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ABSTRACTObjectiveTo formulate guidelines for screening of diabetic retinopathy (DR) for the World Health Organization (WHO) South-East Asia Region (SEAR) aligned with the current infrastructure and human resources for health (HRH).DesignA consultative group discussion of technical experts of the International Agency for the Prevention of Blindness (IAPB) from SEAR.ParticipantsIAPB country chairs and DR technical experts from SEAR countries.MethodsData related to DR in SEAR was collected from published literature on available DM and DR guidelines and the participating experts. The 10 SEAR countries (the Democratic Republic of Korea was not included for lack of sufficient data) were divided into 3 resource levels (low, medium, and high) based on gross national income/per capita, cataract service indicators (cataract surgical rate and cataract surgical service), current infrastructure and available HRH. Two countries each were assigned to low (Myanmar, Timor-Leste) and high resource (India, Thailand) levels, and the remaining 6 countries (Bangladesh, Bhutan, Indonesia, Maldives, Nepal, Sri Lanka) were assigned the medium resource level. The DR care system was divided into 3 levels of care (essential, recommended, and desirable) and 3 levels of service delivery (primary, secondary, and tertiary).Main outcome measuresPrimary, secondary, and tertiary level guidelines for screening of DRResultsNine WHO SEAR countries participated in the formulation of the new country-specific DR screening guidelines. The DR screening recommendations were: advocacy at the community level, visual acuity measurement, and non-mydriatic fundus photography at the primary level, comprehensive eye examination and retinal laser at the secondary level, and intravitreal therapy and vitrectomy at the tertiary level. The systemic care of DM and hypertension are recommended at all levels commiserating with their care capabilities.ConclusionsThe DR guidelines for the SEAR region are the first region-specific and resource-aligned recommendations for comprehensive DR care in each country of the region. In the future, the new technological advances in retinal camera technology, teleophthalmology, and artificial intelligence should be included within the structure of the public DR care system.

Background: With a prevalence of 3.1%, approximately, 450 000 children in Bangladesh are having severe acute malnutrition (SAM). There is currently no national community-based program run by government to take care of these children, one of the reasons being lack of access to ready-to-use therapeutic food (RUTF).Objective: To develop RUTF using locally available food ingredients and test its acceptability.Methods: A checklist was prepared for all food ingredients available and commonly consumed in Bangladesh that have the potential of being used for developing a RUTF. Linear programming was used to identify the combinations of nutrients that would result in an ideal RUTF. To test the acceptability of 2 local RUTFs compared to the prototype RUTF, Plumpy’Nut, a clinical trial with a crossover design was conducted among 30 children in the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. The acceptability was determined by using the mean proportion of offered food consumed by the children themselves.Results: Two RUTFs were developed, one based on chickpea and the other on rice–lentils. The total energy content of 100 g of chickpea and rice–lentil-based RUTF were 537.4 and 534.5 kcal, protein 12.9 and 13.5 g, and fat 31.8 and 31.1 g, respectively, without any significant difference among the group. On an average, 85.7% of the offered RUTF amount was consumed by the children in 3 different RUTF groups which implies that all types of RUTF were well accepted by the children.Conclusion: Ready-to-use therapeutic foods were developed using locally available food ingredients—rice, lentil, and chickpeas. Chickpea-based and rice–lentil-based RUTF were well accepted by children with SAM.

ObjectiveWe systematically evaluated health and nutrition programmes to identify context-specific interventional packages that might help to prioritise the implementation of programmes for reducing stunting in low and middle income countries (LMICs).MethodsElectronic databases were used to systematically review the literature published between 1980 and 2015. Additional articles were identified from the reference lists and grey literature. Programmes were identified in which nutrition-specific and nutrition-sensitive interventions had been implemented for children under 5 years of age in LMICs. The primary outcome was a change in stunting prevalence, estimated as the average annual rate of reduction (AARR). A realist approach was applied to identify mechanisms underpinning programme success in particular contexts and settings.FindingsFourteen programmes, which demonstrated reductions in stunting, were identified from 19 LMICs. The AARR varied from 0.6 to 8.4. The interventions most commonly implemented were nutrition education and counselling, growth monitoring and promotion, immunisation, water, sanitation and hygiene, and social safety nets. A programme was considered to have effectively reduced stunting when AARR≥3%. Successful interventions were characterised by a combination of political commitment, multi-sectoral collaboration, community engagement, community-based service delivery platform, and wider programme coverage and compliance. Even for similar interventions the outcome could be compromised if the context differed.InterpretationFor all settings, a combination of interventions was associated with success when they included health and nutrition outcomes and social safety nets. An effective programme for stunting reduction embraced country-level commitment together with community engagement and programme context, reflecting the complex nature of exposures of relevance.PROSPERO registration numberCRD42016043772.

Severe acute malnutrition (SAM) is a common condition that kills children and intellectually maims those who survive. Close to 20 million children under the age of 5 years suffer from SAM globally, and about 1 million of them die each year. Much of this burden takes place in Asia. Six countries in Asia together have more than 12 million children suffering from SAM: 0.6 million in Afghanistan, 0.6 million in Bangladesh, 8.0 million in India, 1.2 million in Indonesia, 1.4 million in Pakistan, and 0.6 million in Yemen. This article is based on a review of SAM burden and intervention programs in Asian countries where, despite the huge numbers of children suffering from the condition, the coverage of interventions is either absent on a national scale or poor. Countries in Asia have to recognize SAM as a major problem and mobilize internal resources for its management. Screening of children in the community for SAM and appropriate referral and back referral require good health systems. Improving grassroots services will not only contribute to improving management of SAM, it will also improve infant and young child feeding and nutrition in general. Ready-to-use therapeutic food (RUTF), the key to home management of SAM without complications, is still not endorsed by many countries because of its unavailability in the countries and its cost. It should preferably be produced locally from locally available food ingredients. Countries in Asia that do not have the capacity to produce RUTF from locally available food ingredients can benefit from other countries in the region that can produce it. Health facilities in all high-burden countries should be staffed and equipped to treat children with SAM. A continuous cascade of training of health staff on management of SAM can offset the damage that results from staff attrition or transfers. The basic nutrition interventions, which include breastfeeding, appropriate complementary feeding, micronutrient supplementation, and management of acute malnutrition, should be scaled up in Asian countries that are plagued with the burden of malnutrition.

Background To achieve the United Nations Millennium Development Goals, particularly reduction in child mortality (Millennium Development Goal 4), effective interventions to address severe and moderate acute malnutrition (SAM and MAM) among children under 5 years of age must be implemented and brought to scale alongside preventive measures. Bangladesh has an estimated 600,000 children with SAM, for a prevalence of 4%, while 1.8 million children suffer from MAM.Objective To assess the feasibility and constraints of community-based management of acute malnutrition (CMAM), a relatively new approach, in managing SAM and MAMamong children in Bangladesh.Methods The methodology involved desk reviews of documents by searching through PubMed and other databases for published literature on CMAM in Bangladesh. We also did a hand search of policy and program documents, including the draft National Nutrition Policy 2013; the Health, Nutrition, Population Sector Development Program document of the Ministry of Health and Family Welfare, Government of Bangladesh; the Sixth Five Year Plan; and the Operational Plans of the National Nutrition Services of Bangladesh.Results The conventional approach in Bangladesh has been to treat children suffering fromSAM and associated complications in hospital settings. There is no program to take care of children with MAM. There is a dearth of local evidence to operationalize and implement CMAM in the context of Bangladesh. This paper summarizes the scientific literature and rationale for the implementation of CMAM in Bangladesh. It also provides recommendations to improve health strategies related to CMAM, discusses diets being developed that may result in better implementation of CMAM, and offers recommendations for areas of additional necessary research.Conclusions A recommended approach for Bangladesh on the management of acute malnutrition would be to integrate CMAM into the rollout of the National Nutrition Services so that screening, identification, referral, and treatment of acutely malnourished children could be effectively managed within the community-based health service delivery system. Given that the vast majority of children are suffering from MAM and could be treated with locally developed food supplements, a significant emphasis of the CMAM approach in Bangladesh should be to screen and treat MAM. Over time, this would also result in fewer SAM cases. However, even with this approach, there would still be a small number of children who have SAM and who ideally should be treated with specialized therapeutic foods. While the Government of Bangladesh is awaiting full-scale production of a local ready-to-use therapeutic food (RUTF), an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis.

Background Iron deficiency is a major cause of anemia and the most prevalent nutrient deficiency among pregnant women in developing countries. The use of iron and folic acid supplements to treat and prevent iron-deficiency anemia has limited effectiveness, mainly due to poor adherence. Home fortification with a micronutrient powder for pregnant women may be an effective and acceptable alternative to traditional drug models.Objective To d etermine whether home fortification with micronutrient powders is at least as efficacious as iron and folic acid tablets for improving hemoglobin concentration in pregnant women.Methods A cluster-randomized noninferiority trial was conducted in the rural subdistrict of Kaliganj in central Bangladesh. Pregnant women (gestational age 14–22 weeks, n= 478), were recruited from 42 community-based Antenatal Care Centres. Each centre was randomly allocated to receive either a micronutrient powder (containing iron, folic acid, vitamin C, and zinc) or iron and folic acid tablets. Changes in hemoglobin from baseline were compared across groups using a linear mixed-effects regression model.Results At enrolment, the overall prevalence of anemia was 45% (n= 213/478). After the intervention period, the mean hemoglobin concentrations among women receiving the micronutrient powder were not inferior to those among women receiving tablets (109.5 ± 12.9 vs 112.0 ± 11.2 g/L; 95% CI, -0.757 to 5.716). Adherence to the micronutrient powder was lower than adherence to tablets (57.5 ± 22.5% vs 76.0 ± 13.7%; 95% CI, -22.39 to -12.94); however, in both groups, increased adherence was positively correlated with hemoglobin concentration.Conclusions The micronutrient powder was at least as efficacious as the iron and folic acid tablets in controlling moderate to severe anemia during pregnancy.

This study aimed to explore the causes, types, and consequences of authorship conflicts among the researchers of selected research institutions in Dhaka, Bangladesh; and to suggest ways to reduce conflicts. A sample of 100 researchers was given a semi-structured questionnaire; 45 subjects responded. The responses were confidential and anonymous. Over two-thirds of the respondents were aware of authorship conflicts, and one-third had actually faced conflicts with their co-authors. Of them, four faced conflicts with their juniors, while 13 faced conflicts with their seniors or supervisors. The primary causes of such conflicts appear to be unethical claims of authorship, violation of authorship order, and deprivation of authorship. In most cases, the victims became frustrated and had to give up, and avoided a direct clash to safeguard their job. Four respondents claimed to have been victimized for raising their voice. Conflict was never resolved in seven cases. To reduce conflicts, respondents suggested that authorship should be decided before the study begins, order of authorship must be determined according to contribution, and a standard code of authorship should be followed strictly. Authorship conflicts arise among researchers mostly due to what they regard as unethical practice of their co-authors, supervisors, and department heads in the absence of any formal authorship policy in the institutions. A standard code of authorship, sensitization of researchers to the problem through open discussions and advocacy, and formation of a grievance redress committee are suggested to minimize such conflicts. Although the sample size was small, some of the specific recommendations will be appropriate in many other cases.