospitalized (Bangladesh, 27% [1295/4868]; Nepal, 29% [455/1595]; Pakistan, 48% [1054/2206]), with a median hospital stay of 5 days (IQR, 3-7).While defined clinical complications and deaths were uncommon at the SEAP sites, the high proportion of hospitalizations and prolonged hospital stays highlight illness severity and the need for enteric fever control measures, including the use of typhoid conjugate vaccines.

  View details for DOI 10.1093/cid/ciaa1320

  View details for PubMedID 33258929

• Burden of Culture Confirmed Enteric Fever Cases in Karachi, Pakistan: Surveillance For Enteric Fever in Asia Project (SEAP), 2016-2019. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Yousafzai, M. T., Irfan, S. n., Thobani, R. S., Kazi, A. M., Hotwani, A. n., Memon, A. M., Iqbal, K. n., Qazi, S. H., Saddal, N. S., Rahman, N. n., Dehraj, I. F., Hunzai, M. J., Mehmood, J. n., Garrett, D. O., Saha, S. K., Andrews, J. R., Luby, S. P., Qamar, F. N. 2020; 71 (Supplement_3): S214–S221

  Abstract

  The Surveillance for Enteric Fever in Asia Project (SEAP) is a multicenter, multicountry study conducted in Pakistan, Nepal, and Bangladesh. The objectives of the study were to characterize disease incidence among patients with enteric fever. We report the burden of enteric fever at selected sites of Karachi, Pakistan.During September 2016 to September 2019, prospective surveillance was conducted at inpatient, outpatient, surgical departments, and laboratory networks of Aga Khan University Hospital, Kharadar General Hospital, and surgery units of National Institute of Child Health and Jinnah Postgraduate Medical Centre. Socio-demographic, clinical, and laboratory data were obtained from all suspected or confirmed enteric fever cases.Overall, 22% (2230/10 094) of patients enrolled were culture-positive for enteric fever. 94% (2093/2230) of isolates were Salmonella Typhi and 6% (137/2230) were S. Paratyphi. 15% of isolates multi-drug resistant (MDR) to first-line antibiotics and 60% were extensively drug-resistant (XDR), resistant to first-line antibiotics, fluoroquinolones and third generation cephalosporin.Enteric fever cases have increased during the last 3 years with large proportion of drug resistant S. Typhi cases. However, the burden of paratyphoid is still relatively low. Strengthening the existing surveillance system for enteric fever and antimicrobial resistance at the national level is recommended in Pakistan to inform prevention measures. While typhoid vaccination can significantly decrease the burden of typhoid and may also impact antimicrobial resistance, water, sanitation, and hygiene improvement is highly recommended to prevent the spread of enteric fever.

  View details for DOI 10.1093/cid/ciaa1308

  View details for PubMedID 33258931

• Antimicrobial Resistance in Typhoidal Salmonella: Surveillance for Enteric Fever in Asia Project, 2016-2019. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Qamar, F. N., Yousafzai, M. T., Dehraj, I. F., Shakoor, S. n., Irfan, S. n., Hotwani, A. n., Hunzai, M. J., Thobani, R. S., Rahman, N. n., Mehmood, J. n., Hemlock, C. n., Memon, A. M., Andrews, J. R., Luby, S. P., Garrett, D. O., Longley, A. T., Date, K. n., Saha, S. K. 2020; 71 (Supplement_3): S276–S284

  Abstract

  Clinicians have limited therapeutic options for enteric as a result of increasing antimicrobial resistance, and therefore typhoid vaccination is recommended as a preventive measure. As a part of the Surveillance for Enteric Fever in Asia Project (SEAP), we investigated the extent measured the burden of antimicrobial resistance (AMR) among confirmed enteric fever cases in Bangladesh, Nepal, and Pakistan.From September 2016-September 2019, SEAP recruited study participants of all age groups from its outpatient, inpatient, hospital laboratory, laboratory network, and surgical sites who had a diagnosis of febrile illness that was either suspected or blood culture confirmed for enteric fever. Antimicrobial resistance of isolates was determined by disc diffusion using Clinical and Laboratory Standard Institute cut-off points. We reported the frequency of multidrug resistance (MDR)(resistance to ampicillin, cotrimoxazole, and chloramphenicol), extensive drug resistance (XDR) (MDR plus non-susceptible to fluoroquinolone and any 3rd generation cephalosporins), and fluoroquinolone (FQ) and azithromycin non-susceptibility.We enrolled 8,705 blood culture confirmed enteric fever cases: 4,873 (56%) from Bangladesh, 1,602 (18%) from Nepal and 2,230 (26%) from Pakistan. Of these, 7,591 (87%) were Salmonella Typhi and 1114 (13%) were S. Paratyphi. MDR S. Typhi was identified in 17% (701/4065) of isolates in Bangladesh, and 1% (19/1342) in Nepal. In Pakistan, 16 % (331/2084) of S. Typhi isolates were MDR, and 64% (1319/2074) were XDR. FQ nonsusceptibility among S. Typhi isolates was 98% in Bangladesh, 87% in Nepal, and 95% in Pakistan. Azithromycin non-susceptibility was detected in 77 (2%) in Bangladesh, 9 (.67%) in Nepal and 9 (.59%) isolates in Pakistan. In Pakistan, three (2%) S. Paratyphi isolates were MDR; no MDR S. Paratyphi was reported from Bangladesh or Nepal.Although AMR against S. Paratyphi was low across the three countries, there was widespread drug resistance among S. Typhi, including FQ non-susceptibility and the emergence of XDR S. Typhi in Pakistan, limiting treatment options. As typhoid conjugate vaccine (TCV) is rolled out, surveillance should continue to monitor changes in AMR to inform policies and to monitor drug resistance in S. Paratyphi, for which there is no vaccine.

  View details for DOI 10.1093/cid/ciaa1323

  View details for PubMedID 33258934

• Utilization of Blood Culture in South Asia for the Diagnosis and Treatment of Febrile Illness. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Hemlock, C. n., Luby, S. P., Saha, S. n., Qamar, F. n., Andrews, J. R., Saha, S. K., Tamrakar, D. n., Date, K. n., Longley, A. T., Garrett, D. O., Bogoch, I. I. 2020; 71 (Supplement_3): S266–S275

  Abstract

  Blood culture is the current standard for diagnosing bacteremic illnesses, yet it is not clear how physicians in many low- and middle-income countries utilize blood culture for diagnostic purposes and to inform treatment decisions.We screened suspected enteric fever cases from 6 hospitals in Bangladesh, Nepal, and Pakistan, and enrolled patients if blood culture was prescribed by the treating physician. We used generalized additive regression models to analyze the probability of receiving blood culture by age, and linear regression models to analyze changes by month to the proportion of febrile cases prescribed a blood culture compared with the burden of febrile illness, stratified by hospital. We used logistic regression to analyze predictors for receiving antibiotics empirically. We descriptively reviewed changes in antibiotic therapy by susceptibility patterns and coverage, stratified by country.We screened 30 809 outpatients resulting in 1819 enteric fever cases; 1935 additional cases were enrolled from other hospital locations. Younger outpatients were less likely to receive a blood culture. The association between the number of febrile outpatients and the proportion prescribed blood culture varied by hospital. Antibiotics prescribed empirically were associated with severity and provisional diagnoses, but 31% (1147/3754) of enteric fever cases were not covered by initial therapy; this was highest in Pakistan (50%) as many isolates were resistant to cephalosporins, which were commonly prescribed empirically.Understanding hospital-level communication between laboratories and physicians may improve patient care and timeliness of appropriate antibiotics, which is important considering the rise of antimicrobial resistance.

  View details for DOI 10.1093/cid/ciaa1322

  View details for PubMedID 33258939

• Hospitalization of Pediatric Enteric Fever Cases, Dhaka, Bangladesh, 2017-2019: Incidence and Risk Factors. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Saha, S. n., Sayeed, K. M., Saha, S. n., Islam, M. S., Rahaman, A. n., Islam, M. n., Rahman, H. n., Das, R. n., Hasan, M. M., Uddin, M. J., Tanmoy, A. M., Ahmed, A. S., Luby, S. P., Andrews, J. R., Garrett, D. O., Saha, S. K. 2020; 71 (Supplement_3): S196–S204

  Abstract

  Enteric fever causes substantial morbidity and mortality in low- and middle-income countries. Here, we analyzed Surveillance for Enteric Fever in Asia Project (SEAP) data to estimate the burden of enteric fever hospitalization among children aged <15 years and identify risk factors for hospitalization in Bangladesh.SEAP used hospital surveillance paired with a community-based health-care utilization assessment. In SEAP hospital surveillance, blood was obtained for culture from children aged <15 years with ≥3 days of fever. In the hospital catchment area, a health-care utilization survey (HCUS) was conducted to estimate the proportion of febrile children hospitalized at the study hospitals. We analyzed hospital surveillance and HCUS data to estimate the health care-adjusted incidence of enteric fever hospitalization, and conducted univariable and multivariable logistic regressions.From July 2017 through June 2019, 2243 laboratory-confirmed enteric fever cases were detected in 2 study hospitals; 673 (30%) were hospitalized. The health care-adjusted incidence of enteric fever hospitalization among children <15 years old was 303/100 000 children/year (95% confidence interval [CI], 293-313). Salmonella Typhi contributed most to the enteric fever hospitalization incidence (277/100 000 children/year; 95% CI, 267-287). The incidence was highest among children aged 2 to <5 years (552/100 000 children/year; 95% CI, 522-583), followed by those aged <2 years (316/100 000 children/year; 95% CI, 288-344). Factors independently associated with enteric fever hospitalization included fever duration, diarrhea, vomiting, abdominal pain, and leukocytopenia.We estimated a high burden of hospitalization due to enteric fever among children aged <5 years in Bangladesh. The introduction of a typhoid conjugate vaccine would protect children from typhoid and avert typhoid hospitalizations.

  View details for DOI 10.1093/cid/ciaa1356

  View details for PubMedID 33258942

• Spatial Heterogeneity of Enteric Fever in 2 Diverse Communities in Nepal. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Tamrakar, D. n., Vaidya, K. n., Yu, A. T., Aiemjoy, K. n., Naga, S. R., Cao, Y. n., Bern, C. n., Shrestha, R. n., Karmacharya, B. M., Pradhan, S. n., Qamar, F. N., Saha, S. n., Date, K. n., Longley, A. T., Hemlock, C. n., Luby, S. n., Garrett, D. O., Bogoch, I. I., Andrews, J. R. 2020; 71 (Supplement_3): S205–S213

  Abstract

  Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear.We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence.Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence >200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities.In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever.

  View details for DOI 10.1093/cid/ciaa1319

  View details for PubMedID 33258932

• A Cluster-based, Spatial-sampling Method for Assessing Household Healthcare Utilization Patterns in Resource-limited Settings. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Yu, A. T., Shakya, R. n., Adhikari, B. n., Tamrakar, D. n., Vaidya, K. n., Maples, S. n., Date, K. n., Bogoch, I. I., Bern, C. n., Qamar, F. n., Yousafzai, M. T., Garrett, D. O., Longley, A. T., Hemlock, C. n., Luby, S. n., Aiemjoy, K. n., Andrews, J. R. 2020; 71 (Supplement_3): S239–S247

  Abstract

  Implementation of population-based surveys is resource intensive and logistically demanding, especially in areas with rapidly changing demographics and incomplete or no enumeration of the underlying population and their residences. To remove the need for pre-enumeration and to simplify field logistics for the population healthcare utilization survey used for the Surveillance for Enteric Fever in Asia Project in Nepal, we incorporated a geographic information system-based geosurvey and field mapping system into a single-stage cluster sampling approach.A survey was administered to ascertain healthcare-seeking behavior in individuals with recent suspected enteric fever. Catchment areas were based on residential addresses of enteric fever patients using study facilities; clusters were randomly selected from digitally created grids using available satellite images and all households within clusters were offered enrollment. A tablet-compatible geosurvey and mapping system that allowed for data-syncing and use in areas without cellular data was created using the ArcGIS suite of software.Between January 2017 and November 2018, we surveyed 25 521 households in Nepal (16 769 in urban Kathmandu and 8752 in periurban Kavrepalanchok), representing 84 202 individuals. Overall, the survey participation rate was 90.9%, with geographic heterogeneity in participation rates within each catchment area. Areas with higher average household wealth had lower participation rates.A geographic information system-based geosurvey and field mapping system allowed creation of a virtual household map at the same time as survey administration, enabling a single-stage cluster sampling method to assess healthcare utilization in Nepal for the Surveillance for Enteric Fever in Asia Project . This system removed the need for pre-enumeration of households in sampling areas, simplified logistics and could be replicated in future community surveys.

  View details for DOI 10.1093/cid/ciaa1310

  View details for PubMedID 33258933

• Antibiotic Use Prior to Hospital Presentation Among Individuals With Suspected Enteric Fever in Nepal, Bangladesh, and Pakistan. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Vaidya, K. n., Aiemjoy, K. n., Qamar, F. N., Saha, S. K., Tamrakar, D. n., Naga, S. R., Saha, S. n., Hemlock, C. n., Longley, A. T., Date, K. n., Bogoch, I. I., Garrett, D. O., Luby, S. P., Andrews, J. R. 2020; 71 (Supplement_3): S285–S292

  Abstract

  Antibiotic use prior to seeking care at a hospital may reduce the sensitivity of blood culture for enteric fever, with implications for both clinical care and surveillance. The Surveillance for Enteric Fever in Asia Project (SEAP) is a prospective study of enteric fever incidence in Nepal, Bangladesh, and Pakistan. Nested within SEAP, we evaluated the accuracy of self-reported antibiotic use and investigated the association between antibiotic use and blood culture positivity.Between November 2016 and April 2019, we collected urine samples among a subset of SEAP participants to test for antibiotic use prior to the hospital visit using an antibacterial activity assay. All participants were asked about recent antibiotic use and had a blood culture performed. We used mixed-effect logit models to evaluate the effect of antimicrobial use on blood culture positivity, adjusted for markers of disease severity.We enrolled 2939 patients with suspected enteric fever. Antibiotics were detected in 39% (1145/2939) of urine samples. The correlation between measured and reported antibiotic use was modest (κ = 0.72). After adjusting for disease severity, patients with antibiotics in their urine were slightly more likely to be blood culture positive for enteric fever; however, the effect was not statistically significant (prevalence ratio, 1.22 [95% confidence interval, .99-1.50]).The reliability of self-reported prior antibiotic use was modest among individuals presenting with fever to tertiary hospitals. While antibiotics are likely to reduce the sensitivity of blood culture, our findings indicate that there is still considerable value in performing blood culture for individuals reporting antibiotic use.

  View details for DOI 10.1093/cid/ciaa1333

  View details for PubMedID 33258935

• Diagnostic Value of Clinical Features to Distinguish Enteric Fever From Other Febrile Illnesses in Bangladesh, Nepal, and Pakistan. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Aiemjoy, K. n., Tamrakar, D. n., Saha, S. n., Naga, S. R., Yu, A. T., Longley, A. n., Date, K. n., Hemlock, C. n., Qamar, F. N., Saha, S. K., Luby, S. P., Garrett, D. O., Andrews, J. R., Bogoch, I. I. 2020; 71 (Supplement_3): S257–S265

  Abstract

  Enteric fever, a bacterial infection caused by Salmonella enterica serotypes Typhi and Paratyphi A, frequently presents as a nonlocalizing febrile illness that is difficult to distinguish from other infectious causes of fever. Blood culture is not widely available in endemic settings and, even when available, results can take up to 5 days. We evaluated the diagnostic performance of clinical features, including both reported symptoms and clinical signs, of enteric fever among patients participating in the Surveillance for Enteric Fever in Asia Project (SEAP), a 3-year surveillance study in Bangladesh, Nepal, and Pakistan.Outpatients presenting with ≥3 consecutive days of reported fever and inpatients with clinically suspected enteric fever from all 6 SEAP study hospitals were eligible to participate. We evaluated the diagnostic performance of select clinical features against blood culture results among outpatients using mixed-effect regression models with a random effect for study site hospital. We also compared the clinical features of S. Typhi to S. Paratyphi A among both outpatients and inpatients.We enrolled 20 899 outpatients, of whom 2116 (10.1%) had positive blood cultures for S. Typhi and 297 (1.4%) had positive cultures for S. Paratyphi A. The sensitivity of absence of cough was the highest among all evaluated features, at 65.5% (95% confidence interval [CI], 55.0-74.7), followed by measured fever at presentation at 59.0% (95% CI, 51.6-65.9) and being unable to complete normal activities for 3 or more days at 51.0% (95% CI, 23.8-77.6). A combined case definition of 3 or more consecutive days of reported fever and 1 or more of the following (a) either the absence of cough, (b) fever at presentation, or (c) 3 or more consecutive days of being unable to conduct usual activity--yielded a sensitivity of 94.6% (95% CI, 93.4-95.5) and specificity of 13.6% (95% CI, 9.8-17.5).Clinical features do not accurately distinguish blood culture-confirmed enteric fever from other febrile syndromes. Rapid, affordable, and accurate diagnostics are urgently needed, particularly in settings with limited or no blood culture capacity.

  View details for DOI 10.1093/cid/ciaa1297

  View details for PubMedID 33258936

• Healthcare Utilization Patterns for Acute Febrile Illness in Bangladesh, Nepal, and Pakistan: Results from the Surveillance for Enteric Fever in Asia Project. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Andrews, J. R., Vaidya, K. n., Saha, S. n., Yousafzai, M. T., Hemlock, C. n., Longley, A. n., Aiemjoy, K. n., Yu, A. T., Bogoch, I. I., Tamrakar, D. n., Date, K. n., Saha, S. K., Garrett, D. O., Luby, S. P., Qamar, F. n. 2020; 71 (Supplement_3): S248–S256

  Abstract

  Characterizing healthcare-seeking patterns for acute febrile illness is critical for generating population-based enteric fever incidence estimates from facility-based surveillance data.We used a hybrid model in the Surveillance for Enteric Fever in Asia Project (SEAP) to assess incidence of enteric fever at 6 study hospitals in 3 countries. We recruited individuals presenting to the hospitals and obtained blood cultures to evaluate for enteric fever. For this analysis, we undertook cluster random household surveys in Dhaka, Bangladesh (2 sites); Karachi, Pakistan; Kathmandu, Nepal; and Kavrepalanchok, Nepal between January 2017 and February 2019, to ascertain care-seeking behavior for individuals with 1) fever for ≥3 consecutive days within the past 8 weeks; or 2) fever resulting in hospitalization within the past year. We also collected data about disease severity and household demographics and assets. We used mixed-effect multivariable logistic regression models to identify determinants of healthcare seeking at study hospitals and determinants of culture-confirmed enteric fever.We enrolled 31 841 households (53 926 children) in Bangladesh, 25 510 households (84 196 children and adults) in Nepal, and 21 310 households (108 031 children and adults) in Pakistan. Children <5 years were most likely to be taken to the study hospitals for febrile illness at all sites. Household wealth was positively correlated with healthcare seeking in 4 of 5 study sites, and at least one marker of disease severity was positively associated with healthcare seeking in 3 of 5 catchment areas. Wealth and disease severity were variably predictive of blood culture-confirmed enteric fever.Age, household wealth, and disease severity are important determinants of healthcare seeking for acute febrile illness and enteric fever risk in these communities, and should be incorporated into estimation models for enteric fever incidence.

  View details for DOI 10.1093/cid/ciaa1321

  View details for PubMedID 33258937

• The Surveillance for Enteric Fever in Asia Project (SEAP), Severe Typhoid Fever Surveillance in Africa (SETA), Surveillance of Enteric Fever in India (SEFI), and Strategic Typhoid Alliance Across Africa and Asia (STRATAA) Population-based Enteric Fever Studies: A Review of Methodological Similarities and Differences. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Carey, M. E., MacWright, W. R., Im, J. n., Meiring, J. E., Gibani, M. M., Park, S. E., Longley, A. n., Jeon, H. J., Hemlock, C. n., Yu, A. T., Soura, A. n., Aiemjoy, K. n., Owusu-Dabo, E. n., Terferi, M. n., Islam, S. n., Lunguya, O. n., Jacobs, J. n., Gordon, M. n., Dolecek, C. n., Baker, S. n., Pitzer, V. E., Yousafzai, M. T., Tonks, S. n., Clemens, J. D., Date, K. n., Qadri, F. n., Heyderman, R. S., Saha, S. K., Basnyat, B. n., Okeke, I. N., Qamar, F. N., Voysey, M. n., Luby, S. n., Kang, G. n., Andrews, J. n., Pollard, A. J., John, J. n., Garrett, D. n., Marks, F. n. 2020; 71 (Supplement_2): S102–S110

  Abstract

  Building on previous multicountry surveillance studies of typhoid and others salmonelloses such as the Diseases of the Most Impoverished program and the Typhoid Surveillance in Africa Project, several ongoing blood culture surveillance studies are generating important data about incidence, severity, transmission, and clinical features of invasive Salmonella infections in sub-Saharan Africa and South Asia. These studies are also characterizing drug resistance patterns in their respective study sites. Each study answers a different set of research questions and employs slightly different methodologies, and the geographies under surveillance differ in size, population density, physician practices, access to healthcare facilities, and access to microbiologically safe water and improved sanitation. These differences in part reflect the heterogeneity of the epidemiology of invasive salmonellosis globally, and thus enable generation of data that are useful to policymakers in decision-making for the introduction of typhoid conjugate vaccines (TCVs). Moreover, each study is evaluating the large-scale deployment of TCVs, and may ultimately be used to assess post-introduction vaccine impact. The data generated by these studies will also be used to refine global disease burden estimates. It is important to ensure that lessons learned from these studies not only inform vaccination policy, but also are incorporated into sustainable, low-cost, integrated vaccine-preventable disease surveillance systems.

  View details for DOI 10.1093/cid/ciaa367

  View details for PubMedID 32725221

• Environmental Surveillance as a Tool for Identifying High-risk Settings for Typhoid Transmission. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Andrews, J. R., Yu, A. T., Saha, S. n., Shakya, J. n., Aiemjoy, K. n., Horng, L. n., Qamar, F. n., Garrett, D. n., Baker, S. n., Saha, S. n., Luby, S. P. 2020; 71 (Supplement_2): S71–S78

  Abstract

  Enteric fever remains a major cause of morbidity in developing countries with poor sanitation conditions that enable fecal contamination of water distribution systems. Historical evidence has shown that contamination of water systems used for household consumption or agriculture are key transmission routes for Salmonella Typhi and Salmonella Paratyphi A. The World Health Organization now recommends that typhoid conjugate vaccines (TCV) be used in settings with high typhoid incidence; consequently, governments face a challenge regarding how to prioritize typhoid against other emerging diseases. A key issue is the lack of typhoid burden data in many low- and middle-income countries where TCV could be deployed. Here we present an argument for utilizing environmental sampling for the surveillance of enteric fever organisms to provide data on community-level typhoid risk. Such an approach could complement traditional blood culture-based surveillance or even replace it in settings where population-based clinical surveillance is not feasible. We review historical studies characterizing the transmission of enteric fever organisms through sewage and water, discuss recent advances in the molecular detection of typhoidal Salmonella in the environment, and outline challenges and knowledge gaps that need to be addressed to establish environmental sampling as a tool for generating actionable data that can inform public health responses to enteric fever.

  View details for DOI 10.1093/cid/ciaa513

  View details for PubMedID 32725227

• Consequences of access to water from managed aquifer recharge systems for blood pressure and proteinuria in south-west coastal Bangladesh: a stepped-wedge cluster-randomized trial. International journal of epidemiology Naser, A. M., Doza, S. n., Rahman, M. n., Unicomb, L. n., Ahmed, K. M., Anand, S. n., Selim, S. n., Shamsudduha, M. n., Narayan, K. M., Chang, H. n., Clasen, T. F., Gribble, M. O., Luby, S. P. 2020

  Abstract

  Drinking-water salinity has been associated with high blood pressure (BP) among communities in south-west coastal Bangladesh. We evaluated whether access to water from managed aquifer recharge (MAR)-a hydrogeological intervention to lower groundwater salinity by infiltrating rainwater into the aquifers-can reduce community BP.We conducted a stepped-wedge cluster-randomized trial with five monthly visits between December 2016 and April 2017 in 16 communities. At each visit following baseline, four communities were randomized to access MAR water. Systolic BP was the primary outcome, measured during each visit using Omron® HEM-907 devices. We also measured participants' 24-hour urinary sodium and households' drinking- and cooking-water salinity each visit. We used multilevel regression models to estimate the effects of MAR-water access on participants' BP. The primary analysis was intention-to-treat.In total, 2911 person-visits were conducted in communities randomized to have MAR-water access and 2834 in communities without MAR-water access. Households without MAR-water access predominantly used low-salinity pond water and 42% (range: 26-50% across visits) of households exclusively consumed MAR water when access was provided. Communities randomized to MAR-water access had 10.34 [95% confidence interval (CI): 1.11, 19.58] mmol/day higher mean urinary sodium, 1.96 (95% CI: 0.66, 3.26; p = 0.004) mmHg higher mean systolic BP and 1.44 (95% CI: 0.40, 2.48; p = 0.007) mmHg higher mean diastolic BP than communities without MAR-water access.Our findings do not support the scale-up of MAR systems as a routine drinking-water source, since communities that shifted to MAR water from the lower-salinity pond-water source had higher urinary sodium and BP.

  View details for DOI 10.1093/ije/dyaa098

  View details for PubMedID 32653912

• The biosecurity benefits of genetic engineering attribution. Nature communications Lewis, G., Jordan, J. L., Relman, D. A., Koblentz, G. D., Leung, J., Dafoe, A., Nelson, C., Epstein, G. L., Katz, R., Montague, M., Alley, E. C., Filone, C. M., Luby, S., Church, G. M., Millett, P., Esvelt, K. M., Cameron, E. E., Inglesby, T. V. 2020; 11 (1): 6294

  Abstract

  Biology can be misused, and the risk of this causing widespread harm increases in step with the rapid march of technological progress. A key security challenge involves attribution: determining, in the wake of a human-caused biological event, who was responsible. Recent scientific developments have demonstrated a capability for detecting whether an organism involved in such an event has been genetically modified and, if modified, to infer from its genetic sequence its likely lab of origin. We believe this technique could be developed into powerful forensic tools to aid the attribution of outbreaks caused by genetically engineered pathogens, and thus protect against the potential misuse of synthetic biology.

  View details for DOI 10.1038/s41467-020-19149-2

  View details for PubMedID 33293537

• Hunting Bats for Human Consumption in Bangladesh. EcoHealth Nahar, N. n., Asaduzzaman, M. n., Mandal, U. K., Rimi, N. A., Gurley, E. S., Rahman, M. n., Garcia, F. n., Zimicki, S. n., Sultana, R. n., Luby, S. P. 2020

  Abstract

  Bats are important wildlife to their ecologic system, but they are also a zoonotic disease reservoir. Close bat-human interaction can lead to pathogen spillover. We conducted a qualitative study in two districts of Bangladesh and interviewed 30 bat hunters who hunt bats primarily for consumption, to understand the process and their reasons for hunting bats and their perceptions about bats and bat-borne disease. Most hunters catch bats during winter nights, using a net. Bat meat is used for household consumption, and the surplus is sold to cover household expenditures. They prepare the bat meat at home to sell it in their own and in neighboring communities. They also sell live bats to traditional healers. They report that the bat population has declined compared with 5 or 10 years ago, a decline they attribute to hunting and deforestation. Many have heard of a disease from bat-contaminated date palm sap but do not believe that bats can spread such disease to humans. Close bat-human interaction reported in this study pose a risk of pathogen spillover. Conservation initiatives have the potential to reduce such interaction and so both reduce disease risk and support the ecology.

  View details for DOI 10.1007/s10393-020-01468-x

  View details for PubMedID 31989365

• COMPARING METHODS FOR MODEL CALIBRATION WITH HIGH UNCERTAINTY: MODELING CHOLERA IN BANGLADESH Ryckman, T., Luby, S., Owens, D. K., Bendavid, E., Goldhaber-Fiebert, J. D. SAGE PUBLICATIONS INC. 2020: E186–E187

  View details for Web of Science ID 000509275600163

• A case of primary amebic meningoencephalitis caused by Naegleria fowleri in Bangladesh. Parasitology research Sazzad, H. M., Luby, S. P., Sejvar, J., Rahman, M., Gurley, E. S., Hill, V., Murphy, J. L., Roy, S., Cope, J. R., Ali, I. K. 2019

  Abstract

  We present the first recognized case of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri in a 15-year-old male from Bangladesh. He performed daily nasal rinsing with untreated ground water and bathed in untreated ground water or river water, which likely exposed him to N. fowleri.

  View details for DOI 10.1007/s00436-019-06463-y

  View details for PubMedID 31734864

• Moving towards transformational WASH - Authors' reply. The Lancet. Global health Pickering, A. J., Arnold, B. F., Prendergast, A. J., Null, C., Winch, P. J., Njenga, S. M., Rahman, M., Ntozini, R., Benjamin-Chung, J., Stewart, C. P., Colford, J. M., Luby, S., Humphrey, J. H. 2019; 7 (11): e1494–e1495

  View details for DOI 10.1016/S2214-109X(19)30401-2

  View details for PubMedID 31607462

• Soil ingestion among young children in rural Bangladesh. Journal of exposure science & environmental epidemiology Kwong, L. H., Ercumen, A., Pickering, A. J., Unicomb, L., Davis, J., Leckie, J. O., Luby, S. P. 2019

  Abstract

  Ingestion of soil and dust is a pathway of children's exposure to several environmental contaminants, including lead, pesticides, and fecal contamination. Empirically based estimates of central tendency for soil consumption by children in high-income countries range from 9 to 135 dry mg/day. Using a Monte Carlo simulation, we modeled the mass of soildirectly and indirectly ingested per day by rural Bangladeshi children and identified the parameters that influence the mass ingested. We combined data from observations of direct and indirect ingestion among children with measurements of soil mass on the children's hands, mother's hands, and objects to quantify soil ingestion/day. Estimated geometric mean soil ingestion was 162 dry mg/day for children 3-5 months, 224 dry mg/day for children 6-11 months, 234 dry mg/day for children 12-23 months, 168 dry mg/day for children 24-35 months, and 178 dry mg/day for children 36-47 months old. Across all age groups, children placing their hands in their mouths accounted for 46-78% of total ingestion and mouthing objects contributed 8-12%. Direct ingestion of soil accounted for nearly 40% of soil ingested among children 6-23 months old. Sensitivity analyses identified that the parameters most affecting the estimates were the load of soil on the child's hand, the frequency of hand-to-mouth contacts while not eating, and, for children 6-23 months old, the frequency of direct soil ingestion. In a rural, low-income setting, children's soil consumption was substantially more than the estimates for children in high-income countries. Further characterizing soil ingestion of children in low-income contexts would improve assessments of the risks they face from soil-associated contaminants.

  View details for DOI 10.1038/s41370-019-0177-7

  View details for PubMedID 31673039

• Hospital-based zoonotic disease surveillance in Bangladesh: design, field data and difficulties. Philosophical transactions of the Royal Society of London. Series B, Biological sciences Das, P., Sazzad, H. M., Aleem, M. A., Rahman, M. Z., Rahman, M., Anthony, S. J., Lipkin, W. I., Gurley, E. S., Luby, S. P., Openshaw, J. J. 2019; 374 (1782): 20190019

  Abstract

  Early detection of zoonotic diseases allows for the implementation of early response measures, reducing loss of human life and economic disruption. We implemented a surveillance system in hospitals in Bangladesh to screen acutely ill hospitalized patients with severe respiratory infection and meningoencephalitis for zoonotic exposures. Patients were screened for the risk of zoonotic exposures with five questions covering vocational exposures, sick domestic animal and wild animal contact, and date palm sap consumption in the three weeks preceding illness onset. Patients giving at least one positive response were considered a potential zoonotic exposure. From September 2013 to March 2017, a total of 11 429 hospitalized patients across 14 participating hospitals were screened for exposures. Overall, 2% of patients reported a potential zoonotic exposure in the three-week period prior to becoming ill. Sixteen per cent of hospitalized patients with reported exposures died. After routine surveillance diagnostic testing, 88% of patients admitted to the hospital after a potential zoonotic exposure did not have a laboratory diagnosed aetiology for their illness. Hospital-based surveillance systems such as the Bangladeshi example presented here could play an important future role in the early detection of zoonotic spillover diseases. This article is part of the theme issue 'Dynamic and integrative approaches to understanding pathogen spillover'.

  View details for DOI 10.1098/rstb.2019.0019

  View details for PubMedID 31401956

• Effect of in-line drinking water chlorination at the point of collection on child diarrhoea in urban Bangladesh: a double-blind, cluster-randomised controlled trial. The Lancet. Global health Pickering, A. J., Crider, Y., Sultana, S., Swarthout, J., Goddard, F. G., Anjerul Islam, S., Sen, S., Ayyagari, R., Luby, S. P. 2019; 7 (9): e1247–e1256

  Abstract

  BACKGROUND: Previous blinded trials of household water treatment interventions in low-income settings have failed to detect a reduction in child diarrhoea. Technological advances have enabled the development of automated in-line chlorine dosers that can disinfect drinking water without electricity, while also allowing users to continue their typical water collection practices. We aimed to evaluate the effect of installing novel passive chlorination devices at shared water points on child diarrhoea prevalence in low-income, densely populated communities in urban Bangladesh.METHODS: In this double-blind cluster-randomised controlled trial, 100 shared water points (clusters) in two low-income urban communities in Bangladesh were randomly assigned (1:1) to have their drinking water automatically chlorinated at the point of collection by a solid tablet chlorine doser (intervention group) or to be treated by a visually identical doser that supplied vitamin C (active control group). The trial followed an open cohort design; all children younger than 5 years residing in households accessing enrolled water points were measured every 2-3 months during a 14-month follow-up period (children could migrate into or out of the cluster). The primary outcome was caregiver-reported child diarrhoea (≥3 loose or watery stools in a 24-h period [WHO criteria]) with a 1-week recall, including all available childhood observations in the analyses. This trial is registered with ClinicalTrials.gov, number NCT02606981, and is completed.FINDINGS: Between July 5, 2015, and Nov 11, 2015, 100 water points with 920 eligible households were enrolled into the study and randomly assigned to the treatment (50 water points; 517 children at baseline; 2073 child observations included in the primary analysis) or control groups (50; 519; 2154). Children in the treatment group had less WHO-defined diarrhoea than did children in the control group (control 216 [10·0%] of 2154; treatment 156 [7·5%] of 2073; prevalence ratio 0·77, 95% CI 0·65-0·91). Drinking water at the point of collection at treatment taps had detectable free chlorine residual 83% (mean 0·37 ppm) of the time compared with 0% at control taps (0·00 ppm).INTERPRETATION: Passive chlorination at the point of collection could be an effective and scalable strategy in low-income urban settings for reducing child diarrhoea and for achieving global progress towards Sustainable Development Goal 6.1 to attain universal access to safe and affordable drinking water. Targeting a low chlorine residual (<0·5 ppm) in treated water can increase taste acceptability of chlorinated drinking water while still reducing the risk of diarrhoea.FUNDING: The World Bank.

  View details for DOI 10.1016/S2214-109X(19)30315-8

  View details for PubMedID 31402005

• Effects of complexity of handwashing instructions on handwashing procedure replication in low-income urban slums in Bangladesh: a randomized non-inferiority field trial JOURNAL OF WATER SANITATION AND HYGIENE FOR DEVELOPMENT Amin, N., Sagerman, D. D., Nizame, F. A., Das, K. K., Nuruzzaman, M., Yu, J., Unicomb, L., Luby, S. P., Ram, P. K. 2019; 9 (3): 416–28

  View details for DOI 10.2166/washdev.2019.131

  View details for Web of Science ID 000483570900002

• The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement. BMC medicine Cumming, O., Arnold, B. F., Ban, R., Clasen, T., Esteves Mills, J., Freeman, M. C., Gordon, B., Guiteras, R., Howard, G., Hunter, P. R., Johnston, R. B., Pickering, A. J., Prendergast, A. J., Pruss-Ustun, A., Rosenboom, J. W., Spears, D., Sundberg, S., Wolf, J., Null, C., Luby, S. P., Humphrey, J. H., Colford, J. M. 2019; 17 (1): 173

  Abstract

  BACKGROUND: Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners.MAIN BODY: Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health.CONCLUSION: These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

  View details for DOI 10.1186/s12916-019-1410-x

  View details for PubMedID 31462230

• Broad approaches to cholera control in Asia: Water, sanitation and handwashing. Vaccine Luby, S. P., Davis, J., Brown, R. R., Gorelick, S. M., Wong, T. H. 2019

  Abstract

  Cholera has been eliminated as a public health problem in high-income countries that have implemented sanitation system separating the community's fecal waste from their drinking water and food supply. These expensive, highly-engineered systems, first developed in London over 150 years ago, have not reached low-income high-risk communities across Asia. Barriers to their implementation in communities at highest risk for cholera include the high capital and operating costs for this technological approach, limited capacity and perverse incentives of local governments, and a decreasing availability of water. Interim solutions including household level water treatment, constructing latrines and handwashing promotion have only marginally reduced the risk of cholera and other fecally transmitted diseases. Increased research to develop and policy flexibility to implement a new generation of solutions that are designed specifically to address the physical, financial and political constraints of low-income communities offers the best prospect for reducing the burden of cholera across Asia.

  View details for DOI 10.1016/j.vaccine.2019.07.084

  View details for PubMedID 31383486

• The WASH Benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea. The Lancet. Global health Pickering, A. J., Null, C., Winch, P. J., Mangwadu, G., Arnold, B. F., Prendergast, A. J., Njenga, S. M., Rahman, M., Ntozini, R., Benjamin-Chung, J., Stewart, C. P., Huda, T. M., Moulton, L. H., Colford, J. M., Luby, S. P., Humphrey, J. H. 2019; 7 (8): e1139–e1146

  Abstract

  Child stunting is a global problem and is only modestly responsive to dietary interventions. Numerous observational studies have shown that water quality, sanitation, and handwashing (WASH) in a household are strongly associated with linear growth of children living in the same household. We have completed three randomised efficacy trials testing improved household-level WASH with and without improved infant and young child feeding (IYCF) on stunting and diarrhoea in Bangladesh, Kenya, and Zimbabwe. In all trials, improved IYCF had a statistically significant benefit, but WASH had no effect on linear growth. In observational analyses of data from the control groups of the three trials, baseline sanitation was a strong risk factor for stunting in the study populations, suggesting this frequently reported association might be confounded by unmeasured factors of household wellbeing. WASH interventions reduced diarrhoea in Bangladesh, but not in Kenya or Zimbabwe. Intervention promoters visited participants six times per month in Bangladesh compared with monthly in Kenya and Zimbabwe; a review of the literature shows that virtually all published studies that have reported an effect on diarrhoea through home-based water treatment and handwashing promotion achieved high adherence by visiting participants at daily to fortnightly intervals. Despite achieving substantial behavioural change and significant reduction in infection prevalence for some enteric pathogens, detection of enteropathogens among children in the WASH groups of the trials was typically at ten times higher prevalence compared with high-income countries. Considering these results, we recommend that future research in the WASH sector focus on developing and evaluating interventions that are radically more effective in reducing faecal contamination in the domestic environment than the interventions implemented in these trials.

  View details for DOI 10.1016/S2214-109X(19)30268-2

  View details for PubMedID 31303300

• Groundwater iron has the ground: Low prevalence of anemia and iron deficiency anemia in Bangladesh Reply AMERICAN JOURNAL OF CLINICAL NUTRITION Stewart, C. P., Dewey, K. G., Colford, J. M., Rahman, M., Luby, S. P. 2019; 110 (2): 520

  View details for DOI 10.1093/ajcn/nqz055

  View details for Web of Science ID 000478072300029

• Using healthcare-seeking behaviour to estimate the number of Nipah outbreaks missed by hospital-based surveillance in Bangladesh INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Hegde, S. T., Salje, H., Sazzad, H. S., Hossain, M., Rahman, M., Daszak, P., Klena, J. D., Nichol, S. T., Luby, S. P., Gurley, E. S. 2019; 48 (4): 1219–27

  View details for DOI 10.1093/ije/dyz057

  View details for Web of Science ID 000484383300028

• Hygiene in Restaurants and among Street Food Vendors in Bangladesh. The American journal of tropical medicine and hygiene Nizame, F. A., Alam, M. U., Masud, A. A., Shoab, A. K., Opel, A., Islam, M. K., Luby, S. P., Unicomb, L. 2019

  Abstract

  Poor hand hygiene and food handling put consumers of restaurant and street food at risk of enteric disease, especially in low-income countries. This study aimed to collect hygiene indicators from a nationally representative sample of restaurants and street food vendors. The field team collected data from 50 rural villages and 50 urban administrative units (mahallas). We explored restaurant service staff, cook, and food vendor hygiene practices (N = 300 restaurants and 600 street food vendors), by observing hygiene facilities, food handling, and utensil cleaning. A qualitative assessment explored perceptions of hygiene related to food handling. During restaurant spot checks, 91% (273/300) had soap and water at handwashing location for customers but in only 33% (100) at locations convenient for restaurant staff. Among street food-vending stalls, 11% (68/600) had soap and water when observed. During 90-minute structured observations, cooks used soap to wash hands on 14/514 (3%) of occasions before food preparation, 6/82 (8%) occasions after cutting fish/meat/vegetables, 3/71 (4%) occasions before serving food, and 0/49 (0%) occasions) before hand-mashing food/salad preparation; no street food vendors washed hands with soap during these food-handling events. Most of the qualitative study participants perceived that customers select a vendor based on tastiness of the food, whereas no one mentioned the importance of food hygiene. The study demonstrates widespread poor hygiene and food-handling practices in restaurants and among food vendors. Based on our study findings, we proposed a food premises Hygiene Investigation Model to create action plans to improve food safety.

  View details for DOI 10.4269/ajtmh.18-0896

  View details for PubMedID 31333161

• Groundwater Chemistry and Blood Pressure: A Cross-Sectional Study in Bangladesh. International journal of environmental research and public health Naser, A. M., Clasen, T. F., Luby, S. P., Rahman, M., Unicomb, L., Ahmed, K. M., Doza, S., Ourshalimian, S., Chang, H. H., Stowell, J. D., Narayan, K. M., Shamsudduha, M., Patel, S. A., O'Shea, B., Gribble, M. O. 2019; 16 (13)

  Abstract

  Background: We assessed the association of groundwater chemicals with systolic blood pressure (SBP) and diastolic blood pressure (DBP). Methods: Blood pressure data for ≥35-year-olds were from the Bangladesh Demographic and Health Survey in 2011. Groundwater chemicals in 3534 well water samples from Bangladesh were measured by the British Geological Survey (BGS) in 1998-1999. Participants who reported groundwater as their primary source of drinking water were assigned chemical measures from the nearest BGS well. Survey-adjusted linear regression methods were used to assess the association of each groundwater chemical with the log-transformed blood pressure of the participants. Models were adjusted for age, sex, body mass index, smoking status, geographical region, household wealth, rural or urban residence, and educational attainment, and further adjusted for all other groundwater chemicals. Results: One standard deviation (SD) increase in groundwater magnesium was associated with a 0.992 (95% confidence interval (CI): 0.986, 0.998) geometric mean ratio (GMR) of SBP and a 0.991 (95% CI: 0.985, 0.996) GMR of DBP when adjusted for covariates except groundwater chemicals. When additionally adjusted for groundwater chemicals, one SD increase in groundwater magnesium was associated with a 0.984 (95% CI: 0.972, 0.997) GMR of SBP and a 0.990 (95% CI: 0.979, 1.000) GMR of DBP. However, associations were attenuated following Bonferroni-correction for multiple chemical comparisons in the full-adjusted model. Groundwater concentrations of calcium, potassium, silicon, sulfate, barium, zinc, manganese, and iron were not associated with SBP or DBP in the full-adjusted models. Conclusions: Groundwater magnesium had a weak association with lower SBP and DBP of the participants.

  View details for DOI 10.3390/ijerph16132289

  View details for PubMedID 31261639

• Effect of household relocation on child vaccination and health service utilisation in Dhaka, Bangladesh: a cross-sectional community survey BMJ OPEN Horng, L., Kakoly, N., Abedin, J., Luby, S. P. 2019; 9 (3)

  View details for DOI 10.1136/bmjopen-2018-026176

  View details for Web of Science ID 000471144900256

• The WASH Benefits and SHINE Trials. Interpretation of Findings on Linear Growth and Diarrhoea and Implications for Policy: Perspective of the Investigative Teams (P10-136-19). Current developments in nutrition Humphrey, J., Pickering, A., Null, C., Winch, P., Mangwadu, G., Arnold, B., Prendergast, A., Njenga, S., Rahman, M., Ntozini, R., Benjamin-Chung, J., Stewart, C., Huda, T., Moulton, L., Colford, J., Luby, S. 2019; 3 (Suppl 1)

  Abstract

  Objectives: We recently completed 3 efficacy trials (Bangladesh, Kenya, Zimbabwe) testing the independent and combined effects of improved complementary feeding (CF) and intensive household water quality, sanitation, and hygiene (WASH) on child diarrhea and length-for-age-Z-score (LAZ) at 18 to 24 mo. Intervention uptake was high. In all three trials: CF increased LAZ but WASH had no effect on LAZ. WASH reduced diarrhea in Bangladesh but not in Kenya or Zimbabwe. We present a synthesis of trial findings and their implications.Methods: Reviews of the literature and reanalyses of trial data were conducted.Results: WASH and stunting: Copious observational studies have demonstrated a strong association between household-level WASH and child LAZ. We conducted an observational anlaysis (nested birth cohort) from our control arms. In adjusted analyses of all three trials, having an improved latrine when the pregnant woman was enrolled was associated with 0.2LAZ increase in her child at 18-24 mo. The frequently reported association between household WASH indicators and child growth may be confounded and drawing causal inferance misguided.WASH and diarrhea: Promoters visited intervention households 6 times per month in Bangladesh and monthly in Kenya and Zimbabwe. We conducted a systematic literature review: virtually all evidence that household water chlorination and handwashing reduce diarrhea comes from studies with daily to fortnightly intervention contact. In studies with follow-up after the trial ending, behaviors steeply declined and the effect on child diarrhea disappeared. Household water chlorination and handwashing promotion implemented through sporadic message delivery may not reduce child diarrhea.Enteropathogen transmission: Despite achieving substantial contrast between WASH and non-WASH households, children in the WASH arms still experienced high enteropathogen transmission, illustrating the recalcitrance of pervasive fecal contamination in rural low-income communities to even intense intervention.Conclusions: Household WASH interventions are unlikely to reduce child stunting and may not reduce child diarrhea. We call for substantial investment in research to identify and in programming to deliver much more efficacious interventions.Funding Sources: Bill & Melinda Gates Foundation, USAID, DFID/UKAID, Wellcome Trust.

  View details for DOI 10.1093/cdn/nzz034.P10-136-19

  View details for PubMedID 31224648

• Risk and Response to Biological Catastrophe in Lower Income Countries. Current topics in microbiology and immunology Luby, S., Arthur, R. 2019

  Abstract

  Natural and intentional biological risks threaten human civilization, both through direct human fatality as well as follow-on effects from a collapse of the just-in-time delivery system that provides food, energy and critical supplies to communities globally. Human beings have multiple innate cognitive biases that systematically impair careful consideration of these risks. Residents of low-income countries, especially those who live in rural areas and are less dependent upon global trade, may be the most resilient communities to catastrophic risks, but low-income countries also present a heightened risk for biological catastrophe. Hotspots for the emergence of new zoonotic diseases are predominantly located in low-income countries. Crowded, poorly supplied healthcare facilities in low-income countries provide an optimal environment for new pathogens to transmit to a next host and adapt for more efficient person-to-person transmission. Strategies to address these risks include overcoming our natural biases and recognizing the importance of these risks, avoiding an over-reliance on developing specific biological countermeasures, developing generalized social and behavioral responses and investing in resilience.

  View details for DOI 10.1007/82_2019_162

  View details for PubMedID 31127360

• Reply to S Rahman and S Ireen. The American journal of clinical nutrition Stewart, C. P., Dewey, K. G., Colford, J. M., Rahman, M., Luby, S. P. 2019

  View details for PubMedID 31095285

• Transmission of Nipah Virus-14 Years of Investigations in Bangladesh NEW ENGLAND JOURNAL OF MEDICINE Nikolay, B., Salje, H., Hossain, M., Khan, A., Sazzad, H. S., Rahman, M., Daszak, P., Stroher, U., Pulliam, J. C., Kilpatrick, A., Nichol, S. T., Klena, J. D., Sultana, S., Afroj, S., Luby, S. P., Cauchemez, S., Gurley, E. S. 2019; 380 (19): 1804–14

  View details for DOI 10.1056/NEJMoa1805376

  View details for Web of Science ID 000467769800006

• Drinking Water Salinity, Urinary Macro-Mineral Excretions, and Blood Pressure in the Southwest Coastal Population of Bangladesh. Journal of the American Heart Association Naser, A. M., Rahman, M., Unicomb, L., Doza, S., Gazi, M. S., Alam, G. R., Karim, M. R., Uddin, M. N., Khan, G. K., Ahmed, K. M., Shamsudduha, M., Anand, S., Narayan, K. M., Chang, H. H., Luby, S. P., Gribble, M. O., Clasen, T. F. 2019; 8 (9): e012007

  Abstract

  Background Sodium (Na+) in saline water may increase blood pressure ( BP ), but potassium (K+), calcium (Ca2+), and magnesium (Mg2+) may lower BP . We assessed the association between drinking water salinity and population BP . Methods and Results We pooled 6487 BP measurements from 2 cohorts in coastal Bangladesh. We used multilevel linear models to estimate BP differences across water salinity categories: fresh water (electrical conductivity, <0.7mS/cm), mild salinity (electrical conductivity ≥0.7 and <2mS/cm), and moderate salinity (electrical conductivity ≥2 and <10mS/cm). We assessed whether salinity categories were associated with hypertension using multilevel multinomial logistic models. Models included participant-, household-, and community-level random intercepts. Models were adjusted for age, sex, body mass index ( BMI ), physical activity, smoking, household wealth, alcohol consumption, sleep hours, religion, and salt consumption. We evaluated the 24-hour urinary minerals across salinity categories, and the associations between urinary minerals and BP using multilevel linear models. Compared with fresh water drinkers, mild-salinity water drinkers had lower mean systolic BP (-1.55 [95% CI : -3.22-0.12] mmHg) and lower mean diastolic BP (-1.26 [95% CI : -2.21--0.32] mmHg) adjusted models. The adjusted odds ratio among mild-salinity water drinkers for stage 1 hypertension was 0.60 (95% CI : 0.43-0.84) and for stage 2 hypertension was 0.56 (95% CI : 0.46-0.89). Mild-salinity water drinkers had high urinary Ca2+, and Mg2+, and both urinary Ca2+ and Mg2+ were associated with lower BP. Conclusions Drinking mild-salinity water was associated with lower BP , which can be explained by higher intake of Ca2+ and Mg2+ through saline water.

  View details for PubMedID 31060415

• Drinking Water Salinity, Urinary Macro-Mineral Excretions, and Blood Pressure in the Southwest Coastal Population of Bangladesh JOURNAL OF THE AMERICAN HEART ASSOCIATION Naser, A., Rahman, M., Unicomb, L., Doza, S., Gazi, M., Alam, G., Karim, M., Uddin, M., Khan, G., Ahmed, K., Shamsudduha, M., Anand, S., Narayan, K., Chang, H. H., Luby, S. P., Gribble, M. O., Clasen, T. F. 2019; 8 (9)

  View details for DOI 10.1161/JAHA.119.012007

  View details for Web of Science ID 000484574700048

• Effects of water, sanitation, handwashing and nutritional interventions on soil-transmitted helminth infections in young children: A cluster-randomized controlled trial in rural Bangladesh. PLoS neglected tropical diseases Ercumen, A., Benjamin-Chung, J., Arnold, B. F., Lin, A., Hubbard, A. E., Stewart, C., Rahman, Z., Parvez, S. M., Unicomb, L., Rahman, M., Haque, R., Colford, J. M., Luby, S. P. 2019; 13 (5): e0007323

  Abstract

  BACKGROUND: Soil transmitted helminths (STH) infect >1.5 billion people. Mass drug administration (MDA) effectively reduces infection; however, there is evidence for rapid reinfection and risk of potential drug resistance. We conducted a randomized controlled trial in Bangladesh (WASH Benefits, NCT01590095) to assess whether water, sanitation, hygiene and nutrition interventions, alone and combined, reduce STH in a setting with ongoing MDA.METHODOLOGY/PRINCIPAL FINDINGS: In 2012-2013, we randomized 720 clusters of 5551 pregnant women into water treatment, sanitation, handwashing, combined water+sanitation+handwashing (WSH), nutrition, nutrition+WSH (N+WSH) or control arms. In 2015-2016, we enrolled 7795 children, aged 2-12 years, of 4102 available women for STH follow-up and collected stool from 7187. We enumerated STH infections with Kato-Katz. We estimated intention-to-treat intervention effects on infection prevalence and intensity. Participants and field staff were not blinded; laboratory technicians and data analysts were blinded. Prevalence among controls was 36.8% for A. lumbricoides, 9.2% for hookworm and 7.5% for T. trichiura. Most infections were low-intensity. Compared to controls, the water intervention reduced hookworm by 31% (prevalence ratio [PR] = 0.69 (0.50,0.95), prevalence difference [PD] = -2.83 (-5.16,-0.50)) but did not affect other STH. Sanitation improvements reduced T. trichiura by 29% (PR = 0.71 (0.52,0.98), PD = -2.17 (-4.03,-0.38)), had a similar borderline effect on hookworm and no effect on A. lumbricoides. Handwashing and nutrition interventions did not reduce any STH. WSH and N+WSH reduced hookworm prevalence by 29-33% (WSH: PR = 0.71 (0.52,0.99), PD = -2.63 (-4.95,-0.31); N+WSH: PR = 0.67 (0.50,0.91), PD = -3.00 (-5.14,-0.85)) and marginally reduced A. lumbricoides. Effects on infection intensity were similar.CONCLUSIONS/SIGNIFICANCE: In a low-intensity infection setting with MDA, we found modest but sustained hookworm reduction from water treatment and combined WSH interventions. Impacts were more pronounced on STH species with short vs. long-term environmental survival. Our findings suggest possible waterborne transmission for hookworm. Water treatment and sanitation improvements can augment MDA to interrupt STH transmission.TRIAL REGISTRATION: NCT01590095.

  View details for PubMedID 31050672

• Effects of water, sanitation, handwashing and nutritional interventions on soil-transmitted helminth infections in young children: A cluster-randomized controlled trial in rural Bangladesh PLOS NEGLECTED TROPICAL DISEASES Ercumen, A., Benjamin-Chung, J., Arnold, B. F., Lin, A., Hubbard, A. E., Stewart, C., Rahman, Z., Parvez, S., Unicomb, L., Rahman, M., Haque, R., Colford, J. M., Luby, S. P. 2019; 13 (5)

  View details for DOI 10.1371/journal.pntd.0007323

  View details for Web of Science ID 000470188100025

• Using healthcare-seeking behaviour to estimate the number of Nipah outbreaks missed by hospital-based surveillance in Bangladesh. International journal of epidemiology Hegde, S. T., Salje, H., Sazzad, H. M., Hossain, M. J., Rahman, M., Daszak, P., Klena, J. D., Nichol, S. T., Luby, S. P., Gurley, E. S. 2019

  Abstract

  BACKGROUND: Understanding the true burden of emergent diseases is critical for assessing public-health impact. However, surveillance often relies on hospital systems that only capture a minority of cases. We use the example of Nipah-virus infection in Bangladesh, which has a high case-fatality ratio and frequent person-to-person transmission, to demonstrate how healthcare-seeking data can estimate true burden.METHODS: We fit logistic-regression models to data from a population-based, healthcare-seeking study of encephalitis cases to characterize the impact of distance and mortality on attending one of three surveillance hospital sites. The resulting estimates of detection probabilities, as a function of distance and outcome, are applied to all observed Nipah outbreaks between 2007 and 2014 to estimate the true burden.RESULTS: The probability of attending a surveillance hospital fell from 82% for people with fatal encephalitis living 10km away from a surveillance hospital to 54% at 50km away. The odds of attending a surveillance hospital are 3.2 (95% confidence interval: 1.6, 6.6) times greater for patients who eventually died (i.e. who were more severely ill) compared with those who survived. Using these probabilities, we estimated that 119 Nipah outbreaks (95% confidence interval: 103, 140)-an average of 15 outbreaks per Nipah season-occurred during 2007-14; 62 (52%) were detected.CONCLUSIONS: Our findings suggest hospital-based surveillance missed nearly half of all Nipah outbreaks. This analytical method allowed us to estimate the underlying burden of disease, which is important for emerging diseases where healthcare access may be limited.

  View details for PubMedID 30977803

• Effects of water, sanitation, handwashing, and nutritional interventions on environmental enteric dysfunction in young children: a cluster-randomized controlled trial in rural Bangladesh. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Lin, A., Ali, S., Arnold, B. F., Rahman, M. Z., Alauddin, M., Grembi, J., Mertens, A. N., Famida, S. L., Akther, S., Hossen, M. S., Mutsuddi, P., Shoab, A. K., Hussain, Z., Rahman, M., Unicomb, L., Ashraf, S., Naser, A. M., Parvez, S. M., Ercumen, A., Benjamin-Chung, J., Haque, R., Ahmed, T., Hossain, M. I., Choudhury, N., Jannat, K., Alauddin, S. T., Minchala, S. G., Cekovic, R., Hubbard, A. E., Stewart, C. P., Dewey, K. G., Colford, J. M., Luby, S. P. 2019

  Abstract

  BACKGROUND: We hypothesized that drinking water, sanitation, handwashing (WSH) and nutritional interventions would improve environmental enteric dysfunction (EED), a potential contributor to stunting.METHODS: Within a subsample of a cluster-randomized controlled trial in rural Bangladesh, we enrolled pregnant women in four arms: control, combined WSH, child nutrition counseling plus lipid-based nutrient supplements (N), and combined nutrition plus WSH (N+WSH). Among the birth cohort, we measured biomarkers of gut inflammation (myeloperoxidase, neopterin), permeability (alpha-1-antitrypsin, lactulose, mannitol), and repair (regenerating gene 1beta) at median ages 3, 14, and 28 months. Analysis was intention-to-treat.RESULTS: We assessed 1512 children. At age 3 months, compared to controls, neopterin was reduced by nutrition (-0.21 log nmol/L, CI -0.37, -0.05) and N+WSH (-0.20 log nmol/L, CI -0.34, -0.06) interventions; similar reductions were observed at 14 months. At 3 months, all interventions reduced lactulose and mannitol (-0.60 to -0.69 log mmol/L). At 28 months, myeloperoxidase was elevated in the WSH (0.23 log ng/ml, CI 0.06, 0.39) and nutrition (0.27 log ng/ml, CI 0.07, 0.47) arms and lactulose was higher in the WSH arm (0.30 log mmol/L, CI 0.07, 0.53).CONCLUSIONS: Reductions in permeability and inflammation at ages 3 and 14 months suggest that the interventions promoted healthy intestinal maturation; however, by 28 months the WSH and nutrition arms showed elevated EED biomarkers. These results underscore the importance of better understanding the pathophysiology of EED and targeting interventions early in childhood during the critical period when they are likely to have the largest benefit to intestinal health.(ClinicalTrials.gov NCT01590095).

  View details for PubMedID 30963177

• Effect of household relocation on child vaccination and health service utilisation in Dhaka, Bangladesh: a cross-sectional community survey. BMJ open Horng, L., Kakoly, N. S., Abedin, J., Luby, S. P. 2019; 9 (3): e026176

  Abstract

  OBJECTIVE: To explore the relationship between household relocation and use of vaccination and health services for severe acute respiratory illness (ARI) among children in Dhaka, Bangladesh.DESIGN: Analysis of cross-sectional community survey data from a prior study examining the impact of Haemophilus influenzae type b vaccine introduction in 2009 on meningitis incidence in Bangladesh.SETTING: Communities surrounding two large paediatric hospitals in Dhaka, Bangladesh.PARTICIPANTS: Households with children under 5 years old who either recently relocated <12 months or who were residentially stable living >24 months in their current residence (total n=10020) were selected for this study.PRIMARY OUTCOME MEASURES: Full vaccination coverage among children aged 9-59 months and visits to a qualified medical provider for severe ARI among children under 5 years old.RESULTS: Using vaccination cards with maternal recall, full vaccination was 80% among recently relocated children (n=3795) and 85% among residentially stable children (n=4713; chi2=37.2, p<0.001). Among children with ARI in the prior year, 69% of recently relocated children (n=695) had visited a qualified medical provider compared with 82% of residentially stable children (n=763; chi2=31.9, p<0.001). After adjusting for demographic and socioeconomic characteristics, recently relocated children were less likely to be fully vaccinated (prevalence ratio [PR] 0.97; 95% CI 0.95 to 0.99; p=0.016) and to have visited a qualified medical provider for ARI (PR 0.88; 95%CI 0.84 to 0.93; p<0.001).CONCLUSIONS: Children in recently relocated households in Dhaka, Bangladesh, have decreased use of vaccination and qualified health services for severe ARI.

  View details for PubMedID 30878989

• An epidemic of chikungunya in northwestern Bangladesh in 2011 PLOS ONE Haque, F., Rahman, M., Banu, N., Sharif, A., Jubayer, S., Shamsuzzaman, A. M., Alamgir, A. M., Erasmus, J. H., Guzman, H., Forrester, N., Luby, S. P., Gurley, E. S. 2019; 14 (3): e0212218

  Abstract

  In November 2011, a government hospital physician in Shibganj sub-district of Bangladesh reported a cluster of patients with fever and joint pain or rash. A multi-disciplinary team investigated to characterize the outbreak; confirm the cause; and recommend control and prevention measures.Shibganj's residents with new onset of fever and joint pain or rash between 1 September and 15 December 2011 were defined as chikungunya fever (CHIKF) suspect cases. To estimate the attack rate, we identified 16 outpatient clinics in 16 selected wards across 16 unions in Shibganj and searched for suspect cases in the 80 households nearest to each outpatient clinic. One suspect case from the first 30 households in each ward was invited to visit the nearest outpatient clinic for clinical assessment and to provide a blood sample for laboratory testing and analyses.We identified 1,769 CHIKF suspect cases from among 5,902 residents surveyed (30%). Their median age was 28 (IQR:15-42) years. The average attack rate in the sub-district was 30% (95% CI: 27%-33%). The lowest attack rate was found in children <5 years (15%). Anti-CHIKV IgM antibodies were detected by ELISA in 78% (264) of the 338 case samples tested. In addition to fever, predominant symptoms of serologically-confirmed cases included joint pain (97%), weakness (54%), myalgia (47%), rash (42%), itching (37%) and malaise (31%). Among the sero-positive patients, 79% (209/264) sought healthcare from outpatient clinics. CHIKV was isolated from two cases and phylogenetic analyses of full genome sequences placed these viruses within the Indian Ocean Lineage (IOL). Molecular analysis identified mutations in E2 and E1 glycoproteins and contained the E1 A226V point mutation.The consistently high attack rate by age groups suggested recent introduction of chikungunya in this community. Mosquito control efforts should be enhanced to reduce the risk of continued transmission and to improve global health security.

  View details for PubMedID 30856200

• Planetary Health Alliance 2019 call for abstracts. The Lancet. Planetary health Almada, A., Myers, S. S., Golden, C. D., Burke, K. S., Luby, S. P. 2019

  View details for PubMedID 30777733

• Age-related changes to environmental exposure: variation in the frequency that young children place hands and objects in their mouths. Journal of exposure science & environmental epidemiology Kwong, L. H., Ercumen, A., Pickering, A. J., Unicomb, L., Davis, J., Luby, S. P. 2019

  Abstract

  Children are exposed to environmental contaminants through direct ingestion of water, food, soil, and feces, and through indirect ingestion due to mouthing hands and objects. We quantified ingestion among 30 rural Bangladeshi children<4 years old, recording every item touched or mouthed during 6-h video observations that occurred annually for 3 years. We calculated the frequency and duration of mouthing and the prevalence of mouth contacts with soil and feces. We compared the mouthing frequency distributions to those from US children to evaluate the appropriateness of applying the US data to the Bangladeshi context. Median hand mouthing frequency was 97-160times/h and object mouthing 23-50times/h among the five age groups assessed. For more than half of the children, >75% of all hand mouthing was associated with eating. The frequency of hand mouthing not related to eating was similar to the frequency of all hand-mouthing among childrenin the US. Object-mouthing frequency was higher among Bangladeshi children compared to US children. There was low intra-child correlation of mouthing frequencies over our longitudinal visits. Our results suggest that children's hand- and object-mouthing vary by geography and culture and that future exposure assessments can be cross-sectional if the goal is to estimate population-level distributions of mouthing frequencies. Of all observations, a child consumed soil in 23% and feces in 1%.

  View details for PubMedID 30728484

• Sand Barriers around Latrine Pits Reduce Fecal Bacterial Leaching into Shallow Groundwater: A Randomized Controlled Trial in Coastal Bangladesh. Environmental science & technology Naser, A. M., Doza, S., Rahman, M., Ahmed, K. M., Gazi, M. S., Alam, G. R., Karim, M. R., Khan, G. K., Uddin, M. N., Mahmud, M. I., Ercumen, A., Rosenbaum, J., Annis, J., Luby, S. P., Unicomb, L., Clasen, T. F. 2019

  Abstract

  We evaluated the effectiveness of a sand barrier around latrine pits in reducing fecal indicator bacteria (FIB) leaching into shallow groundwater. We constructed 68 new offset single pit pour flush latrines in the Galachipa subdistrict of coastal Bangladesh. We randomly assigned 34 latrines to include a 50 cm thick sand barrier under and around the pit and 34 received no sand barrier. Four monitoring wells were constructed around each pit to collect water samples at baseline and subsequent nine follow-up visits over 24 months. Samples were tested using the IDEXX Colilert method to enumerate E. coli and thermotolerant coliforms most probable number (MPN). We determined the difference in mean log10MPN FIB counts/100 mL in monitoring well samples between latrines with and without a sand barrier using multilevel linear models and reported cluster robust standard error. The sand barrier latrine monitoring well samples had 0.38 mean log10MPN fewer E. coli (95% CI: 0.16, 0.59; p = 0.001) and 0.38 mean log10MPN fewer thermotolerant coliforms (95% CI: 0.14, 0.62; p = 0.002), compared to latrines without sand barriers, a reduction of 27% E. coli and 24% thermotolerant coliforms mean counts. A sand barrier can modestly reduce the risk presented by pit leaching.

  View details for PubMedID 30653305

• Effect of Neighborhood Sanitation Coverage on Fecal Contamination of the Household Environment in Rural Bangladesh. The American journal of tropical medicine and hygiene Huda, T. M., Schmidt, W., Pickering, A. J., Unicomb, L., Mahmud, Z. H., Luby, S. P., Biran, A. 2019

  Abstract

  Enteric pathogens can be transmitted within the household and the surrounding neighborhood. The objective of this study was to understand the effect of neighborhood-level sanitation coverage on contamination of the household environment with levels of fecal indicator bacteria in rural Bangladesh. We conducted spot-check observations of sanitation facilities in neighboring households (NHs) within a 20-m radius of target households with children aged 6-24 months. Sanitation facilities were defined as improved (a private pit latrine with a slab or better) or unimproved. Fecal coliforms (FCs) on children's hands and sentinel toy balls were measured and used as indicators of household-level fecal contamination. We visited 1,784 NHs surrounding 428 target households. On average, sentinel toy balls had 2.11(standard deviation [SD] = 1.37) log10 colony-forming units (CFUs) of FCs/toy ball and children's hands had 2.23 (SD = 1.15) log10 CFU of FCs/two hands. Access to 100% private improved sanitation coverage in the neighborhood was associated with a small and statistically insignificant difference in contamination of sentinel toy balls (difference in means = -0.13 log10 CFU/toy ball; 95% confidence intervals [CI]: -0.64, 0.39; P = 0.63) and children's hands (difference in means = -0.11 log10 CFU/two hands; 95% CI: -0.53, 0.32; P = 0.62). Improved sanitation coverage in the neighborhood had limited measurable effect on FCs in the target household environment. Other factors such as access to improved sanitation in the household, absence of cow dung, presence of appropriate water drainage, and optimal handwashing practice may be more important in reducing FCs in the household environment.

  View details for PubMedID 30675846

• Effects of lipid-based nutrient supplements and infant and young child feeding counseling with or without improved water, sanitation, and hygiene (WASH) on anemia and micronutrient status: results from 2 cluster-randomized trials in Kenya and Bangladesh. The American journal of clinical nutrition Stewart, C. P., Dewey, K. G., Lin, A., Pickering, A. J., Byrd, K. A., Jannat, K., Ali, S., Rao, G., Dentz, H. N., Kiprotich, M., Arnold, C. D., Arnold, B. F., Allen, L. H., Shahab-Ferdows, S., Ercumen, A., Grembi, J. A., Naser, A. M., Rahman, M., Unicomb, L., Colford, J. M., Luby, S. P., Null, C. 2019

  Abstract

  Background: Anemia in young children is a global health problem. Risk factors include poor nutrient intake and poor water quality, sanitation, or hygiene.Objective: We evaluated the effects of water quality, sanitation, handwashing, and nutrition interventions on micronutrient status and anemia among children in rural Kenya and Bangladesh.Design: We nested substudies within 2 cluster-randomized controlled trials enrolling pregnant women and following their children for 2 y. These substudies included 4 groups: water, sanitation, and handwashing (WSH); nutrition (N), including lipid-based nutrient supplements (LNSs; ages 6-24 mo) and infant and young child feeding (IYCF) counseling; WSH+N; and control. Hemoglobin and micronutrient biomarkers were measured after 2 y of intervention and compared between groups using generalized linear models with robust SEs.Results: In Kenya, 699 children were assessed at a mean±SD age of 22.1±1.8 mo, and in Bangladesh 1470 participants were measured at a mean±SD age of 28.0±1.9 mo. The control group anemia prevalences were 48.8% in Kenya and 17.4% in Bangladesh. There was a lower prevalence of anemia in the 2 N intervention groups in both Kenya [N: 36.2%; prevalence ratio (PR): 0.74; 95% CI: 0.58, 0.94; WSH+N: 27.3%; PR: 0.56; 95% CI: 0.42, 0.75] and Bangladesh (N: 8.7%; PR: 0.50; 95% CI: 0.32, 0.78; WSH+N: 7.9%, PR: 0.46; 95% CI: 0.29, 0.73). In both trials, the 2 N groups also had significantly lower prevalences of iron deficiency, iron deficiency anemia, and low vitamin B-12 and, in Kenya, a lower prevalence of folate and vitamin A deficiencies. In Bangladesh, the WSH group had a lower prevalence of anemia (12.8%; PR: 0.74; 95% CI: 0.54, 1.00) than the control group, whereas in Kenya, the WSH+N group had a lower prevalence of anemia than did the N group (PR: 0.75; 95% CI: 0.53, 1.07), but this was not significant (P=0.102).Conclusions: IYCF counseling with LNSs reduced the risks of anemia, iron deficiency, and low vitamin B-12. Effects on folate and vitamin A varied between studies. Improvements in WSH also reduced the risk of anemia in Bangladesh but did not provide added benefit over the nutrition-specific intervention. These trials were registered at clinicaltrials.gov as NCT01590095 (Bangladesh) and NCT01704105 (Kenya).

  View details for PubMedID 30624600

• Impact of a Large-Scale Handwashing Intervention on Reported Respiratory Illness: Findings from a Cluster-Randomized Controlled Trial. The American journal of tropical medicine and hygiene Najnin, N., Leder, K., Forbes, A., Unicomb, L., Winch, P. J., Ram, P. K., Nizame, F. A., Arman, S., Begum, F., Biswas, S., Cravioto, A., Luby, S. P. 2019

  Abstract

  We assessed the impact of handwashing promotion on reported respiratory illness as a secondary outcome from among > 60,000 low-income households enrolled in a cluster-randomized trial conducted in Bangladesh. Ninety geographic clusters were randomly allocated into three groups: cholera-vaccine-only; vaccine-plus-behavior-change (handwashing promotion and drinking water chlorination); and control. Data on respiratory illness (fever plus either cough or nasal congestion or breathing difficulty within previous 2 days) and intervention uptake (presence of soap and water at handwashing station) were collected through monthly surveys conducted among a different subset of randomly selected households during the intervention period. We determined respiratory illness prevalence across groups and used log-binomial regression to examine the association between respiratory illness and presence of soap and water in the handwashing station. Results were adjusted for age, gender, wealth, and cluster-randomized design. The vaccine-plus-behavior-change group had more handwashing stations with soap and water present than controls (45% versus 25%; P < 0.001). Reported respiratory illness prevalence was similar across groups (vaccine-plus-behavior-change versus control: 2.8% versus 2.9%; 95% confidence interval [CI]: -0.008, 0.006; P = 0.6; cholera-vaccine-only versus control: 3.0% versus 2.9%; 95% CI: -0.006, 0.009; P = 0.4). Irrespective of intervention assignment, respiratory illness was lower among people who had soap and water present in the handwashing station than among those who did not (risk ratioadjusted: 0.82; 95% CI: 0.69-0.98). With modest uptake of the handwashing intervention, we found no impact of this large-scale intervention on respiratory illness. However, those who actually had a handwashing station with soap and water had less illness. This suggests improving the effectiveness of handwashing promotion in achieving sustained behavior change could result in health benefits.

  View details for PubMedID 30608050

• Effectiveness of a large-scale handwashing promotion intervention on handwashing behavior in Dhaka, Bangladesh. Tropical medicine & international health : TM & IH Wichaidit, W. n., Biswas, S. n., Begum, F. n., Yeasmin, F. n., Nizame, F. A., Najnin, N. n., Leontsini, E. n., Winch, P. J., Unicomb, L. n., Luby, S. P., Ram, P. K. 2019

  Abstract

  The behavioral effect of large-scale handwashing promotion programs has been infrequently evaluated, and variation in the effect over time has not been described. We assess the effect of a large-scale handwashing promotion program on handwashing outcomes in a community setting in Dhaka, Bangladesh.We analyzed data from a cluster-randomized trial that included 3 arms: vaccine-and-behavior-change intervention (VBC), vaccine-only (V), and no intervention (Control). Data collectors randomly selected different subsets of households each month during the study period and assessed: 1) temporal variation in availability of soap and water at handwashing place; 2) the use of water and soap by participants when asked to demonstrate handwashing, and; 3) handwashing behavior according to structured observation. We used log-binomial regression analyses to calculate prevalence ratios (PR) and 95% confidence intervals and compare outcomes by study arms.Data collectors surveyed 9325 households over 28 months. In VBC, there was a significant positive trend on availability of water and soap from baseline to 9 months after the start of the intervention (p-for-trends < 0.001), and no significant trend during months 10-28 (p-for-trend = 0.297). In the entire study period, availability of water and soap was higher in VBC (43%) than in V (23%) (PR = 1.92; CI = 1.72, 2.15) and Control (28%) (PR = 1.53; CI = 1.38, 1.69) households. There were no differences between study arms with regard to use of soap during handwashing demonstrations. Observed handwashing with soap after toilet use was higher in VBC (17%) than in V (8%) (PR = 1.47, CI = 0.58, 3.75) and Control (2%) (PR = 3.47, CI = 0.48, 23.33) groups. At other possible pathogen-transmission events, the prevalence of handwashing with soap was ≤ 3%.VBC households maintained soap and water for handwashing, but the prevalence of observed handwashing was low in all study arms. The results underscore the need to strengthen scalable behavior change approaches. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/tmi.13277

  View details for PubMedID 31173422

• Microbiological contamination of young children's hands in rural Bangladesh: Associations with child age and observed hand cleanliness as proxy. PloS one Parvez, S. M., Azad, R., Pickering, A. J., Kwong, L. H., Arnold, B. F., Rahman, M. J., Rahman, M. Z., Alam, M., Sen, D., Islam, S., Rahman, M., Colford, J. M., Luby, S. P., Unicomb, L., Ercumen, A. 2019; 14 (9): e0222355

  Abstract

  BACKGROUND: Hands are a route of transmission for fecal-oral pathogens. This analysis aimed to assess associations between hand E. coli contamination and child age and determine if observed hand cleanliness can serve as a proxy for E. coli contamination on young children's hands.METHODS: Trained field workers collected hand rinse samples from children aged 1-14 months in 584 households in rural Bangladesh and assessed the visual cleanliness of child hands (fingernails, finger pads and palms). Samples were analyzed using the IDEXX most probable number (MPN) methodto enumerate E. coli. We assessed if child age (immobile children aged 1-4 months vs. mobile children aged 5-14 months) is associated with log10 E. coli counts on hands using generalized estimating equations (GEE). We estimated the log10 difference in hand E. coli counts associated with the cleanliness of different hand parts using a multivariable GEE model.We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for dirty fingernails, fingerpads, palms and overall hands (the three observed parts combined) against binary E. coli presence on hands.RESULTS: E. coli was detected on 43% of child hands. Children in the mobile age range had 0.17 log10 MPN higher E. coli on hands than those in the immobile age range (Deltalog10 = 0.17, 95% CI = 0.02, 0.32, p = 0.03). Children with visible dirt particles on finger pads had 0.46 log10 MPN higher E. coli on hands than those with clean finger pads (Deltalog10 = 0.46, 95% CI = 0.05, 0.87, p = 0.03). Dirty fingernails indicated binary E. coli presence with 81% sensitivity and 26% specificity while dirty fingerpads and palms indicated E. coli presence with 29% sensitivity and 75-77% specificity. The PPV was 45-48% and NPV 59-65% for all three types of observations.CONCLUSION: Hand contamination with E. coli was prevalent among young children in rural Bangladesh, with higher levels of contamination among mobile children. Studies should assess if strategies to remove animal feces from the courtyard, provide designated hygienic play spaces for children and deliver targeted messaging to mothers to wipe or wash children's hands after contact with animals and animal feces reduce child hand contamination. Visible hand cleanliness was a poor predictor of E. coli presence on young children's hands so other low-cost field measurements are needed to accurately detect fecal contamination on hands.

  View details for DOI 10.1371/journal.pone.0222355

  View details for PubMedID 31504064

• Correction to: Age-related changes to environmental exposure: variation in the frequency that young children place hands and objects in their mouths. Journal of exposure science & environmental epidemiology Kwong, L. H., Ercumen, A. n., Pickering, A. J., Unicomb, L. n., Davis, J. n., Luby, S. P. 2019

  Abstract

  An amendment to this paper has been published and can be accessed via a link at the top of the paper.

  View details for DOI 10.1038/s41370-019-0160-3

  View details for PubMedID 31455796

• The Typhoid Fever Surveillance in Africa Program: Geospatial Sampling Frames for Household-based Studies: Lessons Learned From a Multicountry Surveillance Network in Senegal, South Africa, and Sudan. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Baker, S. n., Ali, M. n., Deerin, J. F., Eltayeb, M. A., Cruz Espinoza, L. M., Gasmelseed, N. n., Im, J. n., Panzner, U. n., Kalckreuth, V. V., Keddy, K. H., Pak, G. D., Park, J. K., Park, S. E., Sooka, A. n., Sow, A. G., Tall, A. n., Luby, S. n., Meyer, C. G., Marks, F. n. 2019; 69 (Supplement_6): S474–S482

  Abstract

  Robust household sampling, commonly applied for population-based investigations, requires sampling frames or household lists to minimize selection bias. We have applied Google Earth Pro satellite imagery to constitute structure-based sampling frames at sites in Pikine, Senegal; Pietermaritzburg, South Africa; and Wad-Medani, Sudan. Here we present our experiences in using this approach and findings from assessing its applicability by determining positional accuracy.Printouts of satellite imagery combined with Global Positioning System receivers were used to locate and to verify the locations of sample structures (simple random selection; weighted-stratified sampling). Positional accuracy was assessed by study site and administrative subareas by calculating normalized distances (meters) between coordinates taken from the sampling frame and on the ground using receivers. A higher accuracy in conjunction with smaller distances was assumed. Kruskal-Wallis and Dunn multiple pairwise comparisons were performed to evaluate positional accuracy by setting and by individual surveyor in Pietermaritzburg.The median normalized distances and interquartile ranges were 0.05 and 0.03-0.08 in Pikine, 0.09 and 0.05-0.19 in Pietermaritzburg, and 0.05 and 0.00-0.10 in Wad-Medani, respectively. Root mean square errors were 0.08 in Pikine, 0.42 in Pietermaritzburg, and 0.17 in Wad-Medani. Kruskal-Wallis and Dunn comparisons indicated significant differences by low- and high-density setting and interviewers who performed the presented approach with high accuracy compared to interviewers with poor accuracy.The geospatial approach presented minimizes systematic errors and increases robustness and representativeness of a sample. However, the findings imply that this approach may not be applicable at all sites and settings; its success also depends on skills of surveyors working with aerial data. Methodological modifications are required, especially for resource-challenged sites that may be affected by constraints in data availability and area size.

  View details for DOI 10.1093/cid/ciz755

  View details for PubMedID 31665783

• High prevalence of taeniasis and Taenia solium cysticercosis in children in western Sichuan, China. Acta tropica Li, T. n., Chen, X. n., Wang, H. n., Openshaw, J. J., Zhong, B. n., Felt, S. A., Ito, A. n., Luby, S. P. 2019: 105133

  Abstract

  Data in China on human Taenia infections, including Taenia solium cysticercosis, is largely lacking. We aimed to determine the prevalence of taeniasis with all three human Taenia species as well as T. solium cysticercosis in primary school-aged children in minority areas of western Sichuan, China. During April 2016 to December 2017, we did a cross-sectional study in five western Sichuan Province primary schools in Liangshan (3 schools), Ganzi (1 school) and Aba (1 school) prefectures. Diagnosis of taeniasis was made by stool microscopy for presence of Taenia eggs, as well as recovery of taeniid tapeworms or proglottids by medicinal treatment followed by species identification using multiplex PCR. Diagnosis of T. solium cysticercosis was made serologically using an ELISA with low-molecular-weight antigens purified from T. solium cyst fluid to detect specific IgG antibodies. A total of 1,672 children were screened for taeniasis and 1,639 were evaluated for cysticercosis antibodies. Overall prevalence of taeniasis was 7.5% but was as high as 15.6% at one school site (e.g., Shuiluo). Of the three known human Taenia species, adult T. solium tapeworms were detected in 42 children from four of the five schools (all three schools in Liangshan and one in Aba), giving a prevalence of T. solium taeniasis of 2.5% (95% confidence interval 0-6.7%). Cysticercosis antibody seropositivity by school varied from 2.3% to 15.6% (overall 7.5%). T. solium taeniasis carriers were more likely to have cysticercosis antibodies than chlidren without T. solium taeniasis (43.6% vs 6.6%). Schools with higher prevalences of T. solium taeniasis were more likely to have children with human cysticercosis IgG antibodies. This study discloses a high prevalence of taeniasis and T. solium cysticercosis in primary school-aged children in minority areas of western Sichuan, suggesting an urgent necessity for school-based disease control.

  View details for DOI 10.1016/j.actatropica.2019.105133

  View details for PubMedID 31415736

• Predictors of Enteric Pathogens in the Domestic Environment from Human and Animal Sources in Rural Bangladesh. Environmental science & technology Fuhrmeister, E. R., Ercumen, A. n., Pickering, A. J., Jeanis, K. M., Ahmed, M. n., Brown, S. n., Arnold, B. F., Hubbard, A. E., Alam, M. n., Sen, D. n., Islam, S. n., Kabir, M. H., Kwong, L. H., Islam, M. n., Unicomb, L. n., Rahman, M. n., Boehm, A. B., Luby, S. P., Colford, J. M., Nelson, K. L. 2019

  Abstract

  Fecal indicator organisms are measured to indicate the presence of fecal pollution, yet the association between indicators and pathogens varies by context. The goal of this study was to empirically evaluate the relationships between indicator Escherichia coli, microbial source tracking markers, select enteric pathogen genes, and potential sources of enteric pathogens in 600 rural Bangladeshi households. We measured indicators and pathogen genes in stored drinking water, soil, and on mother and child hands. Additionally, survey and observational data on sanitation and domestic hygiene practices were collected. Log10 concentrations of indicator E. coli were positively associated with the prevalence of pathogenic E. coli genes in all sample types. Given the current need to rely on indicators to assess fecal contamination in the field, it is significant that in this study context indicator E. coli concentrations, measured by IDEXX Colilert-18, provided quantitative information on the presence of pathogenic E. coli in different sample types. There were no significant associations between the human fecal marker (HumM2) and human-specific pathogens in any environmental sample type. There was an increase in the prevalence of Giardia lamblia genes, any E. coli virulence gene, and the specific E. coli virulence genes stx1/2 with every log10 increase in the concentration of the animal fecal marker (BacCow) on mothers' hands. Thus, domestic animals were important contributors to enteric pathogens in these households.

  View details for DOI 10.1021/acs.est.8b07192

  View details for PubMedID 31356066

• Piloting a Shared Source Water Treatment Intervention among Elementary Schools in Bangladesh. The American journal of tropical medicine and hygiene Yeasmin, F. n., Sultana, F. n., Unicomb, L. n., Nizame, F. A., Rahman, M. M., Kabir, H. n., Winch, P. J., Luby, S. P. 2019

  Abstract

  Hundreds of thousands of children continue to die each year from diarrhea. We piloted a low-cost liquid chlorine point-of-use (POU) water treatment among elementary school children in Bangladesh. We began the 1-month intervention in four schools (two urban and two rural) by introducing POU drinking water hardware and behavior change communication. We trained teachers to deliver sessions encouraging students to drink chlorinated water from their own small plastic bottles to avoid disease transmission. We used cue cards and flip charts as visual aids. We evaluated the acceptability, feasibility, and potential for sustainability after 1 month and after 14 months of the intervention. During 1-month follow-up, among 141 drinking events observed, 141 students (100%) drank chlorinated water. In 93 or 66% of events, students used their own bottles, and in 43 (30%) of the events, they used common cups or hands washed before drinking. During the 14-month follow-up, we observed 732 drinking events. In 653 of 732 events (89%), students drank chlorinated water; in 78 events (11%), they consumed water from untreated drinking water sources. Among those who consumed chlorinated water, 20% (131/653) used their own bottles to drink water, 72% (467/653) used common cups, and 8% (55/653) used both hands to drink water. Most stated that they drank chlorinated water because it is safe, it has health benefits, and treatment reduces germs. Introduction of specific hardware, weekly hygiene sessions, and education materials enabled schools to treat water at POU and students to consume treated water.

  View details for DOI 10.4269/ajtmh.18-0984

  View details for PubMedID 31549607

• Effectiveness of a Behavior Change Intervention with Hand Sanitizer Use and Respiratory Hygiene in Reducing Laboratory-Confirmed Influenza among Schoolchildren in Bangladesh: A Cluster Randomized Controlled Trial. The American journal of tropical medicine and hygiene Biswas, D. n., Ahmed, M. n., Roguski, K. n., Ghosh, P. K., Parveen, S. n., Nizame, F. A., Rahman, M. Z., Chowdhury, F. n., Rahman, M. n., Luby, S. P., Sturm-Ramirez, K. n., Iuliano, A. D. 2019

  Abstract

  Schoolchildren are commonly linked to influenza transmission. Handwashing with soap has been shown to decrease infections; however, improving handwashing practices using soap and water is difficult in low-resource settings. In these settings, alternative hygiene options, such as hand sanitizer, could improve handwashing promotion to reduce influenza virus infections. We conducted a cluster randomized control trial in 24 primary schools in Dhaka to assess the effectiveness of hand sanitizer and a respiratory hygiene education intervention in reducing influenza-like illness (ILI) and laboratory-confirmed influenza during June-September 2015. Twelve schools were randomly selected to receive hand sanitizer and respiratory hygiene education, and 12 schools received no intervention. Field staff actively followed children daily to monitor for new ILI episodes (cough with fever) through school visits and by phone if a child was absent. When an illness episode was identified, medical technologists collected nasal swabs to test for influenza viruses. During the 10-week follow-up period, the incidence of ILI per 1,000 student-weeks was 22 in the intervention group versus 27 in the control group (P-value = 0.4). The incidence of laboratory-confirmed influenza was 53% lower in the intervention schools (3/1,000 person-weeks) than in the control schools (6/1,000 person-weeks) (P-value = 0.01). Hand sanitizer and respiratory hygiene education can help to reduce the risk of influenza virus transmission in schools.

  View details for DOI 10.4269/ajtmh.19-0376

  View details for PubMedID 31701861

• Molecular mechanism of azithromycin resistance among typhoidal Salmonella stains in Bangladesh identified through passive pediatric surveillance. PLoS neglected tropical diseases Hooda, Y. n., Sajib, M. S., Rahman, H. n., Luby, S. P., Bondy-Denomy, J. n., Santosham, M. n., Andrews, J. R., Saha, S. K., Saha, S. n. 2019; 13 (11): e0007868

  Abstract

  With the rise in fluoroquinolone-resistant Salmonella Typhi and the recent emergence of ceftriaxone resistance, azithromycin is one of the last oral drugs available against typhoid for which resistance is uncommon. Its increasing use, specifically in light of the ongoing outbreak of extensively drug-resistant (XDR) Salmonella Typhi (resistant to chloramphenicol, ampicillin, cotrimoxazole, streptomycin, fluoroquinolones and third-generation cephalosporins) in Pakistan, places selective pressure for the emergence and spread of azithromycin-resistant isolates. However, little is known about azithromycin resistance in Salmonella, and no molecular data are available on its mechanism.We conducted typhoid surveillance in the two largest pediatric hospitals of Bangladesh from 2009-2016. All typhoidal Salmonella strains were screened for azithromycin resistance using disc diffusion and resistance was confirmed using E-tests. In total, we identified 1,082 Salmonella Typhi and Paratyphi A strains; among these, 13 strains (12 Typhi, 1 Paratyphi A) were azithromycin-resistant (MIC range: 32-64 μg/ml) with the first case observed in 2013. We sequenced the resistant strains, but no molecular basis of macrolide resistance was identified by the currently available antimicrobial resistance prediction tools. A whole genome SNP tree, made using RAxML, showed that the 12 Typhi resistant strains clustered together within the 4.3.1.1 sub-clade (H58 lineage 1). We found a non-synonymous single-point mutation exclusively in these 12 strains in the gene encoding AcrB, an efflux pump that removes small molecules from bacterial cells. The mutation changed the conserved amino acid arginine (R) at position 717 to a glutamine (Q). To test the role of R717Q present in azithromycin-resistant strains, we cloned acrB from azithromycin-resistant and sensitive strains, expressed them in E. coli, Typhi and Paratyphi A strains and tested their azithromycin susceptibility. Expression of AcrB-R717Q in E. coli and Typhi strains increased the minimum inhibitory concentration (MIC) for azithromycin by 11- and 3-fold respectively. The azithromycin-resistant Paratyphi A strain also contained a mutation at R717 (R717L), whose introduction in E. coli and Paratyphi A strains increased MIC by 7- and 3-fold respectively, confirming the role of R717 mutations in conferring azithromycin resistance.This report confirms 12 azithromycin-resistant Salmonella Typhi strains and one Paratyphi A strain. The molecular basis of this resistance is one mutation in the AcrB protein at position 717. This is the first report demonstrating the impact of this non-synonymous mutation in conferring macrolide resistance in a clinical setting. With increasing azithromycin use, strains with R717 mutations may spread and be acquired by XDR strains. An azithromycin-resistant XDR strain would shift enteric fever treatment from outpatient departments, where patients are currently treated with oral azithromycin, to inpatient departments to be treated with injectable antibiotics like carbapenems, thereby further burdening already struggling health systems in endemic regions. Moreover, with the dearth of novel antimicrobials in the horizon, we risk losing our primary defense against widespread mortality from typhoid. In addition to rolling out the WHO prequalified typhoid conjugate vaccine in endemic areas to decrease the risk of pan-resistant Salmonella Typhi strains, it is also imperative to implement antimicrobial stewardship and water sanitation and hygiene intervention to decrease the overall burden of enteric fever.

  View details for DOI 10.1371/journal.pntd.0007868

  View details for PubMedID 31730615

• Isolation and Full-Genome Characterization of Nipah Viruses from Bats, Bangladesh EMERGING INFECTIOUS DISEASES Anderson, D. E., Islam, A., Crameri, G., Todd, S., Islam, A., Khan, S. U., Foord, A., Rahman, M. Z., Mendenhall, I. H., Luby, S. P., Gurley, E. S., Daszak, P., Epstein, J. H., Wang, L. 2019; 25 (1): 166–70

  Abstract

  Despite molecular and serologic evidence of Nipah virus in bats from various locations, attempts to isolate live virus have been largely unsuccessful. We report isolation and full-genome characterization of 10 Nipah virus isolates from Pteropus medius bats sampled in Bangladesh during 2013 and 2014.

  View details for DOI 10.3201/eid2501.180267

  View details for Web of Science ID 000453546600026

  View details for PubMedID 30561301

• Epidemiology of Typhoid and Paratyphoid: Implications for Vaccine Policy. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Saha, S. n., Islam, M. S., Sajib, M. S., Saha, S. n., Uddin, M. J., Hooda, Y. n., Hasan, M. n., Amin, M. R., Hanif, M. n., Shahidullah, M. n., Islam, M. n., Luby, S. P., Andrews, J. R., Saha, S. K. 2019; 68 (Supplement_2): S117–S123

  Abstract

  Typhoid and paratyphoid remain the most common bloodstream infections in many resource-poor settings. The World Health Organization recommends typhoid conjugate vaccines for country-specific introduction, but questions regarding typhoid and paratyphoid epidemiology persist, especially regarding their severity in young children.We conducted enteric fever surveillance in Bangladesh from 2004 through 2016 in the inpatient departments of 2 pediatric hospitals and the outpatient departments of 1 pediatric hospital and 1 private consultation clinic. Blood cultures were conducted at the discretion of the treating physicians; cases of culture-confirmed typhoid/paratyphoid were included. Hospitalizations and durations of hospitalizations were used as proxies for severity in children <12 years old.We identified 7072 typhoid and 1810 paratyphoid culture-confirmed cases. There was no increasing trend in the proportion of paratyphoid over the 13 years. The median age in the typhoid cases was 60 months, and 15% of the cases occurred in children <24 months old. The median age of the paratyphoid cases was significantly higher, at 90 months (P < .001); 9.4% were in children <24 months old. The proportion of children (<12 years old) hospitalized with typhoid and paratyphoid (32% and 21%, respectively) decreased with age; there was no significant difference in durations of hospitalizations between age groups. However, children with typhoid were hospitalized for longer than those with paratyphoid.Typhoid and paratyphoid fever are common in Dhaka, including among children under 2 years old, who have equivalent disease severity as older children. Early immunization with typhoid conjugate vaccines could avert substantial morbidity, but broader efforts are required to reduce the paratyphoid burden.

  View details for PubMedID 30845325

• Complementary feeding practices among rural Bangladeshi mothers: Results from WASH Benefits study MATERNAL AND CHILD NUTRITION Jannat, K., Luby, S. P., Unicomb, L., Rahman, M., Winch, P. J., Parvez, S. M., Das, K. K., Leontsini, E., Ram, P. K., Stewart, C. P. 2019; 15 (1): e12654

  Abstract

  Inappropriate complementary feeding contributes to linear growth faltering in early childhood. Behaviour change interventions have been effective at improving practice, but few studies have investigated the effects of multicomponent integrated interventions. We conducted a cluster-randomized controlled trial in rural Bangladesh in which geographic clusters were randomized into seven arms: water treatment (W), sanitation (S), handwashing (H), water, sanitation, and handwashing (WSH), improved nutrition with infant and young child feeding messages and lipid-based nutrient supplementation for 6- to 24-month olds (N), N+WSH, and control. The objective of this paper was to examine the independent and combined effects of interventions on indicators of complementary feeding. Approximately 1 and 2 years after initiation of the intervention, research assistants surveyed mothers about infant feeding practices. Complementary feeding was examined using the World Health Organization indicators of infant and young child feeding practices. We used Poisson regression models to estimate prevalence ratios and linear regression models for prevalence differences with clustered sandwich estimators to adjust for clustering. A total of 4,718 households from 720 clusters were surveyed at year 1 and 4,667 at year 2. The children in the nutrition arms had a higher prevalence of meeting the minimum dietary diversity score compared with controls (year 1: N: 66.4%; N+WSH: 65.0% vs. C:32.4%; year 2: N: 91.5%; N+WSH: 91.6% vs. C:77.7%). Children in the nutrition arms received diverse food earlier than the children in control arm. In addition, the average consumption of lipid-based nutrient supplementation was >90% in each follow-up. Nutrition-specific interventions could be integrated with nutrition-sensitive interventions such as WSH without compromising the uptake of the nutrition intervention.

  View details for PubMedID 30101576

• Transmission of Nipah Virus - 14 Years of Investigations in Bangladesh. The New England journal of medicine Nikolay, B. n., Salje, H. n., Hossain, M. J., Khan, A. K., Sazzad, H. M., Rahman, M. n., Daszak, P. n., Ströher, U. n., Pulliam, J. R., Kilpatrick, A. M., Nichol, S. T., Klena, J. D., Sultana, S. n., Afroj, S. n., Luby, S. P., Cauchemez, S. n., Gurley, E. S. 2019; 380 (19): 1804–14

  Abstract

  Nipah virus is a highly virulent zoonotic pathogen that can be transmitted between humans. Understanding the dynamics of person-to-person transmission is key to designing effective interventions.We used data from all Nipah virus cases identified during outbreak investigations in Bangladesh from April 2001 through April 2014 to investigate case-patient characteristics associated with onward transmission and factors associated with the risk of infection among patient contacts.Of 248 Nipah virus cases identified, 82 were caused by person-to-person transmission, corresponding to a reproduction number (i.e., the average number of secondary cases per case patient) of 0.33 (95% confidence interval [CI], 0.19 to 0.59). The predicted reproduction number increased with the case patient's age and was highest among patients 45 years of age or older who had difficulty breathing (1.1; 95% CI, 0.4 to 3.2). Case patients who did not have difficulty breathing infected 0.05 times as many contacts (95% CI, 0.01 to 0.3) as other case patients did. Serologic testing of 1863 asymptomatic contacts revealed no infections. Spouses of case patients were more often infected (8 of 56 [14%]) than other close family members (7 of 547 [1.3%]) or other contacts (18 of 1996 [0.9%]). The risk of infection increased with increased duration of exposure of the contacts (adjusted odds ratio for exposure of >48 hours vs. ≤1 hour, 13; 95% CI, 2.6 to 62) and with exposure to body fluids (adjusted odds ratio, 4.3; 95% CI, 1.6 to 11).Increasing age and respiratory symptoms were indicators of infectivity of Nipah virus. Interventions to control person-to-person transmission should aim to reduce exposure to body fluids. (Funded by the National Institutes of Health and others.).

  View details for PubMedID 31067370

• Effect of Neighborhood Sanitation Coverage on Fecal Contamination of the Household Environment in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Huda, T., Schmidt, W., Pickering, A. J., Unicomb, L., Mahmud, Z., Luby, S. P., Biran, A. 2019; 100 (3): 717–26

  View details for DOI 10.4269/ajtmh.16-0996

  View details for Web of Science ID 000460416400047

• Inconsistency in Diarrhea Measurements when Assessing Intervention Impact in a Non-Blinded Cluster-Randomized Controlled Trial. The American journal of tropical medicine and hygiene Najnin, N. n., Leder, K. n., Forbes, A. n., Unicomb, L. n., Qadri, F. n., Ram, P. K., Winch, P. J., Begum, F. n., Biswas, S. n., Parvin, T. n., Yeasmin, F. n., Cravioto, A. n., Luby, S. P. 2019

  Abstract

  To explore the consistency in impact evaluation based on reported diarrhea, we compared diarrhea data collected through two different surveys and with observed diarrhea-associated hospitalization for children aged ≤ 5 years from a non-blinded cluster-randomized trial conducted over 2 years in urban Dhaka. We have previously reported that the interventions did not reduce diarrhea-associated hospitalization for children aged ≤ 5 years in this trial. We randomly allocated 90 geographic clusters comprising > 60,000 low-income households into three groups: cholera vaccine only, vaccine plus behavior change (cholera vaccine and handwashing plus drinking water chlorination promotion), and control. We calculated reported diarrhea prevalence within the last 2 days using data collected from two different survey methods. The "census" data were collected from each household every 6 months for updating household demographic information. The "monthly survey" data were collected every month from a subset of randomly selected study households for monitoring the uptake of behavior change interventions. We used binomial regression with a logarithmic link accounting for clustering to compare diarrhea prevalence across intervention and control groups separately for both census and monthly survey data. No intervention impact was detected in the census (vaccine only versus control: 2.32% versus 2.53%; P = 0.49; vaccine plus behavior change versus control: 2.44% versus 2.53%; P = 0.78) or in the vaccine only versus control in the monthly survey (3.39% versus 3.80%; P = 0.69). However, diarrhea prevalence was lower in the vaccine-plus-behavior-change group than control in the monthly survey (2.08% versus 3.80%; P = 0.02). Although the reasons for different observed treatment effects in the census and monthly survey data in this study are unclear, these findings emphasize the importance of assessing objective outcomes along with reported outcomes from non-blinded trials.

  View details for DOI 10.4269/ajtmh.18-0872

  View details for PubMedID 31162005

• Effects of lipid-based nutrient supplements and infant and young child feeding counseling with or without improved water, sanitation, and hygiene (WASH) on anemia and micronutrient status: results from 2 cluster-randomized trials in Kenya and Bangladesh AMERICAN JOURNAL OF CLINICAL NUTRITION Stewart, C. P., Dewey, K. G., Lin, A., Pickering, A. J., Byrd, K. A., Jannat, K., Ali, S., Rao, G., Dentz, H. N., Kiprotich, M., Arnold, C. D., Arnold, B. F., Allen, L. H., Shahab-Ferdows, S., Ercumen, A., Grembi, J. A., Naser, A., Rahman, M., Unicomb, L., Colford, J. M., Luby, S. P., Null, C. 2019; 109 (1): 148–64

  View details for DOI 10.1093/ajcn/nqy239

  View details for Web of Science ID 000460472500017

• Comparison of Urinary Sodium and Blood Pressure Relationship From the Spot Versus 24-Hour Urine Samples. Journal of the American Heart Association Naser, A. M., Rahman, M. n., Unicomb, L. n., Doza, S. n., Anand, S. n., Chang, H. H., Luby, S. P., Clasen, T. F., Narayan, K. M. 2019; 8 (21): e013287

  Abstract

  Background We compared the relationship between sodium (Na) intake and blood pressure when Na intake was estimated from first- and second-morning spot urine samples using the INTERSALT (International Study on Salt and Blood Pressure) formula, versus directly measured 24-hour samples. Methods and Results We collected 24-hour urine and first- and second-morning voids of 383 participants in coastal Bangladesh for 2 visits. We measured participants' blood pressure using an Omron® HEM-907 monitor. To assess the shape of the relationship between urinary Na and blood pressure, we created restricted cubic spline plots adjusted for age, sex, body mass index, smoking and alcohol consumption, physical activities, religion, sleep hours, and household wealth. To assess multicollinearity, we reported variance inflation factors, tolerances, and Leamer's and Klein's statistics following linear regression models. The mean daily urinary Na was 122 (SD 26) mmol/d for the first; 122 (SD 27) mmol/d for the second; and 134 (SD 70) mmol/d for the 24-hour samples. The restricted cubic spline plots illustrated no association between first-morning urinary Na and systolic blood pressure until the 90th percentile distribution followed by a downward relationship; a nonlinear inverse-V-shaped relationship between second-morning urinary Na and systolic blood pressure; and a monotonic upward relationship between 24-hour urinary Na and systolic blood pressure. We found no evidence of multicollinearity for the 24-hour urinary Na model. Conclusions The urinary Na and systolic blood pressure relationship varied for 3 urinary Na measurements. Twenty-four-hour urinary Na captured more variability of Na intake compared with spot urine samples, and its regression models were not affected by multicollinearity.

  View details for DOI 10.1161/JAHA.119.013287

  View details for PubMedID 31615314

• HEALTHCARE UTILIZATION IN PATIENTS WITH SUSPECTED ENTERIC FEVER Yu, A. T., Shakya, R., Bern, C., Adhikari, B., Tamrakar, D., Vaidya, K., Barkume, C., Garrett, D., Luby, S., Bogoch, I., Andrews, J. AMER SOC TROP MED & HYGIENE. 2019: 30–31

  View details for Web of Science ID 000507364502097

• NIPAH VACCINE TRIALS- ASSESSING THE FEASIBILITY BASED ON PREVIOUS OUTBREAKS IN BANGLADESH Nikolay, B., Salje, H., Lipsitch, M., Luby, S. P., Cauchemez, S., Gurley, E. S. AMER SOC TROP MED & HYGIENE. 2019: 265–66

  View details for Web of Science ID 000507364503221

• NIPAH VIRUS INFECTION IN 2018-19 NIPAH SEASON IN BANGLADESH Nazneen, A., Rahman, M., Sultana, S., Satter, S., Klena, J. D., Sturat, N. T., Luby, S. P., Gurley, E. S., Flora, M., Rahman, M. AMER SOC TROP MED & HYGIENE. 2019: 265

  View details for Web of Science ID 000507364503219

• MODIFYING TOILETS TO MAKE THEM CHILD FRIENDLY IN RURAL BANGLADESH Huda, T., Amin, R., Al Masud, A., Leontsini, E., Rahman, M., Jahir, T., Das, J., Yeasmin, F., Nizame, F., Shoab, A., Kwong, L., Luby, S. P., Winch, P. J. AMER SOC TROP MED & HYGIENE. 2019: 195

  View details for Web of Science ID 000507364502636

• The HPAfrica protocol: Assessment of health behaviour and population-based socioeconomic, hygiene behavioural factors - a standardised repeated cross-sectional study in multiple cohorts in sub-Saharan Africa. BMJ open Pak, G. D., Haselbeck, A. H., Seo, H. W., Osei, I., Amuasi, J., Breiman, R. F., Cruz Espinosa, L. M., Holm, M., Im, J., Jang, G. H., Jeon, H. J., Luby, S. P., Lunguya-Metila, O., MacWright, W., Mogeni, O. D., Okeke, I. N., Owusu-Dabo, E., Park, J. K., Park, S. E., Popoola, O., Seo, H. J., Soura, A. B., Teferi, M., Toy, T., Chon, Y., Rafindrakalia, M., Rakotozandrindrainy, R., Meyer, C. G., Marks, F., Panzner, U. 2018; 8 (12): e021438

  Abstract

  INTRODUCTION: The objective of the Health Population Africa (HPAfrica) study is to determine health behaviour and population-based factors, including socioeconomic, ethnographic, hygiene and sanitation factors, at sites of the Severe Typhoid Fever in Africa (SETA) programme. SETA aims to investigate healthcare facility-based fever surveillance in Burkina Faso, the Democratic Republic of the Congo, Ethiopia, Ghana, Madagascar and Nigeria. Meaningful disease burden estimates require adjustment for health behaviour patterns, which are assumed to vary among a study population.METHODS AND ANALYSIS: For the minimum sample size of household interviews required, the assumptions of an infinite population, a design effect and age-stratification and sex-stratification are considered. In the absence of a population sampling frame or household list, a spatial approach will be used to generate geographic random points with an Aeronautical Reconnaissance Coverage Geographic Information System tool. Printouts of Google Earth Pro satellite imagery visualise these points. Data of interest will be assessed in different seasons by applying population-weighted stratified sampling. An Android-based application and a web service will be developed for electronic data capturing and synchronisation with the database server in real time. Sampling weights will be computed to adjust for possible differences in selection probabilities. Descriptive data analyses will be performed in order to assess baseline information of each study population and age-stratified and sex-stratified health behaviour. This will allow adjusting disease burden estimates. In addition, multivariate analyses will be applied to look into associations between health behaviour, population-based factors and the disease burden as determined in the SETA study.ETHICS AND DISSEMINATION: Ethic approvals for this protocol were obtained by the Institutional Review Board of the International Vaccine Institute (No. 2016-0003) and by all collaborating institutions of participating countries. It is anticipated to disseminate findings from this study through publication on a peer-reviewed journal.

  View details for PubMedID 30573477

• An update from hospital-based surveillance for rotavirus gastroenteritis among young children in Bangladesh, July 2012 to June 2017 VACCINE Satter, S. M., Aliabadi, N., Gastanaduy, P. A., Haque, W., Mamun, A., Flora, M. S., Zaman, K., Rahman, M., Heffelfinger, J. D., Luby, S. P., Gurley, E. S., Parashar, U. D. 2018; 36 (51): 7811–15

  Abstract

  In preparation for the introduction of a rotavirus vaccine into the routine immunization program of Bangladesh in 2018, we report data and highlight evolving genotypes from five years of active hospital-based rotavirus surveillance which began in July 2012.We enrolled and collected fresh stool from every fourth child < 5 years admitted with acute gastroenteritis (AGE) at 8 participating surveillance hospitals. Rotavirus infections were detected by enzyme immune assay. Twenty-five percent of rotavirus isolates were genotyped using reverse transcription polymerase chain reaction.We found that 64% (4832/7562) of children < 5 years of age admitted with AGE had evidence of rotavirus infection. The majority (57%) of patients with rotavirus infection were <12 months of age. The most common strains were G1P[8] (43%), G12P[8] (15%) and G9P[8] (9%); 11% of children had mixed infection.G3P[8], which has not been reported in Bangladesh since 2001, was documented for the first time in our surveillance system.The high burden of rotavirus-associated hospitalizations highlights the potential value of rotavirus vaccination in Bangladesh. Continued surveillance is important for monitoring the impact of vaccination as well as monitoring evolving genotypes.

  View details for PubMedID 29793894

• Epidemiology of childhood intussusception in Bangladesh: Findings from an active national hospital based surveillance system, 2012-2016 VACCINE Satter, S. M., Aliabadi, N., Yen, C., Gastanaduy, P. A., Ahmed, M., Mamun, A., Islam, K., Flora, M. S., Rahman, M., Zaman, K., Rahman, M., Heffelfinger, J. D., Luby, S. P., Gurley, E. S., Parashar, U. D. 2018; 36 (51): 7805–10

  Abstract

  Rotavirus vaccines have significantly decreased the burden of diarrheal diseases in countries that have introduced them into their immunization programs. In some studies, there has been a small association between rotavirus vaccines and intussusception in post-marketing surveillance, highlighting the importance of tracking incidence before and after vaccine introduction. The objective of this study was to describe the epidemiology of intussusception among Bangladeshi children pre-vaccine introduction.We conducted active, hospital-based surveillance for intussusception at 7 tertiary care hospitals with pediatric surgical facilities during July 2012 to September 2016. Hospitalized children under 2years of age were identified according to Brighton Collaboration level 1 criteria for intussusception. The frequency and proportion of intussusception among overall surgical admissions, as well as the demographic and clinical information of the cases is described.Overall 153 cases of intussusception among children <2years-old were identified at participating sites over the enrolment period, confirmed by Level 1 Brighton criteria. These cases represented 2% of all surgical admissions under 2years of age. One hundred twelve cases (73%) were male; the median age was 7months; and the median duration of hospitalization was 7days. One hundred forty-six (95%) children with intussusception required surgery, and 11 (7%) died.Confirmed cases of intussusception represented nearly 2% of pediatric surgical admissions at tertiary referral centers in Bangladesh during the study period and 7% of children with intussusception died. Given the high burden of rotavirus disease in Bangladesh, vaccine introduction is warranted, however, further studies after introduction of rotavirus vaccine are necessary to determine any association between vaccine and intussusception in this setting.

  View details for PubMedID 28941622

  View details for PubMedCentralID PMC5864564

• Urban Slums: A Supportive Ecosystem for Typhoidal Salmonellae JOURNAL OF INFECTIOUS DISEASES Luby, S. P. 2018; 218: S250–S254

  View details for DOI 10.1093/infdis/jiy324

  View details for Web of Science ID 000463874100010

• Integrating Facility-Based Surveillance With Healthcare Utilization Surveys to Estimate Enteric Fever Incidence: Methods and Challenges JOURNAL OF INFECTIOUS DISEASES Andrews, J. R., Barkume, C., Yu, A. T., Saha, S. K., Qamar, F. N., Garrett, D., Luby, S. P. 2018; 218: S268–S276

  View details for DOI 10.1093/infdis/jiy494

  View details for Web of Science ID 000463874100012

• Case-Fatality Ratio of Blood Culture-Confirmed Typhoid Fever in Dhaka, Bangladesh JOURNAL OF INFECTIOUS DISEASES Yu, A. T., Amin, N., Rahman, M., Gurley, E. S., Rahman, K., Luby, S. P. 2018; 218: S222–S226

  View details for DOI 10.1093/infdis/jiy543

  View details for Web of Science ID 000463874100006

• Comparison of Strategies and Incidence Thresholds for Vi Conjugate Vaccines Against Typhoid Fever: A Cost-effectiveness Modeling Study JOURNAL OF INFECTIOUS DISEASES Lo, N. C., Gupta, R., Stanaway, J. D., Garrett, D. O., Bogoch, I. I., Luby, S. P., Andrews, J. R. 2018; 218: S232–S242

  View details for DOI 10.1093/infdis/jix598

  View details for Web of Science ID 000463874100008

• Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Child Enteric Protozoan Infections in Rural Bangladesh: A Cluster-Randomized Controlled Trial CLINICAL INFECTIOUS DISEASES Lin, A., Ercumen, A., Benjamin-Chung, J., Arnold, B. F., Das, S., Haque, R., Ashraf, S., Parvez, S. M., Unicomb, L., Rahman, M., Hubbard, A. E., Stewart, C. P., Colford, J. M., Luby, S. P. 2018; 67 (10): 1515–22

  Abstract

  We evaluated effects of individual and combined water, sanitation, handwashing (WSH), and nutritional interventions on protozoan infections in children.We randomized geographical clusters of pregnant women in rural Bangladesh into chlorinated drinking water, hygienic sanitation, handwashing, nutrition, combined WSH, nutrition plus WSH (N+WSH), or control arms. Participants were not masked. After approximately 2.5 years of intervention, we measured Giardia, Cryptosporidium, and Entamoeba histolytica prevalence and infection intensity by multiplex real-time polymerase chain reaction of child stool. Analysis was intention-to-treat.Between May 2012 and July 2013, we randomized 5551 pregnant women. At follow-up, among 4102 available women, we enrolled 6694 children into the protozoan assessment. We analyzed stool from 5933 children (aged ~31 months) for protozoan infections. Compared with 35.5% prevalence among controls, Giardia infection prevalence was lower in the sanitation (26.5%; prevalence ratio [PR], 0.75 [95% confidence interval {CI}, .64-.88]), handwashing (28.2%; PR, 0.80 [95% CI, .66-.96]), WSH (29.7%; PR, 0.83 [95% CI, .72-.96]), and N+WSH (26.7%; PR, 0.75 [95% CI, .64-.88]) arms. Water and nutrition interventions had no effect. Low prevalence of E. histolytica and Cryptosporidium (<2%) resulted in imprecise effect estimates.Individual handwashing and hygienic sanitation interventions significantly reduced childhood Giardia infections, and there were no effects of chlorinated drinking water and nutrition improvements in this context. Combined WSH interventions provided no additional benefit. To reduce Giardia infection, individual WSH interventions may be more feasible and cost-effective than combined interventions in similar rural, low-income settings.NCT01590095.

  View details for PubMedID 29669039

  View details for PubMedCentralID PMC6206106

• Do Sanitation Improvements Reduce Fecal Contamination of Water, Hands, Food, Soil, and Flies? Evidence from a Cluster-Randomized Controlled Trial in Rural Bangladesh ENVIRONMENTAL SCIENCE & TECHNOLOGY Ercumen, A., Pickering, A. J., Kwong, L. H., Mertens, A., Arnold, B. F., Benjamin-Chung, J., Hubbard, A. E., Alam, M., Sen, D., Islam, S., Rahman, M., Kullmann, C., Chase, C., Ahmed, R., Parvez, S., Unicomb, L., Rahman, M., Ram, P. K., Clasen, T., Luby, S. P., Colford, J. M. 2018; 52 (21): 12089–97

  Abstract

  Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). Following approximately 4 months of intervention, we enrolled households in the trial's control, sanitation and combined WSH arms to assess whether sanitation improvements, alone and coupled with water treatment and handwashing, reduce fecal contamination in the domestic environment. We quantified fecal indicator bacteria in samples of drinking and ambient waters, child hands, food given to young children, courtyard soil and flies. In the WSH arm, E. coli prevalence in stored drinking water was reduced by 62% (prevalence ratio=0.38 (0.32, 0.44)) and E. coli concentration by 1-log (log10 = -0.88 (-1.01, -0.75)). The interventions did not reduce E. coli along other sampled pathways. Ambient contamination remained high among intervention households. Potential reasons include non-community-level sanitation coverage, child open defecation, animal fecal sources or naturalized E. coli in the environment. Future studies should explore potential threshold effects of different levels of community sanitation coverage on environmental contamination.

  View details for PubMedID 30256095

  View details for PubMedCentralID PMC6222553

• Effects of Single and Combined Water, Sanitation and Handwashing Interventions on Fecal Contamination in the Domestic Environment: A Cluster-Randomized Controlled Trial in Rural Bangladesh ENVIRONMENTAL SCIENCE & TECHNOLOGY Ercumen, A., Mertens, A., Arnold, B. F., Benjamin-Chung, J., Hubbard, A. E., Ahmed, M., Kabir, M., Khalil, M., Kumar, A., Rahman, M., Parvez, S., Unicomb, L., Rahman, M., Ram, P. K., Clasen, T., Luby, S. P., Colford, J. M. 2018; 52 (21): 12078–88

  Abstract

  Water, sanitation and hygiene interventions have varying effectiveness in reducing fecal contamination in the domestic environment; delivering them in combination could yield synergies. We conducted environmental assessments within a randomized controlled trial in Bangladesh that implemented single and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). After one and two years of intervention, we quantified fecal indicator bacteria in samples of drinking water (from source or storage), child hands, children's food and sentinel objects. In households receiving single water treatment interventions, E. coli prevalence in stored drinking water was reduced by 50% and concentration by 1-log. E. coli prevalence in food was reduced by 30% and concentration by 0.5-log in households receiving single water treatment and handwashing interventions. Combined WSH did not reduce fecal contamination more effectively than its components. Interventions did not reduce E. coli in groundwater, on child hands and on objects. These findings suggest that WSH improvements reduced contamination along the direct transmission pathways of stored water and food but not along indirect upstream pathways. Our findings support implementing water treatment and handwashing to reduce fecal exposure through water and food but provide no evidence that combining interventions further reduces exposure.

  View details for PubMedID 30256102

  View details for PubMedCentralID PMC6222549

• Case-Fatality Ratio of Blood Culture-Confirmed Typhoid Fever in Dhaka, Bangladesh. The Journal of infectious diseases Yu, A. T., Amin, N., Rahman, M. W., Gurley, E. S., Rahman, K. M., Luby, S. P. 2018

  Abstract

  With impending rollout of new conjugate typhoid vaccines, better estimates of typhoid case-fatality ratio are needed for countries to set priorities for public health programs. We enrolled 1425 patients of all ages with blood culture-confirmed Salmonella Typhi from laboratory networks serving inpatients and outpatients in Dhaka, Bangladesh. Participants were asked about symptoms and complications including death experienced over a median 3-month period following blood culture diagnosis. Four fatal cases were identified (case-fatality ratio of 0.3% [95% confidence interval, .05%-.55%]). Applying this case-fatality ratio to global typhoid burden estimates would reduce deaths by 70%.

  View details for PubMedID 30304448

• A Low-Cost, Community Knowledge Approach to Estimate Maternal and Jaundice-Associated Mortality in Rural Bangladesh. The American journal of tropical medicine and hygiene Paul, R. C., Gidding, H. F., Nazneen, A., Banik, K. C., Sumon, S. A., Paul, K. K., Luby, S. P., Gurley, E. S., Hayen, A. 2018

  Abstract

  In the absence of a civil registration system, a house-to-house survey is often used to estimate cause-specific mortality in low- and middle-income countries. However, house-to-house surveys are resource and time intensive. We applied a low-cost community knowledge approach to identify maternal deaths from any cause and jaundice-associated deaths among persons aged ≥ 14 years, and stillbirths and neonatal deaths in mothers with jaundice during pregnancy in five rural communities in Bangladesh. We estimated the method's sensitivity and cost savings compared with a house-to-house survey. In the five communities with a total of 125,570 population, we identified 13 maternal deaths, 60 deaths among persons aged ≥ 14 years associated with jaundice, five neonatal deaths, and four stillbirths born to a mother with jaundice during pregnancy over the 3-year period before the survey using the community knowledge approach. The sensitivity of community knowledge method in identifying target deaths ranged from 80% for neonatal deaths to 100% for stillbirths and maternal deaths. The community knowledge approach required 36% of the staff time to undertake compared with the house-to-house survey. The community knowledge approach was less expensive but highly sensitive in identifying maternal and jaundice-associated mortality, as well as all-cause adult mortality in rural settings in Bangladesh. This method can be applied in rural settings of other low- and middle-income countries and, in conjunction with hospital-based hepatitis diagnoses, used to monitor the impact of programs to reduce the burden of cause-specific hepatitis mortality, a current World Health Organization priority.

  View details for PubMedID 30298803

• Health-Care Facility Water, Sanitation, and Health-Care Waste Management Basic Service Levels in Bangladesh: Results from a Nation-Wide Survey. The American journal of tropical medicine and hygiene Unicomb, L., Horng, L., Alam, M., Halder, A. K., Shoab, A. K., Ghosh, P. K., Islam, M. K., Opel, A., Luby, S. P. 2018; 99 (4): 916–23

  Abstract

  We conducted a nationally representative cross-sectional study of 875 health-care facilities (HCFs) to determine water, sanitation, and health-care waste disposal service levels in Bangladesh for doctors, staff, and patients/caregivers in 2013. We calculated proportions and prevalence ratios to compare urban versus rural and government versus other HCFs. We report World Health Organization (WHO)-defined basic HCF service levels. The most common HCF was nongovernmental private (80%, 698/875), with an average of 25 beds and 12 admissions per day. There was an improved water source inside the HCF for doctors (79%, 95% confidence intervals [CI]: 75, 82), staff (59%, 95% CI: 55, 64), and patients/caregivers (59%, 95% CI: 55, 63). Improved toilets for doctors (81%, 95% CI: 78, 85) and other staff (73%, 95% CI: 70, 77) were more common than for patients/caregivers (54%, 95% CI: 50, 58). Forty-three percentage (434/875) of HCFs had no disposal method for health-care waste. More urban than rural and more government than other HCFs had an improved water source on the premises and improved toilets for staff. WHO-defined basic service levels were detected in > 90% of HCFs for drinking water, among 46-77% for sanitation, and 68% for handwashing at point of care but 26% near toilets. Forty-seven percentage of HCFs attained basic health-care waste management service levels. Patient/caregiver access to water, sanitation, and hygiene facilities is inadequate in many HCFs across Bangladesh. Improving facilities for this group should be an integral part of accreditation.

  View details for PubMedID 30152311

• The Drivers and Impacts of Selling Soil for Brick Making in Bangladesh ENVIRONMENTAL MANAGEMENT Biswas, D., Gurley, E. S., Rutherford, S., Luby, S. P. 2018; 62 (4): 792–802

  Abstract

  Soil degradation is an important threat to sustainable agriculture. In Bangladesh, brick production contributes to soil loss as the country relies on clay-rich soil for brick making. An in-depth understanding of why farmers sell soil and the corresponding impacts on agricultural productivity is critical for developing and implementing new policies for utilizing alternate materials and methods in Bangladesh and other areas that continue to rely on fired clay bricks as their primary building material. A team of anthropologists conducted 120 structured interviews and 20 in-depth interviews in two different geographical areas in Bangladesh to understand the incentives for and impacts of selling soil. The primary reason farmers sold soil was pressure from neighboring farmers who had previously sold soil. Once neighboring property owners had sold soil, then farmers felt they needed to sell their soil to level their land with the neighboring plot to avoid future production loss. Short-term monetary gain from selling soil was also a strong motivator helping farmers manage acute financial crises. In addition, farmers are frequently compelled to sell soil for brick making because of coercive practices by brick-owners and their soil brokers. In this study, farmers reported 40-80% reduction in crop production and 40-70% reduction in income due to soil removal. The loss of the soil reduces agricultural yields leading to both short- and longer-term impacts on crop production that influence the country's food security.

  View details for PubMedID 29858621

  View details for PubMedCentralID PMC6153635

• Serial Measurements of Soap Weights and Soap Availability to Describe Handwashing Behavior. The American journal of tropical medicine and hygiene Gadgil, M. A., Sharker, Y., Unicomb, L., Ram, P. K., Luby, S. P. 2018; 99 (4): 899–904

  Abstract

  Available measures of handwashing are prone to bias. We tested the feasibility and reliability of weighing soap at repeated visits and subtracting the measured weight from the prior weight to assess daily per capita soap consumption in a low-income community in Dhaka, Bangladesh. Fieldworkers approached 220 households twice weekly over 2 months. They interviewed participants, weighed soap, and assessed hand cleanliness and the presence of a handwashing station. Respondents used bar soap (91% [201]) and laundry detergent cakes (39% [85]) for handwashing as well as for bathing and laundry. Ninety-eight percent of households had bar soap present on at least one visit, although only 50% had bar soap at every visit during the 2-month period. Fieldworkers observed a soap fragment on the wall near the latrine in 27% (470) of visits. Households consumed a mean 1.5 g of bar soap and 3.2 g detergent cake per person per day. Daily per capita soap consumption was similar in households visited by fieldworkers after different intervals (2, 3, 4, or 5 days). Soap consumption was not associated with household wealth, education of the household head, the presence of a handwashing station, the presence of water or soap at a handwashing station, or palm inspections of the mother or child. Soap weight measurements were an objective, reliable measure of soap consumption that provided different information from other handwashing indicators. The frequent use of a soap product for purposes other than handwashing complicates using soap consumption as a handwashing measure.

  View details for PubMedID 30141393

• Morbidity and mortality due to shigella and enterotoxigenic Escherichia coli diarrhoea: the Global Burden of Disease Study 1990-2016. The Lancet. Infectious diseases Khalil, I. A., Troeger, C., Blacker, B. F., Rao, P. C., Brown, A., Atherly, D. E., Brewer, T. G., Engmann, C. M., Houpt, E. R., Kang, G., Kotloff, K. L., Levine, M. M., Luby, S. P., MacLennan, C. A., Pan, W. K., Pavlinac, P. B., Platts-Mills, J. A., Qadri, F., Riddle, M. S., Ryan, E. T., Shoultz, D. A., Steele, A. D., Walson, J. L., Sanders, J. W., Mokdad, A. H., Murray, C. J., Hay, S. I., Reiner, R. C. 2018

  Abstract

  BACKGROUND: Shigella and enterotoxigenic Escherichia coli (ETEC) are bacterial pathogens that are frequently associated with diarrhoeal disease, and are a significant cause of mortality and morbidity worldwide. The Global Burden of Diseases, Injuries, and Risk Factors study 2016 (GBD 2016) is a systematic, scientific effort to quantify the morbidity and mortality due to over 300 causes of death and disability. We aimed to analyse the global burden of shigella and ETEC diarrhoea according to age, sex, geography, and year from 1990 to 2016.METHODS: We modelled shigella and ETEC-related mortality using a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We used a compartmental meta-regression tool to model the incidence of shigella and ETEC, which enforces an association between incidence, prevalence, and remission on the basis of scientific literature, population representative surveys, and health-care data. We calculated 95% uncertainty intervals (UIs) for the point estimates.FINDINGS: Shigella was the second leading cause of diarrhoeal mortality in 2016 among all ages, accounting for 212 438 deaths (95% UI 136 979-326 913) and about 13·2% (9·2-17·4) of all diarrhoea deaths. Shigella was responsible for 63 713 deaths (41 191-93 611) among children younger than 5 years and was frequently associated with diarrhoea across all adult age groups, increasing in elderly people, with broad geographical distribution. ETEC was the eighth leading cause of diarrhoea mortality in 2016 among all age groups, accounting for 51 186 deaths (26 757-83 064) and about 3·2% (1·8-4·7) of diarrhoea deaths. ETEC was responsible for about 4·2% (2·2-6·8) of diarrhoea deaths in children younger than 5 years.INTERPRETATION: The health burden of bacterial diarrhoeal pathogens is difficult to estimate. Despite existing prevention and treatment options, they remain a major cause of morbidity and mortality globally. Additional emphasis by public health officials is needed on a reduction in disease due to shigella and ETEC to reduce disease burden.FUNDING: Bill & Melinda Gates Foundation.

  View details for PubMedID 30266330

• Integrating Facility-Based Surveillance With Healthcare Utilization Surveys to Estimate Enteric Fever Incidence: Methods and Challenges. The Journal of infectious diseases Andrews, J. R., Barkume, C., Yu, A. T., Saha, S. K., Qamar, F. N., Garrett, D., Luby, S. P. 2018

  Abstract

  Cohort studies and facility-based sentinel surveillance are common approaches to characterizing infectious disease burden, but present trade-offs; cohort studies are resource-intensive and may alter disease natural history, while sentinel surveillance underestimates incidence in the population. Hybrid surveillance, whereby facility-based surveillance is paired with a community-based healthcare utilization assessment, represents an alternative approach to generating population-based disease incidence estimates with moderate resource investments. Here, we discuss this method in the context of the Surveillance for Enteric Fever in Asia Project (SEAP) study. We describe how data are collected and utilized to adjust enteric fever incidence for blood culture sensitivity, facility-based enrollment, and healthcare seeking, incorporating uncertainty in these parameters in the uncertainty around incidence estimates. We illustrate how selection of surveillance sites and their coverage may influence precision and bias, and we identify approaches in the study design and analysis to minimize and control for these biases. Rigorously designed hybrid surveillance systems can be an efficient approach to generating population-based incidence estimates for infectious diseases.

  View details for PubMedID 30184162

• Typhoid Fever: Way Forward. The American journal of tropical medicine and hygiene Bhutta, Z. A., Gaffey, M. F., Crump, J. A., Steele, D., Breiman, R. F., Mintz, E. D., Black, R. E., Luby, S. P., Levine, M. M. 2018; 99 (3_Suppl): 89–96

  Abstract

  The Tackling Typhoid supplement shows that typhoid fever continues to be a problem globally despite socioeconomic gains in certain settings. Morbidity remains high in many endemic countries, notably in sub-Saharan Africa and South Asia. In addition, antimicrobial resistance is a growing issue that poses a challenge for clinical management. The findings from this supplement revealed that outside of high-income countries, there were few reliable population-based estimates of typhoid and paratyphoid fever derived from surveillance systems. This indicates the need for monitoring systems that can also characterize the effectiveness of interventions, particularly in low- and middle-income settings. The country case studies indicated that gains in economic conditions, education, and environmental health may be associated with reductions in typhoid fever burden. Over the study period, the effect is mainly notable in countries with higher baseline levels of economic development, female literacy, and investments in public sanitation. High burden countries must continue to invest in strategies at the local level to address environmental factors such as access to safe drinking water and improved public sanitation that are known to interrupt transmission or diminish the risk of acquiring typhoid. Developing more effective vaccines and incorporating appropriate immunization strategies that target populations with the greatest risk could potentially alleviate disease burden.

  View details for PubMedID 30047361

• Typhoid conjugate vaccines: a new tool in the fight against antimicrobial resistance. The Lancet. Infectious diseases Andrews, J. R., Baker, S., Marks, F., Alsan, M., Garrett, D., Gellin, B. G., Saha, S. K., Qamar, F. N., Yousafzai, M. T., Bogoch, I. I., Antillon, M., Pitzer, V. E., Kim, J., John, J., Gauld, J., Mogasale, V., Ryan, E. T., Luby, S. P., Lo, N. C. 2018

  Abstract

  Typhoid fever is an acute systemic infectious disease responsible for an estimated 12-20 million illnesses and over 150 000 deaths annually. In March, 2018, a new recommendation was issued by WHO for the programmatic use of typhoid conjugate vaccines in endemic countries. Health economic analyses of typhoid vaccines have informed funding decisions and national policies regarding vaccine rollout. However, by focusing only on averted typhoid cases and their associated costs, traditional cost-effectiveness analyses might underestimate crucial benefits of typhoid vaccination programmes, because the potential effect of typhoid vaccines on the treatment of patients with non-specific acute febrile illnesses is not considered. For every true case of typhoid fever, three to 25 patients without typhoid disease are treated with antimicrobials unnecessarily, conservatively amounting to more than 50 million prescriptions per year. Antimicrobials for suspected typhoid might therefore be an important selective pressure for the emergence and spread of antimicrobial resistance globally. We propose that large-scale, more aggressive typhoid vaccination programmes-including catch-up campaigns in children up to 15 years of age, and vaccination in lower incidence settings-have the potential to reduce the overuse of antimicrobials and thereby reduce antimicrobial resistance in many bacterial pathogens. Funding bodies and national governments must therefore consider the potential for broad reductions in antimicrobial use and resistance in decisions related to the rollout of typhoid conjugate vaccines.

  View details for PubMedID 30170987

• Where backyard poultry raisers seek care for sick poultry: implications for avian influenza prevention in Bangladesh BMC PUBLIC HEALTH Rimi, N., Sultana, R., Ishtiak-Ahmed, K., Haider, N., Azziz-Baumgartner, E., Nahar, N., Luby, S. P. 2018; 18: 969

  Abstract

  In Bangladesh, backyard poultry raisers lack awareness of avian influenza and infrequently follow government recommendations for its prevention. Identifying where poultry raisers seek care for their ill poultry might help the government better plan how to disseminate avian influenza prevention and control recommendations.In order to identify where backyard poultry raisers seek care for their ill poultry, we conducted in-depth and informal interviews: 70 with backyard poultry raisers and six with local poultry healthcare providers in two villages, and five with government veterinary professionals at the sub-district and union levels in two districts during June-August 2009.Most (86% [60/70]) raisers sought care for their backyard poultry locally, 14% used home remedies only and none sought care from government veterinary professionals. The local poultry care providers provided advice and medications (n = 6). Four local care providers had shops in the village market where raisers sought healthcare for their poultry and the remaining two visited rural households to provide poultry healthcare services. Five of the six local care providers did not have formal training in veterinary medicine. Local care providers either did not know about avian influenza or considered avian influenza to be a disease common among commercial but not backyard poultry. The government professionals had degrees in veterinary medicine and experience with avian influenza and its prevention. They had their offices at the sub-district or union level and lacked staffing to reach the backyard raisers at the village level.The local poultry care providers provided front line healthcare to backyard poultry in villages and were a potential source of information for the rural raisers. Integration of these local poultry care providers in the government's avian influenza control programs is a potentially useful approach to increase poultry raisers' and local poultry care providers' awareness about avian influenza.

  View details for PubMedID 30075714

• A Randomized Controlled Trial to Measure Spillover Effects of a Combined Water, Sanitation, and Handwashing Intervention in Rural Bangladesh AMERICAN JOURNAL OF EPIDEMIOLOGY Benjamin-Chung, J., Amin, N., Ercumen, A., Arnold, B. F., Hubbard, A. E., Unicomb, L., Rahman, M., Luby, S. P., Colford, J. M. 2018; 187 (8): 1733–44

  Abstract

  Water, sanitation, and handwashing interventions may confer spillover effects on neighbors of intervention recipients by interrupting pathogen transmission. We measured geographically local spillovers in WASH Benefits, a cluster-randomized trial in rural Bangladesh, by comparing outcomes among neighbors of intervention vs. control participants. WASH Benefits randomly allocated geographically-defined clusters to a compound-level intervention (chlorinated drinking water, upgraded sanitation, and handwashing promotion) or control. From January to August 2015, in 180 clusters, we enrolled 1,799 neighboring children age-matched to trial participants that would have been eligible for WASH Benefits had they been conceived slightly earlier or later. After 28 months of intervention, we quantified fecal indicator bacteria in toy rinse and drinking water samples, measured soil-transmitted helminth infections, and recorded caregiver-reported diarrhea and respiratory illness. Neighbors' characteristics were balanced across arms. The prevalence of detectable E. coli in tubewell samples was lower for neighbors of intervention vs. control trial participants (prevalence ratio = 0.83; 0.73, 0.95). There was no difference in fecal indicator bacteria prevalence between arms for other environmental samples. Prevalence was similar in neighbors of intervention vs. control participants for soil-transmitted helminth infection, diarrhea, and respiratory illness. A compound-level water, sanitation, and handwashing intervention reduced neighbors' tubewell water contamination but did not impact neighboring children's health.

  View details for PubMedID 29596644

  View details for PubMedCentralID PMC6070113

• Urban Slums: A Supportive Ecosystem for Typhoidal Salmonellae. The Journal of infectious diseases Luby, S. P. 2018

  Abstract

  The typhoidal Salmonellae were controlled in cities in North America and Europe in the late 19th and early 20th century by development of centralized water treatment systems. In the early 21st century, large urban centers where drinking water routinely mixes with human feces have the highest burden of typhoid fever. Although improving municipal drinking water quality is the most robust approach to reduce enteric fever burden, the high costs and managerial capacity that such systems require and decreasing per capita water availability requires new approaches to reach the highest risk communities. The spread of antimicrobial resistance threatens to increase the burden of enteric fever much sooner than the extension of safe reliable water service delivery can be implemented. Thus, vaccination is an important interim measure.

  View details for PubMedID 30060082

• Fecal Indicator Bacteria along Multiple Environmental Transmission Pathways (Water, Hands, Food, Soil, Flies) and Subsequent Child Diarrhea in Rural Bangladesh ENVIRONMENTAL SCIENCE & TECHNOLOGY Pickering, A. J., Ercumen, A., Arnold, B. F., Kwong, L. H., Parvez, S., Alam, M., Sen, D., Islam, S., Kullmann, C., Chase, C., Ahmed, R., Unicomb, L., Colford, J. M., Luby, S. P. 2018; 52 (14): 7928–36

  View details for DOI 10.1021/acs.est.8b00928

  View details for Web of Science ID 000439397800039

• Achieving optimal technology and behavioral uptake of single and combined interventions of water, sanitation hygiene and nutrition, in an efficacy trial (WASH benefits) in rural Bangladesh TRIALS Parvez, S., Azad, R., Rahman, M., Unicomb, L., Ram, P. K., Naser, A., Stewart, C. P., Jannat, K., Rahman, M., Leontsini, E., Winch, P. J., Luby, S. P. 2018; 19: 358

  Abstract

  Uptake matters for evaluating the health impact of water, sanitation and hygiene (WASH) interventions. Many large-scale WASH interventions have been plagued by low uptake. For the WASH Benefits Bangladesh efficacy trial, high uptake was a prerequisite. We assessed the degree of technology and behavioral uptake among participants in the trial, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.This study is a cluster randomized trial comprised of geographically matched clusters among four districts in rural Bangladesh. We randomly allocated 720 clusters of 5551 pregnant women to individual or combined water, sanitation, handwashing, and nutrition interventions, or a control group. Behavioral objectives included; drinking chlorine-treated, safely stored water; use of a hygienic latrine and safe feces disposal at the compound level; handwashing with soap at key times; and age-appropriate nutrition behaviors (pregnancy to 24 months) including a lipid-based nutrition supplement (LNS). Enabling technologies and behavior change were promoted by trained local community health workers through periodic household visits. To monitor technology and behavioral uptake, we conducted surveys and spot checks in 30-35 households per intervention arm per month, over a 20-month period, and structured observations in 324 intervention and 108 control households, approximately 15 months after interventions commenced.In the sanitation arms, observed adult use of a hygienic latrine was high (94-97% of events) while child sanitation practices were moderate (37-54%). In the handwashing arms, handwashing with soap was more common after toilet use (67-74%) than nonintervention arms (18-40%), and after cleaning a child's anus (61-72%), but was still low before food handling. In the water intervention arms, more than 65% of mothers and index children were observed drinking chlorine-treated water from a safe container. Reported LNS feeding was > 80% in nutrition arms. There was little difference in uptake between single and combined intervention arms.Rigorous implementation of interventions deployed at large scale in the context of an efficacy trial achieved high levels of technology and behavioral uptake in individual and combined WASH and nutrition intervention households. Further work should assess how to achieve similar uptake levels under programmatic conditions.WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095 . Registered on April 30, 2012.

  View details for PubMedID 29976251

• WASH Benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial TRIALS Unicomb, L., Begum, F., Leontsini, E., Rahman, M., Ashraf, S., Naser, A., Nizame, F. A., Jannat, K., Hussain, F., Parvez, S., Arman, S., Mobashara, M., Luby, S. P., Winch, P. J. 2018; 19: 359

  Abstract

  Water, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.Community Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2-2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study.Sufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers.The intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness.ClinicalTrials.gov, ID: NCC01590095 . Registered on 2 May 2012.

  View details for PubMedID 29976247

• WASH Benefits Bangladesh trial: system for monitoring coverage and quality in an efficacy trial TRIALS Rahman, M., Ashraf, S., Unicomb, L., Mainuddin, A. M., Parvez, S., Begum, F., Das, K., Naser, A., Hussain, F., Clasen, T., Luby, S. P., Leontsini, E., Winch, P. J. 2018; 19: 360

  Abstract

  Researchers typically report more on the impact of public health interventions and less on the degree to which interventions were followed implementation fidelity. We developed and measured fidelity indicators for the WASH Benefits Bangladesh study, a large-scale efficacy trial, in order to identify gaps between intended and actual implementation.Community health workers (CHWs) delivered individual and combined water, sanitation, handwashing (WSH) and child nutrition interventions to 4169 enrolled households in geographically matched clusters. Households received free enabling technologies (insulated water storage container; sani-scoop, potty, double-pit, pour-flush latrine; handwashing station, soapy-water storage bottle), and supplies (chlorine tablets, lipid-based nutrient supplements, laundry detergent sachets) integrated with parallel behavior-change promotion. Behavioral objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviors. We administered monthly surveys and spot-checks to households from randomly selected clusters for 6 months early in the trial. If any fidelity measures fell below set benchmarks, a rapid response mechanism was triggered.In the first 3 months, functional water seals were detected in 33% (14/42) of latrines in the sanitation only arm; 35% (14/40) for the combined WSH arm; and 60% (34/57) for the combined WSH and Nutrition arm, all falling below the pre-set benchmark of 80%. Other fidelity indicators met the 65 to 80% uptake benchmarks. Rapid qualitative investigations determined that households concurrently used their own latrines with broken water seals in parallel with those provided by the trial. In consultation with the households, we closed pre-existing latrines without water seals, increased the CHWs' visit frequency to encourage correct maintenance of latrines with water seals, and discouraged water-seal removal or breakage. At the sixth assessment, 86% (51/59) of households were in sanitation only; 92% (72/78) in the combined WSH; and 93% (71/76) in the combined WSH and Nutrition arms had latrines with functional water seals.An intensive implementation fidelity monitoring and rapid response system proved beneficial for this efficacy trial. To implement a routine program at scale requires further research into an adaptation of fidelity monitoring that supports program effectiveness.WASH Benefits Bangladesh: ClinicalTrials.gov, ID: NCT01590095 . Registered on 30 April 2012.

  View details for PubMedID 29976234

• Fecal Indicator Bacteria along Multiple Environmental Transmission Pathways (Water, Hands, Food, Soil, Flies) and Subsequent Child Diarrhea in Rural Bangladesh. Environmental science & technology Pickering, A. J., Ercumen, A., Arnold, B. F., Kwong, L. H., Parvez, S. M., Alam, M., Sen, D., Islam, S., Kullmann, C., Chase, C., Ahmed, R., Unicomb, L., Colford, J. M., Luby, S. P. 2018

  Abstract

  Enteric pathogens can be transmitted through multiple environmental pathways, yet little is known about the relative contribution of each pathway to diarrhea risk among children. We aimed to identify fecal transmission pathways in the household environment associated with prospectively measured child diarrhea in rural Bangladesh. We measured the presence and levels of Escherichia coli in tube wells, stored drinking water, pond water, child hand rinses, courtyard soil, flies, and food in 1843 households. Gastrointestinal symptoms among children ages 0-60 months were recorded concurrently at the time of environmental sample collection and again a median of 6 days later. Incident diarrhea (3 or more loose stools in a 24-h period) was positively associated with the concentration of E. coli on child hands measured on the first visit (incidence rate ratio [IRR] = 1.23, 95% CI 1.06, 1.43 for a log10 increase), while other pathways were not associated. In cross-sectional analysis, there were no associations between concurrently measured environmental contamination and diarrhea. Our findings suggest higher levels of E. coli on child hands are strongly associated with subsequent diarrheal illness rates among children in rural Bangladesh.

  View details for PubMedID 29902374

• Epidemiology of Otitis Media With Otorrhea Among Bangladeshi Children: Baseline Study for Future Assessment of Pneumococcal Conjugate Vaccine Impact PEDIATRIC INFECTIOUS DISEASE JOURNAL Naziat, H., Saha, S., Islam, M., Saha, S., Uddin, M. J., Hussain, M., Luby, S. P., Darmstadt, G. L., Whitney, C. G., Gessner, B. D., Saha, S. K. 2018; 37 (7): 715–21

  Abstract

  Otitis media (OM) poses a high disease burden on Bangladeshi children, but little is known about its etiologies. We conducted a surveillance study in the largest pediatric hospital to characterize pathogens responsible for OM.In the outpatient ear-nose-throat department of Dhaka Shishu Hospital, which serves 0 to 18-year-old children, we collected ear swabs from OM children with otorrhea from April 2014 to March 2015. We cultured all specimens for bacterial pathogens and assessed serotype and antimicrobial susceptibility of Streptococcus pneumoniae (Spn) and Haemophilus influenzae (Hi) isolates.We recorded 1111 OM episodes; 88% (981/1111) involved otorrhea, and we collected samples from 91% (891/981) of these children. Fifty-one percent (452/891) were culture positive (contaminants excluded), with Hi (21%, 187/891) and Spn (18%, 164/891) most commonly detected. Overall, 45 distinct single and mixed pathogens were revealed. Dominant pneumococcal serotypes were 19A, 19F, 3 and 14; 98% of Hi isolates were nontypeable. Pneumococcal conjugate vaccine (PCV)10 and PCV10 + 6A serotypes accounted for 8% and 9% of all OM and 46% and 49% of pneumococcus-positive cases, respectively, and were more likely to be nonsusceptible to at least 1 antibiotic (erythromycin and/or trimethoprim-sulfamethoxazole) than nonvaccine serotypes (91% vs. 77%). Staphylococcus aureus (9%, 83/891) and Pseudomonas aeruginosa (4%, 38/891) were also found.Nontypeable Hi (NTHi) and Spn are predominant causes of OM in Bangladesh. PCV10, introduced in March 2015, is likely to reduce pneumococcal and overall OM burden. Data collected post-PCV10 will provide comprehensive insight into the effects of this vaccine on these pathogens.

  View details for PubMedID 29634626

• Avian influenza surveillance in domestic waterfowl and environment of live bird markets in Bangladesh, 2007-2012 SCIENTIFIC REPORTS Khan, S., Gurley, E. S., Gerloff, N., Rahman, M. Z., Simpson, N., Rahman, M., Haider, N., Chowdhury, S., Balish, A., Zaman, R., Nasreen, S., Das, B., Azziz-Baumgartner, E., Sturm-Ramirez, K., Davis, C., Donis, R. O., Luby, S. P. 2018; 8: 9396

  Abstract

  Avian influenza viruses, including highly pathogenic strains, pose severe economic, animal and public health concerns. We implemented live bird market surveillance in Bangladesh to identify the subtypes of avian influenza A viruses in domestic waterfowl and market environments. We collected waterfowl samples monthly from 4 rural sites from 2007 to 2012 and environmental samples from 4 rural and 16 urban sites from 2009 to 2012. Samples were tested through real-time RT-PCR, virus culture, and sequencing to detect and characterize avian influenza A viruses. Among 4,308 waterfowl tested, 191 (4.4%) were positive for avian influenza A virus, including 74 (1.9%) avian influenza A/H5 subtype. The majority (99%, n = 73) of the influenza A/H5-positive samples were from healthy appearing waterfowl. Multiple subtypes, including H1N1, H1N3, H3N2, H3N6, H3N8, H4N1, H4N2, H4N6, H5N1 (clades 2.2.2, 2.3.2.1a, 2.3.4.2), H5N2, H6N1, H7N9, H9N2, H11N2 and H11N3, H11N6 were detected in waterfowl and environmental samples. Environmental samples tested positive for influenza A viruses throughout the year. Avian influenza viruses, including H5N1 and H9N2 subtypes were also identified in backyard and small-scale raised poultry. Live bird markets could be high-risk sites for harboring the viruses and have the potential to infect naive birds and humans exposed to them.

  View details for PubMedID 29925854

• Implications of WASH Benefits trials for water and sanitation LANCET GLOBAL HEALTH Arnold, B. F., Null, C., Luby, S. P., Colford, J. M. 2018; 6 (6): E616–E617

  View details for PubMedID 29706562

• Prevalence of elevated blood lead levels among pregnant women and sources of lead exposure in rural Bangladesh: A case control study. Environmental research Forsyth, J. E., Saiful Islam, M., Parvez, S. M., Raqib, R., Sajjadur Rahman, M., Marie Muehe, E., Fendorf, S., Luby, S. P. 2018; 166: 1–9

  Abstract

  Prenatal and early childhood lead exposures impair cognitive development. We aimed to evaluate the prevalence of elevated blood lead levels (BLLs) among pregnant women in rural Bangladesh and to identify sources of lead exposure. We analyzed the BLLs of 430 pregnant women randomly selected from rural communities in central Bangladesh. Fifty-seven cases were selected with the highest BLLs, ≥ 7 mug/dL, and 59 controls were selected with the lowest BLLs, < 2 mug/dL. An exposure questionnaire was administered and soil, rice, turmeric, water, traditional medicine, agrochemical, and can samples were analyzed for lead contamination. Of all 430 women, 132 (31%) had BLLs > 5 mug/dL. Most women with elevated BLLs were spatially clustered. Cases were 2.6 times more likely than controls to consume food from a can (95% CI 1.0-6.3, p = 0.04); 3.6 times more likely to use Basudin, a specific brand of pesticide (95% CI 1.6-7.9, p = 0.002); 3.6 times more likely to use Rifit, a specific brand of herbicide (95% CI 1.7-7.9, p = 0.001); 2.9 times more likely to report using any herbicides (95% CI 1.2-7.3, p = 0.02); and 3.3 times more likely to grind rice (95% CI 1.3-8.4, p = 0.01). Five out of 28 food storage cans were lead-soldered. However, there was minimal physical evidence of lead contamination from 382 agrochemical samples and 129 ground and unground rice samples. Among 17 turmeric samples, one contained excessive lead (265 mug/g) and chromium (49 mug/g). Overall, we found evidence of elevated BLLs and multiple possible sources of lead exposure in rural Bangladesh. Further research should explicate and develop interventions to interrupt these pathways.

  View details for PubMedID 29804028

• Characterization of the Spatial and Temporal Distribution of Nipah Virus Spillover Events in Bangladesh, 2007-2013 JOURNAL OF INFECTIOUS DISEASES Cortes, M. C., Cauchemez, S., Lefrancq, N., Luby, S. P., Hossein, M., Sazzad, H. S., Rahman, M., Daszak, P., Salje, H., Gurley, E. S. 2018; 217 (9): 1390–94

  Abstract

  Nipah virus is a zoonotic virus harbored by bats and lethal to humans. Bat-to-human spillovers occur every winter in Bangladesh. However, there is significant heterogeneity in the number of spillovers detected by district and year that remains unexplained. We analyzed data from all 57 spillovers during 2007-2013 and found that temperature differences explained 36% of the year-to-year variation in the total number of spillovers each winter and that distance to surveillance hospitals explained 45% of spatial heterogeneity. Interventions to prevent human infections may be most important during colder winters. Further work is needed to understand how dynamics of bat infections explains spillover risk.

  View details for PubMedID 29351657

  View details for PubMedCentralID PMC5894074

• Barriers to and motivators of handwashing behavior among mothers of neonates in rural Bangladesh BMC PUBLIC HEALTH Parveen, S., Nasreen, S., Allen, J. V., Kamm, K. B., Khan, S., Akter, S., Lopa, T., Zaman, K., El Arifeen, S., Luby, S. P., Ram, P. K. 2018; 18: 483

  Abstract

  To design a maternal handwashing intervention for the newborn period, this qualitative study explored drivers of handwashing among mothers and other caregivers of neonates and infants in two rural areas of Bangladesh.We conducted 40 semi-structured observation sessions to observe handwashing behaviors of primiparous and multiparous mothers of neonates, and to understand the contextual factors that facilitated or hampered those behaviors. We then conducted 64 interviews with mothers of neonates and mothers of infants and 6 group discussions with mothers of infants, other female caregivers and fathers to explore perceptions, beliefs, and practices related to handwashing in the neonatal period. Based on a conceptual model and the Theory of Reasoned Action/Theory of Planned Behavior, we developed a conceptual model a priori, we performed thematic analysis to explain determinants of maternal handwashing behaviors.We conducted 200 h of observation among mothers of neonates. The age range of participating mothers varied between 17 and 25 years and their maximum education was up to 10th grade of schooling. Mothers, other female caregivers and fathers perceived a need to wash hands with or without soap before eating or before feeding a child by hand to prevent diarrhea. Mothers expressed the importance of washing their hands before holding a baby but were rarely observed doing so. All respondents prioritized using soap for visible dirt or feces; otherwise, water alone was considered sufficient. Lack of family support, social norms of infrequent handwashing, perceptions of frequent contact with water as a health threat and mothers' restricted movement during first 40 days of neonate's life, and childcare and household responsibilities adversely impacted handwashing behavior.Addressing emotive drivers of handwashing within existing social norms by engaging family members, ensuring handwashing facilities and clarifying neonatal health threats may improve maternal handwashing behavior in the neonatal period.

  View details for PubMedID 29642885

• Unsafe disposal of feces of children < 3 years among households with latrine access in rural Bangladesh: Association with household characteristics, fly presence and child diarrhea PLOS ONE Islam, M., Ercumen, A., Ashraf, S., Rahman, M., Shoab, A. K., Luby, S. P., Unicomb, L. 2018; 13 (4): e0195218

  Abstract

  Young children frequently defecate in the living environment in low-income countries. Unsafe child feces disposal has been associated with risk of diarrhea. Additionally, reported practices can underestimate socially undesirable unhygienic behaviors. This analysis aimed to assess (1) the sensitivity of reported child feces disposal practices as an indicator for observed presence of human feces in the domestic environment, (2) household characteristics associated with reported unsafe feces disposal and (3) whether unsafe feces disposal is associated with fly presence and diarrhea among children <3 years.We recorded caregiver-reported feces disposal practices for children <3 years; unsafe disposal was defined as feces put/rinsed into a drain, ditch, bush or garbage heap or left on the ground and safe disposal as feces put/rinsed into latrine or specific pit or buried. We conducted spot checks for human feces, counted flies in the compound and recorded caregiver-reported child diarrhea prevalence among 803 rural Bangladeshi households. We assessed associations using generalized estimating equations (GEE) and generalized linear models (GLM) with robust standard errors.Unsafe disposal of child feces was reported by 80% of households. Reported disposal practices had high sensitivity (91%) but low positive predictive value (15%) as an indicator of observed feces in the compound. Unsafe disposal was more common among households that reported daily adult open defecation (PR: 1.13, 1.02-1.24) and had children defecating in a nappy or on the ground versus in a potty (PR: 2.92, 1.98-4.32), and less common in households where adults reported always defecating in latrines (PR: 0.91, 0.84-0.98). The presence of observed human feces was similarly associated with these household characteristics. Reported unsafe feces disposal or observed human feces were not associated with fly detection or child diarrhea.Despite access to on-site sanitation, unsafe child feces disposal was reported by the majority of households. However, this practices was not associated with diarrhea; suggesting that child feces may not be the most important fecal exposure. Before resources are invested to improve child feces management practices, studies should explore whether these contribute meaningfully to risk of enteric disease.

  View details for PubMedID 29621289

• Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh): a cluster-randomised controlled trial LANCET CHILD & ADOLESCENT HEALTH Tofail, F., Fernald, L. H., Das, K. K., Rahman, M., Ahmed, T., Jannat, K. K., Unicomb, L., Arnold, B. F., Ashraf, S., Winch, P. J., Kariger, P., Stewart, C. P., Colford, J. M., Luby, S. P. 2018; 2 (4): 255–68

  Abstract

  Poor nutrition and hygiene make children vulnerable to delays in growth and development. We aimed to assess the effects of water quality, sanitation, handwashing, and nutritional interventions individually or in combination on the cognitive, motor, and language development of children in rural Bangladesh.In this cluster-randomised controlled trial, we enrolled pregnant women in their first or second trimester from rural villages of Gazipur, Kishoreganj, Mymensingh, and Tangail districts of central Bangladesh, with an average of eight women per cluster. Groups of eight geographically adjacent clusters were block-randomised, using a random number generator, into six intervention groups (all of which received weekly visits from a community health promoter for the first 6 months and every 2 weeks for the next 18 months) and a double-sized control group (no intervention or health promoter visit). The six intervention groups were: chlorinated drinking water; improved sanitation; handwashing with soap; combined water, sanitation, and handwashing; improved nutrition through counselling and provision of lipid-based nutrient supplements; and combined water, sanitation, handwashing, and nutrition. Here, we report on the prespecified secondary child development outcomes: gross motor milestone achievement assessed with the WHO module at age 1 year, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at age 2 years. Masking of participants was not possible. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01590095.Between May 31, 2012, and July 7, 2013, 5551 pregnant women residing in 720 clusters were enrolled. Index children of 928 (17%) enrolled women were lost to follow-up in year 1 and an additional 201 (3%) in year 2. 4757 children were assessed at 1 year and 4403 at 2 years. At year 1, compared with the control group, the combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the standing alone milestone (hazard ratio 1·19, 95% CI 1·01-1 ·40), and the nutrition group had a higher rate of attaining the walking alone milestone (1·32, 95% CI 1·07-1·62). The combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the walking alone milestone than those in the water, sanitation, and handwashing group (1·29, 1·01-1·65). At 2 years, we noted beneficial effects in the combined EASQ score in all intervention groups, with effect sizes smallest in the water treatment group (difference 0·15, 95% CI 0·04 to 0·26 vs control) and largest in the combined water, sanitation, handwashing, and nutrition treatment group (0·37, 0·27-0·46).Improvements in water quality, handwashing, sanitation, or nutrition supported by intensive interpersonal communication, when delivered either individually or in combination, contributed to improvements in child development. A crucial next step is to establish whether similar effects can be achieved with reduced intensity of promoter contacts that could be supported in large-scale interventions.Bill & Melinda Gates Foundation.

  View details for PubMedID 29616235

• Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial LANCET GLOBAL HEALTH Luby, S. P., Rahman, M., Arnold, B. F., Unicomb, L., Ashraf, S., Winch, P. J., Stewart, C. P., Begum, F., Hussain, F., Benjamin-Chung, J., Leontsini, E., Naser, A. M., Parvez, S. M., Hubbard, A. E., Lin, A., Nizame, F. A., Jannat, K., Ercumen, A., Ram, P. K., Das, K. K., Abedin, J., Clasen, T. F., Dewey, K. G., Fernald, L. C., Null, C., Ahmed, T., Colford, J. M. 2018; 6 (3): E302–E315

  Abstract

  Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering.The WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095.Between May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46-0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45-0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53-0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49-0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47-0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70-1·13). Compared with control (mean length-for-age Z score -1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15-0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02-0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth.Nutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions.Bill & Melinda Gates Foundation.

  View details for PubMedID 29396217

• Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial LANCET GLOBAL HEALTH Null, C., Stewart, C. P., Pickering, A. J., Dentz, H. N., Arnold, B. F., Arnold, C. D., Benjamin-Chung, J., Clasen, T., Dewey, K. G., Fernald, L. H., Hubbard, A. E., Kariger, P., Lin, A., Luby, S. P., Mertens, A., Njenga, S. M., Nyambane, G., Ram, P. K., Colford, J. M. 2018; 6 (3): E316–E329

  Abstract

  Poor nutrition and exposure to faecal contamination are associated with diarrhoea and growth faltering, both of which have long-term consequences for child health. We aimed to assess whether water, sanitation, handwashing, and nutrition interventions reduced diarrhoea or growth faltering.The WASH Benefits cluster-randomised trial enrolled pregnant women from villages in rural Kenya and evaluated outcomes at 1 year and 2 years of follow-up. Geographically-adjacent clusters were block-randomised to active control (household visits to measure mid-upper-arm circumference), passive control (data collection only), or compound-level interventions including household visits to promote target behaviours: drinking chlorinated water (water); safe sanitation consisting of disposing faeces in an improved latrine (sanitation); handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate maternal, infant, and young child feeding plus small-quantity lipid-based nutrient supplements from 6-24 months (nutrition); and combined water, sanitation, handwashing, and nutrition. Primary outcomes were caregiver-reported diarrhoea in the past 7 days and length-for-age Z score at year 2 in index children born to the enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704105.Between Nov 27, 2012, and May 21, 2014, 8246 women in 702 clusters were enrolled and randomly assigned an intervention or control group. 1919 women were assigned to the active control group; 938 to passive control; 904 to water; 892 to sanitation; 917 to handwashing; 912 to combined water, sanitation, and handwashing; 843 to nutrition; and 921 to combined water, sanitation, handwashing, and nutrition. Data on diarrhoea at year 1 or year 2 were available for 6494 children and data on length-for-age Z score in year 2 were available for 6583 children (86% of living children were measured at year 2). Adherence indicators for sanitation, handwashing, and nutrition were more than 70% at year 1, handwashing fell to less than 25% at year 2, and for water was less than 45% at year 1 and less than 25% at year 2; combined groups were comparable to single groups. None of the interventions reduced diarrhoea prevalence compared with the active control. Compared with active control (length-for-age Z score -1·54) children in nutrition and combined water, sanitation, handwashing, and nutrition were taller by year 2 (mean difference 0·13 [95% CI 0·01-0·25] in the nutrition group; 0·16 [0·05-0·27] in the combined water, sanitation, handwashing, and nutrition group). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth.Behaviour change messaging combined with technologically simple interventions such as water treatment, household sanitation upgrades from unimproved to improved latrines, and handwashing stations did not reduce childhood diarrhoea or improve growth, even when adherence was at least as high as has been achieved by other programmes. Counselling and supplementation in the nutrition group and combined water, sanitation, handwashing, and nutrition interventions led to small growth benefits, but there was no advantage to integrating water, sanitation, and handwashing with nutrition. The interventions might have been more efficacious with higher adherence or in an environment with lower baseline sanitation coverage, especially in this context of high diarrhoea prevalence.Bill & Melinda Gates Foundation, United States Agency for International Development.

  View details for PubMedID 29396219

• Spillover effects in epidemiology: parameters, study designs and methodological considerations INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Benjamin-Chung, J., Arnold, B. F., Berger, D., Luby, S. P., Miguel, E., Colford, J. M., Hubbard, A. E. 2018; 47 (1): 332–47

  Abstract

  Many public health interventions provide benefits that extend beyond their direct recipients and impact people in close physical or social proximity who did not directly receive the intervention themselves. A classic example of this phenomenon is the herd protection provided by many vaccines. If these 'spillover effects' (i.e. 'herd effects') are present in the same direction as the effects on the intended recipients, studies that only estimate direct effects on recipients will likely underestimate the full public health benefits of the intervention. Causal inference assumptions for spillover parameters have been articulated in the vaccine literature, but many studies measuring spillovers of other types of public health interventions have not drawn upon that literature. In conjunction with a systematic review we conducted of spillovers of public health interventions delivered in low- and middle-income countries, we classified the most widely used spillover parameters reported in the empirical literature into a standard notation. General classes of spillover parameters include: cluster-level spillovers; spillovers conditional on treatment or outcome density, distance or the number of treated social network links; and vaccine efficacy parameters related to spillovers. We draw on high quality empirical examples to illustrate each of these parameters. We describe study designs to estimate spillovers and assumptions required to make causal inferences about spillovers. We aim to advance and encourage methods for spillover estimation and reporting by standardizing spillover parameter nomenclature and articulating the causal inference assumptions required to estimate spillovers.

  View details for PubMedID 29106568

  View details for PubMedCentralID PMC5837695

• Can you taste it? Taste detection and acceptability thresholds for chlorine residual in drinking water in Dhaka, Bangladesh SCIENCE OF THE TOTAL ENVIRONMENT Crider, Y., Sultana, S., Unicomb, L., Davis, J., Luby, S. P., Pickering, A. J. 2018; 613: 840–46

  Abstract

  Chlorination is a low-cost, effective method for drinking water treatment, but aversion to the taste or smell of chlorinated water can limit use of chlorine treatment products. Forced choice triangle tests were used to evaluate chlorine detection and acceptability thresholds for two common types of chlorine among adults in Dhaka, Bangladesh, where previous studies have found low sustained uptake of chlorine water treatment products. The median detection threshold was 0.70mg/L (n=25, SD=0.57) for water dosed with liquid sodium hypochlorite (NaOCl) and 0.73mg/L (n=25, SD=0.83) for water dosed with solid sodium dichloroisocyanurate (NaDCC). Median acceptability thresholds (based on user report) were 1.16mg/L (SD=0.70) for NaOCl and 1.26mg/L (SD=0.67) for NaDCC. There was no significant difference in detection or acceptability thresholds for dosing with NaOCl versus NaDCC. Although users are willing to accept treated water in which they can detect the taste of chlorine, their acceptability limit is well below the 2.0mg/L that chlorine water treatment products are often designed to dose. For some settings, reducing dose may increase adoption of chlorinated water while still providing effective disinfection.

  View details for PubMedID 28942317

• Prevalence and risk factors for Taenia solium cysticercosis in school-aged children: A school based study in western Sichuan, People's Republic of China. PLoS neglected tropical diseases Openshaw, J. J., Medina, A. n., Felt, S. A., Li, T. n., Huan, Z. n., Rozelle, S. n., Luby, S. P. 2018; 12 (5): e0006465

  Abstract

  Taenia solium cysticercosis affects millions of impoverished people worldwide and can cause neurocysticercosis, an infection of the central nervous system which is potentially fatal. Children may represent an especially vulnerable population to neurocysticercosis, due to the risk of cognitive impairment during formative school years. While previous epidemiologic studies have suggested high prevalence in rural China, the prevalence in children as well as risk factors and impact of disease in low-resource areas remain poorly characterized.Utilizing school based sampling, we conducted a cross-sectional study, administering a questionnaire and collecting blood for T. solium cysticercosis antibodies in 2867 fifth and sixth grade students across 27 schools in west Sichuan. We used mixed-effects logistic regression models controlling for school-level clustering to study associations between risk factors and to characterize factors influencing the administration of deworming medication. Overall prevalence of cysticercosis antibodies was 6%, but prevalence was significantly higher in three schools which all had prevalences of 15% or higher. Students from households owning pigs (adjusted odds ratio [OR] 1.81, 95% CI 1.08-3.03), from households reporting feeding their pigs human feces (adjusted OR 1.49, 95% CI 1.03-2.16), and self-reporting worms in their feces (adjusted OR 1.85, 95% CI 1.18-2.91) were more likely to have cysticercosis IgG antibodies. Students attending high prevalence schools were more likely to come from households allowing pigs to freely forage for food (OR 2.26, 95% CI 1.72-2.98) and lacking a toilet (OR 1.84, 95% CI 1.38-2.46). Children who were boarding at school were less likely to have received treatment for gastrointestinal worms (adjusted OR 0.58, 95% CI 0.42-0.80).Our study indicates high prevalences of cysticercosis antibodies in young school aged children in rural China. While further studies to assess potential for school-based transmission are needed, school-based disease control may be an important intervention to ensure the health of vulnerable pediatric populations in T. solium endemic areas.

  View details for PubMedID 29738570

  View details for PubMedCentralID PMC5959190

• Phase I of the Surveillance for Enteric Fever in Asia Project (SEAP): An Overview and Lessons Learned. The Journal of infectious diseases Barkume, C. n., Date, K. n., Saha, S. K., Qamar, F. N., Sur, D. n., Andrews, J. R., Luby, S. P., Khan, M. I., Freeman, A. n., Yousafzai, M. T., Garrett, D. n. 2018

  Abstract

  The objective of Phase I of the Surveillance for Enteric Fever in Asia Project (SEAP), a multiphase surveillance study characterizing the burden of disease in South Asia, was to inform data collection for prospective surveillance and to capture clinical aspects of disease.Through a retrospective record review conducted at hospitals in Bangladesh, India, Nepal, and Pakistan, we examined laboratory and clinical records to assess the culture positivity rate for Salmonella Typhi and Salmonella Paratyphi, age and sex distribution, and antimicrobial susceptability in each country.Of all blood cultures performed in Bangladesh, India, Nepal, and Pakistan, 1.5%, 0.43%, 2%, and 1.49%, respectively, were positive for S. Typhi and 0.24%, 0.1%, 0.5%, and 0.67%, respectively, were positive for S. Paratyphi. A higher proportion of laboratory-confirmed infections in Bangladesh and Pakistan were aged ≤5 years, while India and Nepal had a higher proportion of participants aged 15-25 years. In all countries, the sex of the majority of participants was male. The majority of isolates in all countries were resistant to fluoroquinolones, with a high proportion also resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole.Enteric fever remains endemic in South Asia. Data generated by this study can help inform strategies for implementation and evaluation of prevention and control measures.

  View details for PubMedID 30304505

• Evaluating PCR-Based Detection of Salmonella Typhi and Paratyphi A in the Environment as an Enteric Fever Surveillance Tool. The American journal of tropical medicine and hygiene Saha, S. n., Tanmoy, A. M., Andrews, J. R., Sajib, M. S., Yu, A. T., Baker, S. n., Luby, S. P., Saha, S. K. 2018

  Abstract

  With prequalification of a typhoid conjugate vaccine by the World Health Organization, countries are deciding whether and at what geographic scale to provide the vaccine. Optimal local data to clarify typhoid risk are expensive and often unavailable. To determine whether quantitative real-time PCR can be used as a tool to detect typhoidal Salmonella DNA in the environment and approximate the burden of enteric fever, we tested water samples from urban Dhaka, where enteric fever burden is high, and rural Mirzapur, where enteric fever burden is low and sporadic. Sixty-six percent (38/59) of the water sources of Dhaka were contaminated with typhoidal Salmonella DNA, in contrast to none of 33 samples of Mirzapur. If these results can be replicated in larger scale in Bangladesh and other enteric fever endemic areas, drinking water testing could become a low-cost approach to determine the presence of typhoidal Salmonella in the environment that can, in turn, guide informed-design of blood culture-based surveillance and thus assist policy decisions on investing to control typhoid.

  View details for PubMedID 30426919

• Comparison of Strategies and Incidence Thresholds for Vi Conjugate Vaccines Against Typhoid Fever: A Cost-effectiveness Modeling Study. The Journal of infectious diseases Lo, N. C., Gupta, R. n., Stanaway, J. D., Garrett, D. O., Bogoch, I. I., Luby, S. P., Andrews, J. R. 2018

  Abstract

  Typhoid fever remains a major public health problem globally. While new Vi conjugate vaccines hold promise for averting disease, the optimal programmatic delivery remains unclear. We aimed to identify the strategies and associated epidemiologic conditions under which Vi conjugate vaccines would be cost-effective.We developed a dynamic, age-structured transmission and cost-effectiveness model that simulated multiple vaccination strategies with a typhoid Vi conjugate vaccine from a societal perspective. We simulated 10-year vaccination programs with (1) routine immunization of infants (aged <1 year) through the Expanded Program on Immunization (EPI) and (2) routine immunization of infants through the EPI plus a 1-time catch-up campaign in school-aged children (aged 5-14 years). In the base case analysis, we assumed a 0.5% case-fatality rate for all cases of clinically symptomatic typhoid fever and defined strategies as highly cost-effective by using the definition of a low-income country (defined as a country with a gross domestic product of $1045 per capita). We defined incidence as the true number of clinically symptomatic people in the population per year.Vi conjugate typhoid vaccines were highly cost-effective when administered by routine immunization activities through the EPI in settings with an annual incidence of >50 cases/100000 (95% uncertainty interval, 40-75 cases) and when administered through the EPI plus a catch-up campaign in settings with an annual incidence of >130 cases/100000 (95% uncertainty interval, 50-395 cases). The incidence threshold was sensitive to the typhoid-related case-fatality rate, carrier contribution to transmission, vaccine characteristics, and country-specific economic threshold for cost-effectiveness.Typhoid Vi conjugate vaccines would be highly cost-effective in low-income countries in settings of moderate typhoid incidence (50 cases/100000 annually). These results were sensitive to case-fatality rates, underscoring the need to consider factors contributing to typhoid mortality (eg, healthcare access and antimicrobial resistance) in the global vaccination strategy.

  View details for PubMedID 29444257

• EVIDENCE CONSISTENT WITH SCHOOL BASED TRANSMISSION OF <it>TAENIA SOLIUM</it> CYSTICERCOSIS IN PRIMARY SCHOOLS, SOUTHWEST CHINA Openshaw, J., Chedid, C., Medina, A., Felt, S., Li, T., Huan, Z., Rozelle, S., Luby, S. AMER SOC TROP MED & HYGIENE. 2018: 7

  View details for Web of Science ID 000461386602022

• HIGH-THROUGHPUT MULTI-PARALLEL NL-QPCR CHIP FOR THE DETECTION OF 17 ENTERIC PATHOGENS Grembi, J., Mayer-Blackwell, K., Luby, S., Spormann, A. AMER SOC TROP MED & HYGIENE. 2018: 199–200

  View details for Web of Science ID 000461386602645

• Hepatitis B Surface Antigen Seroprevalence among Prevaccine and Vaccine Era Children in Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Paul, R. C., Rahman, M., Wiesen, E., Patel, M., Banik, K. C., Sharif, A. R., Sultana, S., Rahman, M., Liyanage, J., Abeysinghe, N., Kamili, S., Murphy, T., Luby, S. P., Mast, E. E. 2018; 99 (3): 764–71

  Abstract

  Bangladesh introduced hepatitis B vaccine in a phased manner during 2003-2005 into the routine childhood vaccination schedule. This study was designed to evaluate the impact of the introduction of hepatitis B vaccine in Bangladesh by comparing hepatitis B surface antigen (HBsAg) prevalence among children born before and after vaccine introduction and to estimate the risk of vertical transmission of chronic hepatitis B virus (HBV) infection from mother to infant. We also evaluated the field sensitivity and specificity of an HBsAg point-of-care test strip. We selected a nationally representative sample of 2,100 prevaccine era and 2,100 vaccine era children. We collected a 5-mL blood sample from each child. One drop of blood was used to perform rapid HBsAg testing. If a child had a positive HBsAg test result with the rapid test, a blood sample was collected from the mother of the HBsAg-positive child and from the mothers of two subsequently enrolled HBsAg-negative children. All samples were tested for serologic markers of HBV infection using standard enzyme-linked immunosorbent assay. One (0.05%) child in the vaccine era group and 27 (1.2%; 95% confidence interval [CI]: 0.8-1.7%) children in the prevaccine era group were HBsAg positive. Mothers of HBsAg-positive children were more likely to be HBsAg positive than mothers of HBsAg-negative children (odds ratios = 4.7; 95% CI: 1.0-21.7%). Sensitivity of the HBsAg rapid test was 91.2% (95% CI: 76.6-98.1%) and specificity was 100% (95% CI: 99.9-100%). The study results suggest that even without a birth dose, the hepatitis B vaccine program in Bangladesh was highly effective in preventing chronic HBV infection among children.

  View details for PubMedID 30014817

• DEVELOPING A PUBLIC HEALTH TOOL TO MONITOR THE TRANSMISSION POTENTIAL OF NIPAH VIRUS DURING OUTBREAKS Nikolay, B., Salje, H., Sazzad, H., Flora, M., Luby, S., Cauchemez, S., Gurley, E. AMER SOC TROP MED & HYGIENE. 2018: 661

  View details for Web of Science ID 000461386605152

• MEASURING IMPACT OF MENSTRUAL HYGIENE MANAGEMENT INTERVENTIONS ON SCHOOLS ATTENDANCE AND WOMEN'S EDUCATION IN BANGLADESH Sultana, F., Sharmin, S., Khan, S., Nuruzzaman, M., Akand, F., Hossain, R., Rafiquzzaman, M., Sayeed, M., Rahman, M., Azam, M., Rahman, M., Unicomb, L., Winch, P., Luby, S. AMER SOC TROP MED & HYGIENE. 2018: 196

  View details for Web of Science ID 000461386602634

• SAND BARRIERS AROUND PIT LATRINES REDUCE FECAL BACTERIAL LEACHING I0NTO SHALLOW AQUIFER: A RANDOMIZED CONTROLLED TRIAL IN COASTAL BANGLADESH Naser, A., Doza, S., Rahman, M., Ahmed, K., Gazi, M., Alam, G., Karim, M., Uddin, M., Mahmud, M., Ercumen, A., Rosenbaum, J., Annis, J., Luby, S., Unicomb, L., Clasen, T. AMER SOC TROP MED & HYGIENE. 2018: 429–30

  View details for Web of Science ID 000461386604065

• SOCIAL AND ENTOMOLOGICAL DRIVERS INTERCONNECT IN DRIVING SPATIAL PROPAGATION OF CHIKUNGUNYA VIRUS IN BANGLADESH ten Bosch, Q., Salje, H., Paul, K., Naser, A., Rahman, M., Heffelfinger, J., Alam, S., Al-Amin, H., Rahman, Z., Afroj, S., Cummings, D., Paul, R., Luby, S., Gurley, E., Cauchemez, S. AMER SOC TROP MED & HYGIENE. 2018: 204

  View details for Web of Science ID 000461386602659

• EFFECT OF DRINKING WATER CHLORINATION AT THE POINT-OF-COLLECTION ON CHILD DIARRHEA IN DHAKA, BANGLADESH: A DOUBLE-BLIND CLUSTER-RANDOMIZED CONTROLLED TRIAL Pickering, A., Sultana, S., Crider, Y., Islam, S., Goddard, F., Swarthout, J., Sen, S., Ayyagari, R., Luby, S. AMER SOC TROP MED & HYGIENE. 2018: 430–31

  View details for Web of Science ID 000461386604068

• Acceptability and Feasibility of Sharing a Soapy Water System for Handwashing in a Low-Income Urban Community in Dhaka, Bangladesh: A Qualitative Study AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Sultana, F., Unicomb, L. E., Nizame, F. A., Dutta, N., Ram, P. K., Luby, S. P., Winch, P. J. 2018; 99 (2): 502–12

  Abstract

  Handwashing with soap at key times is an effective means of reducing pathogen transmission. In a low-income community in urban Dhaka, we piloted and evaluated the acceptability and feasibility of a shared handwashing intervention. This included promotion by community health promoters of a homemade solution of detergent powder mixed with water and stored in a 1.5-L reclaimed mineral water bottle. Community health promoters encouraged sharing of the recurrent detergent cost among compound members. Of 152 participating compounds, fieldworkers randomly selected 60 for qualitative assessment. Fieldworkers conducted 30 in-depth interviews and five focus group discussions among purposively selected compound members. The reclaimed bottles served as an easily accessible dispenser for the soapy water, which could feasibly be retained next to the toilet and kitchen areas for communal use. Bottles functioned as a positive reminder for handwashing at recommended key times. Most compounds (45/60, 75%) shared a common soapy water system and its associated costs. There was reluctance to prepare soapy water for shared use in the remaining 25%. Soapy water was an acceptable hand cleaning agent, with the bottle as a feasible dispenser. It was simple in design, cost-effective, replicable, popular with intervention recipient, and neighboring nonrecipients, and commonly shared among nonrelated households. The need to share expenses and product preparation served as a barrier. Developing a sustainable maintenance system, therefore, is critical to ensuring the public health benefits of handwashing with soap.

  View details for PubMedID 29893204

  View details for PubMedCentralID PMC6090367

• EFFECTS OF WATER, SANITATION, HANDWASHING, AND NUTRITIONAL INTERVENTIONS ON ENVIRONMENTAL ENTERIC DYSFUNCTION IN YOUNG CHILDREN: A CLUSTER-RANDOMIZED CONTROLLED TRIAL IN RURAL KENYA Lin, A., Achando, B., Rao, G., Dentz, H., Arnold, B., Pickering, A., Stewart, C., Mertens, A., Alauddin, M., Nekesa, C., Buleti, J., Cheruiyot, P., Meerkerk, T., Arnold, C., Rahman, M., Wolfe, M., Mureithi, M., Byrd, K., Kiprotich, M., Nyambane, G., Njenga, S., Alauddin, S., Minchala, S., Cekovic, R., Williams, A., Mahoney, R., Hubbard, A., Dewey, K., Luby, S., Colford, J., Null, C. AMER SOC TROP MED & HYGIENE. 2018: 244–45

  View details for Web of Science ID 000461386603112

• Fecal Contamination on Produce from Wholesale and Retail Food Markets in Dhaka, Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Harris, A. R., Islam, M., Unicomb, L., Boehm, A. B., Luby, S., Davis, J., Pickering, A. J. 2018; 98 (1): 287–94

  Abstract

  Fresh produce items can become contaminated with enteric pathogens along the supply chain at the preharvest (e.g., irrigation water, soil, fertilizer) or postharvest (e.g., vendor handling or consumer handling) stages. This study assesses the concentrations of fecal indicator bacteria Escherichia coli, enterococci (ENT), and Bacteriodales on surfaces of carrots, eggplants, red amaranth leaves, and tomatoes obtained from both a wholesale market (recently harvested) and neighborhood retail markets in Dhaka, Bangladesh. We detected E. coli in 100% of carrot and red amaranth rinses, 92% of eggplant rinses, and 46% of tomato rinses. Using a molecular microbial source tracking assay, we found that 32% of produce samples were positive for ruminant fecal contamination. Fecal indicator bacteria were more likely to be detected on produce collected in retail markets compared with that in the wholesale market; retail market produce were 1.25 times more likely to have E. coli detected (P = 0.03) and 1.24 times more likely to have ENT detected (P = 0.03) as compared with wholesale market produce. Bacteriodales was detected in higher concentrations in retail market produce samples compared with wholesale market produce samples (0.40 log10 gene copies per 100 cm2 higher, P = 0.03). Our results suggest that ruminant and general fecal contamination of produce in markets in Dhaka is common, and suggest that unsanitary conditions in markets are an important source of produce fecal contamination postharvest.

  View details for PubMedID 29165214

  View details for PubMedCentralID PMC5928698

• Incidence of Acute Diarrhea-Associated Death among Children < 5 Years of Age in Bangladesh, 2010-12 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Ahmed, M., Abedin, J., Alam, K., Al Mamun, A., Paul, R. C., Rahman, M., Iuliano, A., Sturm-Ramirez, K., Parashar, U., Luby, S. P., Gurley, E. S. 2018; 98 (1): 281–86

  Abstract

  Although acute diarrheal deaths have declined globally among children < 5 years, it may still contribute to childhood mortality as an underlying or contributing cause. The aim of this project was to estimate the incidence of acute diarrhea-associated deaths, regardless of primary cause, among children < 5 years in Bangladesh during 2010-12. We conducted a survey in 20 unions (administrative units) within the catchment areas of 10 tertiary hospitals in Bangladesh. Through social networks, our field team identified households where children < 5 years were reported to have died during 2010-12. Trained data collectors interviewed caregivers of the deceased children and recorded illness symptoms, health care seeking, and other information using an abbreviated international verbal autopsy questionnaire. We classified the deceased based upon the presence of diarrhea before death. We identified 880 deaths, of which 36 (4%) died after the development of acute diarrhea, 17 (2%) had diarrhea-only in the illness preceding death, and 19 (53%) had cough or difficulty breathing in addition to diarrhea. The estimated annual incidence of all-cause mortality in the unions < 13.6 km of the tertiary hospitals was 26 (95% confidence interval [CI] 16-37) per 1,000 live births compared with the mortality rate of 37 (95% CI 26-49) per 1,000 live births in the unions located ≥ 13.6 km. Diarrhea contributes to childhood death at a higher proportion than when considering it only as the sole underlying cause of death. These data support the use of interventions aimed at preventing acute diarrhea, especially available vaccinations for common etiologies, such as rotavirus.

  View details for PubMedID 29141756

• Nipah Virus Contamination of Hospital Surfaces during Outbreaks, Bangladesh, 2013-2014 EMERGING INFECTIOUS DISEASES Hassan, M., Sazzad, H. S., Luby, S. P., Sturm-Ramirez, K., Bhuiyan, M., Rahman, M., Islam, M., Stroher, U., Sultana, S., Kafi, M., Daszak, P., Rahman, M., Gurley, E. S. 2018; 24 (1): 15–21

  Abstract

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

  View details for DOI 10.3201/eid2401.161758

  View details for Web of Science ID 000418918500003

  View details for PubMedID 29260663

  View details for PubMedCentralID PMC5749460

• Effect of Groundwater Iron on Residual Chlorine in Water Treated with Sodium Dichloroisocyanurate Tablets in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Naser, A., Higgins, E. M., Arman, S., Ercumen, A., Ashraf, S., Das, K. K., Rahman, M., Luby, S. P., Unicomb, L. 2018; 98 (4): 977–83

  Abstract

  We assessed the ability of sodium dichloroisocyanurate (NaDCC) to provide adequate chlorine residual when used to treat groundwater with variable iron concentration. We randomly selected 654 tube wells from nine subdistricts in central Bangladesh to measure groundwater iron concentration and corresponding residual-free chlorine after treating 10 L of groundwater with a 33-mg-NaDCC tablet. We assessed geographical variations of iron concentration using the Kruskal-Wallis test and examined the relationships between the iron concentrations and chlorine residual by quantile regression. We also assessed whether user-reported iron taste in water and staining of storage vessels can capture the presence of iron greater than 3 mg/L (the World Health Organization threshold). The median iron concentration among measured wells was 0.91 (interquartile range [IQR]: 0.36-2.01) mg/L and free residual chlorine was 1.3 (IQR: 0.6-1.7) mg/L. The groundwater iron content varied even within small geographical regions. The median free residual chlorine decreased by 0.29 mg/L (95% confidence interval: 0.27, 0.33, P < 0.001) for every 1 mg/L increase in iron concentration. Owner-reported iron staining of the storage vessel had a sensitivity of 92%, specificity of 75%, positive predictive value of 41%, and negative predictive value of 98% for detecting > 3 mg/L iron in water. Similar findings were observed for user-reported iron taste in water. Our findings reconfirm that chlorination of groundwater that contains iron may result in low-level or no residual. User reports of no iron taste or no staining of storage containers can be used to identify low-iron tube wells suitable for chlorination. Furthermore, research is needed to develop a color-graded visual scale for iron staining that corresponds to different iron concentrations in water.

  View details for PubMedID 29436334

  View details for PubMedCentralID PMC5928807

• A Cross Sectional Study of the Association between Sanitation Type and Fecal Contamination of the Household Environment in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Huda, T., Schmidt, W., Pickering, A. J., Mahmud, Z., Islam, M., Rahman, M., Luby, S. P., Biran, A. 2018; 98 (4): 967–76

  Abstract

  We conducted a cross sectional study to assess 1) the association between access to basic sanitation and fecal contamination of sentinel toy balls and 2) if other sanitation factors such as shared use and cleanliness are associated with fecal contamination of sentinel toy balls. We assessed sanitation facilities in 454 households with a child aged 6-24 months in rural Bangladesh. We defined "basic" sanitation as access to improved sanitation facilities (pit latrine with a slab or better) not shared with other households. In each household, an identical toy ball was given to the target child. After 24 hours, the balls were rinsed to enumerate fecal coliforms as an indicator of household fecal contamination. Households with basic sanitation had lower fecal coliform contamination than households with no access to basic sanitation (adjusted difference in means: -0.31 log10 colony forming units [CFU]/toy ball; 95% confidence interval [CI]: -0.61, -0.01). Shared sanitation facilities of otherwise improved type were more likely to have visible feces on the latrine slab compared with private facilities. Among households with access to improved sanitation, households with no visible feces on the latrine slab had less toy ball contamination than households with visible feces on the latrine slab (adjusted difference in means: -0.38 log10 CFU/toy ball; 95% CI: -0.77, 0.02). Access to basic sanitation may prevent fecal contamination of the household environment. An Improved sanitation facility used by an individual household may be better in preventing household fecal contamination compared with improved facilities shared with other households.

  View details for PubMedID 29436345

  View details for PubMedCentralID PMC5928805

• Prevalence and Association of Escherichia coli and Diarrheagenic Escherichia coli in Stored Foods for Young Children and Flies Caught in the Same Households in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Doza, S., Rahman, M., Islam, M., Kwong, L. H., Unicomb, L., Ercumen, A., Pickering, A. J., Parvez, S., Naser, A., Ashraf, S., Das, K., Luby, S. P. 2018; 98 (4): 1031–38

  Abstract

  Consumption of contaminated stored food can cause childhood diarrhea. Flies carry enteropathogens, although their contribution to food contamination remains unclear. We investigated the role of flies in contaminating stored food by collecting food and flies from the same households in rural Bangladesh. We selected 182 households with children ≤ 24 months old that had stored foods for later feeding at room temperature for ≥ 3 hours. We collected food samples and captured flies with fly tapes hung by the kitchen. We used the IDEXX Quanti-Tray System (Colilert-18 media; IDEXX Laboratories, Inc., Westbrook, ME) to enumerate Escherichia coli with the most probable number (MPN) method. Escherichia coli-positive IDEXX wells were analyzed by polymerase chain reaction for pathogenic E. coli genes (eae, ial, bfp, ipaH, st, lt, aat, aaiC, stx1, and stx2). Escherichia coli was detected in 61% (111/182) of food samples, with a mean of 1.1 log10 MPN/dry g. Fifteen samples (8%) contained pathogenic E. coli; seven (4%) had enteropathogenic E. coli (EPEC) genes (eae and/or bfp); and 10 (5%) had enteroaggregative E. coli genes (aat and/or aaiC). Of flies captured in 68 (37%) households, E. coli was detected in 41 (60%, mean 2.9 log10 MPN/fly), and one fly (1%) had an EPEC gene (eae). For paired fly-food samples, each log10 MPN E. coli increase in flies was associated with a 0.31 log10 MPN E. coli increase in stored food (95% confidence interval: 0.07, 0.55). In rural Bangladesh, flies possibly a likely route for fecal contamination of stored food. Controlling fly populations may reduce contamination of food stored for young children.

  View details for PubMedID 29436348

  View details for PubMedCentralID PMC5928814

• Efficacy of trivalent influenza vaccine against laboratory-confirmed influenza among young children in a randomized trial in Bangladesh VACCINE Rolfes, M. A., Goswami, D., Sharmeen, A., Yeasmin, S., Parvin, N., Nahar, K., Rahman, M., Barends, M., Ahmed, D., Rahman, M., Bresee, J., Luby, S., Moulton, L. H., Santosham, M., Fry, A. M., Brooks, W. 2017; 35 (50): 6967–76

  Abstract

  Few trials have evaluated influenza vaccine efficacy (VE) in young children, a group particularly vulnerable to influenza complications. We aimed to estimate VE against influenza in children aged <2 years in Bangladesh; a subtropical setting, where influenza circulation can be irregular.Children aged 6-23 months were enrolled 1:1 in a parallel, double-blind, randomized controlled trial of trivalent inactivated influenza vaccine (IIV3) versus inactivated polio vaccine (IPV); conducted August 2010-March 2014 in Dhaka, Bangladesh. Children received two pediatric doses of vaccine, one month apart, and were followed for one year for febrile and respiratory illness. Field assistants conducted weekly home-based, active surveillance and ill children were referred to the study clinic for clinical evaluation and nasopharyngeal wash specimen collection. Analysis included all children who received a first vaccine dose and compared yearly incidence of reverse transcription polymerase chain reaction (RT-PCR)-confirmed influenza between trial arms. The VE was estimated as 1-(rate ratio of illness) × 100%, using unadjusted Poisson regression. The trial was registered with ClinicalTrials.gov, number NCT01319955.Across four vaccination rounds, 4081 children were enrolled and randomized, contributing 2576 child-years of observation to the IIV3 arm and 2593 child-years to the IPV arm. Influenza incidence was 10 episodes/100 child-years in the IIV3 arm and 15 episodes/100 child-years in the IPV arm. Overall, the VE was 31% (95% confidence interval 18, 42%) against any RT-PCR-confirmed influenza. The VE varied by season, but was similar by influenza type/subtype and participant age and sex.Vaccination of young children with IIV3 provided a significant reduction in laboratory-confirmed influenza; however, exploration of additional influenza vaccine strategies, such as adjuvanted vaccines or standard adult vaccine doses, is warranted to find more effective influenza vaccines for young children in low-income countries.

  View details for DOI 10.1016/j.vaccine.2017.10.074

  View details for Web of Science ID 000418971100008

  View details for PubMedID 29100706

  View details for PubMedCentralID PMC5723570

• Impact of adding hand-washing and water disinfection promotion to oral cholera vaccination on diarrhoea-associated hospitalization in Dhaka, Bangladesh: evidence from a cluster randomized control trial INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Najnin, N., Leder, K., Qadri, F., Forbes, A., Unicomb, L., Winch, P. J., Ram, P. K., Leontsini, E., Nizame, F. A., Arman, S., Begum, F., Biswas, S. K., Clemens, J. D., Ali, M., Cravioto, A., Luby, S. P. 2017; 46 (6): 2056–66

  Abstract

  Information on the impact of hygiene interventions on severe outcomes is limited. As a pre-specified secondary outcome of a cluster-randomized controlled trial among >400 000 low-income residents in Dhaka, Bangladesh, we examined the impact of cholera vaccination plus a behaviour change intervention on diarrhoea-associated hospitalization.Ninety neighbourhood clusters were randomly allocated into three areas: cholera-vaccine-only; vaccine-plus-behaviour-change (promotion of hand-washing with soap plus drinking water chlorination); and control. Study follow-up continued for 2 years after intervention began. We calculated cluster-adjusted diarrhoea-associated hospitalization rates using data we collected from nearby hospitals, and 6-monthly census data of all trial households.A total of 429 995 people contributed 500 700 person-years of data (average follow-up 1.13 years). Vaccine coverage was 58% at the start of analysis but continued to drop due to population migration. In the vaccine-plus-behaviour-change area, water plus soap was present at 45% of hand-washing stations; 4% of households had detectable chlorine in stored drinking water. Hospitalization rates were similar across the study areas [events/1000 person-years, 95% confidence interval (CI), cholera-vaccine-only: 9.4 (95% CI: 8.3-10.6); vaccine-plus-behaviour-change: 9.6 (95% CI: 8.3-11.1); control: 9.7 (95% CI: 8.3-11.6)]. Cholera cases accounted for 7% of total number of diarrhoea-associated hospitalizations.Neither cholera vaccination alone nor cholera vaccination combined with behaviour-change intervention efforts measurably reduced diarrhoea-associated hospitalization in this highly mobile population, during a time when cholera accounted for a small fraction of diarrhoea episodes. Affordable community-level interventions that prevent infection from multiple pathogens by reliably separating faeces from the environment, food and water, with minimal behavioural demands on impoverished communities, remain an important area for research.

  View details for PubMedID 29025064

  View details for PubMedCentralID PMC5837384

• High prevalence of Taenia solium taeniasis and cysticercosis in Tibetan schoolchildren in western Sichuan, China: a cross-sectional study Li, T., Openshaw, J. J., Chen, X., Medina, A. C., Felt, S. A., Zhou, H., Rozelle, S. D., Luby, S. P. ELSEVIER SCIENCE INC. 2017: S89

  View details for Web of Science ID 000440459400090

• Effects of water, sanitation, handwashing and nutritional interventions on telomere length among children in a cluster-randomized controlled trial in rural Bangladesh ELIFE Lin, A., Arnold, B. F., Mertens, A. N., Lin, J., Benjamin-Chung, J., Ali, S., Hubbard, A. E., Stewart, C. P., Shoab, A. K., Rahman, M., Hossen, M., Mutsuddi, P., Famida, S. L., Akther, S., Rahman, M., Unicomb, L., Dhabhar, F. S., Fernald, L. H., Colford, J. M., Luby, S. P. 2017; 6

  Abstract

  Background: Shorter childhood telomere length (TL) and more rapid TL attrition are widely regarded as manifestations of stress. However, the potential effects of health interventions on child TL are unknown. We hypothesized that a water, sanitation, handwashing (WSH), and nutritional intervention would slow TL attrition during the first two years of life. Methods: In a trial in rural Bangladesh (ClinicalTrials.gov, NCT01590095), we randomized geographical clusters of pregnant women into individual water treatment, sanitation, handwashing, nutrition, combined WSH, combined nutrition plus WSH (N + WSH), or control arms. We conducted a substudy enrolling children from the control arm and the N + WSH intervention arm. Participants and outcome assessors were not masked; analyses were masked. Relative TL was measured at 1 and 2 years after intervention, and the change in relative TL was reported. Analysis was intention-to-treat. Findings: Between May 2012 and July 2013, in the overall trial, we randomized 720 geographical clusters of 5551 pregnant women to a control or an intervention arm. In this substudy, after 1 year of intervention, we assessed a total of 662 children (341 intervention and 321 control) and 713 children after 2 years of intervention (383 intervention and 330 control). Children in the intervention arm had significantly shorter relative TL compared with controls after 1 year of intervention (difference -163 base pairs (bp), p=0.001). Between years 1 and 2, TL increased in the intervention arm (+76 bp) and decreased in the controls (-23 bp) (p=0.050). After 2 years, there was no difference between the arms (p=0.305). Interpretation: Our unexpected finding of increased telomere attrition during the first year of life in the intervention group suggests that rapid telomere attrition during this critical period could reflect the improved growth in the intervention group, rather than accumulated stress. Funding: The Bill and Melinda Gates Foundation.

  View details for PubMedID 28980942

• Integration of enteric fever surveillance into the WHO-coordinated Invasive Bacterial-Vaccine Preventable Diseases (IB-VPD) platform: A low cost approach to track an increasingly important disease PLOS NEGLECTED TROPICAL DISEASES Saha, S., Islam, M., Uddin, M. J., Saha, S., Das, R. C., Baqui, A. H., Santosham, M., Black, R. E., Luby, S. P., Saha, S. K. 2017; 11 (10): e0005999

  Abstract

  Lack of surveillance systems and accurate data impede evidence-based decisions on treatment and prevention of enteric fever, caused by Salmonella Typhi/Paratyphi. The WHO coordinates a global Invasive Bacterial-Vaccine Preventable Diseases (IB-VPD) surveillance network but does not monitor enteric fever. We evaluated the feasibility and sustainability of integrating enteric fever surveillance into the ongoing IB-VPD platform.The IB-VPD surveillance system uses WHO definitions to enroll 2-59 month children hospitalized with possible pneumonia, sepsis or meningitis. We expanded this surveillance system to additionally capture suspect enteric fever cases during 2012-2016, in two WHO sentinel hospitals of Bangladesh, by adding inclusion criteria of fever ≥102°F for ≥3 days, irrespective of other manifestations. Culture-positive enteric fever cases from in-patient departments (IPD) detected in the hospital laboratories but missed by the expanded surveillance, were also enrolled to assess completion. Costs for this integration were calculated for the additional personnel and resources required.In the IB-VPD surveillance, 5,185 cases were enrolled; 3% (N = 171/5185) were positive for microbiological growth, of which 55% (94/171) were culture-confirmed cases of enteric fever (85 Typhi and 9 Paratyphi A). The added inclusion criteria for enteric fever enrolled an additional 1,699 cases; 22% (358/1699) were positive, of which 85% (349/358) were enteric fever cases (305 Typhi and 44 Paratyphi A). Laboratory surveillance of in-patients of all ages enrolled 311 additional enteric fever cases (263 Typhi and 48 Paratyphi A); 9% (28/311) were 2-59 m and 91% (283/311) >59 m. Altogether, 754 (94+349+311) culture-confirmed enteric fever cases were found, of which 471 were 2-59 m. Of these 471 cases, 94% (443/471) were identified through the hospital surveillances and 6% (28/471) through laboratory results. Twenty-three percent (170/754) of all cases were children <2 years. Additional cost for the integration was USD 44,974/year, a 27% increase to the IB-VPD annual expenditure.In a setting where enteric disease is a substantial public health problem, we could integrate enteric fever surveillance into the standard IB-VPD surveillance platform at a modest cost.

  View details for PubMedID 29073137

• Convergence of Humans, Bats, Trees, and Culture in Nipah Virus Transmission, Bangladesh EMERGING INFECTIOUS DISEASES Gurley, E. S., Hegde, S. T., Hossain, K., Sazzad, H. S., Hossain, M., Rahman, M., Sharker, M., Salje, H., Islam, M., Epstein, J. H., Khan, S. U., Kilpatrick, A., Daszak, P., Luby, S. P. 2017; 23 (9): 1446–53

  Abstract

  Preventing emergence of new zoonotic viruses depends on understanding determinants for human risk. Nipah virus (NiV) is a lethal zoonotic pathogen that has spilled over from bats into human populations, with limited person-to-person transmission. We examined ecologic and human behavioral drivers of geographic variation for risk of NiV infection in Bangladesh. We visited 60 villages during 2011-2013 where cases of infection with NiV were identified and 147 control villages. We compared case villages with control villages for most likely drivers for risk of infection, including number of bats, persons, and date palm sap trees, and human date palm sap consumption behavior. Case villages were similar to control villages in many ways, including number of bats, persons, and date palm sap trees, but had a higher proportion of households in which someone drank sap. Reducing human consumption of sap could reduce virus transmission and risk for emergence of a more highly transmissible NiV strain.

  View details for DOI 10.3201/eid2309.161922

  View details for Web of Science ID 000407786000002

  View details for PubMedID 28820130

  View details for PubMedCentralID PMC5572889

• Stepped-wedge cluster-randomised controlled trial to assess the cardiovascular health effects of a managed aquifer recharge initiative to reduce drinking water salinity in southwest coastal Bangladesh: study design and rationale BMJ OPEN Naser, A., Unicomb, L., Doza, S., Ahmed, K., Rahman, M., Uddin, M., Quraishi, S. B., Selim, S., Shamsudduha, M., Burgess, W., Chang, H. H., Gribble, M. O., Clasen, T. F., Luby, S. P. 2017; 7 (9): e015205

  Abstract

  Saltwater intrusion and salinisation have contributed to drinking water scarcity in many coastal regions globally, leading to dependence on alternative sources for water supply. In southwest coastal Bangladesh, communities have few options but to drink brackish groundwater which has been associated with high blood pressure among the adult population, and pre-eclampsia and gestational hypertension among pregnant women. Managed aquifer recharge (MAR), the purposeful recharge of surface water or rainwater to aquifers to bring hydrological equilibrium, is a potential solution for salinity problem in southwest coastal Bangladesh by creating a freshwater lens within the brackish aquifer. Our study aims to evaluate whether consumption of MAR water improves human health, particularly by reducing blood pressure among communities in coastal Bangladesh.The study employs a stepped-wedge cluster-randomised controlled community trial design in 16 communities over five monthly visits. During each visit, we will collect data on participants' source of drinking and cooking water and measure the salinity level and electrical conductivity of household stored water. At each visit, we will also measure the blood pressure of participants ≥20 years of age and pregnant women and collect urine samples for urinary sodium and protein measurements. We will use generalised linear mixed models to determine the association of access to MAR water on blood pressure of the participants.The study protocol has been reviewed and approved by the Institutional Review Boards of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). Informed written consent will be taken from all the participants. This study is funded by Wellcome Trust, UK. The study findings will be disseminated to the government partners, at research conferences and in peer-reviewed journals.NCT02746003; Pre-results.

  View details for PubMedID 28864689

• A Controlled Trial to Reduce the Risk of Human Nipah Virus Exposure in Bangladesh ECOHEALTH Nahar, N., Paul, R. C., Sultana, R., Sumon, S., Banik, K., Abedin, J., Asaduzzaman, M., Garcia, F., Zimicki, S., Rahman, M., Gurley, E. S., Luby, S. P. 2017; 14 (3): 501–17

  Abstract

  Human Nipah virus (NiV) infection, often fatal in Bangladesh, is primarily transmitted by drinking raw date palm sap contaminated by Pteropus bats. We assessed the impact of a behavior change communication intervention on reducing consumption of potentially NiV-contaminated raw sap. During the 2012-2014 sap harvesting seasons, we implemented interventions in two areas and compared results with a control area. In one area, we disseminated a "do not drink raw sap" message and, in the other area, encouraged only drinking sap if it had been protected from bat contamination by a barrier ("only safe sap"). Post-intervention, 40% more respondents in both intervention areas reported knowing about a disease contracted through raw sap consumption compared with control. Reported raw sap consumption decreased in all areas. The reductions in the intervention areas were not significantly greater compared to the control. Respondents directly exposed to the "only safe sap" message were more likely to report consuming raw sap from a protected source than those with no exposure (25 vs. 15%, OR 2.0, 95% CI 1.5-2.6, P < 0.001). While the intervention increased knowledge in both intervention areas, the "only safe sap" intervention reduced exposure to potentially NiV-contaminated sap and should be considered for future dissemination.

  View details for PubMedID 28905152

• If I do not have enough water, then how could I bring additional water for toilet cleaning?! Addressing water scarcity to promote hygienic use of shared toilets in Dhaka, Bangladesh TROPICAL MEDICINE & INTERNATIONAL HEALTH Saxton, R. E., Yeasmin, F., Alam, M., Al-Masud, A., Dutta, N., Yeasmin, D., Luby, S. P., Unicomb, L., Winch, P. J. 2017; 22 (9): 1099–1111

  Abstract

  Provision of toilets is necessary but not sufficient to impact health as poor maintenance may impair toilet function and discourage their consistent use. Water in urban slums is both scarce and a prerequisite for toilet maintenance behaviours. We describe the development of behaviour change communications and selection of low-cost water storage hardware to facilitate adequate flushing among users of shared toilets.We conducted nine focus group discussions and six ranking exercises with adult users of shared toilets (50 females, 35 males), then designed and implemented three pilot interventions to facilitate regular flushing and improve hygienic conditions of shared toilets. We conducted follow-up assessments 1 and 2 months post-pilot including nine in-depth interviews and three focus group discussions with adult residents (23 females, 15 males) and three landlords in the pilot communities.Periodic water scarcity was common in the study communities. Residents felt embarrassed to carry water for flushing. Reserving water adjacent to the shared toilet enabled slum residents to flush regularly. Signs depicting rules for toilet use empowered residents and landlords to communicate these expectations for flushing to transient tenants. Residents in the pilot reported improvements in cleanliness and reduced odour inside toilet cubicles.Our pilot demonstrates the potential efficacy of low-cost water storage and behaviour change communications to improve maintenance of and user satisfaction with shared toilets in urban slum settings.

  View details for PubMedID 28656596

• Piloting a low-cost hardware intervention to reduce improper disposal of solid waste in communal toilets in low-income settlements in Dhaka, Bangladesh. BMC public health Yeasmin, F., Luby, S. P., Saxton, R. E., Nizame, F. A., Alam, M. U., Dutta, N. C., Masud, A. A., Yeasmin, D., Layden, A., Rahman, H., Abbott, R., Unicomb, L., Winch, P. J. 2017; 17 (1): 682

  Abstract

  Bangladesh faces daunting challenges in addressing the sanitation needs of its urban poor. Maintaining the cleanliness and functionality of communal toilets is dependent upon periodic emptying of fecal sludge, and cooperation between users of communal toilets. Trash disposal into latrines can block the outflow pipes, rendering the toilets non-functional.Pre-intervention: We conducted in-depth interviews with five operators of fecal sludge emptying equipment and five adult residents who were also caregivers of children. We identified factors contributing to improper disposal of trash into communal toilets, a barrier to operation of the equipment, in low-income communities of Dhaka, Bangladesh. Intervention design: We developed behavior change communication materials to discourage waste disposal in toilets, and promote use of waste bins. We conducted six focus group discussions with adult male, female, landlord and children to select the preferred design for waste bins to be placed inside toilets, and finalize communication materials. Post-intervention: We then pilot-tested an intervention package to promote appropriate trash disposal practices and thus facilitate periodic removal of fecal sludge when the latrine pits become full. We conducted 20 in-depth interviews and four focus group discussions with community residents, landlords and cleaners of communal toilets.Barriers to appropriate waste disposal included lack of private location for disposal of menstrual hygiene products, limited options for formal trash collection and disposal, and the use of plastic bags for disposing children's feces. A pilot intervention including behavior change communication and trash bins was implemented in two urban slum communities. Spot checks confirmed that the bins were in place and used. Respondents described positive improvements in the appearance of the toilet and surrounding environment.The current practice on the part of local residents of disposing of waste into toilets impedes the safe removal of fecal sludge and impairs toilet functionality. Residents reported positive changes in toilet cleanliness and usability resulting from this intervention, and this both improves the user experience with toilets, and also promotes the sustainability of the entrepreneurial model of Vacutug operators supported by WSUP.

  View details for DOI 10.1186/s12889-017-4693-x

  View details for PubMedID 28851334

  View details for PubMedCentralID PMC5576109

• Animal Feces Contribute to Domestic Fecal Contamination: Evidence from E-coli Measured in Water, Hands, Food, Flies, and Soil in Bangladesh ENVIRONMENTAL SCIENCE & TECHNOLOGY Ercumen, A., Pickering, A. J., Kwong, L. H., Arnold, B. F., Parvez, S., Alam, M., Sen, D., Islam, S., Kullmann, C., Chase, C., Ahmed, R., Unicomb, L., Luby, S. P., Colford, J. M. 2017; 51 (15): 8725–34

  Abstract

  Fecal-oral pathogens are transmitted through complex, environmentally mediated pathways. Sanitation interventions that isolate human feces from the environment may reduce transmission but have shown limited impact on environmental contamination. We conducted a study in rural Bangladesh to (1) quantify domestic fecal contamination in settings with high on-site sanitation coverage; (2) determine how domestic animals affect fecal contamination; and (3) assess how each environmental pathway affects others. We collected water, hand rinse, food, soil, and fly samples from 608 households. We analyzed samples with IDEXX Quantitray for the most probable number (MPN) of E. coli. We detected E. coli in source water (25%), stored water (77%), child hands (43%), food (58%), flies (50%), ponds (97%), and soil (95%). Soil had >120 000 mean MPN E. coli per gram. In compounds with vs without animals, E. coli was higher by 0.54 log10 in soil, 0.40 log10 in stored water and 0.61 log10 in food (p < 0.05). E. coli in stored water and food increased with increasing E. coli in soil, ponds, source water and hands. We provide empirical evidence of fecal transmission in the domestic environment despite on-site sanitation. Animal feces contribute to fecal contamination, and fecal indicator bacteria do not strictly indicate human fecal contamination when animals are present.

  View details for PubMedID 28686435

  View details for PubMedCentralID PMC5541329

• Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey BMJ OPEN Alam, M., Luby, S. P., Halder, A. K., Islam, K., Opel, A., Shoab, A. K., Ghosh, P. K., Rahman, M., Mahon, T., Unicomb, L. 2017; 7 (7): e015508

  Abstract

  Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls.We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering.Among schoolgirls who reached menarche, 41% (931) reported missing school, an average of 2.8 missed days per menstrual cycle. Students who felt uncomfortable at school during menstruation (99% vs 32%; APD=58%; CI 54 to 63) and who believed menstrual problems interfere with school performance (64% vs 30%; APD=27; CI 20 to 33) were more likely to miss school during menstruation than those who did not. School absence during menstruation was less common among girls attending schools with unlocked toilet for girls (35% vs 43%; APD=-5.4; CI -10 to -1.6). School absence was more common among girls who were forbidden from any activities during menstruation (41% vs 33%; APD=9.1; CI 3.3 to 14).Risk factors for school absence included girl's attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction. Enabling girls to manage menstruation at school by providing knowledge and management methods prior to menarche, privacy and a positive social environment around menstrual issues has the potential to benefit students by reducing school absence.

  View details for PubMedID 28694347

• A large-scale behavior change intervention to prevent Nipah transmission in Bangladesh: components and costs. BMC research notes Nahar, N., Asaduzzaman, M., Sultana, R., Garcia, F., Paul, R. C., Abedin, J., Sazzad, H. M., Rahman, M., Gurley, E. S., Luby, S. P. 2017; 10 (1): 225

  Abstract

  Nipah virus infection (NiV) is a bat-borne zoonosis transmitted to humans through consumption of NiV-contaminated raw date palm sap in Bangladesh. The objective of this analysis was to measure the cost of an NiV prevention intervention and estimate the cost of scaling it up to districts where spillover had been identified.We implemented a behavior change communication intervention in two districts, testing different approaches to reduce the risk of NiV transmission using community mobilization, interpersonal communication, posters and TV public service announcements on local television during the 2012-2014 sap harvesting seasons. In one district, we implemented a "no raw sap" approach recommending to stop drinking raw date palm sap. In another district, we implemented an "only safe sap" approach, recommending to stop drinking raw date palm sap but offering the option of drinking safe sap. This is sap covered with a barrier, locally called bana, to interrupt bats' access during collection. We conducted surveys among randomly selected respondents two months after the intervention to measure the proportion of people reached. We used an activity-based costing method to calculate the cost of the intervention.The implementation cost of the "no raw sap" intervention was $30,000 and the "only safe sap" intervention was $55,000. The highest cost was conducting meetings and interpersonal communication efforts. The lowest cost was broadcasting the public service announcements on local TV channels. To scale up a similar intervention in 30 districts where NiV spillover has occurred, would cost between $2.6 and $3.5 million for one season. Placing the posters would cost $96,000 and only broadcasting the public service announcement through local channels in 30 districts would cost $26,000.Broadcasting a TV public service announcement is a potential low cost option to advance NiV prevention. It could be supplemented with posters and targeted interpersonal communication, in districts with a high risk of NiV spillover.

  View details for DOI 10.1186/s13104-017-2549-1

  View details for PubMedID 28651646

  View details for PubMedCentralID PMC5485710

• Disease ecology, health and the environment: a framework to account for ecological and socio-economic drivers in the control of neglected tropical diseases PHILOSOPHICAL TRANSACTIONS OF THE ROYAL SOCIETY B-BIOLOGICAL SCIENCES Garchitorena, A., Sokolow, S. H., Roche, B., Ngonghala, C. N., Jocque, M., Lund, A., Barry, M., MORDECAI, E. A., Daily, G. C., Jones, J. H., Andrews, J. R., Bendavid, E., Luby, S. P., LaBeaud, A. D., Seetah, K., Guegan, J. F., Bonds, M. H., De Leo, G. A. 2017; 372 (1722)

  Abstract

  Reducing the burden of neglected tropical diseases (NTDs) is one of the key strategic targets advanced by the Sustainable Development Goals. Despite the unprecedented effort deployed for NTD elimination in the past decade, their control, mainly through drug administration, remains particularly challenging: persistent poverty and repeated exposure to pathogens embedded in the environment limit the efficacy of strategies focused exclusively on human treatment or medical care. Here, we present a simple modelling framework to illustrate the relative role of ecological and socio-economic drivers of environmentally transmitted parasites and pathogens. Through the analysis of system dynamics, we show that periodic drug treatments that lead to the elimination of directly transmitted diseases may fail to do so in the case of human pathogens with an environmental reservoir. Control of environmentally transmitted diseases can be more effective when human treatment is complemented with interventions targeting the environmental reservoir of the pathogen. We present mechanisms through which the environment can influence the dynamics of poverty via disease feedbacks. For illustration, we present the case studies of Buruli ulcer and schistosomiasis, two devastating waterborne NTDs for which control is particularly challenging.This article is part of the themed issue 'Conservation, biodiversity and infectious disease: scientific evidence and policy implications'.

  View details for DOI 10.1098/rstb.2016.0128

  View details for PubMedID 28438917

• Clean water, clean hands or new vaccines? The Journal of infection Luby, S. P. 2017; 74 Suppl 1: S18-S22

  Abstract

  Throughout human history, pathogens transmitted through feces from person to person have caused substantial mortality. Over a century ago civil engineers in high income countries developed approaches to collect and remove feces from the environment that in communities with high incomes and strong governments markedly reduced the burden of enteric disease. These approaches, however, have not been successfully extended to impoverished communities in low income countries. Water/sanitation/hygiene professionals have attempted, with only limited success, to reduce fecal exposure and human disease in the absence of definitive civil engineering approaches. Medical professionals have worked to develop vaccines against some of the most important fecal oral pathogens. Each of these approaches needs further development and adaptation to optimally address the burden of fecally transmitted diseases in impoverished communities.

  View details for DOI 10.1016/S0163-4453(17)30186-X

  View details for PubMedID 28646956

• Behaviour change intervention to improve shared toilet maintenance and cleanliness in urban slums of Dhaka: A cluster-randomized controlled trial. Tropical medicine & international health Alam, M., Winch, P. J., Saxton, R. E., Nizame, F. A., Yeasmin, F., Norman, G., Masud, A., Begum, F., Rahman, M., Hossain, K., Layden, A., Unicomb, L., Luby, S. P. 2017

  Abstract

  Shared toilets in urban slums are often unclean and poorly maintained, discouraging consistent use and thereby limiting impacts on health and quality of life. We developed behaviour change interventions to support shared toilet maintenance and improve user satisfaction. We report the intervention effectiveness on improving shared toilet cleanliness.We conducted a cluster-randomised controlled trial among users of 1226 shared toilets in 23 Dhaka slums. We assessed baseline toilet cleanliness in January 2015. The six-month intervention included provision of hardware (bin for solid waste, 4 l flushing bucket, 70 l water reservoir), and behaviour change communication (compound meetings, interpersonal household sessions, signs depicting rules for toilet use). We estimated the adjusted difference in difference (DID) to assess outcomes and accounted for clustering effects using generalised estimating equations.Compared to controls, intervention toilets were more likely to have water available inside toilet cubicles (DID: +4.7%, 95% CI: 0.2, 9.2), access to brush/broom for cleaning (DID: +8.4%, 95% CI: 2, 15) and waste bins (DID: +63%, 95% CI: 59, 66), while less likely to have visible faeces inside the pan (DID: -13%, 95% CI: -19, -5), the smell of faeces (DID: -7.6%, 95% CI: -14, -1.3) and household waste inside the cubicle (DID: -4%, 95% CI: -7, -1).In one of few efforts to promote shared toilet cleanliness, intervention compounds were significantly more likely to have cleaner toilets after six months. Future research might explore how residents can self-finance toilet maintenance, or employ mass media to reduce per-capita costs of behaviour change.

  View details for DOI 10.1111/tmi.12902

  View details for PubMedID 28556458

• Advantages and limitations for users of double pit pour-flush latrines: a qualitative study in rural Bangladesh. BMC public health Hussain, F., Clasen, T., Akter, S., Bawel, V., Luby, S. P., Leontsini, E., Unicomb, L., Barua, M. K., Thomas, B., Winch, P. J. 2017; 17 (1): 515-?

  Abstract

  In rural Bangladesh, India and elsewhere, pour-flush pit latrines are the most common sanitation system. When a single pit latrine becomes full, users must empty it themselves and risk exposure to fresh feces, pay an emptying service to remove pit contents or build a new latrine. Double pit pour-flush latrines may serve as a long-term sanitation option including high water table areas because the pits do not need to be emptied immediately and the excreta decomposes into reusable soil.Double pit pour-flush latrines were implemented in rural Bangladesh for 'hardcore poor' households by a national NGO, BRAC. We conducted interviews, focus groups, and spot checks in two low-income, rural areas of Bangladesh to explore the advantages and limitations of using double pit latrines compared to single pit latrines.The rural households accepted the double pit pour-flush latrine model and considered it feasible to use and maintain. This latrine design increased accessibility of a sanitation facility for these low-income residents and provided privacy, convenience and comfort, compared to open defecation. Although a double pit latrine is more costly and requires more space than a single pit latrine the households perceived this sanitation system to save resources, because households did not need to hire service workers to empty pits or remove decomposed contents themselves. In addition, the excreta decomposition process produced a reusable soil product that some households used in homestead gardening. The durability of the latrine superstructures was a problem, as most of the bamboo-pole superstructure broke after 6-18 months of use.Double pit pour-flush latrines are a long-term improved sanitation option that offers users several important advantages over single pit pour-flush latrines like in rural Bangladesh which can also be used in areas with high water table. Further research can provide an understanding of the comparative health impacts and effectiveness of the model in preventing human excreta from entering the environment.

  View details for DOI 10.1186/s12889-017-4412-7

  View details for PubMedID 28545427

• Provision versus promotion to develop a handwashing station: the effect on desired handwashing behavior BMC PUBLIC HEALTH Biswas, D., Nizame, F. A., Sanghvi, T., Roy, S., Luby, S. P., Unicomb, L. E. 2017; 17

  Abstract

  Diarrhea prevalence increases from around the time that complementary foods are introduced. Improving caregiver's hand hygiene during food preparation could reduce complementary food contamination and enteric pathogen transmission. Washing hands with soap is more common when water and soap are together at a convenient location. We conducted a three-month pilot intervention to evaluate two options for setting up handwashing stations: i) provide a handwashing station, or ii) help the family to make their own from available materials. Additionally, we assessed the feasibility of this intervention to be integrated with a child feeding program.We conducted the intervention among two groups; 40 households received a free of cost handwashing station and another 40 households were motivated to place their own soap/soapy-water and water vessel near the food preparation and child feeding area. Community health workers encouraged caregivers to wash hands with soap/soapy-water before food preparation and feeding a child. They either assisted study participants to install the study-provided handwashing station at the recommended place or encouraged caregivers to develop their own. Field researchers assessed placement and composition of handwashing stations and the feasibility of integrating handwashing and nutrition messages.By end of the trial, 39/40 households developed their own handwashing station, comprising a bucket, mug and bar soap/soapy-water of which 60% (6/10) households were observed with a functional and complete handwashing station set. Observed handwashing with soap was detected among 8/10 households from the study-provided handwashing station group and 5/10 among households who had made their own handwashing station. Sixty-seven of the 76 caregivers recalled integrated intervention messages on social and health benefits of infant and young child feeding correctly; and all recalled key handwashing with soap times, before food preparation and feeding a child.Encouraging households to develop their own handwashing station with soap and water to place at a food preparation/child feeding location is feasible over the short term. In the absence of large-scale provision of handwashing stations, caregivers can be encouraged to create and use their own. Integrating handwashing with soap into a nutrition intervention was feasible and acceptable and should be considered by policy makers.

  View details for DOI 10.1186/s12889-017-4316-6

  View details for Web of Science ID 000400819300002

  View details for PubMedID 28476170

• Behavioral antecedents for handwashing in a low-income urban setting in Bangladesh: an exploratory study BMC PUBLIC HEALTH Rahman, M. J., Nizame, F. A., Unicomb, L., Luby, S. P., Winch, P. J. 2017; 17

  Abstract

  Health programs commonly promote handwashing by drawing attention to potential fecal contamination in the environment. The underlying assumption is that the thought of fecal contamination will result in disgust, and motivate people to wash their hands with soap. However, this has not proven sufficient to achieve high rates of handwashing with soap at key times. We argue that handwashing with soap is influenced by broader range of antecedents, many unrelated to fecal contamination, that indicate to people when and where to wash their hands. This exploratory study aimed to identify and characterize this broader range of handwashing antecedents for use in future handwashing promotion efforts.First, an initial list of behavioral antecedents was elicited through unstructured interviews, focus group discussions and observation with residents, from a low-income community in Dhaka, Bangladesh, who were also recipients of a handwashing intervention. Then, photographs representing three categories of behavioral antecedents were taken: activities of daily living, visual or tactile sensations, and handwashing-related hardware and activities. Finally, the research team conducted ranking exercises with a new set of participants, from the same area, to assess the perceived importance of each antecedent illustrated by the photographs. The research team probed about perceptions regarding how and why that particular antecedent, represented by the photograph, influences handwashing behavior.After coming out of the bathroom and dirt (moyla) on hands were the two antecedents that ranked highest. In all the categories, intervention-related antecedents (three key times for handwashing which included handwashing after coming out of the bathroom, after cleaning a child's anus and before food preparation; intervention provided items that included handwashing station, soapy water bottle, handwashing reminders from posters and community health provider visits) that were being promoted actively in this community were perceived favorably in the qualitative responses, but did not consistently rank higher than non-intervention items. However, many other antecedents were reported to influence when and where people wash their hands: cutting greasy fish, starting a meal, contact with oil and fat stuck to dishes, oil and lice from hair, sweat, unwashed vegetables, reminders from son and daughter or observing others wash hands, and observing the sunset.Beyond well-recognized antecedents related to fecal contact and dirt on hands, we identified a broader set of antecedents not reported in the literature. Adopting a handwashing promotional strategy to highlight existing antecedents that people themselves have identified as important can help inform the content of an intervention that is more relatable and effective in increasing handwashing practices.

  View details for DOI 10.1186/s12889-017-4307-7

  View details for Web of Science ID 000400819300004

  View details for PubMedID 28476100

• An epidemiological study of avian influenza A (H5) virus in nomadic ducks and their raising practices in northeastern Bangladesh, 2011-2012 INFLUENZA AND OTHER RESPIRATORY VIRUSES Sarkar, S., Khan, S. U., Mikolon, A., Rahman, M. Z., Abedin, J., Zeidner, N., Sturm-Ramirez, K., Luby, S. P. 2017; 11 (3): 275-282

  Abstract

  In Bangladesh, nomadic duck flocks are groups of domestic ducks reared for egg production that are moved to access feeding sites beyond their owners' village boundaries and are housed overnight in portable enclosures in scavenging areas. The objectives of this study were to measure the prevalence of influenza A virus RNA and H5-specific antibodies in nomadic ducks and to characterize nomadic duck raising practices in northeastern Bangladesh.We tested duck egg yolk specimens by competitive ELISA to detect antibodies against avian influenza A (H5) and environmental fecal samples by real-time reverse-transcription polymerase chain reaction (rRT-PCR) to detect influenza A virus RNA and H5 subtype.The median age of the ducks was 24 months (range: 8-36 months) and the median flock size was 300 ducks (range: 105-1100). Of 1860 egg yolk samples, 556 (30%, 95% confidence interval (CI): 28-32) were positive for antibodies against H5 and 58 flocks (94%) had at least one egg with H5-specific antibodies. Of 496 fecal samples, 121 (24%, 95% CI: 22-29) had detectable influenza A RNA. Thirty-three flocks (53%) had at least one fecal sample positive for influenza A RNA.Nomadic ducks in Bangladesh are commonly infected with avian influenza A (H5) virus and may serve as a bridging host for transmission of avian influenza A (H5) virus or other avian influenza A viruses subtypes between wild waterfowl, backyard poultry, and humans in Bangladesh.

  View details for DOI 10.1111/irv.12438

  View details for Web of Science ID 000400361000010

  View details for PubMedCentralID PMC5410719

• Scaling Up a Water, Sanitation, and Hygiene Program in Rural Bangladesh: The Role of Program Implementation. American journal of public health Benjamin-Chung, J., Sultana, S., Halder, A. K., Ahsan, M. A., Arnold, B. F., Hubbard, A. E., Unicomb, L., Luby, S. P., Colford, J. M. 2017; 107 (5): 694-701

  Abstract

  To evaluate whether the quality of implementation of a water, sanitation, and hygiene program called SHEWA-B and delivered by UNICEF to 20 million people in rural Bangladesh was associated with health behaviors and sanitation infrastructure access.We surveyed 33 027 households targeted by SHEWA-B and 1110 SHEWA-B hygiene promoters in 2011 and 2012. We developed an implementation quality index and compared the probability of health behaviors and sanitation infrastructure access in counterfactual scenarios over the range of implementation quality.Forty-seven percent of households (n = 14 622) had met a SHEWA-B hygiene promoter, and 47% of hygiene promoters (n = 527) could recall all key program messages. The frequency of hygiene promoter visits was not associated with improved outcomes. Higher implementation quality was not associated with better health behaviors or infrastructure access. Outcomes differed by only 1% to 3% in scenarios in which all clusters received low versus high implementation quality.SHEWA-B did not meet UNICEF's ideal implementation quality in any area. Improved implementation quality would have resulted in marginal changes in health behaviors or infrastructure access. This suggests that SHEWA-B's design was suboptimal for improving these outcomes.

  View details for DOI 10.2105/AJPH.2017.303686

  View details for PubMedID 28323462

• Spillover effects on health outcomes in low- and middle-income countries: a systematic review. International journal of epidemiology Benjamin-Chung, J., Abedin, J., Berger, D., Clark, A., Jimenez, V., Konagaya, E., Tran, D., Arnold, B. F., Hubbard, A. E., Luby, S. P., Miguel, E., Colford, J. M. 2017

  Abstract

  Many interventions delivered to improve health may benefit not only direct recipients but also people in close physical or social proximity. Our objective was to review all published literature about the spillover effects of interventions on health outcomes in low-middle income countries and to identify methods used in estimating these effects.We searched 19 electronic databases for articles published before 2014 and hand-searched titles from 2010 to 2013 in five relevant journals. We adapted the Cochrane Collaboration's quality grading tool for spillover estimation and rated the quality of evidence.A total of 54 studies met inclusion criteria. We found a wide range of terminology used to describe spillovers, a lack of standardization among spillover methods and poor reporting of spillovers in many studies. We identified three primary mechanisms of spillovers: reduced disease transmission, social proximity and substitution of resources within households. We found the strongest evidence for spillovers through reduced disease transmission, particularly vaccines and mass drug administration. In general, the proportion of a population receiving an intervention was associated with improved health. Most studies were of moderate or low quality. We found evidence of publication bias for certain spillover estimates but not for total or direct effects. To facilitate improved reporting and standardization in future studies, we developed a reporting checklist adapted from the CONSORT framework specific to reporting spillover effects.We found the strongest evidence for spillovers from vaccines and mass drug administration to control infectious disease. There was little high quality evidence of spillovers for other interventions.

  View details for DOI 10.1093/ije/dyx039

  View details for PubMedID 28449030

• Incidences and Costs of Illness for Diarrhea and Acute Respiratory Infections for Children < 5 Years of Age in Rural Bangladesh. American journal of tropical medicine and hygiene Halder, A. K., Luby, S. P., Akhter, S., Ghosh, P. K., Johnston, R. B., Unicomb, L. 2017; 96 (4): 953-960

  Abstract

  AbstractUnderstanding illness costs associated with diarrhea and acute respiratory infections (ARI) could guide prevention and treatment strategies. This study aimed to determine incidence of childhood diarrhea and ARI and costs of homecare, hospitalization, and outpatient treatment by practitioner type in rural Bangladesh. From each of 100 randomly selected population clusters we sampled 17 households with at least one child < 5 years of age. Childhood diarrhea incidence was 3,451 and ARI incidence was 5,849/1,000 child-years. For diarrhea and ARI outpatient care per 1,000 child-years, parents spent more on unqualified ($2,361 and $4,822) than qualified health-care practitioners ($113 and $947). For outpatient care, visits to unqualified health-care practitioners were at least five times more common than visits to qualified practitioners. Costs for outpatient care treatment by unqualified health-care practitioners per episode of illness were similar to those for qualified health-care practitioners. Homecare costs were similar for diarrhea and ARI ($0.16 and $0.24) as were similar hospitalization costs per episode of diarrhea and ARI ($35.40 and $37.76). On average, rural Bangladeshi households with children < 5 years of age spent 1.3% ($12 of $915) of their annual income managing diarrhea and ARI for those children. The majority of childhood illness management cost comprised visits to unqualified health-care practitioners. Policy makers should consider strategies to increase the skills of unqualified health-care practitioners, use community health workers to provide referral, and promote homecare for diarrhea and ARI. Incentives to motivate existing qualified physicians who are interested to work in rural Bangladesh could also be considered.

  View details for DOI 10.4269/ajtmh.16-0005

  View details for PubMedID 28167594

• Biosecurity Conditions in Small Commercial Chicken Farms, Bangladesh 2011-2012. EcoHealth Rimi, N. A., Sultana, R., Muhsina, M., UDDIN, B., Haider, N., Nahar, N., Zeidner, N., Sturm-Ramirez, K., Luby, S. P. 2017

  Abstract

  In Bangladesh, highly pathogenic avian influenza H5N1 is endemic in poultry. This study aimed to understand the biosecurity conditions and farmers' perception of avian influenza biosecurity in Bangladeshi small commercial chicken farms. During 2011-2012, we conducted observations, in-depth interviews and group discussions with poultry farmers in 16 farms and in-depth interviews with seven local feed vendors from two districts. None of the farms were completely segregated from people, backyard poultry, other animals, households, other poultry farms or large trees. Wild birds and rodents accessed the farms for poultry feed. Farmers usually did not allow the buyers to bring egg trays inside their sheds. Spraying disinfectant in the shed and removing feces were the only regular cleaning and disinfection activities observed. All farmers sold or used untreated feces as fish feed or fertilizer. Farmers were more concerned about Newcastle disease and infectious bursal disease than about avian influenza. Farmers' understanding about biosecurity and avian influenza was influenced by local vendors. While we seldom observed flock segregation, some farmers used measures that involved additional cost or effort to protect their flocks. These farmers could be motivated by interventions to protect their investment from diseases they consider harmful. Future interventions could explore the feasibility and effectiveness of low-cost alternative biosecurity measures.

  View details for DOI 10.1007/s10393-017-1224-2

  View details for PubMedID 28289988

• Influenza B virus outbreak at a religious residential school for boys in Northern Bangladesh, 2011. Influenza and other respiratory viruses Haque, F., Sturm-Ramirez, K., Homaira, N., Gurley, E. S., Hossain, M. J., Hasan, S. M., Chowdhury, S., Sarkar, S., Khan, A. K., Rahman, M., Rahman, M., Luby, S. P. 2017; 11 (2): 165-169

  Abstract

  National media reported a febrile illness among dormitory residents of a boys' religious school. We investigated the outbreak to identify cause.Individuals with fever (>100°F) and cough or sore throat between 1 and 13 August 2011 were influenza-like-illness (ILI) case-patients. We collected histories and specimens from hospitalized case-patients and visited campus to explore environmental context.All 28 case-patients were dormitory residents including 27 hospitalizations. Accommodation space per resident was <0.8 square metres. Nasal and oropharyngeal swabs from 22 case-patients were positive for influenza B virus using real-time reverse transcription polymerase chain reaction (rRT-PCR).Overcrowding likely facilitated transmission leading to this dormitory outbreak.

  View details for DOI 10.1111/irv.12430

  View details for PubMedID 27603154

• Influenza B virus outbreak at a religious residential school for boys in Northern Bangladesh, 2011 INFLUENZA AND OTHER RESPIRATORY VIRUSES Haque, F., Sturm-Ramirez, K., Homaira, N., Gurley, E. S., Hossain, M. J., Hasan, S. M., Chowdhury, S., Sarkar, S., Khan, A. K., Rahman, M., Rahman, M., Luby, S. P. 2017; 11 (2): 165-169

  View details for DOI 10.1111/irv.12430

  View details for Web of Science ID 000394961400008

• Prevalence and clinical presentation of Rickettsia, Coxiella, Leptospira, Bartonella and chikungunya virus infections among hospital-based febrile patients from December 2008 to November 2009 in Bangladesh BMC INFECTIOUS DISEASES Faruque, L. I., Zaman, R. U., Gurley, E. S., Massung, R. F., Alamgir, A. S., Galloway, R. L., Powers, A. M., Bai, Y., Kosoy, M., Nicholson, W. L., Rahman, M., Luby, S. P. 2017; 17

  Abstract

  We conducted a study to identify Rickettsia, Coxiella, Leptospira, Bartonella, and Chikungunya virus infections among febrile patients presenting at hospitals in Bangladesh.We collected blood samples from patients at six tertiary hospitals from December 2008 to November 2009 and performed laboratory tests at the United States Centers for Disease Control and Prevention (CDC).Out of 720 enrolled patients, 263 (37%) were infected with Rickettsia; 132 patients had immunofluorescence antibody titer >64 against spotted fever, 63 patients against scrub typhus fever and 10 patients against typhus fever. Ten patients were identified with Coxiella. We isolated Leptospira from two patients and Bartonella from one patient. Ten patients had antibodies against Chikungunya virus. The proportion of patients who died was higher with rickettsial fever (5%) compared to those without a diagnosis of rickettsial infection (2%). None of the patients were initially diagnosed with rickettsial fever.Rickettsial infections are frequent yet under-recognized cause of febrile illness in Bangladesh. Clinical guidelines should be revised so that local clinicians can diagnose rickettsial infections and provide appropriate drug treatment.

  View details for DOI 10.1186/s12879-017-2239-6

  View details for Web of Science ID 000397383500003

  View details for PubMedID 28193163

• Surveillance at Private Laboratories Identifies Small Outbreaks of Hepatitis E in Urban Bangladesh. American journal of tropical medicine and hygiene Sazzad, H. M., Labrique, A. B., Teo, C., Luby, S. P., Gurley, E. S. 2017; 96 (2): 395-399

  Abstract

  Although large outbreaks of hepatitis E are regularly identified in south Asia, the majority of south Asian countries lack surveillance systems for this disease, which has hindered burden of disease estimates and prioritization of resources for prevention. Our study aimed to identify small hepatitis E outbreaks through a sentinel private laboratory in Dhaka, Bangladesh. We identified patients with detectable IgM antibody against hepatitis E virus. We defined a small outbreak as at least two laboratory-confirmed cases or ≥ 2 acute jaundice cases from the sentinel cases' family, neighborhood, or workplace. From November 2008 to November 2009, we identified 29 small outbreaks of hepatitis E from one private laboratory. The median number of cases in each outbreak was three. Cases were identified every month. Eighteen outbreaks occurred among families or neighbors, and 11 in the workplace. Among 103 cases identified as part of outbreaks, 31 (30%) sought care for diagnosis. In Bangladesh, collaboration between government public health surveillance and private laboratories can strengthen capacity for outbreak detection and improve estimates of disease burden.

  View details for DOI 10.4269/ajtmh.16-0411

  View details for PubMedID 27994104

• Nonrandomized Trial of Feasibility and Acceptability of Strategies for Promotion of Soapy Water as a Handwashing Agent in Rural Bangladesh. The American journal of tropical medicine and hygiene Ashraf, S., Nizame, F. A., Islam, M., Dutta, N. C., Yeasmin, D., Akhter, S., Abedin, J., Winch, P. J., Ram, P. K., Unicomb, L., Leontsini, E., Luby, S. P. 2017; 96 (2): 421-429

  Abstract

  We conducted a nonrandomized trial of strategies to promote soapy water for handwashing in rural Bangladesh and measured uptake. We enrolled households with children < 3 years for three progressively intensive study arms: promotion of soapy water (N = 120), soapy water promotion plus handwashing stations (N = 103), and soapy water promotion, stations plus detergent refills (N = 90); we also enrolled control households (N = 72). Our handwashing stations included tap-fitted buckets and soapy water bottles. Community promoters visited households and held community meetings to demonstrate soapy water preparation and promote handwashing at key times. Field workers measured uptake 4 months later. In-depth interviews and focus group discussions assessed factors associated with uptake. More households had soapy water at the handwashing place in progressively intensive arms: 18% (promotion), 60% (promotion plus station), and 71% (promotion, station with refills). Compared with the promotion-only arm, more households that received stations had soapy water at the primary handwashing station (44%, P ≤ 0.001; 71%, P < 0.001 with station plus detergent refill). Qualitative findings highlighted several dimensions that affected use: contextual (shared courtyard), psychosocial (perceived value), and technology dimensions (ease of use, convenience). Soapy water may increase habitual handwashing by addressing barriers of cost and availability of handwashing agents near water sources. Further research should inform optimal strategies to scale-up soapy water as a handwashing agent to study health impact.

  View details for DOI 10.4269/ajtmh.16-0304

  View details for PubMedID 28025233

  View details for PubMedCentralID PMC5303048

• Escherichia coli contamination of child complementary foods and association with domestic hygiene in rural Bangladesh. Tropical medicine & international health Parvez, S. M., Kwong, L., Rahman, M. J., Ercumen, A., Pickering, A. J., Ghosh, P. K., Rahman, M. Z., Das, K. K., Luby, S. P., Unicomb, L. 2017

  Abstract

  To determine the frequency and concentration of Escherichia coli in child complementary food and its association with domestic hygiene practices in rural Bangladesh.A total of 608 households with children <2 years were enrolled. We collected stored complementary food samples, performed spot checks on domestic hygiene and measured ambient temperature in the food storage area. Food samples were analysed using the IDEXX most probable number (MPN) method with Colilert-18 media to enumerate E. coli. We calculated adjusted prevalence ratios (APR) to assess the relationship between E. coli and domestic hygiene practices using modified Poisson regression, adjusting for clustering and confounders.Fifty-eight percentage of stored complementary food was contaminated with E. coli, and high levels of contamination (≥100 MPN/dry g food) were found in 12% of samples. High levels of food contamination were more prevalent in compounds where the food was stored uncovered (APR: 2.0, 95% CI: 1.2-3.2), transferred from the storage pot to the serving dish using hands (APR: 2.0, 95% CI: 1.3-3.2) or stored for >4 h (APR: 2.5, 95% CI: 1.5, 4.2), in compounds where water was unavailable in the food preparation area (APR: 2.6, 95% CI: 1.6, 4.2), where ≥1 fly was captured in the food preparation area (APR: 1.6, 95% CI: 1.0, 2.6), or where the ambient temperature was high (>25-40 °C) in the food storage area (APR: 2.7, 95% CI: 1.5, 4.4).Interventions to keep stored food covered and ensure water availability in the food preparation area would be expected to reduce faecal contamination of complementary foods.

  View details for DOI 10.1111/tmi.12849

  View details for PubMedID 28164415

• 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

• Household-level risk factors for secondary influenza-like illness in a rural area of Bangladesh. Tropical medicine & international health Weaver, A. M., Khatun-E-Jannat, K., Cercone, E., Krytus, K., Sohel, B. M., Ahmed, M., Rahman, M., Azziz-Baumgartner, E., Yu, J., Fry, A. M., Luby, S. P., Ram, P. K. 2017; 22 (2): 187-195

  Abstract

  To describe household-level risk factors for secondary influenza-like illness (ILI), an important public health concern in the low-income population of Bangladesh.Secondary analysis of control participants in a randomised controlled trial evaluating the effect of handwashing to prevent household ILI transmission. We recruited index-case patients with ILI - fever (<5 years); fever, cough or sore throat (≥5 years) - from health facilities, collected information on household factors and conducted syndromic surveillance among household contacts for 10 days after resolution of index-case patients' symptoms. We evaluated the associations between household factors at baseline and secondary ILI among household contacts using negative binomial regression, accounting for clustering by household.Our sample was 1491 household contacts of 184 index-case patients. Seventy-one percentage reported that smoking occurred in their home, 27% shared a latrine with one other household and 36% shared a latrine with >1 other household. A total of 114 household contacts (7.6%) had symptoms of ILI during follow-up. Smoking in the home (RRadj 1.9, 95% CI: 1.2, 3.0) and sharing a latrine with one household (RRadj 2.1, 95% CI: 1.2, 3.6) or >1 household (RRadj 3.1, 95% CI: 1.8-5.2) were independently associated with increased risk of secondary ILI.Tobacco use in homes could increase respiratory illness in Bangladesh. The mechanism between use of shared latrines and household ILI transmission is not clear. It is possible that respiratory pathogens could be transmitted through faecal contact or contaminated fomites in shared latrines.

  View details for DOI 10.1111/tmi.12820

  View details for PubMedID 27889937

• 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

  Abstract

  Mortality in ducks and geese caused by highly pathogenic avian influenza A(H5N1) infection had not been previously identified in Bangladesh. In June-July 2011, we investigated mortality in ducks, geese and chickens with suspected H5N1 infection in a north-eastern district of the country to identify the aetiologic agent and extent of the outbreak and identify possible associated human infections. We surveyed households and farms with affected poultry flocks in six villages in Netrokona district and collected cloacal and oropharyngeal swabs from sick birds and tissue samples from dead poultry. We conducted a survey in three of these villages to identify suspected human influenza-like illness cases and collected nasopharyngeal and throat swabs. We tested all swabs by real-time RT-PCR, sequenced cultured viruses, and examined tissue samples by histopathology and immunohistochemistry to detect and characterize influenza virus infection. In the six villages, among the 240 surveyed households and 11 small-scale farms, 61% (1789/2930) of chickens, 47% (4816/10 184) of ducks and 73% (358/493) of geese died within 14 days preceding the investigation. Of 70 sick poultry swabbed, 80% (56/70) had detectable RNA for influenza A/H5, including 89% (49/55) of ducks, 40% (2/5) of geese and 50% (5/10) of chickens. We isolated virus from six of 25 samples; sequence analysis of the hemagglutinin and neuraminidase gene of these six isolates indicated clade 2.3.2.1a of H5N1 virus. Histopathological changes and immunohistochemistry staining of avian influenza viral antigens were recognized in the brain, pancreas and intestines of ducks and chickens. We identified ten human cases showing signs compatible with influenza-like illness; four were positive for influenza A/H3; however, none were positive for influenza A/H5. The recently introduced H5N1 clade 2.3.2.1a virus caused unusually high mortality in ducks and geese. Heightened surveillance in poultry is warranted to guide appropriate diagnostic testing and detect novel influenza strains.

  View details for DOI 10.1111/tbed.12354

  View details for PubMedID 25892457

• Hospital-based Surveillance for Rotavirus Gastroenteritis Among Young Children in Bangladesh Defining the Potential Impact of a Rotavirus Vaccine Program PEDIATRIC INFECTIOUS DISEASE JOURNAL Satter, S. M., Gastanaduy, P. A., Islam, K., Rahman, M., Rahman, M., Luby, S. P., Heffelfinger, J. D., Parashar, U. D., Gurley, E. S. 2017; 36 (2): 168-172

  View details for DOI 10.1097/INF.0000000000001381

  View details for Web of Science ID 000394352500011

• 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

  Abstract

  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

• Cholera - management and prevention. The Journal of infection Davies, H. G., Bowman, C. n., Luby, S. P. 2017; 74 Suppl 1: S66–S73

  Abstract

  Cholera is an acute secretory diarrhoeal infection caused by the bacterium Vibrio cholerae. It is likely to have originated in the Indian sub-continent; however, it spread to cause six worldwide pandemics between 1817-1923. The ongoing seventh worldwide pandemic of cholera began in 1961. The intensity, duration and severity of cholera epidemics have been increasing, signaling the need for more effective control and prevention measures. The response to the cholera pandemics of the 19th century led to the development of safe and effective sanitation and water systems which have effectively removed the risk of cholera in many settings. However, such systems are not in place to protect billions of people worldwide. Although some progress has been made in expanding access to water in recent years, achieving optimal infrastructure will, in the most optimistic scenario, take decades. Climate change, extreme weather events and rapid urbanisation suggests that alternatives to the current paradigm of providing large centralised water and sanitation systems should be considered, including smaller decentralised systems. The aim of this review paper is to provide an overview of current knowledge regarding management of cholera with a focus on prevention measures including vaccination and water and sanitation interventions.

  View details for PubMedID 28646965

• COMPARISON OF STRATEGIES AND THRESHOLDS FOR VI CONJUGATE VACCINES AGAINST TYPHOID FEVER: A COST-EFFECTIVENESS MODELING STUDY Lo, N. C., Gupta, R., Stanaway, J. D., Garrett, D. O., Bogoch, I. I., Luby, S. P., Andrews, J. R. AMER SOC TROP MED & HYGIENE. 2017: 617

  View details for Web of Science ID 000423215204697

• Pilot Intervention Study of Household Ventilation and Fine Particulate Matter Concentrations in a Low-Income Urban Area, Dhaka, Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Weaver, A. M., Parveen, S., Goswami, D., Crabtree-Ide, C., Rudra, C., Yu, J., Mu, L., Fry, A. M., Sharmin, I., Luby, S. P., Ram, P. K. 2017; 97 (2): 615–23

  Abstract

  Fine particulate matter (PM2.5) is a risk factor for pneumonia; ventilation may be protective. We tested behavioral and structural ventilation interventions on indoor PM2.5 in Dhaka, Bangladesh. We recruited 59 good ventilation (window or door in ≥ 3 walls) and 29 poor ventilation (no window, one door) homes. We monitored baseline indoor and outdoor PM2.5 for 48 hours. We asked all participants to increase ventilation behavior, including opening windows and doors, and operating fans. Where permitted, we installed windows in nine poor ventilation homes, then repeated PM2.5 monitoring. We estimated effects using linear mixed-effects models and conducted qualitative interviews regarding motivators and barriers to ventilation. Compared with poor ventilation homes, good ventilation homes were larger, their residents wealthier and less likely to use biomass fuel. In multivariable linear mixed-effects models, ventilation structures and opening a door or window were inversely associated with the number of hours PM2.5 concentrations exceeded 100 and 250 μg/m3. Outdoor air pollution was positively associated with the number of hours PM2.5 concentrations exceeded 100 and 250 μg/m3. Few homes accepted window installation, due to landlord refusal and fear of theft. Motivators for ventilation behavior included cooling of the home and sunlight; barriers included rain, outdoor odors or noise, theft risk, mosquito entry, and, for fan use, perceptions of wasting electricity or unavailability of electricity. We concluded that ventilation may reduce indoor PM2.5 concentrations but, there are barriers to increasing ventilation and, in areas with high ambient PM2.5 concentrations, indoor concentrations may remain above recommended levels.

  View details for PubMedID 28722632

  View details for PubMedCentralID PMC5544064

• Effectiveness of the Hydrogen Sulfide Test as a Water Quality Indicator for Diarrhea Risk in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Islam, M., Ercumen, A., Naser, A., Unicomb, L., Rahman, M., Arnold, B. F., Colford, J. M., Luby, S. P. 2017; 97 (6): 1867–71

  Abstract

  Microbiological water quality is usually assessed by the identification of Escherichia coli (E. coli), a fecal indicator. The hydrogen sulfide (H2S) test is an inexpensive, easy-to-use, and portable alternative field-based water quality test. Our study evaluated the H2S test's effectiveness as a water quality indicator for diarrhea risk. Field workers collected stored drinking water samples for H2S analysis and detection of E. coli by membrane filtration and measured caregiver-reported diarrhea among children < 5 years in the same households 1 month later. We assessed the association between the H2S test (incubated for 24 hours and 48 hours) and diarrhea prevalence, with 2-day and 7-day symptom recall periods (N = 1,348). We determined the sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of the H2S test compared with E. coli (N = 525). Controlling for potentially confounding covariates, H2S-positive water (at 24 or 48 hours) was not associated with 2-day diarrhea prevalence (24-hour prevalence ratio [PR] = 1.03, 95% confidence interval [CI]: 0.63-1.69; 48-hour PR = 0.89, 95% CI: 0.58-1.38) or 7-day diarrhea prevalence (24-hour PR = 1.17, 95% CI: 0.76-1.78; 48-hour PR = 1.21, 95% CI: 0.81-1.80). The sensitivity, PPV, and NPV of the H2S test was significantly higher when the H2S test was incubated for 48 versus 24 hours whereas specificity showed the opposite trend. H2S test sensitivity, PPV, and NPV increased with increasing E. coli levels, consistent with previous evidence that the H2S test is a useful water quality tool in high-contamination settings. However, our results suggest that the H2S test is not an effective indicator for waterborne diarrhea.

  View details for PubMedID 29141754

  View details for PubMedCentralID PMC5805062

• Pilot of an Elementary School Cough Etiquette Intervention: Acceptability, Feasibility, and Potential for Sustainability AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Sultana, F., Nizame, F. A., Southern, D. L., Unicomb, L., Winch, P. J., Luby, S. P. 2017; 97 (6): 1876–85

  Abstract

  Schools convene many people together for a prolonged time, facilitating spread of respiratory pathogens and amplifying epidemics. Crowded Bangladeshi schools lack the infrastructure to support optimal cough etiquette behaviors. We collected formative data on current practices from four elementary schools, and developed and piloted a low-cost cough etiquette intervention, promoting coughing and sneezing into upper sleeves at four additional schools. We trained teachers to lead behavior change sessions during regular hygiene classes for 4 weeks. We evaluated intervention acceptability, feasibility, and potential for sustainability at 1 month and at 14 months after the intervention commenced. At baseline, among 63 observed students, 58 (92%) coughed/sneezed into open air, five (8%) covered coughs/sneezes with their hands, which were not subsequently washed with soap and water as they judged this infeasible. After 4 weeks, among 70 observed students, 27 (39%) coughed/sneezed into upper sleeves, 33 (47%) into open air, and 10 (12%) covered with hands. After 14 months, among 230 observed students, 13 (6%) used upper sleeves, 154 (67%) coughed/sneezed into open air, and 59 (26%) covered with hands. Students reported that coughing/sneezing into upper sleeves was simple and protected them and their classmates from germs. This school-based intervention was acceptable and feasible, and resulted in short-term reductions in coughing/sneezing into open air, but these habits of comparatively new behavior were not sustained as teachers ceased behavior change session delivery. Strategies to support longer-term adoption of habits should be considered.

  View details for PubMedID 29141703

  View details for PubMedCentralID PMC5805026

• EFFECTS OF A COMBINED WATER QUALITY, SANITATION, HANDWASHING AND NUTRITIONAL INTERVENTION ON TELOMERE LENGTH AMONG YOUNG CHILDREN IN RURAL BANGLADESH Lin, A., Arnold, B. F., Mertens, A. N., Lin, J., Benjamin-Chung, J., Ali, S., Shoab, A. K., Rahman, M., Hossen, M., Mutsuddi, P., Famida, S. L., Akther, S., Rahman, M., Parvez, S. M., Unicomb, L., Dhabhar, F. S., Kariger, P. K., Fernald, L. C., Hubbard, A. E., Stewart, C. P., Colford, J. M., Luby, S. P. AMER SOC TROP MED & HYGIENE. 2017: 399

  View details for Web of Science ID 000423215203651

• SPILLOVER EFFECTS OF A COMBINED WATER, SANITATION AND HANDWASHING INTERVENTION IN RURAL BANGLADESH: A RANDOMIZED CONTROLLED TRIAL Benjamin-Chung, J., Amin, N., Ercumen, A., Arnold, B. F., Hubbard, A., Unicomb, L., Rahman, M., Luby, S. P., Colford, J. M. AMER SOC TROP MED & HYGIENE. 2017: 213

  View details for Web of Science ID 000423215203052

• FECAL INFLAMMATORY BIOMARKERS OF ENVIRONMENTAL ENTERIC DYSFUNCTION ARE NOT ASSOCIATED WITH HEPCIDIN CONCENTRATIONS IN YOUNG BANGLADESHI CHILDREN Byrd, K., Lin, A., Rahman, M., Ali, M., Arnold, C. D., Jannat, K., Luby, S. P., Rahman, M., Dewey, K., Stewart, C. KARGER. 2017: 982

  View details for Web of Science ID 000415605302326

• STRENGTHENING THE PUBLIC HEALTH WORKFORCE IN BANGLADESH THROUGH SCIENTIFIC TRAINING AND MENTORSHIP: A LESSON FOR LOW INCOME COUNTRIES Harun, G., Southern, D., DiazGranados, D., Scott, M., Doan, S., Gurley, E. S., Luby, S. P. AMER SOC TROP MED & HYGIENE. 2017: 69

  View details for Web of Science ID 000423215202223

• Outbreak of Sudden Death with Acute Encephalitis Syndrome Among Children Associated with Exposure to Lychee Orchards in Northern Bangladesh, 2012 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Islam, M., Sharif, A., Sazzad, H. S., Khan, A., Hasan, M., Akter, S., Rahman, M., Luby, S. P., Heffelfinger, J. D., Gurley, E. S. 2017; 97 (3): 949–57

  Abstract

  Recurrent outbreaks of acute encephalitis syndrome (AES) among children in lychee growing areas in Asia highlight the need to better understand the etiology and the context. We conducted a mixed-methods study to identify risk factors for disease, and behaviors and practices around lychee cultivation in an AES outbreak community in northern Bangladesh in 2012. The outbreak affected 14 children; 13 died. The major symptoms included unconsciousness, convulsion, excessive sweating, and frothy discharge. The median time from illness onset to unconsciousness was 2.5 hours. The outbreak corresponded with lychee harvesting season. Multiple pesticides including some banned in Bangladesh were frequently used in the orchards. Visiting a lychee orchard within 24 hours before onset (age-adjusted odds ratio [aOR] = 11.6 [1.02-109.8]) and 3 days (aOR = 7.2 [1.4-37.6]), and family members working in a lychee orchard (aOR = 7.2 [1.7-29.4]) and visiting any garden while pesticides were being applied (aOR = 4.9 [1.0-19.4]) in 3 days preceding illness onset were associated with illness in nearby village analysis. In neighborhood analysis, visiting an orchard that used pesticides (aOR = 8.4 [1.4-49.9]) within 3 days preceding illness onset was associated with illness. Eating lychees was not associated with illness in the case-control study. The outbreak was linked to lychee orchard exposures where agrochemicals were routinely used, but not to consumption of lychees. Lack of acute specimens was a major limitation. Future studies should target collection of environmental and food samples, acute specimens, and rigorous assessment of community use of pesticides to determine etiology.

  View details for PubMedID 28749763

  View details for PubMedCentralID PMC5590581

• Risk Factors Associated with Blood Exposure for Sporadic Hepatitis E in Dhaka, Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Sazzad, H. S., Luby, S. P., Labrique, A. B., Kamili, S., Hayden, T. M., Kamili, N. A., Teo, C., Gurley, E. S. 2017; 97 (5): 1437–44

  Abstract

  Fecal contamination of drinking water is associated with large hepatitis E virus (HEV) outbreaks of genotypes 1 and 2 in endemic areas. Sporadic transmission of HEV genotypes 3 and 4 in high-income countries has been associated with exposure to blood and animal contact. The objective of the study was to identify the risk factors for hepatitis E and the genotype(s) causing sporadic hepatitis E in Dhaka, Bangladesh. We selected, from a diagnostic center in Dhaka between November 2008 and November 2009, cases presenting with jaundice and anti-HEV IgM antibodies and age-matched controls were defined as those with no history of jaundice and normal blood test results. Serum samples were tested for HEV RNA using real-time reverse transcriptase polymerase chain reaction followed by a sequencing and phylogenetic analysis. A total of 109 cases and 109 controls were enrolled. The cases were more likely to be male (adjusted matched odds ratios [mOR] 2.2, 95% CI: 1.2-3.9; P = 0.01), or have reported contact with another person's blood or blood product, or contact with blood-contaminated sharp instruments (adjusted mOR 2.1, 95% CI: 1.1-4.1; P = 0.03) than controls. There were no significant differences between the cases and the controls in terms of reported high-risk sexual intercourse, consumption of undercooked meat, or contact or drinking fecally-contaminated water. The sera from three cases carried HEV RNA, all belonging to genotype 1. Findings from this study suggest that contact with human blood and sharing sharp instruments may transmit sporadic hepatitis E in Dhaka, Bangladesh. Efforts to prevent the transmission of blood-borne pathogens may also prevent sporadic HEV transmission in this endemic setting.

  View details for PubMedID 28820721

  View details for PubMedCentralID PMC5817767

• TYPHOID FEVER CASE FATALITY RATE IN PATIENTS PRESENTING TO A LABORATORY NETWORK IN DHAKA, BANGLADESH Yu, A. T., Amin, N., Rahman, M. W., Luby, S. AMER SOC TROP MED & HYGIENE. 2017: 352

  View details for Web of Science ID 000423215203500

• Evaluating Hospital-Based Surveillance for Outbreak Detection in Bangladesh: Analysis of Healthcare Utilization Data. PLoS medicine Nikolay, B., Salje, H., Sturm-Ramirez, K., Azziz-Baumgartner, E., Homaira, N., Ahmed, M., Iuliano, A. D., Paul, R. C., Rahman, M., Hossain, M. J., Luby, S. P., Cauchemez, S., Gurley, E. S. 2017; 14 (1)

  Abstract

  The International Health Regulations outline core requirements to ensure the detection of public health threats of international concern. Assessing the capacity of surveillance systems to detect these threats is crucial for evaluating a country's ability to meet these requirements.We propose a framework to evaluate the sensitivity and representativeness of hospital-based surveillance and apply it to severe neurological infectious diseases and fatal respiratory infectious diseases in Bangladesh. We identified cases in selected communities within surveillance hospital catchment areas using key informant and house-to-house surveys and ascertained where cases had sought care. We estimated the probability of surveillance detecting different sized outbreaks by distance from the surveillance hospital and compared characteristics of cases identified in the community and cases attending surveillance hospitals. We estimated that surveillance detected 26% (95% CI 18%-33%) of severe neurological disease cases and 18% (95% CI 16%-21%) of fatal respiratory disease cases residing at 10 km distance from a surveillance hospital. Detection probabilities decreased markedly with distance. The probability of detecting small outbreaks (three cases) dropped below 50% at distances greater than 26 km for severe neurological disease and at distances greater than 7 km for fatal respiratory disease. Characteristics of cases attending surveillance hospitals were largely representative of all cases; however, neurological disease cases aged <5 y or from the lowest socioeconomic group and fatal respiratory disease cases aged ≥60 y were underrepresented. Our estimates of outbreak detection rely on suspected cases that attend a surveillance hospital receiving laboratory confirmation of disease and being reported to the surveillance system. The extent to which this occurs will depend on disease characteristics (e.g., severity and symptom specificity) and surveillance resources.We present a new approach to evaluating the sensitivity and representativeness of hospital-based surveillance, making it possible to predict its ability to detect emerging threats.

  View details for DOI 10.1371/journal.pmed.1002218

  View details for PubMedID 28095468

• Assessment of the Acceptability and Feasibility of Child Potties for Safe Child Feces Disposal in Rural Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Hussain, F., Luby, S. P., Unicomb, L., Leontsini, E., Naushin, T., Buckland, A. J., Winch, P. J. 2017; 97 (2): 469–76

  Abstract

  Indiscriminate defecation among young children and the unsafe disposal of their feces increases fecal contamination in the household environment and the risk of diarrheal disease transmission. Improved sanitary technology for children too young to use a latrine may facilitate safe feces disposal and reduce fecal contamination in the household environment. We assessed the acceptability and feasibility of child potties in rural Bangladesh in 2010. Our team introduced child potties into 26 households for 30 days, and conducted semistructured interviews, group discussions, and observations to assess the acceptability and feasibility of their use for parents and children. Residents of this rural Bangladeshi community accepted the child potties and caregivers found them to be a feasible means of managing child feces. The color, shape, design, and size of the potty influenced its acceptability and use. These residents reported that regular use of the potty improved the household's physical environment and caregiver and child personal hygiene. Regular potty use also reduced caregivers' work load by making feces collection and disposal easier. Primary caregivers viewed 4-6 months as the appropriate age to initiate potty training. Sanitation interventions should integrate and emphasize potties for children's feces management to reduce household environmental contamination.

  View details for PubMedID 28722606

  View details for PubMedCentralID PMC5544061

• Impact of an Intensive Perinatal Handwashing Promotion Intervention on Maternal Handwashing Behavior in the Neonatal Period: Findings from a Randomized Controlled Trial in Rural Bangladesh BIOMED RESEARCH INTERNATIONAL Ram, P. K., Nasreen, S., Kamm, K., Allen, J., Kumar, S., Rahman, M. A., Zaman, K., El Arifeen, S., Luby, S. P. 2017

  Abstract

  One-quarter of neonatal deaths are attributed to infections. Maternal handwashing with soap may prevent neonatal sepsis. We examined impact of intensive handwashing promotion on handwashing behavior of mothers of neonates. In Matlab, Bangladesh, we randomly allocated pregnant women at 28-32 weeks' gestation to intensive handwashing promotion or control. Behavior change communicators used a participatory approach to motivate maternal handwashing with soap and provided soap and handwashing stations. In the neonatal period, we observed soap and water at handwashing places and, at the end of the neonatal period, we estimated impact on maternal handwashing by structured observation. Among 253 women enrolled, intervention households were between 5.7 and 15.2 times as likely as control households to have soap and water present at the handwashing station in the baby's sleeping area. Intervention mothers washed hands with soap 4.1 times as frequently as controls (95% CI 2.55-6.59); handwashing with soap at recommended times was infrequent in both intervention (9%) and control (2%) groups. Intensively promoting handwashing with soap resulted in increased availability of soap and water at handwashing places, but only a modest increase in maternal handwashing with soap. Novel approaches to motivating handwashing behavior to protect newborns should be developed and evaluated.

  View details for DOI 10.1155/2017/6081470

  View details for Web of Science ID 000399911200001

  View details for PubMedID 28497058

• An epidemiological study of avian influenza A (H5) virus in nomadic ducks and their raising practices in northeastern Bangladesh, 2011-2012. Influenza and other respiratory viruses Sarkar, S., Khan, S. U., Mikolon, A., Rahman, M. Z., Abedin, J., Zeidner, N., Sturm-Ramirez, K., Luby, S. P. 2016

  Abstract

  In Bangladesh, nomadic duck flocks are groups of domestic ducks reared for egg production that are moved to access feeding sites beyond their owners' village boundaries and are housed overnight in portable enclosures in scavenging areas. The objectives of this study were to measure the prevalence of influenza A virus RNA and H5-specific antibodies in nomadic ducks and to characterize nomadic duck raising practices in northeastern Bangladesh.We tested duck egg yolk specimens by competitive ELISA to detect antibodies against avian influenza A (H5) and environmental fecal samples by real-time reverse-transcription polymerase chain reaction (rRT-PCR) to detect influenza A virus RNA and H5 subtype.The median age of the ducks was 24 months (range: 8-36 months) and the median flock size was 300 ducks (range: 105-1100). Of 1860 egg yolk samples, 556 (30%, 95% confidence interval (CI): 28-32) were positive for antibodies against H5 and 58 flocks (94%) had at least one egg with H5-specific antibodies. Of 496 fecal samples, 121 (24%, 95% CI: 22-29) had detectable influenza A RNA. Thirty-three flocks (53%) had at least one fecal sample positive for influenza A RNA.Nomadic ducks in Bangladesh are commonly infected with avian influenza A (H5) virus and may serve as a bridging host for transmission of avian influenza A (H5) virus or other avian influenza A viruses subtypes between wild waterfowl, backyard poultry, and humans in Bangladesh.

  View details for DOI 10.1111/irv.12438

  View details for PubMedID 27966289

  View details for PubMedCentralID PMC5410719

• 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

  Abstract

  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

• 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

  Abstract

  We evaluated whether provision and promotion of improved sanitation hardware (toilets and child feces management tools) reduced rotavirus and human fecal contamination of drinking water, child hands, and soil among rural Bangladeshi compounds enrolled in a cluster-randomized trial. We also measured host-associated genetic markers of ruminant and avian feces. We found evidence of widespread ruminant and avian fecal contamination in the compound environment; non-human fecal marker occurrence scaled with animal ownership. Strategies for controlling non- human fecal waste should be considered when designing interventions to reduce exposure to fecal contamination in low-income settings. Detection of a human- associated fecal marker and rotavirus was rare and unchanged by provision and promotion of improved sanitation to intervention compounds. The sanitation intervention reduced ruminant fecal contamination in drinking water and general (non-host specific) fecal contamination in soil but overall had limited effects on reducing fecal contamination in the household environment.

  View details for PubMedID 32607385

  View details for PubMedCentralID PMC7326215

• 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

  Abstract

  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

  View details for DOI 10.1021/acs.estlett.6b00382

  View details for Web of Science ID 000387528200003

• 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

  Abstract

  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

• Hospital-Based Surveillance for Rotavirus Gastroenteritis among Young Children in Bangladesh: Defining the Potential Impact of a Rotavirus Vaccine Program. Pediatric infectious disease journal Satter, S., Gastanaduy, P., Islam, K., Rahman, M., Rahman, M., Luby, S., Heffelfinger, J., Parashar, U., Gurley, E. 2016: -?

  Abstract

  In anticipation of introduction of a rotavirus vaccine into the national immunization program of Bangladesh, active hospital-based surveillance was initiated to provide prevaccine baseline data on rotavirus disease.Children 5 years of age and younger admitted with acute gastroenteritis (AGE) (≥3 watery or looser-than-normal stools or ≥1 episode of forceful vomiting) at 7 hospitals throughout Bangladesh were identified. Clinical information and stool specimens were collected from every 4th patient. Specimens were tested for rotavirus antigen by enzyme immunoassays; 25% of detected rotaviruses were genotyped.From July 2012 to June 2015, rotavirus was detected in 2432 (64%) of 3783 children hospitalized for AGE. Eight enrolled children died, including 4 (50%) who were rotavirus positive. Rotavirus was detected year-round in Bangladesh with peak detection rates of >80% during November-February. Most (86%) rotavirus AGE cases were 6-23 months of age. Sixty-nine percent of children with rotavirus had severe disease (Vesikari score, ≥11). Among 543 strains genotyped, G1P[8] (31%) and G12P[8] (29%) were the most common.Rotavirus is a major cause of morbidity in Bangladeshi children, accounting for nearly two-thirds of AGE hospitalizations. These data highlight the potential value of rotavirus vaccination in Bangladesh, and will be the key for future measurement of vaccine impact.

  View details for PubMedID 27798545

• 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: -?

  Abstract

  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

• Safe distances between groundwater-based water wells and pit latrines at different hydrogeological conditions in the Ganges Atrai floodplains of Bangladesh JOURNAL OF HEALTH POPULATION AND NUTRITION Islam, M. S., Mahmud, Z. H., Islam, M. S., Saha, G. C., Zahid, A., Ali, A. H., Hassan, M. Q., Islam, K., Jahan, H., Hossain, Y., Hasan, M. M., Cairncross, S., Carter, R., Luby, S. P., Cravioto, A., Endtz, H. P., Faruque, S. M., Clemens, J. D. 2016; 35

  Abstract

  Groundwater drawn from shallow tubewells in Bangladesh is often polluted by nearby pit latrines, which are commonly used toilets in rural and sub-urban areas of the country.To determine the minimum safe distance of a tubewell from a pit latrine in different hydrogeological conditions of Bangladesh, 20 monitoring wells were installed at three study sites (Manda, Mohanpur and Bagmara) with the vertical and horizontal distances ranging from 18-47 to 2-15 m, respectively. Water samples were collected three times in three seasons and tested for faecal coliforms (FC) and faecal streptococci (FS) as indicators of contamination. Soil samples were analysed for texture, bulk density and hydraulic conductivity following standard procedures. Sediment samples were collected to prepare lithological logs.When the shallow aquifers at one of the three sites (Mohanpur) were overlained by 18-23-m-thick aquitards, the groundwater of the monitoring wells was found contaminated with a lateral and vertical distances of 2 and 31 m, respectively. However, where the aquitard was only 9 m thick, contamination was found up to lateral and vertical distances of 4.5 and 40.5 m, respectively. The soil textures of all the sites were mainly composed of loam and sandy loam. The hydraulic conductivities in the first aquifer at Manda, Mohanpur and Bagmara were 5.2-7.3, 8.2 and 1.4-15.7 m/h, respectively.The results showed that the safe distance from the tubewell to the pit latrine varied from site to site depending on the horizontal and vertical distances of the tubewell as well as hydrogeological conditions of a particular area.

  View details for DOI 10.1186/s41043-016-0063-z

  View details for Web of Science ID 000383426200001

  View details for PubMedID 27542826

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4973173

• Raising Backyard Poultry in Rural Bangladesh: Financial and Nutritional Benefits, but Persistent Risky Practices. Transboundary and emerging diseases Shanta, I. S., Hasnat, M. A., Zeidner, N., Gurley, E. S., Azziz-Baumgartner, E., Sharker, M. A., Hossain, K., KHAN, S. U., Haider, N., Bhuyan, A. A., Hossain, M. A., Luby, S. P. 2016

  Abstract

  Poultry is commonly raised by households in rural Bangladesh. In 2007, the Government of Bangladesh began a mass media campaign to disseminate 10 recommended precautions to prevent transmission of H5N1 from poultry to humans. This longitudinal study explored the contribution of backyard poultry on household economy and nutrition and compared poultry-raising practices to government recommendations. From 2009 to 2012, we enrolled a nationally representative sample of 2489 primary backyard poultry raisers from 115 rural villages selected by probability proportional to population size. Researchers interviewed the raisers to collect data on poultry-raising practices. They followed the raisers for 2-12 months to collect data on household income and nutrition from poultry. Income from backyard poultry flocks accounted for 2.8% of monthly household income. Return on annual investment (ROI) per flock was 480%. Yearly, median family consumption of eggs was one-fifth of the total produced eggs and three poultry from their own flock. Respondents' reported practices conflicted with government recommendations. Sixty per cent of raisers had never heard of avian influenza or 'bird flu'. Among the respondents, 85% handled sick poultry or poultry that died due to illness, and 49% slaughtered or defeathered sick poultry. In 37% of households, children touched poultry. Fifty-eight per cent never washed their hands with soap after handling poultry, while <1% covered their nose and mouth with a cloth when handling poultry. Only 3% reported poultry illness and deaths to local authorities. These reported practices did not improve during the study period. Raising backyard poultry in rural Bangladesh provides important income and nutrition with an excellent ROI. Government recommendations to reduce the risk of avian influenza transmission did not impact the behaviour of poultry producers. Further research should prioritize developing interventions that simultaneously reduce the risk of avian influenza transmission and increase productivity of backyard poultry.

  View details for DOI 10.1111/tbed.12536

  View details for PubMedID 27311406

• 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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC4924020

• 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

  Abstract

  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

  Abstract

  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: -?

  Abstract

  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

  View details for PubMedCentralID PMC5086320

• 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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC4806969

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC4806916

• 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

  Abstract

  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

  View details for DOI 10.2166/washdev.2016.027

  View details for Web of Science ID 000374578500004

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC4739641

• 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-?

  Abstract

  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 families.ClinicalTrials.gov NCT01899378 . Registered July 10, 2013.

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

  View details for PubMedID 26832746

  View details for PubMedCentralID PMC4736167

• 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-?

  Abstract

  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

  View details for PubMedCentralID PMC4995615

• 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-?

  Abstract

  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

  View details for PubMedCentralID PMC4974711

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4675679

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4696915

• 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): e0004256

  Abstract

  The combination of deworming and improved sanitation or hygiene may result in greater reductions in soil-transmitted helminth (STH) infection than any single intervention on its own. We measured STH prevalence in rural Bangladesh and assessed potential interactions among deworming, hygienic latrines, and household finished floors.We conducted a cross-sectional survey (n = 1,630) in 100 villages in rural Bangladesh to measure three exposures: self-reported deworming consumption in the past 6 months, access to a hygienic latrine, and household flooring material. We collected stool samples from children 1-4 years, 5-12 years, and women 15-49 years. We performed mini-FLOTAC on preserved stool samples to detect Ascaris lumbricoides, Enterobius vermicularis, hookworm, and Trichuris trichiura ova. Approximately one-third (32%) of all individuals and 40% of school-aged children had an STH infection. Less than 2% of the sample had moderate/heavy intensity infections. Deworming was associated with lower Ascaris prevalence (adjusted prevalence ratio (PR) = 0.53; 95% CI 0.40, 0.71), but there was no significant association with hookworm (PR = 0.93, 95% CI 0.60, 1.44) or Trichuris (PR = 0.90, 95% CI 0.74, 1.08). PRs for hygienic latrine access were 0.91 (95% CI 0.67,1.24), 0.73 (95% CI 0.43,1.24), and 1.03 (95% CI 0.84,1.27) for Ascaris, hookworm, and Trichuris, respectively. Finished floors were associated with lower Ascaris prevalence (PR = 0.56, 95% CI 0.32, 0.97) but not associated with hookworm (PR = 0.48 95% CI 0.16,1.45) or Trichuris (PR = 0.98, 95% CI 0.72,1.33). Across helminths and combinations of exposures, adjusted prevalence ratios for joint exposures were consistently more protective than those for individual exposures.We found moderate STH prevalence in rural Bangladesh among children and women of childbearing age. This study is one of the first to examine independent and combined associations with deworming, sanitation, and hygiene. Our results suggest that coupling deworming with sanitation and flooring interventions may yield more sustained reductions in STH prevalence.

  View details for DOI 10.1371/journal.pntd.0004256

  View details for PubMedID 26624994

  View details for PubMedCentralID PMC4666415

• 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)

  Abstract

  The combination of deworming and improved sanitation or hygiene may result in greater reductions in soil-transmitted helminth (STH) infection than any single intervention on its own. We measured STH prevalence in rural Bangladesh and assessed potential interactions among deworming, hygienic latrines, and household finished floors.We conducted a cross-sectional survey (n = 1,630) in 100 villages in rural Bangladesh to measure three exposures: self-reported deworming consumption in the past 6 months, access to a hygienic latrine, and household flooring material. We collected stool samples from children 1-4 years, 5-12 years, and women 15-49 years. We performed mini-FLOTAC on preserved stool samples to detect Ascaris lumbricoides, Enterobius vermicularis, hookworm, and Trichuris trichiura ova. Approximately one-third (32%) of all individuals and 40% of school-aged children had an STH infection. Less than 2% of the sample had moderate/heavy intensity infections. Deworming was associated with lower Ascaris prevalence (adjusted prevalence ratio (PR) = 0.53; 95% CI 0.40, 0.71), but there was no significant association with hookworm (PR = 0.93, 95% CI 0.60, 1.44) or Trichuris (PR = 0.90, 95% CI 0.74, 1.08). PRs for hygienic latrine access were 0.91 (95% CI 0.67,1.24), 0.73 (95% CI 0.43,1.24), and 1.03 (95% CI 0.84,1.27) for Ascaris, hookworm, and Trichuris, respectively. Finished floors were associated with lower Ascaris prevalence (PR = 0.56, 95% CI 0.32, 0.97) but not associated with hookworm (PR = 0.48 95% CI 0.16,1.45) or Trichuris (PR = 0.98, 95% CI 0.72,1.33). Across helminths and combinations of exposures, adjusted prevalence ratios for joint exposures were consistently more protective than those for individual exposures.We found moderate STH prevalence in rural Bangladesh among children and women of childbearing age. This study is one of the first to examine independent and combined associations with deworming, sanitation, and hygiene. Our results suggest that coupling deworming with sanitation and flooring interventions may yield more sustained reductions in STH prevalence.

  View details for DOI 10.1371/journal.pntd.0004256

  View details for Web of Science ID 000368345100032

  View details for PubMedCentralID PMC4666415

• 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

  View details for DOI 10.1016/j.vaccine.2015.09.039

  View details for Web of Science ID 000366791200048

• 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

  Abstract

  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 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

  Abstract

  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

  View details for DOI 10.1016/S0140-6736(15)61140-0

  View details for PubMedID 26164097

• 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

  View details for DOI 10.1016/j.esd.2015.07.003

  View details for Web of Science ID 000361780600008

• 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

  Abstract

  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 ClinicalTrials.gov, 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

  Abstract

  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): e0003907

  Abstract

  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

  View details for PubMedCentralID PMC4498910

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC4498910

• Towards sustainable public health surveillance for enteric fever VACCINE Luby, S. P., Saha, S., Andrews, J. R. 2015; 33: C3-C7

  View details for DOI 10.1016/j.vaccine.2015.02.054

  View details for Web of Science ID 000357439400002

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

  Abstract

  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

• 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)

  Abstract

  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 Bangladesh.ClinicalTrials.gov NCT00880659.

  View details for DOI 10.1371/journal.pone.0125200

  View details for Web of Science ID 000356100900004

  View details for PubMedID 26066651

  View details for PubMedCentralID PMC4465839

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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 ClinicalTrials.gov, 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

  Abstract

  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

  View details for PubMedCentralID PMC4458811

• 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

  Abstract

  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

• Performance of Kala-Azar Surveillance in Gaffargaon Subdistrict of Mymensingh, Bangladesh PLOS NEGLECTED TROPICAL DISEASES Rahman, K. M., Samarawickrema, I. V., Harley, D., Olsen, A., Butler, C. D., Sumon, S. A., Biswas, S. K., Luby, S. P., Sleigh, A. C. 2015; 9 (4)

  Abstract

  Elimination of kala-azar is planned for South Asia requiring good surveillance along with other strategies. We assessed surveillance in Gaffargaon upazila (a subdistrict of 13 unions) of Mymensingh district, Bangladesh highly endemic for kala-azar.In 4703 randomly sampled households, within nine randomly sampled villages, drawn from three randomly sampled unions, we actively searched for kala-azar cases that had occurred between January 2010 and December 2011. We then searched for medical records of these cases in the patient registers of Gaffargaon upazila health complex (UHC). We investigated factors associated with the medical recording by interviewing the cases and their families. We also did a general observation of UHC recording systems and interviewed health staff responsible for the monthly reports of kala-azar cases.Our active case finding detected 58 cases, but 29 were not recorded in the Gaffargaon UHC. Thus, only 50% (95% CI: 37%-63%) of kala-azar cases were reported via the government passive surveillance system. Interviews with health staff based in the study UHC revealed the heavy reporting burden for multiple diseases, variation in staff experience, high demands on the staff time and considerable complexity in the recording system. After adjusting for kala-azar treatment drug, recording was found more likely for those aged 18 years or more, males, receiving supply and administration of drug at the UHC, and more recent treatment.Fifty percent of kala-azar cases occurring in one highly endemic area of Bangladesh were recorded in registers that were the source for monthly reports to the national surveillance system. Recording was influenced by patient, treatment, staff and system factors. Our findings have policy implications for the national surveillance system. Future studies involving larger samples and including interviews with health authorities at more central level and surveillance experts at the national level will generate more precise and representative evidence on the performance of kala-azar surveillance in Bangladesh.

  View details for DOI 10.1371/journal.pntd.0003531

  View details for Web of Science ID 000354972200005

  View details for PubMedID 25860258

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4378465

• 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): e0118397

  Abstract

  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

  View details for PubMedCentralID PMC4348460

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4666517

• 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

  Abstract

  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

• 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

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC4238985

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC4130310

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC4177832

• 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

  View details for DOI 10.1016/j.jdeveco.2014.02.010

  View details for Web of Science ID 000342244200002

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4125272

• 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

  View details for DOI 10.4269/ajtmh.13-0484

  View details for Web of Science ID 000338750700029

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4181799

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4006726

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4015594

• 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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC3966716

• 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

  View details for DOI 10.1111/1365-2664.12212

  View details for Web of Science ID 000332835600011

• Roosting behaviour and habitat selection of Pteropus giganteus reveals potential links to Nipah virus epidemiology. The 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

  Abstract

  1. Flying foxes Pteropus spp. play a key role in forest regeneration as seed dispersers and are also the reservoir of many viruses, including Nipah virus in Bangladesh. Little is known about their habitat requirements, particularly in South Asia. Identifying Pteropus habitat preferences could assist in understanding the risk of zoonotic disease transmission broadly, and in Bangladesh, could help explain the spatial distribution of human Nipah virus cases. 2. We analysed characteristics of Pteropus giganteus roosts and constructed an ecological niche model to identify suitable habitat in Bangladesh. We also assessed the distribution of suitable habitat in relation to the location of human Nipah virus cases. 3. Compared to non-roost trees, P. giganteus roost trees are taller with larger diameters, and are more frequently canopy trees. Colony size was larger in densely forested regions and smaller in flood-affected areas. Roosts were located in areas with lower annual precipitation and higher human population density than non-roost sites. 4. We predicted that 2-17% of Bangladesh's land area is suitable roosting habitat. Nipah virus outbreak villages were 2.6 times more likely to be located in areas predicted as highly suitable habitat for P. giganteus compared to non-outbreak villages. 5. Synthesis and applications. Habitat suitability modelling may help identify previously undocumented Nipah outbreak locations and improve our understanding of Nipah virus ecology by highlighting regions where there is suitable bat habitat but no reported human Nipah virus. Conservation and public health education is a key component of P. giganteus management in Bangladesh due to the general misunderstanding and fear of bats that are a reservoir of Nipah virus. Affiliation between Old World fruit bats (Pteropodidae) and people is common throughout their range, and in order to conserve these keystone bat species and prevent emergence of zoonotic viruses, it is imperative that we continue to improve our understanding of Pteropus resource requirements and routes of virus transmission from bats to people. Results presented here can be utilized to develop land management strategies and conservation policies that simultaneously protect fruit bats and public health.

  View details for DOI 10.1111/1365-2664.12212

  View details for PubMedID 24778457

  View details for PubMedCentralID PMC4000083

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3932152

• 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

  Abstract

  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 2.3.2.1 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 2.3.2.1-specific 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

  Abstract

  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

  View details for DOI 10.1177/1077801213520579

  View details for Web of Science ID 000331705000005

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4681270

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3934972

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3929649

• 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

  Abstract

  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 ClinicalTrials.gov, 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., Ziaur Rahman, M., Luby, S. P., Zeidner, N., Donis, R. O., Sturm-Ramirez, K., Davis, C. T. 2014; 450-451: 297-307

  Abstract

  In Bangladesh, little is known about the genomic composition and antigenicity of highly pathogenic avian influenza A(H5N1) viruses, their geographic distribution, temporal patterns, or gene flow within the avian host population. Forty highly pathogenic avian influenza A(H5N1) viruses isolated from humans and poultry in Bangladesh between 2008 and 2012 were analyzed by full genome sequencing and antigenic characterization. The analysis included viruses collected from avian hosts and environmental sampling in live bird markets, backyard poultry flocks, outbreak investigations in wild birds or poultry and from three human cases. Phylogenetic analysis indicated that the ancestors of these viruses reassorted (1) with other gene lineages of the same clade, (2) between different clades and (3) with low pathogenicity avian influenza A virus subtypes. Bayesian estimates of the time of most recent common ancestry, combined with geographic information, provided evidence of probable routes and timelines of virus spread into and out of Bangladesh.

  View details for DOI 10.1016/j.virol.2013.12.023

  View details for PubMedID 24503093

• 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

  View details for DOI 10.1016/j.virol.2013.12.023

  View details for Web of Science ID 000331485500033

• 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

  Abstract

  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

• The risk of misclassifying subjects within principal component based asset index. Emerging themes in epidemiology Sharker, M. Y., Nasser, M., Abedin, J., Arnold, B. F., Luby, S. P. 2014; 11: 6-?

  Abstract

  The asset index is often used as a measure of socioeconomic status in empirical research as an explanatory variable or to control confounding. Principal component analysis (PCA) is frequently used to create the asset index. We conducted a simulation study to explore how accurately the principal component based asset index reflects the study subjects' actual poverty level, when the actual poverty level is generated by a simple factor analytic model. In the simulation study using the PC-based asset index, only 1% to 4% of subjects preserved their real position in a quintile scale of assets; between 44% to 82% of subjects were misclassified into the wrong asset quintile. If the PC-based asset index explained less than 30% of the total variance in the component variables, then we consistently observed more than 50% misclassification across quintiles of the index. The frequency of misclassification suggests that the PC-based asset index may not provide a valid measure of poverty level and should be used cautiously as a measure of socioeconomic status.

  View details for DOI 10.1186/1742-7622-11-6

  View details for PubMedID 24987446

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC3828262

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3773273

• 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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC3764173

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3760253

• 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

  Abstract

  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

  View details for DOI 10.4269/ajtmh.12-0629

  View details for Web of Science ID 000321939600022

• 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

  Abstract

  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

  Abstract

  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

• Sustained improvements in handwashing indicators more than 5years after a cluster-randomised, community-based trial of handwashing promotion in Karachi, Pakistan TROPICAL MEDICINE & INTERNATIONAL HEALTH Bowen, A., Agboatwalla, M., Ayers, T., Tobery, T., Tariq, M., Luby, S. P. 2013; 18 (3): 259-267

  Abstract

  To evaluate handwashing behaviour 5 years after a handwashing intervention in Karachi, Pakistan.In 2003, we randomised neighbourhoods to control, handwashing promotion, or handwashing promotion and water treatment. Intervention households were given soap +/- water treatment product and weekly handwashing education for 9 months. In 2009, we re-enrolled 461 households from the three study groups: control (160), handwashing (141), and handwashing + water treatment (160) and assessed hygiene-related outcomes, accounting for clustering.Intervention households were 3.4 times more likely than controls to have soap at their handwashing stations during the study visit [293/301 (97%) vs. 45/159 (28%), P < 0.0001]. While nearly all households reported handwashing after toileting, intervention households more commonly reported handwashing before cooking [relative risk (RR) 1.2 (95% confidence interval (CI) 1.0-1.4)] and before meals [RR 1.7 (95% CI, 1.3-2.1)]. Control households cited a mean of 3.87 occasions for washing hands; handwashing households, 4.74 occasions; and handwashing + water treatment households, 4.78 occasions (P < 0.0001). Households reported purchasing a mean of 0.65 (control), 0.91 (handwashing) and 1.1 (handwashing + water treatment) bars of soap/person/month (P < 0.0001).Five years after receiving handwashing promotion, intervention households were more likely to have soap at the household handwashing station, know key times to wash hands and report purchasing more soap than controls, suggesting habituation of improved handwashing practices in this population. Intensive handwashing promotion may be an effective strategy for habituating hygiene behaviours and improving health.

  View details for DOI 10.1111/tmi.12046

  View details for Web of Science ID 000315103700004

  View details for PubMedID 23294343

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3582809

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3559054

• 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

  Abstract

  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

  View details for PubMedCentralID PMC4666596

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3559038

• Challenges to Evaluating Respiratory Syncytial Virus Mortality in Bangladesh, 2004-2008 PLOS ONE Stockman, L. J., Brooks, W. A., Streatfield, P. K., Rahman, M., Goswami, D., Nahar, K., Rahman, M. Z., Luby, S. P., Anderson, L. J. 2013; 8 (1)

  Abstract

  Acute lower respiratory illness is the most common cause of death among children, globally. Data are not available to make accurate estimates on the global mortality from respiratory syncytial virus (RSV), specifically.Respiratory samples collected from children under 5 years of age during 2004 to 2008 as part of population-based respiratory disease surveillance in an urban community in Dhaka, Bangladesh were tested for RSV, human metapneumovirus (HMPV), human parainfluenza virus (PIV) types 1, 2, and 3, influenza and adenovirus by RT-PCR. Verbal autopsy data were used to identify children who died from respiratory illness in a nearby rural community. Significance of the correlation between detections and community respiratory deaths was determined using Spearman's coefficient.RSV activity occurred during defined periods lasting approximately three months but with no clear seasonal pattern. There was no significant correlation between respiratory deaths and detection of any of the respiratory viruses studied.Outbreaks of respiratory viruses may not be associated with deaths in children in the study site; however, the few respiratory deaths observed and community-to-community variation in the timing of outbreaks may have obscured an association. An accurate assessment of respiratory virus-associated deaths will require detections and death data to come from the same location and a larger study population.

  View details for DOI 10.1371/journal.pone.0053857

  View details for Web of Science ID 000314023600023

  View details for PubMedID 23365643

• 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
• Cholera Outbreaks in Urban Bangladesh In 2011. Epidemiology (Sunnyvale, Calif.) Haque, F., Hossain, M. J., Kundu, S. K., Naser, A. M., Rahman, M., Luby, S. P. 2013; 3

  Abstract

  In 2011, a multidisciplinary team investigated two diarrhoea outbreaks affecting urban Bangladeshi communities from the districts of Bogra and Kishorganj to identify etiology, pathways of transmission, and factors contributing to these outbreaks.We defined case-patients with severe diarrhoea as residents from affected communities admitted with ≥3 loose stools per day. We listed case-patients, interviewed and examined them, and collected rectal swabs. We visited the affected communities to explore the water and sanitation infrastructure. We tested the microbial load of water samples from selected case household taps, tube wells, and pump stations. We conducted anthropological investigations to understand community perceptions regarding the outbreaks.We identified 21 case-patients from Bogra and 84 from Kishorganj. The median age in Bogra was 23 years, and 21 years in Kishorganj. There were no reported deaths. We isolated Vibrio in 29% (5/17) of rectal swabs from Bogra and in 40% (8/20) from Kishorganj. We found Vibrio in 1/8 tap water samples from Bogra and in both of the samples from Kishorganj. We did not find Vibrio in water samples from pumps or tube wells in either outbreak. Ground water extracted through deep tube wells was supplied intermittently through interconnected pipes without treatment in both areas. We found leakages in the water pipes in Bogra, and in Kishorganj water pipes passed through open sewers.The rapid onset of severe diarrhoea predominantly affecting adults and the isolation of cholera in rectal swabs confirmed that these outbreaks were caused by Vibrio cholerae. The detection of Vibrio in water samples organisms from taps but not from pumps or tube wells, suggested contamination within the pipes. Safe water provision is difficult in municipalities where supply is intermittent, and where pipes commonly leak. Research to develop and evaluate water purification strategies could identify appropriate approaches for ensuring safe drinking water in resource-poor cities.

  View details for PubMedID 26702366

• Risk practices for animal and human anthrax in Bangladesh: an exploratory study. Infection ecology & epidemiology Islam, M. S., Hossain, M. J., Mikolon, A., Parveen, S., Khan, M. S., Haider, N., Chakraborty, A., Titu, A. M., Rahman, M. W., Sazzad, H. M., Rahman, M., Gurley, E. S., Luby, S. P. 2013; 3

  Abstract

  From August 2009 to October 2010, International Centre for Diarrheal Disease Research, Bangladesh and the Institute of Epidemiology, Disease Control and Research together investigated 14 outbreaks of anthrax which included 140 animal and 273 human cases in 14 anthrax-affected villages. Our investigation objectives were to explore the context in which these outbreaks occurred, including livestock rearing practices, human handling of sick and dead animals, and the anthrax vaccination program.Field anthropologists used qualitative data-collection tools, including 15 hours of unstructured observations, 11 key informant interviews, 32 open-ended interviews, and 6 group discussions in 5 anthrax-affected villages.Each cattle owner in the affected communities raised a median of six ruminants on their household premises. The ruminants were often grazed in pastures and fed supplementary rice straw, green grass, water hyacinth, rice husk, wheat bran, and oil cake; lactating cows were given dicalcium phosphate. Cattle represented a major financial investment. Since Islamic law forbids eating animals that die from natural causes, when anthrax-infected cattle were moribund, farmers often slaughtered them on the household premises while they were still alive so that the meat could be eaten. Farmers ate the meat and sold it to neighbors. Skinners removed and sold the hides from discarded carcasses. Farmers discarded the carcasses and slaughtering waste into ditches, bodies of water, or open fields. Cattle in the affected communities did not receive routine anthrax vaccine due to low production, poor distribution, and limited staffing for vaccination.Slaughtering anthrax-infected animals and disposing of butchering waste and carcasses in environments where ruminants live and graze, combined with limited vaccination, provided a context that permitted repeated anthrax outbreaks in animals and humans. Because of strong financial incentives, slaughtering moribund animals and discarding carcasses and waste products will likely continue. Long-term vaccination coverage for at-risk animal populations may reduce anthrax infection.

  View details for DOI 10.3402/iee.v3i0.21356

  View details for PubMedID 24298326

• 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

  Abstract

  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

• 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)

  Abstract

  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 (http://www.clinicaltrials.gov): NCT01590095 (Bangladesh), NCT01704105 (Kenya).

  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

  Abstract

  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

  View details for PubMedCentralID PMC4629474

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3519295

• Association Between Intensive Handwashing Promotion and Child Development in Karachi, Pakistan A Cluster Randomized Controlled Trial ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Bowen, A., Agboatwalla, M., Luby, S., Tobery, T., Ayers, T., Hoekstra, R. M. 2012; 166 (11): 1037-1044

  Abstract

  To evaluate associations between handwashing promotion and child growth and development.Cluster randomized controlled trial.Informal settlements in Karachi, Pakistan.A total of 461 children who were enrolled in a trial of household-level handwashing promotion in 2003 and were younger than 8 years at reassessment in 2009.In 2003, neighborhoods were randomized to control (n = 9), handwashing promotion (n = 9), or handwashing promotion and drinking water treatment (n = 10); intervention households received free soap and weekly handwashing promotion for 9 months.Anthropometrics and developmental quotients measured with the Battelle Developmental Inventory II at 5 to 7 years of age.Overall, 24.9% (95% CI, 20.0%-30.6%) and 22.1% (95% CI, 18.0%-26.8%) of children had z scores that were more than 2 SDs below the expected z scores for height and body mass index for age, respectively; anthropometrics did not differ significantly across study groups. Global developmental quotients averaged 104.4 (95% CI, 101.9-107.0) among intervention children and 98.3 (95% CI, 93.1-103.4) among control children (P = .04). Differences of similar magnitude were measured across adaptive, personal-social, communication, cognitive, and motor domains.Although growth was similar across groups, children randomized to the handwashing promotion during their first 30 months of age attained global developmental quotients 0.4 SDs greater than those of control children at 5 to 7 years of age. These gains are comparable to those of at-risk children enrolled in publicly funded preschools in the United States and suggest that handwashing promotion could improve child well-being and societal productivity.clinicaltrials.gov Identifier: NCT01538953.

  View details for DOI 10.1001/archpediatrics.2012.1181

  View details for Web of Science ID 000310686400007

  View details for PubMedID 22986783

• 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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC3414453

• 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

  Abstract

  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

  Abstract

  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

• Backyard poultry raising in Bangladesh: a valued resource for the villagers and a setting for zoonotic transmission of avian influenza. A qualitative study RURAL AND REMOTE HEALTH Sultana, R., Nahar, N., Rimi, N. A., Azad, S., Islam, M. S., Gurley, E. S., Luby, S. P. 2012; 12 (3)

  Abstract

  Backyard poultry raising is common in rural communities and a valued resource that provides food and income for subsistence farmers. Close contact with infected backyard poultry has been associated with H5N1 human cases in different countries. The emergence of this virus within Bangladesh means that backyard poultry raisers are at risk of avian influenza infections. The aim of this study was to understand why people raise backyard poultry and to characterize people's regular interaction with their poultry.In 2008, a qualitative study was conducted in two villages from two districts of Bangladesh. In a social mapping exercise the villagers drew all the households in their village: 115 households in the village in Netrokona and 85 households in the village in Rajshahi District. Selected were 40 households (20 households from each of the two villages) for data collection through in-depth interviews (n=40) and household mapping (n=40), and observation sessions (n=16).In both villages, 92% of households raised backyard poultry. The majority of the owners was female and used the money earned from poultry raising to purchase cooking ingredients, clothing, and agricultural seeds, and pay for children's education expenses. The households consumed poultry meat and eggs. In the village in Netrokona, 80% (85/106) of households kept poultry inside the bedroom. In the village in Rajshahi, 87% (68/78) of households had separate cage/night sheds. During feeding the poultry and cleaning the poultry raising areas, villagers came into contact with poultry and poultry feces. Poultry scavenged for food on the floor, bed, in the food pot and around the place where food was cooked. Poultry drank from and bathed in the same body of water that villagers used for bathing and washing utensils and clothes.Although raising poultry provides essential support to the families' livelihoods, it exposes them to the risk of avian influenza through close contact with their poultry. Simple warnings to avoid poultry contact are unlikely to change practices that are essential to household survival. Interventions that help to protect poultry flocks and improve household profitability are more likely to be practiced.

  View details for Web of Science ID 000318412500007

  View details for PubMedID 22950607

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC3403762

• 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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC3324868

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3316528

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3285198

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3310473

• 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

  Abstract

  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
• Clinical and Epidemiologic Features of Diarrheal Disease due to Aeromonas hydrophila and Plesiomonas shigelloides Infections Compared with Those due to Vibrio cholerae Non-O1 and Vibrio parahaemolyticus in Bangladesh. ISRN microbiology Klontz, E. H., Faruque, A. S., Das, S. K., Malek, M. A., Islam, Z., Luby, S. P., Klontz, K. C. 2012; 2012: 654819-?

  Abstract

  Using data from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) from 1996 to 2001, we compared the clinical features of diarrhea in patients with stool specimens yielding only A. hydrophila (189 patients; 1.4% of 13,970 patients screened) or P. shigelloides (253 patients) compared to patients with sole V. cholerae non-O1 infection (99 patients) or V. parahaemolyticus infection (126 patients). Patients exhibited similar frequencies of fever (temperature >37.8°C), stools characterized as watery, and stools containing visible mucus. Dehydration was observed more often among patients with V. parahaemolyticus or V. cholerae non-O1 infection. Compared to patients infected with V. parahaemolyticus, those with A. hydrophila, P. shigelloides, or V. cholerae non-O1 infection were less likely to report visible blood in the stool and, on microscopic examination, less likely to exhibit stool red blood cell and white blood cell counts exceeding 20 cells per high power field. The proportion of patients reporting subjective cure at the time of discharge was significantly smaller for those infected with V. parahaemolyticus. These findings suggest that A. hydrophila and P. shigelloides produce diarrheal disease that is less severe than that resulting from infection with V. cholerae non-O1 or V. parahaemolyticus.

  View details for DOI 10.5402/2012/654819

  View details for PubMedID 23762755

• Epidemiology of Henipavirus Disease in Humans HENIPAVIRUS: ECOLOGY, MOLECULAR VIROLOGY, AND PATHOGENESIS Luby, S. P., Gurley, E. S. 2012; 359: 25-40

  View details for DOI 10.1007/82_2012_207

  View details for Web of Science ID 000330362500004

• 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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC3260571

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3310083

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3247110

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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC3276487

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3235024

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3205635

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3182309

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3197608

• Inequalities in Care-seeking for Febrile Illness of Under-five Children in Urban Dhaka, Bangladesh JOURNAL OF HEALTH POPULATION AND NUTRITION Najnin, N., Bennett, C. M., Luby, S. P. 2011; 29 (5): 523-531

  Abstract

  Fever is an easily-recognizable primary sign for many serious childhood infections. In Bangladesh, 31% of children aged less than five years (under-five children) die from serious infections, excluding confirmed acute respiratory infections or diarrhoea. Understanding healthcare-seeking behaviour for children with fever could provide insights on how to reduce this high rate of mortality. Data from a cross-sectional survey in the catchment areas of two tertiary-level paediatric hospitals in Dhaka, Bangladesh, were analyzed to identify the factors associated with the uptake of services from trained healthcare providers for under-five children with reported febrile illness. Health and demographic data were collected in a larger study of 7,865 children using structured questionnaires. Data were selected from 1,290 of these under-five children who were taken to any healthcare provider for febrile illness within two months preceding the date of visit by the study team. Certified doctors were categorized as 'trained', and other healthcare providers were categorized as 'untrained'. Healthcare-seeking behaviours were analyzed in relation to these groups. A wealth index was constructed using principal component analysis to classify the households into socioeconomic groups. The odds ratios for factors associated with healthcare-seeking behaviours were estimated using logistic regression with adjustment for clustering. Forty-one percent of caregivers (n=529) did not seek healthcare from trained healthcare providers. Children from the highest wealth quintile were significantly more likely [odds ratio (OR)=5.6, 95% confidence interval (CI) 3.4-9.2] to be taken to trained healthcare providers compared to the poorest group. Young infants were more likely to be taken to trained healthcare providers compared to the age-group of 4-<5 years (OR=1.6, 95% CI 1.1-2.4). Male children were also more likely to be taken to trained healthcare providers (OR=1.5, 95% CI 1.2-1.9) as were children with decreased level of consciousness (OR=5.3, 95% CI 2.0-14.2). Disparities across socioeconomic groups and gender persisted in seeking quality healthcare for under-five children with febrile illness in urban Dhaka. Girls from poor families were less likely to access qualified medical care. To reduce child mortality in the short term, health education and behaviour-change communication interventions should target low-income caregivers to improve their recognition of danger-signs; reducing societal inequalities remains an important long-term goal.

  View details for Web of Science ID 000296910300013

  View details for PubMedID 22106759

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3163879

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3163873

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3144840

• Estimating the Effect of Recurrent Infectious Diseases on Nutritional Status: Sampling Frequency, Sample-size, and Bias JOURNAL OF HEALTH POPULATION AND NUTRITION Schmidt, W., Genser, B., Luby, S. P., Chalabi, Z. 2011; 29 (4): 317-326

  Abstract

  There is an ongoing interest in studying the effect of common recurrent infections and conditions, such as diarrhoea, respiratory infections, and fever, on the nutritional status of children at risk of malnutrition. Epidemiological studies exploring this association need to measure infections with sufficient accuracy to minimize bias in the effect estimates. A versatile model of common recurrent infections was used for exploring how many repeated measurements of disease are required to maximize the power and logistical efficiency of studies investigating the effect of infectious diseases on malnutrition without compromising the validity of the estimates. Depending on the prevalence and distribution of disease within a population, 15-30 repeat measurements per child over one year should be sufficient to provide unbiased estimates of the association between infections and nutritional status. Less-frequent measurements lead to a bias in the effect size towards zero, especially if disease is rare. In contrast, recall error can lead to exaggerated effect sizes. Recall periods of three days or shorter may be preferable compared to longer recall periods. The results showed that accurate estimation of the association between recurrent infections and nutritional status required closer follow-up of study participants than studies using recurrent infections as an outcome measure. The findings of the study provide guidance for choosing an appropriate sampling strategy to explore this association.

  View details for Web of Science ID 000294666200004

  View details for PubMedID 21957670

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3141792

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC3125291

• The Variability of Childhood Diarrhea in Karachi, Pakistan, 2002-2006 AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Agboatwalla, M., Hoekstra, R. M. 2011; 84 (6): 870-877

  Abstract

  Diarrhea burden is often estimated using cross-sectional surveys. We measured variability in diarrhea prevalence among children < 5 years of age living in squatter settlements in central Karachi, Pakistan. We pooled data from non-intervention control households from studies conducted from 2002 through 2006. The prevalence of diarrhea varied on average by 29% from one week to the next, by 37% from one month to the next, and during peak diarrhea season by 32% from one year to the next. During 24 months when the same nine neighborhoods were under surveillance, each month the prevalence of diarrhea varied by at least an order of magnitude from the lowest to the highest prevalence neighborhood, and each neighborhood recorded the highest diarrhea prevalence during at least one month. Cross-sectional surveys are unreliable measures of diarrhea prevalence.

  View details for DOI 10.4269/ajtmh.2011.10-0364

  View details for Web of Science ID 000291333200007

  View details for PubMedID 21633021

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3062441

• Hygiene: new hopes, new horizons LANCET INFECTIOUS DISEASES Curtis, V., Schmidt, W., Luby, S., Florez, R., Toure, O., Biran, A. 2011; 11 (4): 312-321

  Abstract

  Although promotion of safe hygiene is the single most cost-effective means of preventing infectious disease, investment in hygiene is low both in the health and in the water and sanitation sectors. Evidence shows the benefit of improved hygiene, especially for improved handwashing and safe stool disposal. A growing understanding of what drives hygiene behaviour and creative partnerships are providing fresh approaches to change behaviour. However, some important gaps in our knowledge exist. For example, almost no trials of the effectiveness of interventions to improve food hygiene in developing countries are available. We also need to figure out how best to make safe hygiene practices matters of daily routine that are sustained by social norms on a mass scale. Full and active involvement of the health sector in getting safe hygiene to all homes, schools, and institutions will bring major gains to public health.

  View details for Web of Science ID 000289275600019

  View details for PubMedID 21453872

• Community perceptions of bloody diarrhoea in an urban slum in South Asia: implications for introduction of a Shigella vaccine. Epidemiology and infection Arvelo, W., Blum, L. S., Nahar, N., von Seidlein, L., Nahar, L., Pack, R. P., Brooks, A. W., Pach, A., Breiman, R. F., Luby, S. P., Ram, P. K. 2011; 139 (4): 599-605

  Abstract

  Understanding local perceptions of disease causation could help public health officials improve strategies to prevent bloody diarrhoea. A cross-sectional survey was conducted in Dhaka, Bangladesh to elicit community beliefs about the causes of and prevention strategies for bloody diarrhoea. Between March and June 2003, we interviewed 541 randomly selected respondents. Overall, 507 (93%) respondents perceived that a vaccine could prevent bloody diarrhoea. If a vaccine provided lifetime protection, 445 (83%) respondents stated that they would opt to get the vaccine and would pay a median of $0·05 (range U.S.$0·01-0·15) for it, equivalent to <1% of their median weekly income. There was almost universal perception that an effective vaccine to prevent bloody diarrhoea was highly beneficial and acceptable. While respondents valued a vaccine for prevention of bloody diarrhoea, they were only willing to pay minimally for it. Therefore, achieving a high rate of Shigella vaccine coverage may require subsidy of vaccine purchase.

  View details for DOI 10.1017/S0950268810001391

  View details for PubMedID 20546637

• Changing species distribution and antimicrobial susceptibility pattern of Shigella over a 29-year period (1980-2008) EPIDEMIOLOGY AND INFECTION Khatun, F., Faruque, A. S., Koeck, J. L., Olliaro, P., Millet, P., Paris, N., Malek, M. A., Salam, M. A., Luby, S. 2011; 139 (3): 446-452

  Abstract

  We studied changes in species distribution and antimicrobial resistance patterns of Shigella during 1980-2008, using the Diarrhoeal Diseases Surveillance system of Dhaka Hospital of ICDDR,B. In hospitalized patients Shigella prevalence decreased steadily from 8-12% in the 1980s to 3% in 2008. Endemic S. flexneri was the most commonly isolated species (54%). Epidemic S. dysenteriae type 1 had two peaks in 1984 and 1993, but was not found after 2000, except for one case in 2004. The therapeutic options are now limited: in 2008 a total of 33% of S. flexneri were resistant to ciprofloxacin and 57% to mecillinam. In the <5 years age group, severely underweight, wasted and stunted children were more at risk of shigellosis compared to well-nourished children (P<0·001). Although hospitalization for Shigella diarrhoea is decreasing, the high levels of antimicrobial resistance and increased susceptibility of malnourished children continue to pose an ongoing risk.

  View details for DOI 10.1017/S0950268810001093

  View details for Web of Science ID 000287612600015

  View details for PubMedID 20478088

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

• Is Structured Observation a Valid Technique to Measure Handwashing Behavior? Use of Acceleration Sensors Embedded in Soap to Assess Reactivity to Structured Observation AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Ram, P. K., Halder, A. K., Granger, S. P., Jones, T., Hall, P., Hitchcock, D., Wright, R., Nygren, B., Islam, M. S., Molyneaux, J. W., Luby, S. P. 2010; 83 (5): 1070-1076

  Abstract

  Structured observation is often used to evaluate handwashing behavior. We assessed reactivity to structured observation in rural Bangladesh by distributing soap containing acceleration sensors and performing structured observation 4 days later. Sensors recorded the number of times soap was moved. In 45 participating households, the median number of sensor soap movements during the 5-hour time block on pre-observation days was 3.7 (range 0.3-10.6). During the structured observation, the median number of sensor soap movements was 5.0 (range 0-18.0), a 35% increase, P = 0.0004. Compared with the same 5-hour time block on pre-observation days, the number of sensor soap movements increased during structured observation by ≥ 20% in 62% of households, and by ≥ 100% in 22% of households. The increase in sensor soap movements during structured observation, compared with pre-observation days, indicates substantial reactivity to the presence of the observer. These findings call into question the validity of structured observation for measurement of handwashing behavior.

  View details for DOI 10.4269/ajtmh.2010.09.0763

  View details for Web of Science ID 000284184600022

  View details for PubMedID 21036840

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC2958840

• Coping strategies for financial burdens in families with childhood pneumonia in Bangladesh BMC PUBLIC HEALTH Alamgir, N. I., Naheed, A., Luby, S. P. 2010; 10

  Abstract

  This study aimed to determine the out-of pocket expenditure and coping strategies adopted by families of children admitted in a hospital in Bangladesh with pneumonia.Trained interviewers surveyed parents of 90 children and conducted in-depth interviews with six families below the age of 5 years who were admitted to the largest pediatric hospital in Bangladesh with a diagnosis of pneumonia. We estimated the total cost of illness associated with hospitalization and explored the coping strategies of the families.The mean expenditure of the families for the illness episode was US$ 94 (±SD 52.5) with 75% having spent more than half of their total monthly expenditure on this hospitalization. Three fourths (68/90, 76%) of the families managed the expenditure by borrowing, mortgaging or selling assets; 64% had to borrow the full cost of hospitalization and 10% borrowed from the formal sector with a monthly interest rate of 5 to 30%. The burden was highest for the people from poor income strata. Families earning ≤US$ 59 per month were 10 times more likely than families earning ≥US$ 59 per month to borrow money (OR = 10.0, 95% CI: 2.8-38.8). To repay their debts, 22% of families reported that they would work extra hours and 50% planned to reduce spending on food and education for their children.Coping strategies adopted by the families to manage the out-of-pocket expenditure for children requiring hospitalization were catastrophic for the majority of the families. Efforts to prevent childhood pneumonia for example, by vaccination against the most common pathogens, by improving air quality and by improving childhood nutrition can provide a double advantage. They can prevent both disease and poverty.

  View details for DOI 10.1186/1471-2458-10-622

  View details for Web of Science ID 000284067700001

  View details for PubMedID 20955627

• Determinants of Use of Household-level Water Chlorination Products in Rural Kenya, 2003-2005 INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH DuBois, A. E., Crump, J. A., Keswick, B. H., Slutsker, L., Quick, R. E., Vulule, J. M., Luby, S. P. 2010; 7 (10): 3842-3852

  Abstract

  Household-level water treatment products provide safe drinking water to at-risk populations, but relatively few people use them regularly; little is known about factors that influence uptake of this proven health intervention. We assessed uptake of these water treatments in Nyanza Province, Kenya, November 2003-February 2005. We interviewed users and non-user controls of a new household water treatment product regarding drinking water and socioeconomic factors. We calculated regional use-prevalence of these products based on 10 randomly selected villages in the Asembo region of Nyanza Province, Kenya. Thirty-eight percent of respondents reported ever using household-level treatment products. Initial use of a household-level product was associated with having turbid water as a source (adjusted odds ratio [AOR] = 16.6, p = 0.007), but consistent usage was more common for a less costly and more accessible product that did not address turbidity. A combination of social marketing, retail marketing, and donor subsidies may be necessary to extend the health benefits of household-level water treatment to populations most at risk.

  View details for DOI 10.3390/ijerph7103842

  View details for Web of Science ID 000283576600016

  View details for PubMedID 21139864

• 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

  Abstract

  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

  View details for PubMedCentralID PMC2944374

• 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

  Abstract

  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

• Efficacy of pentavalent rotavirus vaccine against severe rotavirus gastroenteritis in infants in developing countries in Asia: a randomised, double-blind, placebo-controlled trial. Lancet Zaman, K., Dang, D. A., Victor, J. C., Shin, S., Yunus, M., Dallas, M. J., Podder, G., Vu, D. T., Le, T. P., Luby, S. P., Le, H. T., Coia, M. L., Lewis, K., Rivers, S. B., Sack, D. A., Schödel, F., Steele, A. D., Neuzil, K. M., Ciarlet, M. 2010; 376 (9741): 615-623

  Abstract

  Rotavirus vaccine has proved effective for prevention of severe rotavirus gastroenteritis in infants in developed countries, but no efficacy studies have been done in developing countries in Asia. We assessed the clinical efficacy of live oral pentavalent rotavirus vaccine for prevention of severe rotavirus gastroenteritis in infants in Bangladesh and Vietnam.In this multicentre, double-blind, placebo-controlled trial, undertaken in rural Matlab, Bangladesh, and urban and periurban Nha Trang, Vietnam, infants aged 4-12 weeks without symptoms of gastrointestinal disorders were randomly assigned (1:1) to receive three oral doses of pentavalent rotavirus vaccine 2 mL or placebo at around 6 weeks, 10 weeks, and 14 weeks of age, in conjunction with routine infant vaccines including oral poliovirus vaccine. Randomisation was done by computer-generated randomisation sequence in blocks of six. Episodes of gastroenteritis in infants who presented to study medical facilities were reported by clinical staff and from parent recollection. The primary endpoint was severe rotavirus gastroenteritis (Vesikari score >or=11) arising 14 days or more after the third dose of placebo or vaccine to end of study (March 31, 2009; around 21 months of age). Analysis was per protocol; infants who received scheduled doses of vaccine or placebo without intervening laboratory-confirmed naturally occurring rotavirus disease earlier than 14 days after the third dose and had complete clinical and laboratory results were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT00362648.2036 infants were randomly assigned to receive pentavalent rotavirus vaccine (n=1018) or placebo (n=1018). 991 infants assigned to pentavalent rotavirus vaccine and 978 assigned to placebo were included in the per-protocol analysis. Median follow up from 14 days after the third dose of placebo or vaccine until final disposition was 498 days (IQR 480-575). 38 cases of severe rotavirus gastroenteritis (Vesikari score >or=11) were reported during more than 1197 person-years of follow up in the vaccine group, compared with 71 cases in more than 1156 person years in the placebo group, resulting in a vaccine efficacy of 48.3% (95% CI 22.3-66.1) against severe disease (p=0.0005 for efficacy >0%) during nearly 2 years of follow-up. 25 (2.5%) of 1017 infants assigned to receive vaccine and 20 (2.0%) of 1018 assigned to receive placebo had a serious adverse event within 14 days of any dose. The most frequent serious adverse event was pneumonia (vaccine 12 [1.2%]; placebo 15 [1.5%]).In infants in developing countries in Asia, pentavalent rotavirus vaccine is safe and efficacious against severe rotavirus gastroenteritis, and our results support expanded WHO recommendations to promote its global use.PATH (GAVI Alliance grant) and Merck.

  View details for DOI 10.1016/S0140-6736(10)60755-6

  View details for PubMedID 20692031

• Efficacy of pentavalent rotavirus vaccine against severe rotavirus gastroenteritis in infants in developing countries in Asia: a randomised, double-blind, placebo-controlled trial LANCET Zaman, K., Anh, D. D., Victor, J. C., Shin, S., Yunus, M., Dallas, M. J., Podder, G., Thiem, V. D., Mai, L. T., Luby, S. P., Tho, L. H., Coia, M. L., Lewis, K., Rivers, S. B., Sack, D. A., Schoedel, F., Steele, A. D., Neuzil, K. M., Ciarlet, M. 2010; 376 (9741): 615-623

  View details for DOI 10.1016/S0140-6736(10)60755-6

  View details for Web of Science ID 000281309100032

• Sampling strategies to measure the prevalence of common recurrent infections in longitudinal studies. Emerging themes in epidemiology Schmidt, W., Genser, B., Barreto, M. L., Clasen, T., Luby, S. P., Cairncross, S., Chalabi, Z. 2010; 7 (1): 5-?

  Abstract

  Measuring recurrent infections such as diarrhoea or respiratory infections in epidemiological studies is a methodological challenge. Problems in measuring the incidence of recurrent infections include the episode definition, recall error, and the logistics of close follow up. Longitudinal prevalence (LP), the proportion-of-time-ill estimated by repeated prevalence measurements, is an alternative measure to incidence of recurrent infections. In contrast to incidence which usually requires continuous sampling, LP can be measured at intervals. This study explored how many more participants are needed for infrequent sampling to achieve the same study power as frequent sampling.We developed a set of four empirical simulation models representing low and high risk settings with short or long episode durations. The model was used to evaluate different sampling strategies with different assumptions on recall period and recall error.The model identified three major factors that influence sampling strategies: (1) the clustering of episodes in individuals; (2) the duration of episodes; (3) the positive correlation between an individual's disease incidence and episode duration. Intermittent sampling (e.g. 12 times per year) often requires only a slightly larger sample size compared to continuous sampling, especially in cluster-randomized trials. The collection of period prevalence data can lead to highly biased effect estimates if the exposure variable is associated with episode duration. To maximize study power, recall periods of 3 to 7 days may be preferable over shorter periods, even if this leads to inaccuracy in the prevalence estimates.Choosing the optimal approach to measure recurrent infections in epidemiological studies depends on the setting, the study objectives, study design and budget constraints. Sampling at intervals can contribute to making epidemiological studies and trials more efficient, valid and cost-effective.

  View details for DOI 10.1186/1742-7622-7-5

  View details for PubMedID 20678239

• 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

  Abstract

  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

  View details for PubMedCentralID PMC2911199

• 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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC2895649

• 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

  View details for DOI 10.4269/ajtmh.2010.09-0574

  View details for Web of Science ID 000278462600027

• Leptospirosis as a cause of fever in urban Bangladesh. The 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

  Abstract

  We tested paired sera from 584 febrile persons in an low-income urban community in Bangladesh for evidence of Leptospira infection. A total of 8.4% of the persons met criteria for definite or probable infection. Persons with leptospirosis were older than those with undifferentiated fever in this population. The dominant infecting serogroups in Bangladesh differed from serogroups commonly reported in nearby regions.

  View details for DOI 10.4269/ajtmh.2010.09-0574

  View details for PubMedID 20519612

• 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

  Abstract

  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

• Pulmonary Tuberculosis and Drug Resistance in Dhaka Central Jail, the Largest Prison in Bangladesh PLOS ONE Banu, S., Hossain, A., Uddin, M. K., Uddin, M. R., Ahmed, T., Khatun, R., Mahmud, A. M., Hyder, K. A., Lutfor, A. B., Karim, M. S., Zaman, K., Khan, M. A., Barua, P. C., Luby, S. P. 2010; 5 (5)

  Abstract

  There are limited data on TB among prison inmates in Bangladesh. The aim of the study was to determine the prevalence of pulmonary tuberculosis (TB), its drug resistance and risk factors in Dhaka Central Jail, the largest prison in Bangladesh.Cross sectional survey with, active screening of a total number of 11,001 inmates over a period of 2 years. Sputum samples from TB suspects were taken for acid- fast bacilli (AFB) microscopy, culture and drug susceptibility testing.Among 1,781 TB suspects 245 (13.8%) were positive for AFB on microscopy and/or culture. The prevalence rate of sputum- positive pulmonary TB was 2,227/100,000. Fifty three cases (21.6% of 245 cases) were AFB- negative on microscopy but were found positive on culture. Resistance to isoniazid, rifampicin, streptomycin and ethambutol was 11.4%, 0.8%, 22.4% and 6.5% respectively. No multidrug resistance was observed. The main risk factors of TB in prison were exposure to TB patients (adjusted odds ratio 3.16, 95% CI 2.36-4.21), previous imprisonment (1.86, 1.38-2.50), longer duration of stay in prison (17.5 months for TB cases; 1.004, 1.001-1.006) and low body mass index which is less than 18.5 kg/m(2) (5.37, 4.02-7.16).The study results revealed a very high prevalence of TB in the prison population in Dhaka Central Jail. Entry examinations and active symptom screening among inmates are important to control TB transmission inside the prison. Identifying undiagnosed smear-negative TB cases remains a challenge to combat this deadly disease in this difficult setting.

  View details for DOI 10.1371/journal.pone.0010759

  View details for Web of Science ID 000278017400015

  View details for PubMedID 20505826

• 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

  Abstract

  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

• Simple Sari Cloth Filtration of Water Is Sustainable and Continues To Protect Villagers from Cholera in Matlab, Bangladesh MBIO Huq, A., Yunus, M., Sohel, S. S., Bhuiya, A., Emch, M., Luby, S. P., Russek-Cohen, E., Nair, G. B., Sack, R. B., Colwell, R. R. 2010; 1 (1)

  Abstract

  A simple method for filtering water to reduce the incidence of cholera was tested in a field trial in Matlab, Bangladesh, and proved effective. A follow-up study was conducted 5 years later to determine whether the filtration method continued to be employed by villagers and its impact on the incidence of cholera. A total of 7,233 village women collecting water daily for their households in Bangladesh were selected from the same study population of the original field trial for interviewing. Analysis of the data showed that 31% of the women used a filter of which 60% used sari filters for household water. Results showed that sari filtration not only was accepted and sustained by the villagers and benefited them, including their neighbors not filtering water, in reducing the incidence of cholera, the latter being an unexpected benefit.

  View details for DOI 10.1128/mBio.00034-10

  View details for Web of Science ID 000284716600004

  View details for PubMedID 20689750

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC2841199

• 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

  Abstract

  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

• Axonal variant of Guillain-Barre syndrome associated with Campylobacter infection in Bangladesh NEUROLOGY Islam, Z., Jacobs, B. C., van Belkum, A., MOHAMMAD, Q. D., Islam, M. B., Herbrink, P., Diorditsa, S., Luby, S. P., Talukder, K. A., Endtz, H. P. 2010; 74 (7): 581-587

  Abstract

  Campylobacter jejuni enteritis is the predominant bacterial infection preceding Guillain-Barré syndrome (GBS), an acute postinfectious immune-mediated polyradiculoneuropathy. The purpose of this study was to define the clinical phenotype of GBS and the relation with preceding C jejuni infections in Bangladesh.We performed a prospective matched case-control hospital surveillance including 100 patients fulfilling the National Institute of Neurological Disorders and Stroke criteria for GBS from 2006 to 2007 in the Dhaka area of Bangladesh. Detailed clinical, electrophysiologic, serologic, and microbiologic data were obtained with a follow-up of 6 months.GBS affected predominantly young adult males living in rural areas. Sixty-nine percent of the patients had clinical evidence of a preceding infection. The most frequent symptom was diarrhea (36%). The majority of patients had a pure motor variant of GBS (92%) with relatively infrequent cranial nerve involvement (30%). Twenty-five percent of patients required respiratory support. Electrophysiologic studies showed that 67% of patients had an axonal variant of GBS. Eleven patients (14%) died, and 23 (29%) remained severely disabled during the follow-up. Positive C jejuni serology was found in an unprecedented high frequency of 57% as compared with 8% in family controls and 3% in control patients with other neurologic diseases (p < 0.001). C jejuni infection was significantly associated with serum antibodies to the gangliosides GM1 and GD1a, axonal neuropathy, and greater disability.We report an unusually high frequency of the axonal variant of Guillain-Barré syndrome in Bangladesh, associated with preceding Campylobacter jejuni infection, severe residual disability, and high mortality.

  View details for Web of Science ID 000274517100010

  View details for PubMedID 20157160

• 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

  Abstract

  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

  View details for PubMedCentralID PMC2813179

• Recall errors in a weekly survey of diarrhoea in Guatemala: determining the optimal length of recall EPIDEMIOLOGY AND INFECTION Zafar, S. N., Luby, S. P., Mendoza, C. 2010; 138 (2): 264-269

  Abstract

  We measured the recall error, optimal recall length and factors associated with diarrhoea in a weekly survey. Data was taken from a year-long randomized controlled trial in which characteristics of diarrhoeal episodes were recorded weekly. We labelled the recall period as days 1-6; day 1 being the day before the visit. Recall error was the percentage difference between the number of episodes reported to begin on a particular day and the mean for days 1 and 2. Generalized estimating equations were used to determine associations. Recall error was 37% on day 3 and 51% on day 5. The error was less in younger children (by 10%), severe episodes (by 29%) and when blood was present in the stool (by 18%). Diarrhoea was underreported when the recall period extended beyond 2 days. Surveys that use longer recall periods risk underestimating diarrhoea incidence and selectively capturing more severe episodes.

  View details for DOI 10.1017/S0950268809990422

  View details for Web of Science ID 000273842600013

  View details for PubMedID 19653923

• 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

  Abstract

  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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC2795194

• 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)

  Abstract

  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

  View details for PubMedCentralID PMC2779865

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

  Abstract

  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

  View details for PubMedCentralID PMC2784122

• 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

  Abstract

  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

  Abstract

  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

• Intussusception Surveillance in a Rural Demographic Surveillance Area in Bangladesh JOURNAL OF INFECTIOUS DISEASES Zaman, K., Breiman, R. F., Yunus, M., Arifeen, S. E., Mahmud, A., Chowdhury, H. R., Luby, S. P. 2009; 200: S271-S276

  Abstract

  Rotavirus is the leading cause of diarrhea-related morbidity and mortality in developing countries, including Bangladesh. The licensed vaccine Rotashield was withdrawn from the market because of an increased risk of intussusception. This study was undertaken to estimate the background incidence rates of intussusception among children aged <2 years, using retrospective and prospective studies in a rural demographic surveillance area in Bangladesh.All hospital charts of children aged <2 years who presented to the Matlab Hospital and 2 other treatment centers of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), during January 2001-August 2004 were reviewed retrospectively. A prospective surveillance was performed from August 2004 through December 2006 at the 3 treatment centers of ICDDR,B serving Matlab, 4 district and subdistrict government hospitals, and 3 district-based private clinics, to determine population-based rates of intussusception with use of Brighton Collaboration case definitions. All suspected cases of intussusception were referred to the Matlab Hospital by community health research workers for further assessment by a trained medical officer, including performance of an ultrasound examination.In total, 2856 charts of children aged <2 years were reviewed retrospectively, and 4 probable cases and 19 possible cases of intussusception were identified. In the prospective surveillance, of 1508 potential cases, including 41 referred by community health research workers, only 2 cases met the case definition of probable intussusception, and 1 case met the definition of possible intussusception. A total of 123 patients had ultrasound examinations performed. The population-based rates of probable and possible cases of intussusception among children aged <2 years were 0-17.8 and 17.7-81.7 cases per 100,000 children per year, respectively. In the retrospective and prospective surveillance, the rates were 0-18.7 and 0-97 cases per 100,000 children per year, respectively.The incidence of intussusception was low among children in Bangladesh. A surveillance system for intussusception has been fully established in the Matlab surveillance area to diagnose, treat, and refer potential cases. This study provides useful information for detection of intussusception during future studies of new-generation rotavirus vaccines and also provides background incidence rates for comparison when rotavirus vaccines are introduced.

  View details for DOI 10.1086/605047

  View details for Web of Science ID 000270655100031

  View details for PubMedID 19817608

• Effects of local climate variability on transmission dynamics of cholera in Matlab, Bangladesh TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE Islam, M. S., Sharker, M. A., Rheman, S., Hossain, S., Mahmud, Z. H., Islam, M. S., Uddin, A. M., Yunus, M., Osman, M. S., Ernst, R., RECTOR, I., Larson, C. P., Luby, S. P., Endtz, H. P., Cravioto, A. 2009; 103 (11): 1165-1170

  Abstract

  Cholera is considered as a model for climate-related infectious diseases. In Bangladesh, cholera epidemics occur during summer and winter seasons, but it is not known how climate variability influences the seasonality of cholera. Therefore, the variability pattern of cholera events was studied in relation to the variation in local climate variables in Matlab, Bangladesh. Classification and regression tree (CART) and principal component analysis (PCA) were used to study the dependency and variability pattern of monthly total cholera cases. An average temperature <23.25 degrees C corresponded to the lowest average cholera occurrence (23 cases/month). At a temperature of >or=23.25 degrees C and sunshine <4.13h/day, the cholera occurrence was 39 cases/month. With increased sunshine (>or=4.13h/day) and temperature (23.25-28.66 degrees C), the second highest cholera occurrence (44 cases/month) was observed. When the sunshine was >or=4.13h/day and the temperature was >28.66 degrees C, the highest cholera occurrence (54 cases/month) was observed. These results demonstrate that in summer and winter seasons in Bangladesh, temperature and sunshine hours compensate each other for higher cholera incidence. The synergistic effect of temperature and sunshine hours provided the highest number of cholera cases.

  View details for DOI 10.1016/j.trstmh.2009.04.016

  View details for Web of Science ID 000271776800014

  View details for PubMedID 19477477

• 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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC2815955

• Avian Influenza Virus A (H5N1), Detected through Routine Surveillance, in Child, Bangladesh EMERGING INFECTIOUS DISEASES Brooks, W. A., Alamgir, A. S., Sultana, R., Islam, M. S., Rahman, M., Fry, A., Shu, B., Lindstrom, S., Nahar, K., Goswami, D., Haider, M. S., Nahar, S., Butler, E., Hancock, K., Donis, R. O., Davis, C. T., Zaman, R. U., Luby, S. P., Uyeki, T. M., Rahman, M. 2009; 15 (8): 1311-1313

  Abstract

  We identified avian influenza virus A (H5N1) infection in a child in Bangladesh in 2008 by routine influenza surveillance. The virus was of the same clade and phylogenetic subgroup as that circulating among poultry during the period. This case illustrates the value of routine surveillance for detection of novel influenza virus.

  View details for DOI 10.3201/eid1508.090283

  View details for Web of Science ID 000268819100028

  View details for PubMedID 19751601

• 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

  Abstract

  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

• Detection of Antibodies Secreted from Circulating Mycobacterium tuberculosis-Specific Plasma Cells in the Diagnosis of Pediatric Tuberculosis CLINICAL AND VACCINE IMMUNOLOGY Raqib, R., Mondal, D., Karim, M. A., Chowdhury, F., Ahmed, S., Luby, S., Cravioto, A., Andersson, J., Sack, D. 2009; 16 (4): 521-527

  Abstract

  Diagnosis of tuberculosis (TB) in children is difficult because symptoms are often nonspecific or absent in infected children, diagnostic specimens are difficult to obtain from younger children, and >50% have negative TB cultures. Thus, there is an urgent need for improved diagnosis of pediatric TB. This study aimed to evaluate the diagnostic value of a new serological method, the ALS (antibodies in lymphocyte supernatant) assay, for the diagnosis of active TB in children with clinically identified TB. The ALS test is based on the concept that antigen-specific plasma cells are present in the circulation only at times of acute infection and not in latency. A cross-sectional study of pediatric patients (age range, 11 to 167 months) who were clinically identified as TB (n = 58) or non-TB (n = 16) patients was conducted, and they were monitored for 6 months. Healthy children (n = 58) were enrolled as controls. Spontaneous release of TB antigen-specific antibodies by in vitro-cultured, unstimulated peripheral blood mononuclear cells was assessed by an enzyme-linked immunosorbent assay using Mycobacterium bovis bacillus Calmette-Guérin (BCG) as the detecting antigen. Of the patients clinically diagnosed with TB, 15% had culture-confirmed TB, 64% were positive for TB by clinically established scoring charts (K. Edwards, P. N. G. Med. J. 30: 169-178, 1987; G. Stegen, K. Jones, and P. Kaplan, Pediatrics 43: 260-263, 1969; and stop TB Partnership, Childhood TB subgroup, World Health Organization, Int. J. Tuberc. Lung Dis. 10: 1091-1097, 2006), and 91% were TB positive by the ALS method. All TB patients had significantly higher BCG-specific ALS titers at enrollment (optical density [OD], 1.06 +/- 0.32) than healthy-control children (OD, 0.18 +/- 0.06) and non-TB children (OD, 0.21 +/- 0.10) (P = 0.001). The ALS titers declined in children with active disease from enrollment through 6 months following anti-TB therapy (P = 0.001). The ALS assay is a novel diagnostic method with potential applications in the diagnosis of pediatric TB and in subsequent monitoring of treatment effectiveness.

  View details for DOI 10.1128/CVI.00391-08

  View details for Web of Science ID 000264938400013

  View details for PubMedID 19193833

• 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

  Abstract

  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

• Multihospital Surveillance of Pneumonia Burden among Children Aged < 5 Years Hospitalized for Pneumonia in Bangladesh CLINICAL INFECTIOUS DISEASES Naheed, A., Saha, S. K., Breiman, R. F., Khatun, F., Brooks, W. A., El Arifeen, S., Sack, D., Luby, S. P. 2009; 48: S82-S89

  Abstract

  Pneumonia contributes substantially to childhood mortality in Bangladesh. We conducted a study to characterize the disease severity and risk factors for mortality among children hospitalized for pneumonia in Bangladesh.We analyzed data on hospitalization, patient characteristics, and mortality collected by a multicenter hospital-based surveillance of pneumonia in Bangladesh.From May 2004 through April 2007, 4155 children aged 2-59 months who met a pneumonia case definition adopted by GAVI's Pneumococcal Vaccines Accelerated Development and Introduction Plan-sponsored surveillance networks were enrolled after blood culture specimens were obtained. The mean duration (+/-SD) from illness onset to hospital admission was 6+/- days; 1842 children (44%) received antimicrobial treatment before hospitalization, and an additional 924 (22%) received antimicrobial treatment after admission to the hospital. Bacteria were isolated from 161 (4%) of the 4155 specimens, including 10 (6%) Streptococcus pneumoniae isolates and 5 (3%) Haemophilus influenzae type b isolates. The case-fatality rate for pneumonia in the hospital was 4% (150 deaths), and the children who died did so after a median of 2 days of hospitalization (range, 0-24 days). Infancy was highly associated with death due to pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), as were very severe pneumonia (OR, 7.9; 95% CI, 5.6-11.2), a blood culture positive for bacteria (OR, 3.4; 95% CI, 2.0-5.8), severe malnutrition (OR, 4.6; 95% CI, 2.9-7.4), and delayed admission (mean [+/-SD] duration from illness onset to admission, 6+/-6 days, compared with 5+/-4 days for survivors; P< .04).The prevalence of pneumonia among children aged <5 years in hospitals in Bangladesh is high. However, the isolation rate of bacteria is low, possibly because of the high (68%) background use of antibiotics. Multiple risk factors associated with pneumonia case fatality suggest multiple strategies, including vaccines, to reduce pneumonia-related and overall child mortality in Bangladesh.

  View details for DOI 10.1086/596485

  View details for Web of Science ID 000263061800007

  View details for PubMedID 19191623

• Surveillance for Invasive Streptococcus pneumoniae Disease among Hospitalized Children in Bangladesh: Antimicrobial Susceptibility and Serotype Distribution CLINICAL INFECTIOUS DISEASES Saha, S. K., Naheed, A., El Arifeen, S., Islam, M., Al-Emran, H., Amin, R., Fatima, K., Brooks, W. A., Breiman, R. F., Sack, D. A., Luby, S. P. 2009; 48: S75-S81

  Abstract

  Vaccines offer the prospect of primary disease prevention of pneumococcal disease in childhood. For introduction of such vaccines in developing countries, information about disease epidemiology is necessary.We evaluated antimicrobial susceptibility and serotype distribution of invasive Streptococcus pneumoniae disease in children aged <5 years in a network of 7 hospitals in Bangladesh from May 2004 through May 2007.Of 17,969 blood cultures and 3765 cerebrospinal fluid cultures, 139 yielded S. pneumoniae isolates; 94 were from meningitis cases, 13 were from pneumonia cases, and 32 were from sepsis cases. Among the children with positive culture results, 73% were aged <12 months and 90% were aged <24 months. Complete resistance against penicillin, chloramphenicol, and cotrimoxazole was found in 0%, 6%, and 32% of isolates, respectively. Of the 37 serotypes observed, the predominant serotypes were 2 (17%), 1 (12%), 14 (7%), 5 (6%), 7F (6%), 45 (7%), and 12A (4%). Serotypes differed between meningitis cases and nonmeningitis cases, especially for serotype 2 (25% of meningitis cases vs. 0% of pneumonia cases; P < .001). The 7-, 10-, and 13-valent vaccines would cover 20% (95% confidence interval [CI], 13%-27%), 43% (95% CI, 35%-51%), and 50% (95% CI, 42%-58%) of these cases of invasive pneumococcal disease overall, with higher coverage of nonmeningitis cases, compared with meningitis cases (7-valent coverage, 23% vs. 18%; 10-valent coverage, 55% vs. 38%; 13-valent coverage, 66% vs. 42%).High levels of nonsusceptibility to cotrimoxazole and susceptibility to penicillin suggest that penicillin may be a drug of choice for treatment of invasive pneumococcal disease. Although serotype distribution is diverse, with changes over time and differences between syndromes observed, implementation of use of the currently available 10- or 13-valent vaccines would have a substantial impact on pneumococcal disease in Bangladesh.

  View details for DOI 10.1086/596544

  View details for Web of Science ID 000263061800006

  View details for PubMedID 19191622

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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)

  Abstract

  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

  View details for PubMedCentralID PMC2571985

• 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

  Abstract

  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

  Abstract

  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

  View details for PubMedCentralID PMC2740710

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

• Clinical presentation of Nipah virus infection in Bangladesh CLINICAL INFECTIOUS DISEASES Hossain, M. J., Gurley, E. S., Montgomery, J. M., Bell, M., Carroll, D. S., Hsu, V. P., Formenty, P., Croisier, A., Bertherat, E., Faiz, M. A., Azad, A. K., Islam, R., Molla, M. A., Ksiazek, T. G., Rota, P. A., Comer, J. A., Rollin, P. E., Luby, S. P., Breiman, R. F. 2008; 46 (7): 977-984

  Abstract

  In Bangladesh, 4 outbreaks of Nipah virus infection were identified during the period 2001-2004.We characterized the clinical features of Nipah virus-infected individuals affected by these outbreaks. We classified patients as having confirmed cases of Nipah virus infection if they had antibodies reactive with Nipah virus antigen. Patients were considered to have probable cases of Nipah virus infection if they had symptoms consistent with Nipah virus infection during the same time and in the same community as patients with confirmed cases.We identified 92 patients with Nipah virus infection, 67 (73%) of whom died. Although all age groups were affected, 2 outbreaks principally affected young persons (median age, 12 years); 62% of the affected persons were male. Fever, altered mental status, headache, cough, respiratory difficulty, vomiting, and convulsions were the most common signs and symptoms; clinical and radiographic features of acute respiratory distress syndrome of Nipah illness were identified during the fourth outbreak. Among those who died, death occurred a median of 6 days (range, 2-36 days) after the onset of illness. Patients who died were more likely than survivors to have a temperature >37.8 degrees C, altered mental status, difficulty breathing, and abnormal plantar reflexes. Among patients with Nipah virus infection who had well-defined exposure to another patient infected with Nipah virus, the median incubation period was 9 days (range, 6-11 days).Nipah virus infection produced rapidly progressive severe illness affecting the central nervous and respiratory systems. Clinical characteristics of Nipah virus infection in Bangladesh, including a severe respiratory component, appear distinct from clinical characteristics reported during earlier outbreaks in other countries.

  View details for DOI 10.1086/529147

  View details for Web of Science ID 000253817800003

  View details for PubMedID 18444812

• Difficulties in bringing point-of-use water treatment to scale in rural Guatemala AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Mendoza, C., Keswick, B. H., Chiller, T. M., Hoekstra, R. M. 2008; 78 (3): 382-387

  Abstract

  In an earlier study in rural Guatemala, 257 households that received flocculant-disinfectant to treat their drinking water had 39% less diarrhea than 257 control households. Three weeks after completion of the study, national marketing of the flocculant-disinfectant was extended into the study communities. Six months later, we assessed frequency of and characteristics associated with purchase and use of the flocculant-disinfectant by revisiting the original study households and administering a questionnaire. Four hundred sixty-two households (90%) completed the follow-up survey; 22 households (5%) purchased the flocculant-disinfectant within the preceding 2 weeks and used it within the last week. Neither being randomized to the intervention group during the efficacy study nor combined spending on laundry soap, toothpaste, and hand soap in the preceding week was associated with active repeat use. Even after efficacy was demonstrated within their community and an aggressive sophisticated marketing approach, few households purchased flocculant-disinfectant for point-of-use water treatment.

  View details for Web of Science ID 000253928100007

  View details for PubMedID 18337330

• 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

  Abstract

  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

  Abstract

  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

• Invasive pneumococcal disease burden and implications for vaccine policy in urban Bangladesh AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Brooks, W. A., Breiman, R. F., Goswami, D., Hossain, A., Alam, K., Saha, S. K., Nahar, K., Nasrin, D., Ahmed, N., El Arifeen, S., Naheed, A., Sack, D. A., Luby, S. 2007; 77 (5): 795-801

  Abstract

  We undertook active population-based surveillance in 5,000 urban households among children < 5 years old to determine invasive pneumococcal disease (IPD) incidence, serotype distribution, clinical presentation, and antimicrobial resistance, which have not been previously described in population-based studies from the region. IPD was documented by blood culture isolation. From 01 April 2004 to 31 March 2006, 5,903 blood cultures were collected from 6,167 eligible children. Streptococcus pneumoniae was isolated from 34 pneumococcal patients; IPD was clinically associated with pneumonia (24%), upper respiratory infection (62%), and febrile syndromes (14%). Overall, IPD and 13-valent serotype-related IPD incidences were 447 and 276 episodes/100,000 child-years, respectively. Peak IPD incidence occurred during the cool dry seasons. Penicillin, cotrimoxazole, chloramphenicol, and ciprofloxacin resistances were 2.9%, 82.4%, 14.7%, and 24.1%, respectively. Current conjugate vaccines should substantially reduce IPD, childhood pneumonia, and antimicrobial resistance in Bangladesh.

  View details for Web of Science ID 000250735000002

  View details for PubMedID 17984328

• Human metapneumovirus infection among children, Bangladesh EMERGING INFECTIOUS DISEASES Brooks, W. A., Erdman, D., Terebuh, P., Klimov, A., Goswami, D., Sharmeen, A. T., Azim, T., Luby, S., Bridges, C., Breiman, R. 2007; 13 (10): 1611-1613

  Abstract

  We confirmed circulation of human metapneumovirus (HMPV) among children with febrile and respiratory illness in an urban slum in Dhaka, Bangladesh, during active surveillance in 2001. HMPV was the most common single virus identified among febrile children and appears to contribute to the high rates of illness in this population.

  View details for Web of Science ID 000249962800038

  View details for PubMedID 18258022

• Estimating the longitudinal prevalence of diarrhea and other episodic diseases - Continuous versus intermittent surveillance EPIDEMIOLOGY Schmidt, W., Luby, S. P., Genser, B., Barreto, M. L., Clasen, T. 2007; 18 (5): 537-543

  Abstract

  Longitudinal prevalence (ie, the proportion of time with the disease) is used to describe morbidity from diarrhea and other episodic conditions. The aim of this analysis was to compare estimates of longitudinal prevalence based on intermittent sampling at regular intervals with 24- or 48-hour recall, with estimates based on continuous surveillance.Based on 2 real datasets from Brazil and Guatemala, we developed a simulated dataset representing the diarrhea morbidity of 10,000 individuals followed over 365 days.Both the model and the real datasets showed that the standard deviation of the longitudinal prevalence increases with decreasing numbers of days sampled, so that a study sampling only a fraction of days would require a larger sample size. However, due to the correlation of diarrhea between consecutive days, sampling at 7- to 14-day intervals results in relatively small loss of precision and power compared with daily morbidity records, especially when the average diarrheal episode is long. A study based on morbidity data for every seventh day may require only a 5%-24% larger sample size than a study with daily records, depending on the average duration of episodes. Using a recall period of 48 hours instead of 24 hours increases power if the average episode is short.The results question the necessity of continuous surveillance to estimate longitudinal prevalence. In addition to savings in cost and staff time, intermittent sampling of morbidity may improve validity by minimizing recall error and reducing the influence of surveillance on participants' behavior.

  View details for DOI 10.1097/EDEA01361809f3ce

  View details for Web of Science ID 000249000500003

  View details for PubMedID 17603390

• Long-term neurological and functional outcome in Nipah virus infection ANNALS OF NEUROLOGY Sejvar, J. J., Hossain, J., Saba, S. K., Gurley, E. S., Bann, S., Hamadani, J. D., Faiz, M. A., Siddiqui, F. M., Mohammad, Q. D., Mollah, A. H., Uddin, R., Alam, R., Rahman, R., Tan, C. T., Bellini, W., Rota, P., Breiman, R. F., Luby, S. P. 2007; 62 (3): 235-242

  Abstract

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

  View details for DOI 10.1002/ana.21178

  View details for Web of Science ID 000249937000009

  View details for PubMedID 17696217

• 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

  Abstract

  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

  View details for PubMedCentralID PMC2878219

• Epidemiology and risk factors for endemic typhoid fever in Uzbekistan TROPICAL MEDICINE & INTERNATIONAL HEALTH Srikantiah, P., Vafokulov, S., Luby, S. P., Ishmail, T., Earhart, K., Khodjaev, N., Jennings, G., Crump, J. A., Mahoney, F. J. 2007; 12 (7): 838-847

  Abstract

  To investigate the risk factors for infection with endemic typhoid fever in the Samarkand region of Uzbekistan.Case-control study of culture-confirmed bloodstream infection with Salmonella Typhi. Patients were compared to age-matched community controls. Salmonella Typhi isolates were tested for antimicrobial susceptibility.We enrolled 97 patients and 192 controls. The median age of patients was 19 years. In a conditional regression model, consumption of unboiled surface water outside the home [adjusted odds ratio (aOR)=3.0, 95% confidence interval (CI)=1.1-8.2], use of antimicrobials in the 2 weeks preceding onset of symptoms (aOR=12.2, 95% CI 4.0-37.0), and being a student (aOR=4.0, 95% CI 1.4-11.3) were independently associated with typhoid fever. Routinely washing vegetables (aOR 0.06, 95% CI 0.02-0.2) and dining at a tea-house (aOR 0.4, 95% CI 0.2-1.0) were associated with protection against illness. Salmonella Typhi resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole was identified in 6 (15%) of 41 isolates tested.Endemic typhoid fever in Uzbekistan is transmitted by contaminated water. Recent use of antimicrobials also increased risk of infection. Targeted efforts at improving drinking water quality, especially for students and young adults, are likely to decrease transmission of typhoid fever. Measures to decrease the unnecessary use of antimicrobials would be expected to reduce the risk of typhoid fever and decrease the spread of multiple drug-resistant Salmonella Typhi.

  View details for DOI 10.1111/j.1365-3156.2007.01853.x

  View details for Web of Science ID 000247562000006

  View details for PubMedID 17596250

• Faecal contamination of drinking water sources of Dhaka city during the 2004 flood in Bangladesh and use of disinfectants for water treatment JOURNAL OF APPLIED MICROBIOLOGY Islam, M. S., Brooks, A., Kabir, M. S., Jahid, I. K., Islam, M. S., Goswami, D., Nair, G. B., Larson, C., Yukiko, W., Luby, S. 2007; 103 (1): 80-87

  Abstract

  To describe the extent of faecal pollution and point of use water treatment strategy during and after the 2004 flood in Dhaka.A total of 300 water samples were collected from 20 different drinking water sources in Kamalapur, Dhaka city from August 2004 to January 2005. The level of faecal contamination was estimated using measurements of faecal indicator bacteria (total coliforms, faecal coliforms and faecal streptococci) and isolation of Vibrio cholerae was carried out following standard procedures. Total dissolved solids, dissolved oxygen, hardness, chloride and pH were also monitored. The efficacy of four disinfectants including Halotab, Zeoline-200, alum potash and bleaching powder were tested as point of use water treatment agents. The unacceptable level of contamination of total coliforms (TC), faecal coliforms (FC) and faecal streptococci (FS) ranged from 23.8% to 95.2%, 28.6% to 95.2% and 33.3% to 90.0%, respectively. The isolation rates of V. cholerae O1 and O139 were both 0.33%, and non-O1/non-O139 was 7.0%.Water collected during and after floods was contaminated with TC, FC, FS and V. cholerae. Although alum potash, bleaching powder, Halotab and Zeoline-200 were all effective general disinfectants, Halotab and Zeoline-200 were superior to bleaching powder and alum potash against FC.During and after floods, point of use water treatment could reduce waterborne diseases among flood-affected people.

  View details for DOI 10.1111/j.1365-2672.2006.03234.x

  View details for Web of Science ID 000247441000008

  View details for PubMedID 17584454

• Comparing serologic response against enteric pathogens with reported diarrhea to assess the impact of improved household drinking water quality AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Crump, J. A., Mendoza, C. E., Priest, J. W., Glass, R. I., Monroe, S. S., Dauphin, L. A., Bibb, W. F., Lopez, M. B., Alvarez, M., Mintz, E. D., Luby, S. P. 2007; 77 (1): 136-141

  Abstract

  We evaluated enteric infection serology as an alternative outcome measure to diarrhea prevalence in a randomized controlled trial of household-based drinking water treatment; 492 households were randomly assigned to 5 household-based water treatment interventions or control. Individuals were followed weekly over 52 weeks to measure diarrhea prevalence. Study subjects of age

  View details for Web of Science ID 000247979800024

  View details for PubMedID 17620645

• Brucellosis as a cause of acute febrile illness in Egypt TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE Jennings, G. J., Hajjeh, R. A., Girgis, F. Y., Fadeel, M. A., Maksoud, M. A., Wasfy, M. O., El Sayed, N., Srikantiah, P., Luby, S. P., Earhart, K., Mahoney, F. J. 2007; 101 (7): 707-713

  Abstract

  To develop better estimates of brucellosis incidence, we conducted population-based surveillance for acute febrile illness (AFI) in Fayoum governorate (population 2347249), Egypt during two summer periods (2002 and 2003). All hospitals and a representative sample of community healthcare providers were included. AFI patients without obvious etiology were tested for brucellosis by culture and serology. Incidence estimates were calculated adjusting for sampling methodology and study period. Of 4490 AFI patients enrolled, 321 (7%) met the brucellosis case definition. The estimated annual incidence of brucellosis per 100000 population was 64 and 70 in 2002 and 2003, respectively. The median age of brucellosis patients was 26 years and 70% were male; 53% were initially diagnosed as typhoid fever. Close contact with animals and consumption of unpasteurized milk products were associated with brucellosis. The high incidence of brucellosis in Fayoum highlights its public health importance, and the need to implement prevention strategies in humans and animals.

  View details for DOI 10.1016/j.trstmh.2007.02.027

  View details for Web of Science ID 000247665700015

  View details for PubMedID 17442354

• A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Bowen, A., Ma, H., Ou, J., Billhimer, W., Long, T., Mintz, E., Hoekstra, R. M., Luby, S. 2007; 76 (6): 1166-1173

  Abstract

  Intensive handwashing promotion can reduce diarrheal and respiratory disease incidence. To determine whether less intensive, more scalable interventions can improve health, we evaluated a school-based handwashing program. We randomized 87 Chinese schools to usual practices: standard intervention (handwashing program) or expanded intervention (handwashing program, soap for school sinks, and peer hygiene monitors). We compared student absence rates, adjusting for cluster design. In control schools, children experienced a median 2.0 episodes (median 2.6 days) of absence per 100 student-weeks. In standard intervention schools, there were a median 1.2 episodes (P = 0.08) and 1.9 days (P = 0.14) of absence per 100 student-weeks. Children in expanded intervention schools experienced a median 1.2 episodes (P = 0.03) and 1.2 days (P = 0.03) of absence per 100 student-weeks. Provision of a large-scale handwashing promotion program and soap was associated with significantly reduced absenteeism. Similar programs could improve the health of children worldwide.

  View details for Web of Science ID 000247116500032

  View details for PubMedID 17556631

• Field trial of a low cost method to evaluate hand cleanliness TROPICAL MEDICINE & INTERNATIONAL HEALTH Luby, S. P., Agboatwalla, M., Billhimer, W., Hoekstra, R. M. 2007; 12 (6): 765-771

  Abstract

  To evaluate a simple low cost method for measuring hand contamination as an objective assessment of handwashing practices.As part of a larger randomized controlled trial of handwashing promotion with soap conducted in squatter settlements of Karachi, Pakistan, a randomly selected subset of 52 mothers in households receiving soap and handwashing promotion and 28 mothers in control households directly pressed three fingers of their right hand onto MacConkey agar plates on weekly unannounced visits from April to September 2002, and monthly from October 2002 to March 2003. The MacConkey plates were incubated at 44 degrees C for 24 h, and evaluated for growth of thermotolerant coliform bacteria.The proportion of samples that had detectable thermotolerant coliforms (50%) was similar in households that received soap and control households (52%, P = 0.40). In the week after evaluation of the mothers' hands, the proportion of households that reported diarrhoea was similar regardless of whether or not the mother had thermotolerant coliforms detected by direct finger imprint (18.6%vs. 19.1%, Relative Risk 0.99, 95% CI 0.96, 1.03).A three finger direct imprint test using MacConkey agar for thermotolerant coliforms was not a useful method to assess regular handwashing practices with soap in Karachi. Developing better measures of handwashing behaviour remains an important research priority.

  View details for DOI 10.1111/j.1365-3156.2007.01847.x

  View details for Web of Science ID 000247175000009

  View details for PubMedID 17550474

• 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

  Abstract

  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

  View details for PubMedCentralID PMC2870597

• 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

  Abstract

  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

  View details for PubMedCentralID PMC3291367

• Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES Parviz, S., Fatmi, Z., Altaf, A., McCormick, J. B., Fischer-Hoch, S., Rahbarc, M., Luby, S. 2006; 10 (5): 364-371

  Abstract

  To find the prevalence of HIV infection and risk behaviors among injecting drug users (IDUs) in Karachi, Pakistan.A cross-sectional study of IDUs conducted in Karachi, Pakistan from February through June 1996.Of the 242 IDUs, 11 (4%) refused HIV testing. One (0.4%; 95% confidence interval (CI) = 0.37-0.48%) was HIV positive. All subjects were male. Over the past 6 months 47% had engaged in receptive needle sharing, 38% had perceived a change in their social network, 22% had had sexual intercourse, of whom only 7% always used condoms, and none had washed their needles with bleach. Younger age (28 vs. 31 years; p = 0.01), younger age at first injection (25 vs. 28 years; p = 0.001), fewer years of schooling (3 vs. 5 years; p = 0.001), lower monthly income (70 dollars vs. 80 dollars; p = 0.03), inhaling fumes of heroin from a foil in the year before injecting (OR = 4.8; CI = 2.2-10.3), injecting first time with heroin (OR = 3.6; CI = 1.2-12.6), having a temporary job (OR = 2.5; CI = 1.2-5.2), and a perceived change in one's social network (OR = 4.4; CI = 2.4-7.9) were all associated with receptive needle sharing. IDUs who knew about HIV spread through contaminated needles were less likely to share (OR = 0.4; CI 0.2-0.8). In the final logistic regression model receptive needle sharing was associated with inhaling of fumes of heroin on a foil in the year prior to injecting (adjusted OR = 5.6; CI = 2.6-12.0), a perceived change in one's social network (adjusted OR = 4.0; CI = 2.2-7.4), and inversely associated with age at first time of injection (beta = -0.07; p = 0.002).Background HIV prevalence was low among IDUs in Karachi despite high-risk behavior in 1996. In order to control HIV transmission among IDUs in Pakistan, continual HIV surveillance with well-coordinated and effective HIV risk reduction, and drug demand reduction programs need to be implemented among drug users.

  View details for DOI 10.1016/j.ijid.2005.07.010

  View details for Web of Science ID 000240364600008

  View details for PubMedID 16793307

• Enteric pathogens associated with diarrhea in children in Fayoum, Egypt DIAGNOSTIC MICROBIOLOGY AND INFECTIOUS DISEASE El-Mohamady, H., Abdel-Messih, I. A., Youssef, F. G., Said, M., Farag, H., Shaheen, H. I., Rockabrand, D. M., Luby, S. B., Hajjeh, R., Sanders, J. W., Monteville, M. R., Klena, J. D., Frenck, R. W. 2006; 56 (1): 1-5

  Abstract

  In a cross-sectional study of children <60 months old from Fayoum, Egypt, presenting with diarrhea, 46% (162/356) had detectable enteric pathogens. Bacterial pathogens were identified in 25% (89/356), whereas rotavirus and Cryptosporidium were detected in 21% (54/253) and 15% (39/253), respectively. Cryptosporidium is an important pathogen in this region.

  View details for DOI 10.1016/j.diagmicrobio.2006.02.007

  View details for Web of Science ID 000240568000001

  View details for PubMedID 16675181

• 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

  Abstract

  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

  View details for PubMedCentralID PMC1626162

• 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

  Abstract

  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

  Abstract

  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

• Prevalence of hepatitis B among Afghan refugees living in Balochistan, Pakistan INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES Quddus, A., Luby, S. P., Jamal, Z., Jafar, T. 2006; 10 (3): 242-247

  Abstract

  Continued civil war and political instability in Afghanistan have lead to a huge influx of refugees into the neighboring provinces in Pakistan. This study was conducted to estimate seroprevalence of hepatitis B and to identify potential risk factors for hepatitis B virus (HBV) transmission among the refugees living in the camps of Balochistan Province, Pakistan.A cross-sectional survey of hepatitis B surface antigen (HBsAg) was conducted during October 2003. We obtained the registration list to select families randomly from the refugee camps. A husband, wife and one of their children, selected at random, were enrolled in the study. Study subjects with positive laboratory results for HBsAg were compared with those who were negative for HBsAg.Field workers interviewed 301 families with a total of 903 study subjects. Blood specimens of 75 study subjects (8.3%, 95% CI 6.6-10.3) were positive for HBsAg. There were 37 husbands (12.3%, 95% CI 7.2-14.4) and 21 wives (7.0%, 95% CI 4.5-10.6) positive for HBsAg. Out of 301 children, 17 (5.6%, 95% CI 3.4-9.1) were positive for HBsAg. Receiving more than ten injections during the previous year increased the risk of HBV infection (OR 3.5, 95% CI 1.8-6.7). A child positive for HBsAg was more likely to have a positive parent compared to an HBsAg negative child (OR 5.7, 95% CI 2.0-16.5).Hepatitis B is highly endemic among Afghan refugees living in these camps. Unsafe injection practices will continue to cause a steady increase in the magnitude of this health problem until appropriate control measures are taken. The possibility of mother-to-child transmission underscores the need to include vaccination against hepatitis B as part of routine immunization in this population.

  View details for DOI 10.1016/j.ijid.2005.04.007

  View details for Web of Science ID 000237779200012

  View details for PubMedID 16448838

• Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial TROPICAL MEDICINE & INTERNATIONAL HEALTH Luby, S. P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W., Keswick, B., Hoekstra, R. M. 2006; 11 (4): 479-489

  Abstract

  To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap.The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea.Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectant-disinfectant plus hand washing with soap neighbourhoods.With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment.

  View details for DOI 10.1111/j.1365-3156.2006.01592.x

  View details for Web of Science ID 000236220300011

  View details for PubMedID 16553931

• Nipah virus: impact, origins, and causes of emergence. Current infectious disease reports Epstein, J. H., Field, H. E., Luby, S., Pulliam, J. R., Daszak, P. 2006; 8 (1): 59-65

  Abstract

  Nipah virus is an emerging zoonotic pathogen that causes severe febrile encephalitis resulting in death in 40% to 75% of human cases. Nipah virus is considered a biosafety level-4 pathogen and is listed as a select agent with high risk for public health and security due to its high mortality rate in people and the lack of effective vaccines or therapies. The natural reservoir for Nipah virus and related members of the genus Henipavirus are fruit bats of the genus Pteropus. Nipah virus emerged in Malaysia in 1998 as a porcine neurologic and respiratory disease that spread to humans who had contact with live, infected pigs. Research reviewed in this paper suggests that anthropogenic factors, including agricultural expansion and intensification, were the underlying causes of its emergence. Nipah virus has caused five subsequent outbreaks between 2001 and 2005 in Bangladesh. Here, it appears to have spilled over directly from bats to humans, and person-to-person transmission is evident suggesting a heightened public health risk.

  View details for PubMedID 16448602

• Evaluation of blood bank practices in Karachi, Pakistan, and the government's response. JPMA. The Journal of the Pakistan Medical Association Luby, S., Khanani, R., Zia, M., Vellani, Z., Ali, M., Qureshi, A. H., Khan, A. J., Mujeeb, S. A., Shah, S. A., Fisher-Hoch, S. 2006; 56 (1): S25-30

  Abstract

  National legislation in Pakistan regulating blood banks has been introduced several times, but has never been passed. To support provincial-level efforts to develop legislation we conducted a study to evaluate blood-banking practices in Karachi, Pakistan, to identify areas that could be improved.Thirty-seven blood banks were randomly selected from a list of 87 Karachi blood banks. The research team interviewed blood bank personnel, inspected available facilities and equipment, and observed blood collection using structured questionnaires and observation forms.Of the 37 selected facilities, 25 were operational and 24 agreed to participate. Twelve (50%) of the facilities reported regularly utilizing paid blood donors, while only six (25%) actively recruited volunteer donors. During observation only 8% of facilities asked donors about injecting drug use, and none asked donors any questions about high-risk sexual behaviour. While 95% of blood banks had appropriate equipment and reagents to screen for hepatitis B, only 55% could screen for HIV and 23% for hepatitis C. Twenty-nine percent of the facilities were storing blood products outside the WHO recommended temperature limits.Practives at most Karachi blood banks fell well below WHO standards. Findings from this study were instrumental in developing and passing legislation to regulate blood transfusion throughout Sindh Province, and suggest a method for improving blood transfusion practices in other developing countries (HPP 15 (2):217-22).

  View details for PubMedID 16689480

• Knowledge, attitudes and practices regarding sexually transmitted infections among general practitioners and medical specialists in Karachi, Pakistan. JPMA. The Journal of the Pakistan Medical Association Khandwalla, H. E., Luby, S., Rehman, S. 2006; 56 (1): S31-3

  Abstract

  To determine the knowledge, attitudes and practices regarding diagnosis and treatment of sexually transmitted infections (STIs) among specialists that is, dermatologist, gynecologists and urologists and general practitioners (GPs) in Karachi, Pakistan.Interviewers administered structured questionnaires to doctors conducting outpatient clinics at tertiary hospitals and/or private clinics in Karachi. All private clinics within a 10 km radius of the Aga Khan University and all tertiary hospitals having more than 100 inpatient beds were included in the study.One hundred doctors (54 specialists and 46 GPs) responded. Eighty doctors reported seeing at least one STI patient/month. The most commonly diagnosed STI the doctors reported was urethritis/cervicitis syndrome. 50% of the doctors knew the recommended antibiotics for gonorrhea though only 46% of these knew the correct dosage. Specialists were three times more likely to recognize the clinical presentation of herpes and twice as likely to treat chlamydia, syphilis and herpes with appropriate antimicrobials than GPs. 85% of the doctors advised their STI patients regarding condom usage; 36% thought that STI patients had loose sexual morals, 43% believed STI patients were drug addicts. Over 90% of the physicians were willing to attend educational sessions and follow a national STI treatment protocol.Doctors in Karachi, especially GPs, are deficient in appropriately managing and counseling STI patients. Among the specialists, urologists and dermatologists were more likely to manage STIs correctly than gynecologists. Karachi doctors should be educated in the correct management and counseling of STIs to prevent further spread of STIs including AIDS (Sex Transm Inf 2000;76:383-85).

  View details for PubMedID 16689481

• Multivariate analysis of risk factors associated with genital ulcer disease among incarcerated males in Sindh. JPMA. The Journal of the Pakistan Medical Association Akhtar, S., Luby, S. P., Rahbar, M. H. 2006; 56 (1): S34-9

  Abstract

  To evaluate the potential risk behaviors associated with the lifetime risk of self reported genital ulcer disease (GUD) among prison inmates.Prison inmates from 14 prisons of Sindh Province.A cross-sectional study was conducted on 3395 prison inmates during July to December 1994. A questionnaire was used to assess the lifetime risk of self-reported GUD (whether or not the subject was ever affected with GUD up to present age) and to investigate demographic markers and risk behaviors for their possible association with lifetime risk of GUD using logistic regression analysis.The reported lifetime risk of GUD in the study sample was 11.4% (386/3395). In final multivariate logistic regression model the sexual behaviors which were independently associated with GUD were having sexual intercourse with female (adjusted OR = 1.7; 95% CI: 1.3-2.3, P=0.0002), sexual intercourse with a prostitute (adjusted OR = 1.5; 95% CI: 1.2-2.0, P=0.0008), sexual intercourse with man (adjusted OR = 2.2; 95% CI: 1.7-2.7, P=<0.001) and sexual intercourse with man during current incarceration (adjusted OR = 1.9; 95% CI: 1.2-2.9, P=0.0071).Health education needs to re-enforce monogamous relationship for high risk groups such as in our study. Although infrequent condom use was not a risk factor for GUD in this study, yet based on the results of previous studies, promotion of condom use should be the component of health education program (JPMA 50:115;2000).

  View details for PubMedID 16689482

• Reducing diarrhoea in Guatemalan children: randomized controlled trial of flocculant-disinfectant for drinking-water BULLETIN OF THE WORLD HEALTH ORGANIZATION Chiller, T. M., Mendoza, C. E., Lopez, M. B., Alvarez, M., Hoekstra, R. M., Keswick, B. H., Luby, S. P. 2006; 84 (1): 28-35

  Abstract

  To examine the effect of a new point-of-use treatment for drinking-water, a commercially developed flocculant-disinfectant, on the prevalence of diarrhoea in children.We conducted a randomized controlled trial among 514 rural Guatemalan households, divided into 42 neighbourhood clusters, for 13 weeks, from 4 November 2002 through 31 January 2003. Clusters assigned to water treatment with the flocculant-disinfectant were compared with those using their usual water-handling practices. The longitudinal prevalence of diarrhoea was calculated as the proportion of total days with diarrhoea divided by the total number of days of observation. The prevalence of diarrhoea was compared using the Wilcoxon rank-sum test.The 1702 people in households receiving the disinfectant had a prevalence of diarrhoea that was 40% lower than that among the 1699 people using standard water-handling practices (0.9% versus 1.5%; P = 0.001). In households using the flocculant-disinfectant, children < 1 year of age had a 39% lower prevalence of diarrhoea than those in households using their standard practices (3.7% versus 6.0%; P = 0.005).In settings where families rarely treat drinking-water, we introduced a novel flocculant-disinfectant that reduced the longitudinal prevalence of diarrhoea, especially among children aged < 1 year, among whom diarrhoea has been strongly associated with mortality. Successful introduction and use of this product could contribute to preventing diarrhoeal disease globally.

  View details for Web of Science ID 000234438400009

  View details for PubMedID 16501712

• Population-based surveillance of typhoid fever in Egypt AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Srikantiah, P., Girgis, F. Y., Luby, S. P., Jennings, G., Wasfy, M. O., Crump, J. A., Hoekstra, R. M., Anwer, M., Mahoney, F. J. 2006; 74 (1): 114-119

  Abstract

  Credible measures of disease incidence are necessary to guide typhoid fever control efforts. In Egypt, incidence estimates have been derived from hospital-based syndromic surveillance, which may not represent the population with typhoid fever. To determine the population-based incidence of typhoid fever in Fayoum Governorate (pop. 2,240,000), we established laboratory-based surveillance at five tiers of health care. Incidence estimates were adjusted for sampling and test sensitivity. Of 1,815 patients evaluated, cultures yielded 90 (5%) Salmonella Typhi isolates. The estimated incidence of typhoid fever was 59/100,000 persons/year. We estimate 71% of typhoid fever patients are managed by primary care providers. Multidrug-resistant (MDR) Salmonella Typhi (resistant to chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole) was isolated from 26 (29%) patients. Population-based surveillance indicates moderate typhoid fever incidence in Fayoum, and a concerning prevalence of MDR typhoid. The majority of patients are evaluated at the primary care level and would not have been detected by hospital-based surveillance.

  View details for Web of Science ID 000234621800018

  View details for PubMedID 16407354

• Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial BMJ-BRITISH MEDICAL JOURNAL Crump, J. A., Otieno, P. O., Slutsker, L., Keswick, B. H., Rosen, D. H., Hoekstra, R. M., Vulule, J. M., Luby, S. P. 2005; 331 (7515): 478-481

  Abstract

  To compare the effect on prevalence of diarrhoea and mortality of household based treatment of drinking water with flocculant-disinfectant, sodium hypochlorite, and standard practices in areas with turbid water source in Africa.Cluster randomised controlled trial over 20 weeks.Family compounds, each containing several houses, in rural western Kenya.6650 people in 605 family compounds.Water treatment: flocculant-disinfectant, sodium hypochlorite, and usual practice (control).Prevalence of diarrhoea and all cause mortality. Escherichia coli concentration, free residual chlorine concentration, and turbidity in household drinking water as surrogates for effectiveness of water treatment.In children < 2 years old, compared with those in the control compounds, the absolute difference in prevalence of diarrhoea was -25% in the flocculant-disinfectant arm (95% confidence interval -40 to -5) and -17% in the sodium hypochlorite arm (-34 to 4). In all age groups compared with control, the absolute difference in prevalence was -19% in the flocculant-disinfectant arm (-34 to -2) and -26% in the sodium hypochlorite arm (-39 to -9). There were significantly fewer deaths in the intervention compounds than in the control compounds (relative risk of death 0.58, P = 0.036). Fourteen per cent of water samples from control compounds had E coli concentrations < 1 CFU/100 ml compared with 82% in flocculant-disinfectant and 78% in sodium hypochlorite compounds. The mean turbidity of drinking water was 8 nephelometric turbidity units (NTU) in flocculant-disinfectant households, compared with 55 NTU in the two other compounds (P < 0.001).In areas of turbid water, flocculant-disinfectant was associated with a significant reduction in diarrhoea among children < 2 years. This health benefit, combined with a significant reduction in turbidity, suggests that the flocculant-disinfectant is well suited to areas with highly contaminated and turbid water.

  View details for DOI 10.1136/bmj.38512.618681.E0

  View details for Web of Science ID 000231820400013

  View details for PubMedID 16046440

• Comparison of two methods for evaluating the quality of stored drinking water in Abidjan, Côte d'lvoire, and review of other comparisons in the literature. Journal of water and health Macy, J. T., Dunne, E. F., Angoran-Benie, Y. H., Kamelan-Tano, Y., Kouadio, L., Djai, K. A., Luby, S. P. 2005; 3 (3): 221-228

  Abstract

  Membrane filtration, multiple tube fermentation (the standard methods) and Colilert are techniques available for assessing drinking water quality, but there are no published comparisons of Colilert to standard methods in a developing country laboratory. We reviewed the published literature on Colilert and standard methods and conducted a study to compare Colilert with membrane filtration for the detection and enumeration of total coliforms and fecal coliforms (Escherichia coli bacteria) using 35 stored drinking water samples from households in Abidjan, Côte d'lvoire. Our study results are consistent with previous published studies conducted in developed countries. Results from Colilert and membrane filtration correlated for both total coliforms (r2 = 0.81) and E. coli (r2 = 0.93). Colilert is an acceptable method to measure the presence and quantity of coliforms in water samples in a developing country setting.

  View details for PubMedID 16209026

• Effect of handwashing on child health: a randomised controlled trial LANCET Luby, S. P., Agboatwalla, M., Feikin, D. R., Painter, J., Billhimer, W., Altaf, A., Hoekstra, R. M. 2005; 366 (9481): 225-233

  Abstract

  More than 3.5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection every year. We undertook a randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea.In adjoining squatter settlements in Karachi, Pakistan, we randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1.2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat.Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap.Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo.

  View details for Web of Science ID 000230519200031

  View details for PubMedID 16023513

• 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

  Abstract

  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

• Bacteremic typhoid fever in children in an urban slum, Bangladesh EMERGING INFECTIOUS DISEASES Brooks, W. A., Hossain, A., Goswami, D., Sharmeen, A. T., Nahar, K., Alam, K., Ahmed, N., Naheed, A., Nair, G. B., Luby, S., Breiman, R. F. 2005; 11 (2): 326-329

  Abstract

  We confirmed a bacteremic typhoid fever incidence of 3.9 episodes/1,000 person-years during fever surveillance in a Dhaka urban slum. The relative risk for preschool children compared with older persons was 8.9. Our regression model showed that these children were clinically ill, which suggests a role for preschool immunization.

  View details for Web of Science ID 000226856900023

  View details for PubMedID 15752457

• Long-term improvement in unsafe injection practices following community intervention INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES Luby, S., Hoodbhoy, F., Jan, A., Shah, A., Hutin, Y. 2005; 9 (1): 52-59

  Abstract

  A study in 1994 identified frequent unsafe injections as the cause of widespread hepatitis C virus infection in Hafizabad, Pakistan. A simple low cost community education program was assessed to see if it improved injection safety.A local health organization developed educational materials on hepatitis C including advice on how to avoid unnecessary injections and, when injections were necessary, to use a new syringe and needle. Beginning in 1995, this advice was communicated through multiple channels including health education meetings, announcements in mosques, and via pamphlets. In 1998 study workers revisited controls from the 1994 case-control study (along with three of their neighbors of a similar age) to collect information on injection practices in the previous 12 months.Thirty-three percent of the study's participants in 1998 received >or=5 injections in the preceding 12 months compared to 40% of the hepatitis C virus negative controls reported in the year prior to the 1994 study (p=0.85). In 1998 52 persons (34%) brought their own syringe for their most recent injection, a practice that was unreported in 1994. Overall, in 1998 59% of patients received their most recent injection with a new syringe and needle compared to 24% in 1994 (p=0.003).Following this low cost health communication effort, community members took steps to protect themselves from unsafe injections.

  View details for DOI 10.1016/j.ijid.2004.03.007

  View details for Web of Science ID 000226761100010

  View details for PubMedID 15603995

• Rabies deaths in Pakistan: results of ineffective post-exposure treatment INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES Parviz, S., Chotani, R., McCormick, J., Fisher-Hoch, S., Luby, S. 2004; 8 (6): 346-352

  Abstract

  To estimate the incidence of rabies and the effectiveness of post-exposure treatment (PET) in Pakistan.Rabies cases admitted from July 1993 to December 1994 to a public rabies isolation hospital were analyzed. Two samples (one sample each from a separate peripheral site) of a single batch of sheep brain vaccine (SBV) were also tested for potency by the National Institute of Health (NIH) test in May 1997.Forty patients were admitted with a history of clinical rabies. The median age was 22 years and 55% were under 15. Thirteen (23%) victims did not receive any vaccine; the remaining 27 (67%) received SBV only, and of these, 16 (40%) received a full course of SBV. No rabies immunoglobulins (RIG) or cell culture vaccines were administered. There were frequent power blackouts and no back-up supply at the public hospital. In-house potency testing of the vaccine batch by the manufacturer was adequate, although it was not tested by the World Health Organization (WHO) recommended NIH test. Samples of SBV of the same batch collected at the peripheral sites showed no potency. Rabies incidence was estimated to range between 7.0 to 9.8 cases per million annually.A multi-sectorial approach is needed to decrease rabies incidence in Pakistan. Public and healthcare practitioner education on prompt and appropriate PET, especially the use of cost-effective cell culture intradermal regimens, is needed urgently. The NIH test should be employed for vaccine potency testing. An independent agency is needed for monitoring vaccine quality and strategies are needed for maintaining cold chain. SBV should be replaced by locally manufactured second-generation cell culture rabies vaccine. Purified equine rabies immunoglobulin (ERIG) should be manufactured locally to meet national needs. Furthermore, effective dog control strategies should be implemented to decrease the rabies reservoir.

  View details for DOI 10.1016/j.ijid.2004.02.008

  View details for Web of Science ID 000225106900005

  View details for PubMedID 15494256

• Delayed effectiveness of home-based interventions in reducing childhood diarrhea, Karachi, Pakistan AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S. P., Agboatwalla, M., Hoekstra, R. M., Rahbar, M. H., Billhimer, W., Keswick, B. H. 2004; 71 (4): 420-427

  Abstract

  We introduced home drinking water disinfection and handwashing with soap in Karachi squatter settlements to evaluate their effect on diarrhea. In April 2000, 150 households received soap, 76 received dilute bleach and a water storage vessel, and 76 were enrolled as controls. In 2000, among households wealthy enough to own a refrigerator, children in households that received bleach and a vessel had a 73% lower incidence of diarrhea than controls; those that received soap had a 56% lower incidence. There was no reduction in diarrhea in intervention households without a refrigerator. In 2001, households that received bleach and a vessel had a 71% lower incidence of diarrhea and children in households that received soap had a 35% lower incidence than controls. In 2001, the interventions were equally effective in households that had a refrigerator and those that did not. Both of these home-based interventions were ultimately effective in preventing diarrhea, but only households of slightly higher socioeconomic status changed their behavior quickly enough to benefit during the first summer.

  View details for Web of Science ID 000224821000009

  View details for PubMedID 15516637

• Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan - A randomized controlled trial JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Luby, S. P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W. L., Hoekstra, R. M. 2004; 291 (21): 2547-2554

  Abstract

  Washing hands with soap prevents diarrhea, but children at the highest risk of death from diarrhea are younger than 1 year, too young to wash their own hands. Previous studies lacked sufficient power to assess the impact of household handwashing on diarrhea in infants.To evaluate the effect of promoting household handwashing with soap among children at the highest risk of death from diarrhea.A cluster randomized controlled trial of 36 low-income neighborhoods in urban squatter settlements in Karachi, Pakistan. Field workers visited participating households at least weekly from April 15, 2002, to April 5, 2003. Eligible households located in the study area had at least 2 children younger than 15 years, at least 1 of whom was younger than 5 years.Weekly visits in 25 neighborhoods to promote handwashing with soap after defecation and before preparing food, eating, and feeding a child. Within intervention neighborhoods, 300 households (1523 children) received a regular supply of antibacterial soap and 300 households (1640 children) received plain soap. Eleven neighborhoods (306 households and 1528 children) comprised the control group.Incidence density of diarrhea among children, defined as the number of diarrheal episodes per 100 person-weeks of observation.Children younger than 15 years living in households that received handwashing promotion and plain soap had a 53% lower incidence of diarrhea (95% confidence interval [CI], -65% to -41%) compared with children living in control neighborhoods. Infants living in households that received handwashing promotion and plain soap had 39% fewer days with diarrhea (95% CI, -61% to -16%) vs infants living in control neighborhoods. Severely malnourished children (weight for age z score, <-3.0) younger than 5 years living in households that received handwashing promotion and plain soap had 42% fewer days with diarrhea (95% CI, -69% to -16%) vs severely malnourished children in the control group. Similar reductions in diarrhea were observed among children living in households receiving antibacterial soap.In a setting in which diarrhea is a leading cause of child death, improvement in handwashing in the household reduced the incidence of diarrhea among children at high risk of death from diarrhea.

  View details for Web of Science ID 000221738800017

  View details for PubMedID 15173145

• The global burden of typhoid fever BULLETIN OF THE WORLD HEALTH ORGANIZATION Crump, J. A., Luby, S. P., Mintz, E. D. 2004; 82 (5): 346-353

  Abstract

  To use new data to make a revised estimate of the global burden of typhoid fever, an accurate understanding of which is necessary to guide public health decisions for disease control and prevention efforts.Population-based studies using confirmation by blood culture of typhoid fever cases were sought by computer search of the multilingual scientific literature. Where there were no eligible studies, data were extrapolated from neighbouring countries and regions. Age-incidence curves were used to model rates measured among narrow age cohorts to the general population. One-way sensitivity analysis was performed to explore the sensitivity of the estimate to the assumptions. The burden of paratyphoid fever was derived by a proportional method.A total of 22 eligible studies were identified. Regions with high incidence of typhoid fever (>100/100,000 cases/year) include south-central Asia and south-eastAsia. Regions of medium incidence (10-100/100,000 cases/year) include the rest of Asia, Africa, Latin America and the Caribbean, and Oceania, except for Australia and New Zealand. Europe, North America, and the rest of the developed world have low incidence of typhoid fever (<10/100,000 cases/year). We estimate that typhoid fever caused 21,650,974 illnesses and 216,510 deaths during 2000 and that paratyphoid fever caused 5,412,744 illnesses.New data and improved understanding of typhoid fever epidemiology enabled us to refine the global typhoid burden estimate, which remains considerable. More detailed incidence studies in selected countries and regions, particularly Africa, are needed to further improve the estimate.

  View details for Web of Science ID 000221566200007

  View details for PubMedID 15298225

• Rapid assessment of injection practices in Mongolia AMERICAN JOURNAL OF INFECTION CONTROL Logez, S., Soyolgerel, G., Fields, R., Luby, S., Hutin, Y. 2004; 32 (1): 31-37

  Abstract

  Anecdotal reports suggest that unsafe injections may transmit blood-borne pathogens in Mongolia.The Ministry of Health of Mongolia collected information on injection practices, their determinants, and their consequences through interviews and observations of a small convenience sample of prescribers, injection providers, and members of the general population.The 65 members of the general population reported receiving an average of 13 injections per year. New, single-use injection devices were used in the 20 health care facilities visited. There were breaks in infection control practices while administering injections, including observations of 500-mL intravenous infusion bottles used as multiple-dose diluent vials and 8 of the 28 providers (28%) reporting reuse of device on the same patient. Injection providers reported 2.6 needle-stick injuries per year. Contaminated sharps were burned in a drum. Among persons interviewed, 19 of the 21 prescribers (90%) and 49% of the population were aware of the potential risk of HIV transmission through unsafe injections.A multidisciplinary initiative is necessary to achieve safe and appropriate use of injections in Mongolia through (1) behavior change, (2) increasing availability of injection devices and sharps boxes, and (3) appropriate sharps waste management.

  View details for DOI 10.1016/j.ajic.2003.06.006

  View details for Web of Science ID 000189151000008

  View details for PubMedID 14755233

• Effect of point-of-use disinfection, flocculation and combined flocculation-disinfection on drinking water quality in western Kenya JOURNAL OF APPLIED MICROBIOLOGY Crump, J. A., Okoth, G. O., Slutsker, L., Ogaja, D. O., Keswick, B. H., Luby, S. P. 2004; 97 (1): 225-231

  Abstract

  Point-of-use drinking water disinfection with sodium hypochlorite has been shown to improve water quality and reduce diarrhoeal disease. However, the chlorine demand of highly turbid water may render sodium hypochlorite less effective.We evaluated a novel combined flocculant-disinfectant point-of-use water treatment product and compared its effect on drinking water quality with existing technologies in western Kenya. In water from 30 sources, combined flocculant-disinfectant reduced Escherichia coli concentrations to <1 CFU100 ml(-1) for 29 (97%) and reduced turbidity to <5 nephelometric turbidity units (NTU) for 26 (87%). By contrast, water from 30 sources treated with sodium hypochlorite reduced E. coli concentrations to <1 CFU 100 ml(-1) for 25 (83%) and turbidity to <5 NTU for 5 (17%).For source waters over a range of turbidities in western Kenya, combined flocculant-disinfectant product effectively reduces turbidity to <5 NTU and reduces E. coli concentrations to <1 CFU 100 ml(-1).The novel flocculant-disinfectant product may be acceptable to consumers and may be effective in reducing diarrhoeal disease in settings where source water is highly turbid.

  View details for DOI 10.1111/j.1365-2672.2004.02309.x

  View details for Web of Science ID 000221866700024

  View details for PubMedID 15186460

• Elevated blood lead levels among children living in a fishing community, Karachi, Pakistan ARCHIVES OF ENVIRONMENTAL HEALTH Hozhabri, S., White, F., Rahbar, M. H., Agboatwalla, M., Luby, S. 2004; 59 (1): 37-41

  Abstract

  Lead is a widespread environmental contaminant worldwide and is associated with adverse outcomes in children, including impaired neurobehavioral development and learning difficulties. A cross-sectional survey of 53 young children was conducted in a fishing village on an island adjacent to Karachi, Pakistan. Whole blood from each individual was tested for lead levels. Also tested were samples of cooked food, house dust, and drinking water from 36 households. Laboratory determinations were made by the Pakistan Council for Scientific and Industrial Research with quality control by the United States Centers for Disease Control and Prevention. Fifty-two subjects (98%) had blood lead levels above 10 microg/dl (mean 21.60 microg/dl), an internationally recognized threshold for potential neurotoxicity. The mean concentration was 3.90 microg/g in cooked food, 4.02 microg/l in drinking water, and 91.30 microg/g in house dust. These findings indicate possible major health concerns and suggest significant environmental contamination in this community as well as the need to identify locally relevant early childhood exposures.

  View details for Web of Science ID 000230698900006

  View details for PubMedID 16053208

• Prevalence of infection with waterborne pathogens: A seroepidemiologic study in children 6-36 months old in San Juan Sacatepequez, Guatemala AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Steinberg, E. B., Mendoza, C. E., Glass, R., Arana, B., Lopez, M. B., Mejia, M., Gold, B. D., Priest, J. W., Bibb, W., Monroe, S. S., Bern, C., Bell, B. P., Hoekstra, R. M., Klein, R., Mintz, E. D., Luby, S. 2004; 70 (1): 83-88

  Abstract

  Water and sanitation interventions in developing countries have historically been difficult to evaluate. We conducted a seroepidemiologic study with the following goals: 1) to determine the feasibility of using antibody markers as indicators of waterborne pathogen infection in the evaluation of water and sanitation intervention projects; 2) to characterize the epidemiology of waterborne diarrheal infections in rural Guatemala, and 3) to measure the age-specific prevalence of antibodies to waterborne pathogens. Between September and December 1999, all children 6-36 months of age in 10 study villages were invited to participate. We collected sufficient serum from 522 of 590 eligible children, and divided them into six-month age groups for analysis (6-12, 13-18, 19-24, 25-30, and 31-36 months). The prevalence of antibodies was lowest in children 6-12 months old compared with the four older age groups for the following pathogens: enterotoxigenic Escherichia coli (48%, 81%, 80%, 77%, and 83%), Norwalk virus (27%, 61%, 83%, 94%, and 94%), and Cryptosporidium parvum (27%, 53%, 70%, 67%, and 73%). The prevalence of total antibody to hepatitis A virus increased steadily in the three oldest age groups (40%, 28%, 46%, 60%, and 76%). In contrast, the prevalence of antibody to Helicobacter pylori was relatively constant in all five age groups (20%, 19%, 21%, 25%, and 25%). Serology appears to be an efficient and feasible approach for determining the prevalence of infection with selected waterborne pathogens in very young children. Such an approach may provide a suitable, sensitive, and economical alternative to the cumbersome stool collection methods that have previously been used for evaluation of water and sanitation projects.

  View details for Web of Science ID 000188506600014

  View details for PubMedID 14971703

• A randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhea prevention in rural guatemala AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Reller, M. E., Mendoza, C. E., Lopez, M. B., Alvarez, M., Hoekstra, R. M., Olson, C. A., Baier, K. G., Keswick, B. H., Luby, S. P. 2003; 69 (4): 411-419

  Abstract

  We conducted a study to determine if use of a new flocculant-disinfectant home water treatment reduced diarrhea. We randomly assigned 492 rural Guatemalan households to five different water treatment groups: flocculant-disinfectant, flocculant-disinfectant plus a customized vessel, bleach, bleach plus a vessel, and control. During one year of observation, residents of control households had 4.31 episodes of diarrhea per 100 person-weeks, whereas the incidence of diarrhea was 24% lower among residents of households receiving flocculant-disinfectant, 29% lower among those receiving flocculant-disinfectant plus vessel, 25% lower among those receiving bleach, and 12% lower among households receiving bleach plus vessel. In unannounced evaluations of home drinking water, free chlorine was detected in samples from 27% of flocculant-disinfectant households, 35% of flocculant-disinfectant plus vessel households, 35% of bleach households, and 43% of bleach plus vessel households. In a setting where diarrhea was a leading cause of death, intermittent use of home water treatment with flocculant-disinfectant decreased the incidence of diarrhea.

  View details for Web of Science ID 000186469900011

  View details for PubMedID 14640502

• Estimating the incidence of typhoid fever and other febrile illnesses in developing countries EMERGING INFECTIOUS DISEASES Crump, J. A., Yousseg, F. G., Luby, S. P., Wasfy, M. O., Rangel, J. M., Taalat, M., Oun, S. A., Mahoney, F. J. 2003; 9 (5): 539-544

  Abstract

  To measure the incidence of typhoid fever and other febrile illnesses in Bilbeis District, Egypt, we conducted a household survey to determine patterns of health seeking among persons with fever. Then we established surveillance for 4 months among a representative sample of health providers who saw febrile patients. Health providers collected epidemiologic information and blood (for culture and serologic testing) from eligible patients. After adjusting for the provider sampling scheme, test sensitivity, and seasonality, we estimated that the incidence of typhoid fever was 13/100,000 persons per year, and the incidence of brucellosis was 18/100,000 persons per year in the district. This surveillance tool could have wide applications for surveillance for febrile illness in developing countries.

  View details for Web of Science ID 000182569700005

  View details for PubMedID 12737736

• Serological response and poliovirus excretion following different combined oral and inactivated poliovirus vaccines immunization schedules. Vaccine Parent du Châtelet, I., Merchant, A. T., Fisher-Hoch, S., Luby, S. P., Plotkin, S. A., Moatter, T., Agboatwalla, M., McCormick, J. B. 2003; 21 (15): 1710-1718

  Abstract

  A controlled study was conducted in Karachi, Pakistan to compare humoral and mucosal immune responses against polioviruses in infants who received oral poliovirus vaccine (OPV) at birth and at 6, 10, and 14 weeks according to the Expanded Program on Immunization (EPI) with infants who received either three doses of inactivated poliovirus vaccine (IPV) at 6, 10, and 14 weeks together with OPV or one additional dose of IPV at 14 weeks together, with the last dose of OPV. A total of 1429 infants were enrolled; 24-week serum specimens were available for 898 infants (63%). They all received a challenge dose of OPV type 3 at 24 weeks of age. The addition of three doses of IPV to three doses of OPV induced a significantly higher percentage of seropositive children at 24 weeks of age for polio 1 (97% versus 89%, P<0.001) and polio 3 (98% versus 92%) compared to the EPI schedule. However, the one supplemental dose of IPV at 14 weeks did not increase the serological response at 24 weeks. Intestinal immunity against the challenge dose was similar in the three groups. Combined schedules of OPV and IPV in the form of diphtheria-pertussis-tetanus-IPV vaccine (DPT-IPV) may be useful to accelerate eradication of polio in developing countries.

  View details for PubMedID 12639494

• Serological response and pollovirus excretion following different combined oral and inactivated poliovirus vaccines immunization schedules VACCINE du Chatelet, I. P., Merchant, A. T., Fisher-Hoch, S., Luby, S. P., Plotkin, S. A., Moatter, T., Agboatwalla, M., Mc Cormick, J. B. 2003; 21 (15): 1710-1718

  View details for Web of Science ID 000182008000019

• Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan EPIDEMIOLOGY AND INFECTION Usman, H. R., Akhtar, S., Rahbar, M. H., Hamid, S., Moattar, T., Luby, S. P. 2003; 130 (2): 293-300

  Abstract

  A case control study was conducted to identify the association of therapeutic injections with acute hepatitis B virus (HBV) infection in Karachi, Pakistan. We enrolled 67 cases of acute HBV infection (IgM anti-HBc positive) and 247 controls (anti-HBc negative) from four hospitals of Karachi during July 2000-June 2001. Exposure to various risk factors during the period relevant to the incubation period of HBV was recorded both from cases and controls using a structured questionnaire. Multivariate logistic regression analysis of the data showed that cases were more likely to have received one injection (OR = 4.0; 95 % CI 1.4, 11.1), or more than one injection (OR = 6.3; 95 % CI 3.2, 12.4) compared to controls. The estimated population attributable risk (PAR) for therapeutic injections was 53%. Also the cases compared to controls were more likely to have household size of seven or more (OR = 1.9; 95 % CI 0.95, 3.9). This study showed that unsafe therapeutic injections appear to be the major risk factor for acute HBV infection and needs immediate focus from public health stand point.

  View details for DOI 10.1017/S0950268802008178

  View details for Web of Science ID 000182636400016

  View details for PubMedID 12729198

• A novel technology to improve drinking water quality: a microbiological evaluation of in-home flocculation and chlorination in rural Guatemala. Journal of water and health Rangel, J. M., Lopez, B., Mejia, M. A., Mendoza, C., Luby, S. 2003; 1 (1): 15-22

  Abstract

  An estimated 1 billion persons in low-income countries do not have access to improved drinking water. Chlorine, a useful water treatment agent, is less effective in turbid water, and lacks a visible effect, limiting its acceptability. A product incorporating precipitation, coagulation, flocculation, and chlorination technology (combined product) to reduce microbial, organic and heavy metal contaminants in water was evaluated. The combined product's microbiological efficacy in Guatemalan villagers' households was evaluated. One hundred randomly selected households from four neighboring Guatemalan villages were enrolled. Three groups received the combined product and either the Centers for Disease Control (CDC) water storage vessel, a covered bucket with spigot, or no vessel. One group received chlorine bleach and the CDC water storage vessel, and one group no intervention. Household water samples were collected for 4 weeks and Escherichia coli, chlorine, and turbidity levels were measured. Potable water was defined as having less than one E. coli per 100 ml. Eight (8%) baseline water samples were potable. Follow-up water samples were more likely to be potable than control samples (combined product and traditional vessel 83%; combined product and CDC vessel 92%; combined product and covered bucket with spigot 93%; chlorine and CDC vessel 92%; versus control 5%). Among combined product users, 98% reported improved water clarity compared with 45% of chlorine bleach users (p < 0.0001). The combined product technology improved water potability as effectively as chlorine bleach; improved water clarity could motivate more persons to effectively treat their water.

  View details for PubMedID 15384269

• A large cholera outbreak in Kano City, Nigeria: the importance of hand washing with soap and the danger of street-vended water. Journal of water and health Hutin, Y., Luby, S., Paquet, C. 2003; 1 (1): 45-52

  Abstract

  The aim of this study was to identify the risk factors for cholera during an outbreak in Nigeria. Cases were defined as recent onset of acute diarrhoea with dehydration in a patient hospitalised at the Infectious Diseases Hospital in Kano City. Meningitis patients admitted concurrently at the same hospital were recruited as unmatched controls. Data were collected on age, sex, place of residence, hygienic practices, and on food and water consumption. A total of 5600 cholera cases and 340 cholera deaths were reported between December 1995 and May 1996 (attack rate = 86.3 per 100,000 population) in the state of Kano. Compared to the 77 controls, the 102 cases were more likely to have drunk street-vended water (age-adjusted odds ratio (AAOR) = 3.2; 95% confidence interval (CI): 1.4-7.1) and less likely to have drunk tap water in their homes (AAOR = 0.2; 95% CI: 0.1-0.7) or to have washed hands with soap prior to eating food (AAOR = 0.2; 95% CI: 0.1-0.6). While no data suggested that the municipal water supply was contaminated, safe water systems and hand hygiene practices might have prevented a high proportion of cases if implemented early during this outbreak.

  View details for PubMedID 15384272

• Outbreaks of typhoid fever in the United States, 1960-99 EPIDEMIOLOGY AND INFECTION Olsen, S. J., Bleasdale, S. C., Magnano, A. R., Landrigan, C., Holland, B. H., Tauxe, R. V., Mintz, E. D., Luby, S. 2003; 130 (1): 13-21

  Abstract

  Although the incidence of typhoid fever in the United States has been low since the 1940s, Salmonella Typhi continues to cause outbreaks. We reviewed reported outbreaks of typhoid fever from 1960 to 1999. There were 60 outbreaks; in 54, exposure occurred within the United States. These 54 outbreaks accounted for 957 total cases (median 10) and 4 deaths. In 36 (67%) outbreaks the route of transmission was identified, and in 16 (62%) of the 26 foodborne outbreaks an asymptomatic carrier was identified by culture or serology. The median incubation period was 2 weeks. Isolates from 10 (40%) of 25 outbreaks were phage type E1. The average frequency of outbreaks decreased from 1.85/year during 1960-79 to 0.85/year during 1980-99 (P=0.0001). S. Typhi outbreaks in the United States are generally small in size but can cause significant morbidity, and are often foodborne, warranting thorough investigation.

  View details for DOI 10.1017/S0950268802007598

  View details for Web of Science ID 000182506900002

  View details for PubMedID 12613741

• Prevalence and correlates of stunting among children in rural Pakistan PEDIATRICS INTERNATIONAL Shah, S. M., Selwyn, B. J., Luby, S., Merchant, A., Bano, R. 2003; 45 (1): 49-53

  Abstract

  Protein-energy malnutrition remains an important underlying cause of death among preschool children in Pakistan. The present study aimed to estimate the prevalence of stunting and its correlates and to explore the role of sex bias in remote rural villages of south Pakistan.We selected 1878 children less than 3 years of age through stratified random sampling from 64 villages having the number of children enrolled proportionate to the size of each village, in rural Sindh, Pakistan. Trained investigators completed child physical measurements and a maternal interview. The Z-scores for the distribution of height-for-age (stunting) and weight-for-height (wasting) were estimated relative to those of the National Center for Health Statistics/Center for Disease Control (NCHS/CDC) reference population.A total of 483 (26%) of the 1878 children were wasted, 977 (55%) were stunted and 259 (15%) were both wasted and stunted. Mothers who were illiterate were more likely to have children who were stunted (odds ratio (OR) = 1.27, 95% confidence interval (CI) 1.11-1.61). Fathers who earn less than Rs. 1000 (US $20) per month (OR = 1.35, 95% CI 1.12-1.66) were more likely to have children who were stunted. Children living in an overcrowded house were more likely to be stunted (OR = 1.44, 95% CI 1.18-1.75). Male children compared to females were equally likely to be stunted (57 vs 55%, OR 1.03, 95% CI 0.86-1.25).In this region of lower Sindh, stunting is more common than wasting. Female illiteracy, poor household income and overcrowding are important risk factors for stunting. The prevalent belief that in rural Pakistan, parents pay attention to feeding male children at the cost of female children is not proven by these data.

  View details for Web of Science ID 000181648000010

  View details for PubMedID 12654069

• Infection control practices in clinical laboratories in Pakistan INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Mujeeb, S. A., Adil, M. M., Altaf, A., Shah, S. A., Luby, S. 2003; 24 (2): 141-142

  Abstract

  Clinical laboratories in Karachi, Pakistan, were evaluated for adherence to standard precautions using an observational checklist. Among 44 laboratories, gloves were used in 2, protective gowns in 12, disinfectant in 7, and an incinerator in 7. Standard worker safety precautions are not followed at major clinical laboratories in Karachi.

  View details for Web of Science ID 000180983700011

  View details for PubMedID 12602699

• Risk behaviours associated with urethritis and genital ulcer disease in prison inmates, Sindh, Pakistan. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit Akhtar, S., Luby, S. P. 2002; 8 (6): 776-786

  Abstract

  We evaluated the epidemiological differences with respect to demographics, drug use and sexual behaviours associated with lifetime risk of urethritis, genital ulcer disease (GUD) and urethritis and GUD together among 3395 male prisoners in Sindh. Factors associated with urethritis and GUD alone were sex with multiple females, sex with men, and ethnicity. Additional factors associated with urethritis alone were sex with prostitutes, sex with partners having multiple partners and sex with partners believed to be injecting drugs. Behaviours associated with lifetime risk for urethritis and GUD together were sex with multiple females, sex with prostitutes, sex with men, sex with partners believed to be injecting drugs and ethnicity. These relationships were consistently stronger compared to urethritis or GUD alone.

  View details for PubMedID 15568455

• Addicted schoolchildren: Prevalence and characteristics of areca nut chewers among primary school children in Karachi, Pakistan JOURNAL OF PAEDIATRICS AND CHILD HEALTH Shah, S. M., Merchant, A. T., Luby, S. P., Chotani, R. A. 2002; 38 (5): 507-510

  Abstract

  To evaluate the habits of betel quid use and areca nut chewing among school-aged children in Karachi, Pakistan. Areca nut (betel nut) is chewed by itself, in various scented preparations, and in betel quid (containing betel leaf, areca nut, slaked lime, condiments, sweeteners and sometimes tobacco) in various parts of Pakistan and India. It is associated with carcinogenesis, foreign body aspiration in children and oral submucous fibrosis, and may aggravate asthma.We selected a stratified random sample of 160 primary school children between 4 and 16 years of age in Baba Island, Karachi.Seventy-four per cent of the children (118/159) used areca nut and 35% (55/159) used betel quid daily. More boys chewed areca nut than girls (72% vs 30%). The proportion of areca nut users increased by grade (from 48% in first grade to 90% in fifth grade). Most areca users first tried it with a family member (42%) or a friend (26%), and most (68%) consumed three or more packets a day. Children with fathers with three or fewer years of education were more likely to use areca nut (OR 3.2; 95% CI 1.2-8.4), and children whose mothers helped with homework less likely (OR 0.5; 95% CI 0.2-0.91; P = 0.027) to use it. Boys (OR 6.6; 95% CI 2.3-18.7) and areca nut users (OR 8.8; 95% CI2.8-27.0) were more likely to use betel quid.To reduce the use of areca nut, the Pakistan Government should consider imposing taxes on it, limiting advertising and actively communicating its health risks to the public.

  View details for Web of Science ID 000178266600016

  View details for PubMedID 12354270

• The effect of antibacterial soap on impetigo incidence, Karachi, Pakistan AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Luby, S., Agboatwalla, M., Schnell, B. M., Hoekstra, R. M., Rahbar, M. H., Keswick, B. H. 2002; 67 (4): 430-435

  Abstract

  We conducted a study to determine if soap containing 1.2% triclocarban would be effective in reducing the incidence of impetigo. We randomized 162 households in a low-income neighborhood of Karachi, Pakistan, to receive a regular supply of 1.2% triclocarban-containing soap (n = 81) or an identically appearing placebo (n = 81); 79 households in a nearby neighborhood were enrolled as standard practice controls. After adjustment for household clustering and covariates, the incidence of impetigo among children living in households receiving triclocarban-containing soap (1.10 episodes per 100 person-weeks) was 23% lower than in households receiving placebo soap (P = 0.28) and 43% lower than the standard habit and practice controls (P = 0.02). The routine use of triclocarban-containing soap by children living in a community with a high incidence of impetigo was associated with a reduced incidence of impetigo.

  View details for Web of Science ID 000179119400019

  View details for PubMedID 12452499

• Clinical diagnosis of Plasmodium falciparum among children with history of fever, Sindh, Pakistan. International journal of infectious diseases Hozhabri, S., Luby, S. P., Rahbar, M. H., Akhtar, S. 2002; 6 (3): 233-235

  Abstract

  To identify clinical predictors for malaria and develop a clinical algorithm to more accurately identify malaria from non-malaria cases.Four hundred thirty eight children aged 6-120 months attending the rural health center between August 15 and October 5, 1997, in Jhangara town of district Dadu, Sindh were recruited. A standard questionnaire was used to record symptoms and duration of child's illness. Each child was physically examined, had their axillary temperature measured, and blood samples were collected from which Giemsa stained thick and thin blood films were prepared and examined for presence of Plasmodium parasites. The sensitivity and specificity of several candidate algorithms for parasitemia were evaluated using various combinations of identified predictors.Twenty-six of 438 children (6%) were slide positive for malaria. An algorithm comprised of fever 3 days duration and (absence of cough or having rigors) had 100% sensitivity and 63% specificity for detecting P. falciparum.In this low malaria prevalence region, restricting the diagnosis of malaria to persons who had >3 days of fever and absence of cough or rigors, remained highly sensitive but was more specific than current practice. If validated prospectively, this algorithm could reduce misdiagnosis and mis-treatment.

  View details for PubMedID 12718841

• Neonatal tetanus: mortality rate and risk factors in Loralai District, Pakistan INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Quddus, A., Luby, S., Rahbar, M., Pervaiz, Y. 2002; 31 (3): 648-653

  Abstract

  This study was conducted to estimate the neonatal tetanus (NNT) mortality rate and to identify the risk factors for NNT deaths in Loralai District, Pakistan.We conducted a community-based cross-sectional survey during July-September 1997. We stratified the sample proportionate to population of union councils. The most populous village in a union council was selected first. We interviewed the women, selected randomly, who had a live birth in the 18 months preceding the survey. We conducted a matched case-control study to identify the risk factors for NNT deaths. We used the World Health Organization criteria to enrol cases, identified during the cross-sectional survey or registered at the district hospital. We enrolled three community-based controls per case, matched on the area of residence, immunization status and date of birth.Of the 1547 live births, there were 36 neonatal deaths due to tetanus. The NNT mortality rate in the district was 23 per 1000 live births (95% CI: 16-30). For the case-control study, we enrolled 41 cases and 123 controls. Using conditional logistic regression, the risk of NNT death was increased with the use of soil as delivery surface (O.R = 3.2, 95% CI: 1.1-10.2), father's illiteracy (OR = 3.2, 95% CI: 1.3-8.1) and possession of sheep at home (OR = 2, 95% CI: 1.0-5.0). The population attributable risk per cent for soil as delivery surface was 64%.Transmission of infection while using soil as the delivery surface can occur through direct or indirect contamination of the fresh umbilical wound. Use of safer delivery practices in general and clean surfaces in particular should be encouraged to reduce the NNT mortality rate in the area.

  View details for Web of Science ID 000176229200027

  View details for PubMedID 12055169

• Improving private practitioner sick-child case management in two urban communities in Pakistan TROPICAL MEDICINE & INTERNATIONAL HEALTH Luby, S., Zaidi, N., Rehman, S., Northrup, R. 2002; 7 (3): 210-219

  Abstract

  To evaluate if INFECTOM, a multicomponent behaviour change strategy, would alter the care received by children visiting private healthcare providers so that it was more consistent with the IMCI algorithm.Community surveys in two low income communities in Pakistan identified children who had visited healthcare providers in the preceding 2 weeks complaining of diarrhoea, cough or rapid breathing, or fever. Interviewers asked the mothers of these children whether providers performed specific behaviours recommended by the Integrated Management of Childhood Illness (IMCI) algorithm. These data were analysed to generate provider-specific IMCI-related behaviour profiles. A team including community representatives met with the providers, discussed the correct IMCI algorithm behaviour, reviewed the percentage of time each of their practices was consistent with IMCI recommendations, and negotiated a contract with a numerical target for improved practices. This cycle of survey, discussion of results and contracting was repeated three times over 10 months.Twenty-two providers, 13 of whom (59%) had a medical degree, regularly treated children in the two communities. Sixteen of the 21 targeted behaviours (76%) occurred with significantly increased frequency during the course of the intervention. Of the 10 practices that ill children with any of the syndromes should have received, at baseline children averaged receiving 4.3. In the final model, each subsequent round of evaluation was associated with a 0.57 increase in the number of appropriate practices performed at visits to non-Bachelor's Degree in Medicine (MBBS) qualified providers (P < 0.001) and a 0.75 increase among visits to MBBS qualified providers (P=0.004). The percentage of children who received an injection decreased from 70 to 56% (P=0.03).INFECTOM altered the practices of private providers so that they were more consistent with the IMCI algorithm. Efforts to further develop this approach could improve the quality of clinical healthcare in other settings.

  View details for Web of Science ID 000174230200003

  View details for PubMedID 11903983

• Factors associated with elevated blood lead concentrations in children in Karachi, Pakistan BULLETIN OF THE WORLD HEALTH ORGANIZATION Rahbar, M. H., White, F., Agboatwalla, M., Hozhabri, S., Luby, S. 2002; 80 (10): 769-775

  Abstract

  To confirm whether blood lead concentrations in Karachi were as high as reported in 1989 and to identify which types of exposure to lead contribute most to elevated blood lead concentrations in children in Karachi.A total of 430 children aged 36-60 months were selected through a geographically stratified design from the city centre, two suburbs, a rural community and an island situated within the harbour at Karachi. Blood samples were collected from children and a pretested questionnaire was administered to assess the effect of various types of exposure. Cooked food, drinking-water and house dust samples were collected from households.About 80% of children had blood lead concentrations 10 g/dl, with an overall mean of 15.6 g/dl. At the 5% level of significance, houses nearer to the main intersection in the city centre, application of surma to children's eyes, father's exposure to lead at workplace, parents' illiteracy and child's habit of hand- to-mouth activity were among variables associated with elevated lead concentrations in blood.These findings are of public health concern, as most children in Karachi are likely to suffer some degree of intellectual impairment as a result of environmental lead exposure. We believe that there is enough evidence of the continuing problem of lead in petrol to prompt the petroleum industry to take action. The evidence also shows the need for appropriate interventions in reducing the burden due to other factors associated with this toxic element.

  View details for Web of Science ID 000178776800003

  View details for PubMedID 12471396

• Indepth interviews of healthcare providers, patients and carers of infants to identify determinants of therapeutic injections in Sindh, Pakistan XIV INTERNATIONAL AIDS CONFERENCE: PREVENTION SCIENCE Altaf, A., Agboatwalla, M., Luby, S., Hutin, Y., Fatmi, Z., Agha, A. 2002: 201-204

  View details for Web of Science ID 000180241500045

• Salmonella typhimurium infections transmitted by chlorine-pretreated clover sprout seeds AMERICAN JOURNAL OF EPIDEMIOLOGY Brooks, J. T., Rowe, S. Y., Shillam, P., Heltzel, D. M., Hunter, S. B., Slutsker, L., Hoekstra, R. M., Luby, S. P. 2001; 154 (11): 1020-1028

  Abstract

  Raw seed sprouts have caused numerous outbreaks of enteric infections. Presoaking seeds in a 20,000 mg/liter (ppm) calcium hypochlorite solution before sprouting is recommended to reduce bacterial contamination and infection risk. In 1999, the authors investigated an outbreak of Salmonella serotype Typhimurium infections in Colorado. In a case-control study, they matched 20 cases with 58 controls by age, sex, and telephone prefix; 10 (52%) of 19 cases and no controls recalled eating raw alfalfa-style sprouts in the 5 days before the patient's illness (p < 0.00001). Traceback implicated clover sprouts grown from seeds shared by two sprouters. The time period and region over which these sprouts were sold matched the occurrences of 112 culture-confirmed illnesses. Only one of the sprouters presoaked seeds as recommended, and fewer infections were attributable to this sprouter (0.29 vs. 1.13 culture-confirmed infections/50-pound (110.1-kg) bag of seed). After recall of the implicated sprouts and seed, S. Typhimurium illnesses declined. Contaminated raw clover sprouts can cause outbreaks of enteric illness. Presoaking contaminated seeds in a 20,000 mg/liter calcium hypochlorite solution reduces, but does not eliminate, the risk of infection. Until safer production methods are developed, persons eating raw sprouts continue to risk developing potentially serious gastrointestinal illness.

  View details for Web of Science ID 000172578400008

  View details for PubMedID 11724718

• Restaurant-associated outbreak of Salmonella Typhi in Nauru: an epidemiological and cost analysis EPIDEMIOLOGY AND INFECTION Olsen, S. J., Kafoa, B., Win, N. S., Jose, M., Bibb, W., Luby, S., Waidubu, G., O'Leary, M., Mintz, E. 2001; 127 (3): 405-412

  Abstract

  Typhoid fever is endemic in the South Pacific. We investigated an outbreak in Nauru. Through interviews and medical records, we identified 50 persons with onset between 1 October 1998 and 10 May 1999, of fever lasting > or = 3 days and one other symptom. Salmonella Typhi was isolated from 19 (38%) cases. Thirty-two (64%) patients were school-aged children, and 17 (34%) were in four households. Case-control studies of (a) culture-confirmed cases and age- and neighbourhood-matched controls; and (b) household index cases and randomly selected age-matched controls implicated two restaurants: Restaurant M (matched OR [MOR] = 11, 95% confidence interval [CI] = 1.3-96) and Restaurant I (MOR = 5.8, 95% CI = 1.2-29). Food-handlers at both restaurants had elevated anti-Vi antibody titres indicative of carrier state. The annual incidence was 5.0/1000 persons. Outbreak-associated costs were $46,000. Routine or emergency immunization campaigns targeting school-aged children may help prevent or control outbreaks of typhoid fever in endemic disease areas.

  View details for Web of Science ID 000173670600004

  View details for PubMedID 11811872

• Is drinking water in Abidjan, Cote d'Ivoire, safe for infant formula? JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Dunne, E. F., Angoran-Benie, H., Kamelan-Tano, A., Sibailly, T. S., Monga, B. B., Kouadio, L., Roels, T. H., Wiktor, S. Z., Lackritz, E. M., Mintz, E. D., Luby, S. 2001; 28 (4): 393-398

  Abstract

  To survey knowledge, attitudes, and practices regarding water use and infant feeding in the Koumassi District of Abidjan, Côte d'Ivoire, and to evaluate the microbiologic quality of source and stored drinking water.Random-cluster household survey.We randomly selected 20 clusters, each comprising six households with at least 1 child aged < or =3 years. In each household, we administered a questionnaire and collected source and stored drinking water samples and tested these for chlorine levels and for total coliform and fecal bacteria count ( Escherichia coli ).Municipal water was used for drinking in 112 (93%) of 120 households, and in 99 (83%), it was stored for later use. By 1 month of age, 97 (90%) of 108 infants given drinking water were given stored water for drinking. In 8 (66%) of 12 households where children were receiving artificial feeding, formula was prepared from municipal water without additional treatment. Stored water had lower levels of free chlorine than source water (median of 0.05 versus 0.2 mg/dl; p <.001), and E. coli was detected in 36 (41%) of 87 stored water samples and 1 (1%) of 108 source water samples ( p <.001).In the Koumassi District of Abidjan, where municipal water is widely available and of good quality, drinking water is stored in most households, is often contaminated with E. coli, and is given to children at a young age. If replacement feeding is to be more widely used to prevent postnatal transmission of HIV-1, communities using stored water need interventions to make stored water safer.

  View details for Web of Science ID 000172313100014

  View details for PubMedID 11707678

• Microbiologic effectiveness of hand washing with soap in an urban squatter settlement, Karachi, Pakistan EPIDEMIOLOGY AND INFECTION Luby, S. P., Agboatwalla, M., Raza, A., SOBEL, J., Mintz, E. D., Baier, K., Hoekstra, R. M., Rahbar, M. H., Hassan, R., Qureshi, S. M., Gangarosa, E. J. 2001; 127 (2): 237-244

  Abstract

  We conducted a study in a squatter settlement in Karachi, Pakistan where residents report commonly washing their hands to determine if providing soap, encouraging hand washing, and improving wash-water quality would improve hand cleanliness. We allocated interventions to 75 mothers and collected hand-rinse samples on unannounced visits. In the final model compared with mothers who received no hand-washing intervention, mothers who received soap would be expected to have 65% fewer thermotolerant coliform bacteria on their hands (95% CI 40%, 79%) and mothers who received soap, a safe water storage vessel, hypochlorite for water treatment, and instructions to wash their hands with soap and chlorinated water would be expected to have 74% fewer (95% CI 57%, 84%). The difference between those who received soap alone, and those who received soap plus the safe water vessel was not significant (P = 0.26). Providing soap and promoting hand washing measurably improved mothers' hand cleanliness even when used with contaminated water.

  View details for Web of Science ID 000172246300008

  View details for PubMedID 11693501

• Risk factors for hepatitis C virus infection in male adults in Rawalpindi-Islamabad, Pakistan TROPICAL MEDICINE & INTERNATIONAL HEALTH Bari, A., Akhtar, S., Rahbar, M. H., Luby, S. P. 2001; 6 (9): 732-738

  Abstract

  To identify risk factors associated with HCV infection in Islamabad-Rawalpindi.Fifty-seven cases and 180 controls were enrolled from various departments of the nine major hospitals of the Rawalpindi-Islamabad during July-September 1998. Cases were enzyme-linked immunosorbent assay (ELISA) positive for antibodies to HCV (anti-HCV), aged 20-70 years, and residents of Islamabad or Rawalpindi division. Controls were anti-HCV ELISA negatives of the same age range and from the same area. A structured questionnaire was used to collect data on demographic variables and potential risk factors, which was analysed by logistic regression to calculate crude and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) for risk factors.The final multivariate logistic regression model revealed that after adjusting for age, cases were more likely to have received therapeutic injections in the past 10 years (1-10 vs. 0 therapeutic injections; adjusted OR=2.8, 95% CI: 1.1-7.1; > 10 vs. 0 therapeutic injections; adjusted OR=3.1, 95% CI: 1.2-7.9) and were significantly more likely to have daily face (adjusted OR=5.1, 95% CI: 1.5-17.0) and armpit shaves (adjusted OR=2.9, 95% CI: 1.3-6.5) by a barber.HCV control and prevention programs in this region should include safe injection practices and educate men about the risk of HCV infection from contaminated instruments used by barbers.

  View details for Web of Science ID 000171126300010

  View details for PubMedID 11555441

• HIV/AIDS knowledge, attitudes and beliefs based prediction models for practices in prison inmates, Sindh, Pakistan. Southeast Asian journal of tropical medicine and public health Akhtar, S., Luby, S. P., Rahbar, M. H., Azam, I. 2001; 32 (2): 351-361

  Abstract

  This study was conducted on prison inmates in Sindh to determine whether HIV/AIDS related knowledge, attitudes and beliefs can predict their practices which risk HIV infection. A pre-designed questionnaire was administered in this cross-sectional study to collect the data on HIV/AIDS related knowledge, attitudes, beliefs, practices and demographic variables in a systematic sample of 3,395 prison inmates during July 1994. The data on responses of inmates to HIV/AIDS related knowledge, attitudes, and beliefs were analyzed and a clear interpretable factor structure emerged for each set of questions labeled as knowledge, attitude and beliefs. Similarly based on responses of inmates to practice questions, three factors emerged and were labeled as heterosexuality, homosexuality and drugs. The standardized factor scores of inmates for each of these six factors were computed and used in further analyses. Multiple linear regression analyses were carried out separately using heterosexuality, homosexuality and drugs factors score as dependent variables to identify if any of the independent variables (demographic variables, knowledge beliefs and attitude) predict these practice factors. The model for heterosexuality explained 23% of the variance and included HIV/AIDS related knowledge, beliefs, age, ethnicity and marital status and duration of imprisonment (F = 84.33, p < 0.001; R2= 23.0). The predictors in the model for homosexuality together explained 10% of the variance and included significant contribution by belief, martial status, ethnicity, education, age and duration of imprisonment (F = 24.76, p < 0.001; R2= 0.10). The model for drugs had significant contributions from HIV/AIDS related beliefs, marital status and ethnicity (F = 20.10, p < 0.001; R2= 0.03). Implications of prevention program based on these results are considered.

  View details for PubMedID 11556589

• 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

  Abstract

  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

• A low-cost intervention for cleaner drinking water in Karachi, Pakistan. International journal of infectious diseases Luby, S., Agboatwalla, M., Raza, A., SOBEL, J., Mintz, E., Baier, K., Rahbar, M., Qureshi, S., Hassan, R., Ghouri, F., Hoekstra, R. M., GANGAROSA, E. 2001; 5 (3): 144-150

  Abstract

  To pilot test an inexpensive, home-based water decontamination and storage system in a low-income neighborhood of Karachi.Fifty households received a 20-L plastic water storage vessel with a high-quality spout and a regular supply of diluted hypochlorite solution. Twenty-five control households were recruited. Water samples were collected at baseline and during unannounced follow-up visits 1, 3, 6, and 10 weeks later.Baseline drinking water samples among intervention households were contaminated with a mean 9397 colony-forming units (cfu)/100 mL of thermotolerant coliforms compared with a mean 10,990 cfu/100 mL from controls. After intervention the mean concentration of thermotolerant coliforms decreased by 99.8% among the intervention households compared with an 8% reduction among controls. Two years after vessel distribution, 34 (68%) of the families were still using the vessel. Thirteen of the households had stopped using their vessel because it had broken after more than 6 months of use, a pattern most consistent with ultraviolet radiation-induced degradation of the plastic.In a highly contaminated environment, a specifically designed water storage container and in-home water chlorination was acceptable and markedly improved water quality. Where plastic water vessels will be exposed to substantial sunlight, ultraviolet light stabilizers should be incorporated into the plastic.

  View details for PubMedID 11724671

• Patients' perceptions of blood transfusion risks in Karachi, Pakistan. International journal of infectious diseases Luby, S. P., Niaz, Q., SIDDIQUI, S., Mujeeb, S. A., Fisher-Hoch, S. 2001; 5 (1): 24-26

  Abstract

  To evaluate the understanding of and attitudes toward risks of blood transfusions among transfusion recipients in Karachi.One hundred forty-one transfusion recipients from 13 major Karachi hospitals were interviewed. Indications for transfusion were obtained by reviewing the patients' medical records.The most common indications for transfusion were surgical complications (n = 77, 55%), anemia (n = 34, 24%), and generalized weakness (n = 15, 11%). Most recipients (n = 103, 80%) had never heard of viral hepatitis, and 44 (31%) had never heard of acquired immunodeficiency syndrome (AIDS). Ninety-four recipients (66%) believed that generalized weakness was a valid indication for blood transfusion. Sixty-nine recipients (49%) were not willing to pay an increased price for blood that was screened for blood-borne pathogens.Blood recipients in Karachi are unaware of the risks of transfusions, and the reasons given by the ordering physician for many of the transfusions were not consistent with international guidelines. Steps to educate the public about the risks of transfusions and practitioners about the indications for transfusion could prevent blood-borne virus transmission in Karachi.

  View details for PubMedID 11285155

• Therapeutic injections in Pakistan: from the patient's perspective TROPICAL MEDICINE & INTERNATIONAL HEALTH Raglow, G. J., Luby, S. P., Nabi, N. 2001; 6 (1): 69-75

  Abstract

  To investigate the behaviour, knowledge of risks, and attitudes towards injections among patients at a clinic in Karachi.In March 1995, trained staff administered a structured questionnaire to 198 consecutive new adult patients attending a university clinic in Karachi, Pakistan.Half (97:49%) of the patients received injections at their last visit to a health care provider. 3.5% had received 10 or more injections in the last year. 64% felt that injections were more powerful and were willing to pay more for them than for pills. 84% preferred pills or advice over injections if told they were equally effective, 83% believed that a used needle could transmit a fatal disease, and 86% believed that it is usually possible to get better without an injection. 91% reported that the doctor always recommends an injection; few patients (9%) ever asked for one. Injections were given without much regard for the chief complaint of the patient. Sonic needles (n = 21) for the injection came from bowls of water: of those from closed packets (n = 116), 68 were 'cleaned' by wiping ot placing them in water. 91% of patients (180) knew at least one risk of reuse of needles. Patients who knew three or more risks of using unclean needles were 0.14 times as likely to have had more than five injections per year in the last 5 years hut only if the patients had s or more years of education.Patients receive injections from doctors in Pakistan frequently, indiscriminately and often without proper safety precautions. They are aware of both positive and negative aspects of injections but are likely to do what the doctor suggests. Interventions to reduce risky overuse of injections should focus on patients' general education and knowledge of the risks of injections to empower them to choose healthier therapies.

  View details for Web of Science ID 000167703800011

  View details for PubMedID 11263465

• Prevalence of plasmodium slide positivity among the children treated for malaria, Jhangara, Sindh. JPMA. The Journal of the Pakistan Medical Association Hozhabri, S., Akhtar, S., Rahbar, M. H., Luby, S. P. 2000; 50 (12): 401-405

  Abstract

  The aim of the study was to estimate the prevalence of malaria amongst the children with fever or history of fever.Rural Health Centre (RHC), Jhangara, a town near the Manchhar Lake in Taluka Sehwan, District Dadu, Sindh.Four hundred and thirty eight children of 6 months to 10 years of age, who attended above described RHC during August through October 1997.A Sindhi-translated standard questionnaire was used to record symptoms and duration of child's illness. Each child was physically examined, had their axillary temperature measured; and blood samples were collected from which Giemsa stained thick and thin blood films were examined for presence of Plasmodium parasites.The median age of the studied children was 24 months and 57% (250/438) were boys. Fifty three percent (231) of the study subjects were from Jhangara Town, 40% (177) and 7% (30) came from other villages and villages near to the Manchhar Lake respectively. The prevalence of Plasmodium slide positivity was 5.9% (26/438). Among Plasmodium slide positive children, 65% (17/26) were positive for P. falciparum and 35% (9/26) for P. vivax. Among the P. falciparum positive children, 88% (15/26) had scanty (MP, 1-10/100 fields) and 12% (2/26) had moderate density (MP, 10-100/100 fields) of infection. Seventeen percent (6/30) of the children from villages close to Manchhar Lake were Plasmodium slide positive compared to 7% (17/53) and 3% (5/177) from Jhangara town and other villages respectively. Cough, diarrhea, abdominal distention and vomiting were the commonly reported symptoms among the children of all ages at the time of interview. Guardians reported fever as part of the illness in all children, although during physical examination only 128 (29%) had axillary temperature > or = 37.5 degrees C. Pallor as an indicator for anemia, rash and prickly heat were the major recorded observations.The Prevalence of Plasmodium positivity was higher in children who attended from villages close to Manchhar lake, therefore especial measure needs to be considered for this area. In addition, the health care workers in rural Sindh need to adopt appropriate guidelines to differentiate the clinical malarial patients from patients with other potential infectious diseases, which may need other treatment.

  View details for PubMedID 11191438

• Out-of-pocket expenses borne by the users of obstetric services at government hospitals in Karachi, Pakistan. JPMA. The Journal of the Pakistan Medical Association Kadir, M. M., Khan, A., Sadruddin, S., Luby, S. P. 2000; 50 (12): 412-415

  Abstract

  Financing health services is a challenge for health policy makers world over, especially in developing countries. Alternate mechanisms such as user fees are being proposed. However, there is a feeling that in developing countries, users of government hospitals spend appreciable personal income to obtain "free services" at these facilities.This study aimed to measure the extent and the factors associated with of out-of-pocket expenses borne by the users of obstetric care at government hospitals. It also aimed to determine willingness of consumers to bear out of pocket expenses. It was conducted in three government hospitals in Karachi.Seven hundred cases were registered in the study. Sixty-five percent of them had a monthly household income of less than Rupees (Rs.) 3000. Overall, users spent mean of Rs. 590 as out-of-pocket expenses for obstetric services. Of this Rs. 330 was spent on drugs and Rs. 24 on user fees. Thirty-nine percent of the patients were willing to spend out of pocket for services provided at government hospital and 39% declined to do so. Of the patients indicating willingness to spend, 98% agreed to do so for drugs.The results suggest that considerable expenses are borne out of pocket by the users of government hospitals for supposedly "free services". If user fees are to be increased the government needs to provide services for which the people will pay, such as drugs, otherwise increase in this fees will simply add to financial burden on the users.

  View details for PubMedID 11191441

• Knowledge, attitudes, and practices regarding sexually transmitted infections among general practitioners and medical specialists in Karachi, Pakistan SEXUALLY TRANSMITTED INFECTIONS Khandwalla, H. E., Luby, S., Rahman, S. 2000; 76 (5): 383-385

  Abstract

  To determine the knowledge, attitudes, and practices regarding diagnosis and treatment of sexually transmitted infections (STIs) among specialists--that is, dermatologists, gynaecologists and urologists, and general practitioners (GPs) in Karachi, Pakistan.Interviewers administered structured questionnaires to doctors conducting outpatient clinics at tertiary hospitals and/or private clinics in Karachi. All private clinics within a 10 km radius of the Aga Khan University, and all tertiary hospitals having more than 100 inpatient beds were included in the study.100 doctors (54 specialists and 46 GPs) responded. 80 doctors reported seeing at least one STI patient/month. The most commonly diagnosed STI the doctors reported was urethritis/cervicitis syndrome. 50% of the doctors knew the recommended antibiotics for gonorrhoea though only 46% of these knew the correct dosage. Specialists were three times more likely to recognise the clinical presentation of herpes and twice as likely to treat chlamydia, syphilis, and herpes with appropriate antimicrobials than GPs. 85% of the doctors advised their STI patients regarding condom usage; 36% thought that STI patients had loose sexual morals; 43% believed STI patients were drug addicts. Over 90% of the physicians were willing to attend educational sessions and follow a national STI treatment protocol.Doctors in Karachi, especially GPs, are deficient in appropriately managing and counselling STI patients. Among the specialists, urologists and dermatologists were more likely to manage STIs correctly than gynaecologists. Karachi doctors should be educated in the correct management and counselling of STIs to prevent further spread of STIs including AIDS.

  View details for Web of Science ID 000090103000014

  View details for PubMedID 11141857

• Adult mortality in slums of Karachi, Pakistan. JPMA. The Journal of the Pakistan Medical Association Marsh, D. R., Kadir, M. M., HUSEIN, K., Luby, S. P., Siddiqui, R., Khalid, S. B. 2000; 50 (9): 300-306

  Abstract

  Cause-specific death rates are rarely available to guide health interventions for adults in South Asia. We report mortality patterns among Karachi's urban poor.We conducted verbal autopsies for adult deaths under active surveillance during 1990-1993 in five urban slums of Karachi. Two physicians assigned underlying cause of death by consensus. Analysis included cause- and category-specific rates, 45Q15s and comparison with 1991 Japanese national statistics.All 345 adult deaths (15-59 years) in the 5 slums (total population 45,389) were included. Male mortality exceeded female (4.4 vs 3.3/1000, p = .02). Noncommunicable diseases claimed 59% of deaths, communicable and reproductive 27% and injuries, 15%. The leading identified death rates (/100,000) among women were: circulatory disorders (66), maternal causes (33), tuberculosis (30), and burns (23); and among men they were: circulatory disorders (124) tuberculosis (30) and road traffic accidents (30). Overall Karachi adult mortality was 3.7 times Japanese rate. Compared to Japan, adults in Karachi had one to two orders of magnitude excess mortality due to maternal causes, tuberculosis and burns. Circulatory disorders and tuberculosis accounted for 47% of excess male mortality; these plus maternal causes and burns accounted for 55% of excess female mortality.These mortality levels and patterns compel interventions and research for poor urban adults beyond maternal health. Women's health would equally benefit from tuberculosis control or burn prevention. Men need safer travel. Both need improved cardiovascular health.

  View details for PubMedID 11043020

• Evaluation of blood bank practices in Karachi, Pakistan, and the government's response HEALTH POLICY AND PLANNING Luby, S., Khanani, R., Zia, M., Vellani, Z., Ali, M., Qureshi, A. H., Khan, A. J., Mujeeb, S. A., Shah, S. A., Fisher-Hoch, S. 2000; 15 (2): 217-222

  Abstract

  National legislation in Pakistan regulating blood banks has been introduced several times, but has never been passed. To support provincial-level efforts to develop legislation we conducted a study to evaluate blood-banking practices in Karachi, Pakistan, to identify areas that could be improved.Thirty-seven blood banks were randomly selected from a list of 87 Karachi blood banks. The research team interviewed blood bank personnel, inspected available facilities and equipment, and observed blood collection using structured questionnaires and observation forms.Of the 37 selected facilities, 25 were operational and 24 agreed to participate. Twelve (50%) of the facilities reported regularly utilizing paid blood donors, while only six (25%) activity recruited volunteer donors. During observation only 8% of facilities asked donors about injecting drug use, and none asked donors any questions about high-risk sexual behaviour. While 95% of blood banks had appropriate equipment and reagents to screen for hepatitis B, only 55% could screen for HIV and 23% for hepatitis C. Twenty-nine percent of the facilities were storing blood products outside the WHO recommended temperature limits.Practices at most Karachi blood banks fell well below WHO standards. Findings from this study were instrumental in developing and passing legislation to regulate blood transfusion throughout Sindh Province, and suggest a method for improving blood transfusion practices in other developing countries.

  View details for Web of Science ID 000087799300012

  View details for PubMedID 10837045

• Multivariate analysis of risk factors associated with genital ulcer disease among incarcerated males in Sindh. JPMA. The Journal of the Pakistan Medical Association Akhtar, S., Luby, S. P., Rahbar, M. H. 2000; 50 (4): 115-120

  Abstract

  To evaluate the potential risk behaviors associated with the lifetime risk of self reported genital ulcer disease (GUD) among prison inmates.Prison inmates from 14 prisons of Sindh Province.A cross-sectional study was conducted on 3395 prison inmates during July to December, 1994. A questionnaire was used to assess the lifetime risk of self-reported GUD (whether or not the subject was ever affected with GUD up to present age) and to investigate demographic markers and risk behaviors for their possible association with lifetime risk of GUD using logistic regression analysis.The reported lifetime risk of GUD in the study sample was 11.4% (386/3395). In final multivariate logistic regression model the sexual behaviors which were independently associated with GUD were having sexual intercourse with female (adjusted OR = 1.7; 95% CI: 1.3-2.3, P = 0.0002), sexual intercourse with a prostitute (adjusted OR = 1.5; 95% CI: 1.2-2.0, P = 0.0008), sexual intercourse with man (adjusted OR = 2.2; 95% CI: 1.7-2.7, P = < 0.001) and sexual intercourse with man during current incarceration (adjusted OR = 1.9; 95% CI: 1.2-2.9, P = 0.0071).Health education needs to re-enforce monogamous relationship for high risk groups such as in our study. Although infrequent condom use was not a risk factor for GUD in this study, yet based on the results of previous studies, promotion of condom use should be the component of health education program.

  View details for PubMedID 10851831

• Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan BULLETIN OF THE WORLD HEALTH ORGANIZATION Khan, A. J., Luby, S. P., Fikree, F., Karim, A., Obaid, S., Dellawala, S., Mirza, S., Malik, T., Fisher-Hoch, S., MCCORMICK, J. B. 2000; 78 (8): 956-963

  Abstract

  Following reports of frequent deaths associated with jaundice and chronic liver disease among adults in a periurban community of Karachi, Pakistan, an investigation was conducted to evaluate the relationship between injections and viral hepatitis infections, to identify the reasons why patients received frequent injections, and to observe the injection practices employed in clinics. Two hundred and three adult patients were interviewed as they left each of the 18 area clinics. Practitioners were interviewed and three consecutive injections were observed at each clinic. Eighty-one per cent of patients received an injection on the day of the interview. Of the 135 patients who provided a serum sample, 59 (44%) had antibodies against hepatitis C virus and 26 (19%) had antibodies against hepatitis B virus. Patients who received more injections were more likely to be infected with hepatitis C. If oral and injected medications were equally effective, 44% of patients preferred injected medication. None of the practitioners knew that hepatitis C could be transmitted by injections. Non-sterile syringes and needles that had been used earlier in the day on other patients were used for 94% of the observed injections. Interventions to limit injections to those which are safe and clinically indicated are needed to prevent injection-associated infections in Pakistan and other low-income countries.

  View details for Web of Science ID 000088892200003

  View details for PubMedID 10994278

• Limited effectiveness of home drinking water purification efforts in Karachi, Pakistan. International journal of infectious diseases Luby, S. P., Syed, A. H., Atiullah, N., Faizan, M. K., Fisher-Hoch, S. 2000; 4 (1): 3-7

  Abstract

  In many developing-country urban areas, municipally supplied water is not microbiologically safe. This study evaluated drinking water quality and effect of home water purification efforts in Karachi, Pakistan.Members of 300 households, including 100 households who used the Aga Khan University Hospital Laboratory and 200 of their neighbors were interviewed. In 293 consenting households, structured observations were performed and drinking water was analyzed for the presence of coliforms, using the multiple tube fermentation technique.Although 193 of the 293 households (66%) reported using some method to purify their drinking water, including 169 (58%) who boiled their water, only 48 (16%) of the drinking water samples were free of coliforms. Although a combination of boiling and filtering was the most effective method of purification, only 38% of samples that had been boiled and filtered were free of coliforms.Further refinements and evaluations of home-based efforts to purify and store water are needed.

  View details for PubMedID 10689207

• Household members of hepatitis C virus-infected people in Hafizabad, Pakistan: infection by injections from health care providers EPIDEMIOLOGY AND INFECTION Pasha, O., Luby, S. P., Khan, A. J., Shah, S. A., MCCORMICK, J. B., Fisher-Hoch, S. P. 1999; 123 (3): 515-518

  Abstract

  Household members of people with hepatitis C are at increased risk of HCV infection. The prevalence and routes of transmission of HCV to household members in Hafizabad, Pakistan were investigated. Household members of 24 index cases were given a risk factor questionnaire, tested for HCV infection, and the risk factors between the infected and uninfected were compared. Twelve of 74 household members (16.2%) were seropositive for HCV antibody. This was 2(1/2) times the rate of infection in the general population (OR = 2.8; P = 0.01). None of the routes of transmission studied within the household was associated with an increased risk. Household members who received more than 4 injections per year were 11.9 times more likely to be infected than those who had not (P = 0.016). In Hafizabad, the greatest risk for HCV infection to household members of infected people is injections given by health-care workers rather than household contact with infected persons.

  View details for Web of Science ID 000085406000022

  View details for PubMedID 10694166

• Survey of surgical emergencies in a rural population in the Northern Areas of Pakistan TROPICAL MEDICINE & INTERNATIONAL HEALTH Ahmed, M., Shah, M. A., Luby, S., Drago-Johnson, P., Wali, S. 1999; 4 (12): 846-857

  Abstract

  To determine the incidence of specific surgical emergencies in a mountainous rural community in the Northern Areas of Pakistan and to assess use of existing health services, and outcomes related to acute surgical illness events.A cross-sectional population-based survey was conducted. Interviewers visited each of 118 villages in the study area (population 100000), selected a random sample from a total of 9900 households, and interviewed the oldest premenopausal female member (n = 836). Questions were focused on injury, acute abdomen, and/or maternal morbidity occurring in the past year. Cases were included as surgical emergencies when one or more index clinical features indicating a potential for surgical intervention were present. Mortality from a wider range of surgical emergencies was also elicited based on the respondent's lifetime knowledge of the household.The incidence rates were 1531/100000 persons per year for injuries; 1364/100000 for acute abdomen, and 16462/100000 for maternal morbidity. The rate of injuries was 2.7 times higher and that of acute abdomen twice as high in males as in females. The injury rate decreased with advancing age, being 13 times higher in children < 5 years than in adults > 40. By contrast, the rate for acute abdomen showed a rise with advancing age, being 8 times higher in the > 40 age group than in under-fives. Burns, falls and road accidents, in that order, were the commonest forms of injury accounting for 82% of 138 cases. Of 43 burn casualties, 46% were in the age group < 5 years; there was no gender bias. Of 71 casualties from falls and road accidents, 85% were aged 6-40 years; there was 6 : 1 male predominance. The maternal morbidity rate was highest in the age group 25-35 years and may be attributed to the high pregnancy rate in this age bracket. Of 408 patients with acute surgical illness, 85% were managed initially at home or close to home in a health centre, dispensary or civil hospital; 32% eventually sought specialist surgical care. The overall rate for minor and major surgical procedures was 411/100000 persons per year (lowest estimate), and appeared to be low. The rate of operative deliveries at 11.8/1000 deliveries (lowest estimate) was particularly low. The mortality rates were correspondingly high: 55/100000 persons per year for injuries and for acute abdomen (lowest estimates). The maternal mortality ratio was particularly high at 8.9/1000 deliveries (lowest estimate). Annual mortality rates derived from deaths recalled during the respondent's lifetime in the household (mean period = 26 years), tended to corroborate the results of the 1-year survey.The incidence rates for broad categories of serious acute surgical illness in the study population far exceeded the rates of acute surgical intervention. Mortality rates were correspondingly high. Such evidence points to a large unmet surgical need and ought to spur improvements in the health service.

  View details for Web of Science ID 000084856100009

  View details for PubMedID 10632993

• Risk behaviours associated with urethritis in prison inmates, Sindh. JPMA. The Journal of the Pakistan Medical Association Akhtar, S., Luby, S. P., Rahbar, M. H. 1999; 49 (11): 268-273

  Abstract

  To identify sexual risk behaviours associated with lifetime risk of urethritis in prison inmates.A cross-sectional study using a pre-designed questionnaire.Fourteen prisons throughout the Sindh Province, Pakistan.Three thousand three hundred ninety-five prison inmates incarcerated during July, 1994.Lifetime risk of urethritis occurrence (whether or not the subject was ever affected with urethritis up to his present age)Lifetime risk of urethritis occurrence in the study population was 20.8% (706/3395). The final multivariate logistic regression model indicated that risk behaviours associated with lifetime risk of urethritis in this population were 'sexual intercourse with a female' (adjusted OR = 2.18; 95% CI 1.60, 2.95), 'multiple female sexual partners' (adjusted OR = 1.67; 95% CI 1.28, 2.18) and 'sexual intercourse with man' (adjusted OR = 2.75; 95% CI 2.29, 3.31).The prevalence of urethritis in this population was very high. High prevalence of various risky sexual behaviours among inmates indicates, their unawareness as to what precautions they might take to avoid risk of acquiring STDs including HIV. The study subjects meet the characteristics of a core group of STDs transmitters and provides short window of opportunity for STD/HIV control programs to intervene, while they are in detention to reduce the risk not only for this group but also for general population.

  View details for PubMedID 10647238

• Risky behavior of bus commuters and bus drivers in Karachi, Pakistan ACCIDENT ANALYSIS AND PREVENTION Mirza, S., Mirza, M., Chotani, H., Luby, S. 1999; 31 (4): 329-333

  Abstract

  Buses account for a disproportionate number of road traffic accident fatalities in Karachi, Pakistan and other developing countries. Potentially dangerous bus driving and commuting practices that increase risk of road accidents and the effect of traffic police on bus behavior are evaluated. A total of 250 episodes each of disembarking and embarking commuters, buses stopping and moving on the road at ten of Karachi's highest risk intersections for traffic injuries were observed. Of the disembarking passengers, 33% did not wait for the bus to stop; 54% stepped off in the center of the road and 84% did not look out for traffic. Among the embarking commuters, 38% got on moving buses; 73% climbed on buses filled to their outer foot boards and 83% waited for buses on the street. Males were more likely than females to jump off a moving bus (43% versus 1.6%, P < 0.001), get on a moving bus (49% versus 12%, P < 0.001), and run to catch a bus (45% versus 8%, P < 0.001). At the bus stops, 30% of the buses did not stop completely; 46% stopped away from the stop and 79% stopped in the center of the road. Where traffic police were present buses were more likely to race (9% versus 3%, P = 0.05) and to cut off other vehicles (13% versus 2%, P = 0.001) than where police were absent. Risky behavior is common among both Karachi bus drivers and bus commuters. The traditional efforts to regulate bus traffic through traffic police is ineffective.

  View details for Web of Science ID 000080846500006

  View details for PubMedID 10384225

• Does use of a government service depend on distance from the health facility? HEALTH POLICY AND PLANNING NoorAli, R., Luby, S., Rahbar, M. H. 1999; 14 (2): 191-197

  Abstract

  To reduce mortality from common childhood illnesses such as diarrhoea and upper respiratory infections, it is important that health services are available and used appropriately. Physical accessibility to a health facility may influence its use, particularly in rural areas. We assessed whether use of government services for treatment of the three most common acute childhood illnesses (fever, diarrhoea and upper respiratory infections) was influenced by the physical accessibility of the government primary health care centres. We analyzed data from a household survey which was collected between November 1992 and January 1993, from 139 randomly selected villages located around 14 government facilities in Thatta, a rural district of Pakistan. There were 691 children under 5 years of age who suffered from the three acute illnesses; 85% of these children used either a government or a private service. Children living at less than 4 km from a government facility made 22% less use of that facility than those living 4 km or more away. After controlling for the effects of distance from a private facility and treatment cost in a multiple logistic regression model, children living less than 4 km from a government facility were no more likely to use the facility than those living 4 km or more away (Adjusted Odds Ratio: 1.01, 95% Confidence Interval: 0.68-1.50). These results suggest that factors other than distance are the primary determinants of use of government services for treating children in the Thatta district. To increase the use of government health services, policymakers should assess carefully the factors determining the use of existing facilities, before they plan the building of more health facilities. Further studies are needed to examine the management of health facilities and the clients' perception of health-care providers.

  View details for Web of Science ID 000081186600010

  View details for PubMedID 10538722

• Outbreak of Crimean-Congo haemorrhagic fever in Quetta, Pakistan: contact tracing and risk assessment TROPICAL MEDICINE & INTERNATIONAL HEALTH Altaf, A., Luby, S., Ahmed, A. J., Zaidi, N., Khan, A. J., Mirza, S., McCormick, J., Fisher-Hoch, S. 1998; 3 (11): 878-882

  Abstract

  In December 1994 in a private hospital in Quetta, Pakistan, 3 health-workers contracted Crimean-Congo haemorrhagic fever (CCHF) after surgery on a bleeding patient who later died. We conducted a retrospective study to determine transmission risks among contacts. Fifty contacts gave blood for antibody tests and answered questions about exposure. Two of four people exposed percutaneously and one of five with cutaneous exposure contracted CCHE The person with cutaneous exposure was a surgeon who tore his glove during surgery and noted blood on his hand but no cut. There were no anti-CCHF antibodies or CCHF cases among persons whose skin came into contact with body fluids other than blood (0/4), who had skin-to-skin contact (0/16) with patients or were physically close to them (0/21). Three index case relatives reported that although 10 family members had cutaneous exposure, none developed CCHF. The family refused blood tests. CCHF transmission in resource-constrained settings can be limited by focusing on avoiding health worker contact with blood.

  View details for Web of Science ID 000077571000006

  View details for PubMedID 9855399

• Postexposure treatment of rabies in Pakistan CLINICAL INFECTIOUS DISEASES Parviz, S., Luby, S., Wilde, H. 1998; 27 (4): 751-756

  Abstract

  To evaluate compliance with current World Health Organization (WHO) guidelines for postexposure treatment (PET) of rabies, we interviewed all animal bite victims seeking treatment on the same day of each week from 28 December 1994 through 18 January 1995 at the Civil Hospital of Karachi (Pakistan), a major referral center. Of the 143 patients studied, 109 (76%) sustained bleeding transdermal bites (WHO category III). Overall, wounds were not washed with soap or an antiseptic in 69% of victims. All victims received 5% sheep brain-derived vaccine, and only three of the 109 victims with category III bites received rabies immune globulin. PET of rabies in Karachi was deficient by all WHO standards. Although there is a great urgency to improve PET, it will remain a costly and inefficient method of controlling rabies. Reduction of rabies reservoirs is required to decrease human deaths due to rabies in Pakistan and other developing countries in which canine rabies is endemic.

  View details for Web of Science ID 000076493400016

  View details for PubMedID 9798028

• HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh, Pakistan JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Baqi, S., Nabi, N., Hasan, S. N., Khan, A. J., Pasha, O., Kayani, N., Haque, R. A., Haq, I. U., Khurshid, M., Fisher-Hoch, S., Luby, S. P., MCCORMICK, J. B. 1998; 18 (1): 73-79

  Abstract

  To determine prevalence of HIV infection and risk behaviors in commercial sex workers (CSWs), drug users, and prisoners in Sindh, Pakistan.A medical clinic was established in a "red-light" district of Karachi. Eighty-one CSWs who registered at the clinic between November 1993 and June 1994 were provided HIV counseling and testing and administered a risk factor questionnaire. Next, 316 male drug users were tested for HIV-1 antibody from April to July 1994. Finally, a voluntary serosurvey of HIV-1 and HIV-2 and risk behaviors of 3525 prisoners in Sindh was conducted between July 1994 and December 1994. Abbott Recombinant HIV third-generation enzyme-linked immunosorbent assay (ELISA) and confirmatory testing with Western blot analysis were used in all three groups.None of 81 CSWs tested for HIV-1 antibody were positive. None of 316 drug users tested positive for HIV-1 antibody. Of 3441 male prisoners, 1 was HIV-1 infected, and of 84 female prisoners, 1 was HIV-1 infected. No prisoner was positive for HIV-2 antibody.The prevalence of HIV in CSWs, drug users, and prisoners in Sindh is low at present. Intervention programs implemented at this stage can make an impact in HIV prevention.

  View details for Web of Science ID 000073522900011

  View details for PubMedID 9593461

• Expansion of epidemic dengue viral infections to Pakistan. International journal of infectious diseases Paul, R. E., Patel, A. Y., Mirza, S., Fisher-Hoch, S. P., Luby, S. P. 1998; 2 (4): 197-201

  Abstract

  Antibodies to dengue viruses have occasionally been reported in individuals in Pakistan, but the frequency of occurrence of dengue infection in Pakistan is unclear. The first confirmed dengue hemorrhagic fever outbreak in Pakistan occurred in 1994. In October 1995, the authors investigated an outbreak of a febrile illness among employees of a construction contractor at a power generation plant in Baluchistan, Pakistan, to determine the cause of illness and recommend appropriate preventive measures.The work site and living arrangements were inspected, a questionnaire was administered, and serum samples were collected from all consenting contractor employees and their families if they lived at the camp. Sera were analyzed for IgM against dengue virus, using an enzyme-linked immunosorbent assay.Interviews were conducted with 76 persons (mean age, 42y); 95% were men. Forty-two persons (55%) reported having experienced fever, headache, or myalgia in the preceding 6 weeks. Fifty-seven subjects (75%) had IgM antibodies against at least one dengue serotype; 45 subjects (59%) had IgM antibodies against dengue serotype 2.This was an outbreak of dengue fever due to multiple serotypes of dengue virus. This confirms that epidemic dengue infection was present in southern Pakistan for 2 consecutive years.

  View details for PubMedID 9763501

• Risk factors for typhoid fever in an endemic setting, Karachi, Pakistan EPIDEMIOLOGY AND INFECTION Luby, S. P., Faizan, M. K., Fisher-Hoch, S. P., Syed, A., Mintz, E. D., Bhutta, Z. A., MCCORMICK, J. B. 1998; 120 (2): 129-138

  Abstract

  We conducted a study to evaluate risk factors for developing typhoid fever in a setting where the disease is endemic in Karachi, Pakistan. We enrolled 100 cases with blood culture-confirmed Salmonella typhi between July and October 1994 and 200 age-matched neighbourhood controls. Cases had a median age of 5.8 years. In a conditional logistic regression model, eating ice cream (Odds ratio [OR] = 2.3; 95% confidence interval [CI] 1.2-4.2, attributable risk [AR] = 36%), eating food from a roadside cabin during the summer months (OR = 4.6, 95% CI 1.6-13.0; AR = 18%), taking antimicrobials in the 2 weeks preceding the onset of symptoms (OR = 5.7, 95% CI 2.3-13.9, AR = 21%), and drinking water at the work-site (OR = 44.0, 95% CI 2.8-680, AR = 8%) were all independently associated with typhoid fever. There was no difference in the microbiological water quality of home drinking water between cases and controls. Typhoid fever in Karachi resulted from high-dose exposures from multiple sources with individual susceptibility increased by young age and prior antimicrobial use. Improving commercial food hygiene and decreasing unnecessary antimicrobial use would be expected to decrease the burden of typhoid fever.

  View details for Web of Science ID 000073447800003

  View details for PubMedID 9593481

• The relationship between therapeutic injections and high prevalence of hepatitis C infection in Hafizabad, Pakistan EPIDEMIOLOGY AND INFECTION Luby, S. P., Qamruddin, K., Shah, A. A., Omair, A., Pahsa, O., Khan, A. J., MCCORMICK, J. B., Hoodbhouy, F., Fisher-Hoch, S. 1997; 119 (3): 349-356

  Abstract

  To determine the prevalence and routes of transmission of hepatitis C virus (HCV) infection in Hafizabad, Pakistan, we collected sera in 1993 from a geographically based random sample of residents, and in 1994 identified 15 HCV-infected individuals (cases) and 67 age and sex matched uninfected individuals (controls). Initially we approached 504 households, and collected serum from a randomly selected household member in 309 (64%). Twenty persons (6.5%) had anti-HCV antibody; 31% percent had hepatitis B core antibodies, and 4.3% had hepatitis B surface antigen. In the case-control study, persons who received more therapeutic injections (categorized as averaging 1, 2-4, 5-9 or > 10 injections per year in the previous 10 years) were more likely to be infected with HCV (odds ratio 0, 1.5, 2.5 and 6.9 respectively, P = 0.008) compared to persons averaging 0 injections per year. Efforts to limit therapeutic injections to only those that are medically indicated and that use sterile equipment are essential in order to prevent transmission of HCV.

  View details for Web of Science ID 000071230300010

  View details for PubMedID 9440439

• Cardiac effects of standard-dose halofantrine therapy AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Matson, P. A., Luby, S. P., Redd, S. C., Rolka, H. R., Meriwether, R. A. 1996; 54 (3): 229-231

  Abstract

  The antimalarial drug halofantrine hydrochloride has been associated with cardiac arrhythmias. This is a report of a study on the cardiac effects of standard-dose halofantrine (24 mg/kg) on a sample of 48 patients selected from a group of 402 Dega (Montagnard) refugees treated for Plasmodium falciparum infection. Prolongation of the rate-corrected QT interval (QTc) on the electrocardiogram (ECG) was used as an indicator of risk for halofantrine-associated cardiac arrhythmias. We found that standard-dose halofantrine was associated with a lengthening of the mean QTc from 0.04 sec(1/2) to 0.44 sec(1/2). Two patients had a QTc increase of greater than 25%, but none had a follow-up QTc of more than 0.55 sec(1/2), an interval length generally considered to be a risk factor for ventricular arrhythmias. Regression analysis indicated that pretreatment ECGs were poorly predictive of QTc lengthening during therapy, although pretreatment ECGs may be useful to evaluate patients with pre-existing cardiac conditions. The manufacturer has recommended that the halofantrine dose not exceed 24 mg/kg and revised the list of medication contraindications to include some cardiac conditions. Clinicians should weigh a patient's risk, including history of cardiac disease and availability of alternative therapy before use of halofantrine.

  View details for Web of Science ID A1996UE41800002

  View details for PubMedID 8600755

• Front-line management of pulmonary tuberculosis: An analysis of tuberculosis and treatment practices in urban Sindh, Pakistan TUBERCLE AND LUNG DISEASE Marsh, D., Hashim, R., Hassany, F., Hussain, N., Iqbal, Z., Irfanullah, A., Islam, N., Jalisi, F., Janoo, J., Kamal, K., Kara, A., Khan, A., Khan, R., Mirza, O., Mubin, T., PIRZADA, F., Rizvi, N., Hussain, A., Ansari, G., Siddiqui, A., Luby, S. 1996; 77 (1): 86-92

  Abstract

  Karachi and Hyderabad, Pakistan.To describe the level and quality of tuberculosis (TB) case management by non-TB control program (TCP) physicians in urban Sindh, Pakistan.We interviewed 152 adults with pulmonary TB confirmed by Karachi's TB control program regarding the initial management of their TB symptoms before entering the TCP. We also surveyed 65 general practitioners (GPs) attending continuing education seminars with a multiple choice test to assess their management of suspected pulmonary TB. We compared both results to guidelines from the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD).Eighty percent (122/152) of patients first sought GPs. Only 14% of GPs performed any sputum test. At most, 17 (40%) of the 42 patients recalling their GP's treatment, received the recommended 4-drug regimen. However, 68% (45/65) of surveyed GPs chose correct treatment from a multiple choice format. But their initial laboratory investigations, follow-up, and treatment cessation criteria (9%, 9-31%, and 11% correct, respectively) demonstrated under-utilization of sputum tests and over-reliance on unhelpful tests.GPs first saw most of these TCP patients, but their weak management likely hinders TB control. A partnership between TB control programs and GPs could improve case management and hasten TB control.

  View details for Web of Science ID A1996TW24100016

  View details for PubMedID 8733421

• Imported malaria in Montagnard refugees settling in North Carolina: Implications for prevention and control AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Paxton, L. A., Slutsker, L., Schultz, L. J., Luby, S. P., Meriwether, R., Matson, P., Sulzer, A. J. 1996; 54 (1): 54-57

  Abstract

  In the winter of 1992, some 402 Southeast Asian refugees were resettled in North Carolina. They received very limited medical screening before immigration and many arrived in the United States with significant health problems, including several tropical infectious diseases. These refugees had lived for many years in remote areas along the Vietnam-Cambodia border, where there is intense transmission of malaria, including Plasmodium falciparum resistant to most antimalarial drugs available in the United States. Of 322 refugees screened after arrival in North Carolina, 187 (58%) were infected: 33% with P. falciparum, 23.5% with P. vivax, 23.5% with P. malariae, and 2.1% with P. ovale. Most infected persons were asymptomatic and infections with multiple species were common. Because of the documented high infection prevalence and the probable presence of many subpatent infections, all nonpregnant refugees were treated with halofantrine; those with P. vivax or P. ovale infections were given primaquine as well. This group accounted for the largest cluster of malaria cases reported in the United States in the last 50 years. Their rapid relocation, with minimal medical screening prior to arrival, resulted in a significant burden to the refugees and to the health-care system. Coordination between immigration agencies, the public health community, and medical workers in communities where the refugees are settled is critical for U.S.-based management of imported tropical diseases.

  View details for Web of Science ID A1996TU82700012

  View details for PubMedID 8651370

• Verbal autopsy in Karachi slums: Comparing single and multiple cause of child deaths HEALTH POLICY AND PLANNING Marsh, D., HUSEIN, K., Lobo, M., Shah, M. A., Luby, S. 1995; 10 (4): 395-403

  View details for Web of Science ID A1995TL59800006

• A NOSOCOMIAL OUTBREAK OF MYCOBACTERIUM-TUBERCULOSIS JOURNAL OF FAMILY PRACTICE Luby, S., Carmichael, S., Shaw, G., Horan, J., Gamble, W., Jones, J. 1994; 39 (1): 21-25

  Abstract

  The national incidence of tuberculosis (TB) is increasing, and hospitals are a site of transmission. We investigated a nosocomial outbreak of TB at a 160-bed community hospital in South Carolina that highlights the central role that primary care physicians must play to control this epidemic.We reviewed medical records to identify potential source cases. We retrospectively evaluated exposures to suspected source patients and the subsequent tuberculin reactivity of the 38 hospital employees who had a previous negative tuberculin skin test and were assigned to the ward where the outbreak began. We also evaluated the out-of-hospital contacts of TB cases.A review of medical records identified one patient who had died of prostate cancer and chronic cavitary pneumonia but was never in isolation nor evaluated for TB. Ward employees who worked while this patient was hospitalized had an increased risk for skin-test conversion (43% [12 of 28] vs 0% [0 of 9]; relative risk undefined; P = .02). Among employees who worked with this patient, skin-test converters worked more shifts with (median, 10.5 vs 7), dispensed more medication to (median 7 doses vs 1), and wrote more notes on (median 18 vs 5) the index patient than did nonconverters. Five of 12 of the patient's close out-of-hospital contacts had newly recognized positive tuberculin skin tests. Among 20 casual contacts, there were no new skin-test conversions.A high index of suspicion, prompt isolation and diagnostic testing of potentially infectious hospitalized patients, and a thorough investigation of contacts of patients with TB are needed to prevent TB transmission.

  View details for Web of Science ID A1994NX39200018

  View details for PubMedID 8027728

• USING CD4 COUNTS TO EVALUATE THE STAGES AND EPIDEMIOLOGY OF HIV-INFECTION IN SOUTH-CAROLINA PUBLIC CLINIC PATIENTS AMERICAN JOURNAL OF PUBLIC HEALTH Luby, S., Jones, J., Horan, J. 1994; 84 (3): 377-381

  Abstract

  CD4 lymphocyte counts decrease with the duration of human immunodeficiency virus (HIV) infection. We used CD4 counts collected for clinical reasons to evaluate the stage of HIV infection and the epidemiology of recent HIV infections among attendees of South Carolina's public health clinics.We measured the CD4 T-lymphocyte counts of persons newly diagnosed with HIV infection April 1989 through June 1990 at South Carolina public health clinics who returned for follow-up.Of 812 newly diagnosed HIV-infected health department patients, 420 (52%) had their CD4 lymphocyte counts measured. Of these 420, 51 (12%) had CD4 counts of < 200, the level below which prophylaxis for pneumocystis pneumonia prolongs survival, and 193 (46%) had CD4 counts of < 500, the level below which zidovudine may prolong disease-free survival. The highest CD4 counts (> or = 900), which are associated with more recent HIV infection, were more common in females.In South Carolina, almost half of newly reported HIV-infected persons who agreed to CD4 testing at the health department might benefit from immediate drug therapy. Within this population, women may be an emerging risk group that requires specifically directed HIV prevention efforts.

  View details for Web of Science ID A1994NM61800007

  View details for PubMedID 7907458

• OUTBREAK OF GASTROENTERITIS DUE TO SALMONELLA-ENTERITIDIS FROM LOCALLY PRODUCED GRADE-A EGGS, SOUTH-CAROLINA SOUTHERN MEDICAL JOURNAL Luby, S., Jones, J. 1993; 86 (12): 1350-1353

  Abstract

  Recent investigations of outbreaks of Salmonella enteritidis gastroenteritis among humans, especially in the northeastern United States, implicate grade A shell chicken eggs as the likely vehicle of transmission. In April 1991 we investigated an outbreak of S enteritidis infections after a wedding anniversary celebration in Beaufort, South Carolina. Sixty-eight percent of persons who ate a macaroni and cheese dish, but none of the 16 attendees who did not, became ill (P < .001). The chef used six grade A eggs in the macaroni and cheese and may have undercooked it. The egg supplier processed eggs exclusively from farms in South Carolina and North Carolina. This outbreak suggests that the epidemic of S enteritidis in flocks of laying hens the consequent threat of human infection has spread to the Carolinas.

  View details for Web of Science ID A1993MN62200005

  View details for PubMedID 8272910

• A LARGE OUTBREAK OF GASTROENTERITIS CAUSED BY DIARRHEAL TOXIN-PRODUCING BACILLUS-CEREUS JOURNAL OF INFECTIOUS DISEASES Luby, S., Jones, J., Dowda, H., Kramer, J., Horan, J. 1993; 167 (6): 1452-1455

  Abstract

  An outbreak of diarrhea occurred after a university field day. Of 643 attendees who returned mailed questionnaires, 139 (22%) reported illness. Persons who ate barbecued pork, which was unrefrigerated for 18 h after cooking, were five times more likely to become ill than those who did not eat pork (26% vs. 5%; relative risk, 5.4; 95% confidence interval, 1.4-20.9). A leftover pork sample grew a Bacillus cereus isolate, > 10(5) cfu/g, that produced diarrheal toxin. Thirty-four percent of ill persons noted onset of illness outside the 6- to 24-h incubation period traditionally ascribed to B. cereus-mediated diarrhea, and an unusually high percentage (23%) noted fever. B. cereus may cause a wider spectrum of disease than previously described.

  View details for Web of Science ID A1993LD69400033

  View details for PubMedID 8501338

• A LARGE SALMONELLOSIS OUTBREAK ASSOCIATED WITH A FREQUENTLY PENALIZED RESTAURANT EPIDEMIOLOGY AND INFECTION Luby, S. P., Jones, J. L., Horan, J. M. 1993; 110 (1): 31-39

  Abstract

  Between January and June 1990, Restaurant A in Greenville, South Carolina repeatedly failed local health department inspection and was repeatedly sanctioned. In September 1990, two persons, hospitalized with salmonellosis after attending a convention catered by Restaurant A, contacted the South Carolina Department of Health and Environmental Control. We inspected Restaurant A, interviewed food handlers, and surveyed by telephone persons from every sixth business attending the convention. Of 398 persons interviewed, 135 (34%) reported gastroenteritis. Nine had culture-confirmed salmonella infection. People who ate turkey were 4.6 times more likely to become ill than those who did not eat turkey (95% confidence interval 2.0, 10.6). We estimate that of 2430 attendees, 824 became ill. Sanitarians judged Restaurant A's kitchen too small to prepare over 500 meals safely. The cooked turkey was unrefrigerated for several hours, incompletely rewarmed, and rinsed with water to reduce its offensive odour prior to serving. Stronger sanctions may be needed against restaurants that repeatedly fail local health department inspection.

  View details for Web of Science ID A1993KL75900005

  View details for PubMedID 8432321