Search

The Dysphagia Handicap Index (DHI) is commonly utilized for evaluating how dysphagia impacts the quality of life (QoL) of patients across physical, functional, and emotional dimensions. The primary aim of the research was to linguistically validate and culturally adapt the DHI to the Bangla version. A cross-sectional study design was chosen, with Beaton's protocol as the guiding framework for validating and adapting the DHI. It has followed a systematic process of forward translation, participation in expert discussions, and subsequent back translation to obtain a reviewed version. The Bangla version, DHI-Ban, was administered purposefully to 50 dysphagia patients in the Clinical Speech and Language Therapy (SLT) Department of the Centre for the Rehabilitation of the Paralyzed (CRP) and was also administered to 50 healthy individuals for comparison. Of the fifty, eighteen dysphagia subjects were assigned again after two weeks for the retest. The DHI-Ban demonstrated strong internal consistency (Cronbach's α = 0.89) and good test-retest reproducibility (ICC = 0.86). The Spearman test confirmed significant construct validity (p < 0.01), and the Wilcoxon test identified significant differences (p < 0.001) between patients and healthy individuals. Feedback from participants was also taken into account for acceptance and clarity. In conclusion, the adapted DHI-Ban has emerged to be a reliable patient-reported tool for assessing dysphagia in Bangla-speaking individuals. Incorporating the Bangla language framework facilitates its comprehension and effectiveness, further solidifying its reliability., Competing Interests: Declarations. I the undersigned declare that the manuscript is original, has not been published anywhere before and is not currently being considered for publication elsewhere. Ethical approval: Approval has been taken from the ethical board/committee of CRP, Institutional Review Board (IRB) and later accepted by BHPI (Bangladesh health Professions Institute). Then permission has also been taken from the original author of DHI via e-mail and clinical branch of Speech and Language therapy at CRP to run the research study smoothly. Consent to participate: A verbal consent has been taken from the participants to take part in this study. The authors concerned the participants about ins and outs of this study. And they are completely aware that they wouldn’t get anything (money and additional treatment facilities) directly due to joining in the study. This is a voluntary approach and they can withdraw anytime if they don’t want to continue their participation in this study. Besides, authors also assured the participants about maintaining their confidentiality. Financial or non-financial interest: The authors have no involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Competing interests: The authors declare that there is no competing interest associated with this publication., (© 2024. The Author(s).)

Background: Arsenic (As), found in diverse ecosystems, poses major public health risks in various parts of the world. Arsenotrophic bacteria in contaminated environments help reduce toxicity by converting arsenite (AsIII) to less harmful arsenate (AsV). We assumed that Achromobacter aegrifaciens strains from As-contaminated tubewell water and soil would share similar genomic characteristics associated with arsenic detoxification and bioremediation. To investigate this, we employed both culture-dependent and culture-independent viz. whole genome sequencing (WGS) methods to thoroughly elucidate the phenotypic and genotypic features of two A. aegrifaciens strains isolated from As-contaminated tubewell water (BAW48) and soil (BAS32) samples collected in the Bogura district of Bangladesh., Results: Both BAW48 and BAS32 isolates demonstrated As(III) oxidation in the KMNO4 test, which was corroborated by molecular analysis confirming the presence of aioA and arsB genes in both strains. These strains were found to be phylogenetically related to many strains of Achromobacter spp., isolated from biological inorganic reactors, environmental soils, sediments and human clinical samples across diverse geographical regions. Moreover, both strains possessed distinct heavy metal resistance genes conferring resistance to Co, Zn, Cu, Cd, Hg, As, and Cr. Three As gene clusters such as As(III) oxidizing aioBA, As(III) reducing arsRCDAB and the MMA(III) oxidizing ars resistance gene (arsHCsO) cluster were predicted in both genomes of A. aegrifaciens. Further genomic analyses revealed similar profiles in both strains, with mobile genetic elements, antimicrobials and heavy metal resistance genes, virulence genes, and metabolic features. Pangenome and synteny analysis showed that the two genomes are evolutionary distinct from other strains, but closely related to one another., Conclusion: The genomic data confirmed that A. aegrifaciens strains can oxidize As(III) and detoxify heavy metals like As, suggesting their potential for As detoxification and bioremediation. These findings align with our assumption and provide a basis for developing sustainable solutions for bioremediation efforts in As-contaminated environments., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Chest X-ray is an important diagnostic aid frequently used alongside microscopic smear of sputum for the confirmation of pulmonary tuberculosis (TB). However, there is a dearth of literature investigating the clinical and radiological pattern of sputum positive pulmonary TB among adults in Bangladesh. The current study explored these patterns in presentation. This descriptive cross-sectional study was conducted at outpatients in department of medicine of a tertiary care hospital. A total of 50 newly diagnosed adult cases of smear positive pulmonary TB attending at the Directly Observed Treatment Short-course (DOTS) corners were consecutively included. Informed written consent was taken before inclusion. Data were collected through face-to-face interview. Radiological presentation was explored using chest X-ray. Data were analyzed by SPSS version 26.0. The average age of patients was 41.0±17.12 years and majority were male (78.0%). The most prevalent respiratory symptom was cough (80.0%) followed by constitutional symptom like fever (70.0%) and weight loss (72.0%). Wasting was the predominant sign (60.0%). Radiologically both lungs were involved in 32.0%, left lung were involved in 30.0% cases and right lung were involved in 26.0% of cases. Twelve percent (12.0%) of patients had normal chest X-ray. Upper zone involvement was commonly observed in this study's patients (66.0%). The predominant pattern was consolidation (46.0%) followed by fibrosis (26.0%), nodular opacity (12.0%), collapse (10.0%), cavity (6.0%), pleural effusion (2.0%) and bronchiectasis (2.0%). Findings of this study would help familiarize and identify the common clinical and radiological presentations of sputum positive pulmonary TB patients in day-to-day practice.

Objective: To estimate inpatient care costs of childhood severe pneumonia and its urban-rural cost variation, and to predict cost drivers., Design: The study was nested within a cluster randomised trial of childhood severe pneumonia management. Cost per episode of severe pneumonia was estimated from a healthcare provider perspective for children who received care from public inpatient facilities. A bottom-up micro-costing approach was applied and data collected using structured questionnaire and review of the patient record. Multivariate regression analysis determined cost predictors and sensitivity analysis explored robustness of cost parameters., Setting: Eight public inpatient care facilities from two districts of Bangladesh covering urban and rural areas., Patients: Children aged 2-59 months with WHO-classified severe pneumonia., Results: Data on 1252 enrolled children were analysed; 795 (64%) were male, 787 (63%) were infants and 59% from urban areas. Average length of stay (LoS) was 4.8 days (SD ±2.5) and mean cost per patient was US$48 (95% CI: US$46, US$49). Mean cost per patient was significantly greater for urban tertiary-level facilities compared with rural primary-secondary facilities (mean difference US$43; 95% CI: US$40, US$45). No cost variation was found relative to age, sex, malnutrition or hypoxaemia. Type of facility was the most important cost predictor. LoS and personnel costs were the most sensitive cost parameters., Conclusion: Healthcare provider cost of childhood severe pneumonia was substantial for urban located public health facilities that provided tertiary-level care. Thus, treatment availability at a lower-level facility at a rural location may help to reduce overall treatment costs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In Intensive Care Units (ICUs) infection represents the most frequent complication leading to high mortality. Particularly the incidence of fungal infections, especially due to Candida spp., has been increasing during the last years. Over last two decades there is predominance of Non albicans Candida (NAC) infection with increased isolation of novel species and decreased susceptibility. Early identification of Candida species and determination of antifungal susceptibility pattern is essential for effective management. Therefore, the study was conducted to isolate and identify Candida species from the blood samples of the patients suspected of candidemia and assess their antifungal susceptibility pattern. This cross-sectional, descriptive type of observational study was conducted in the Department of Microbiology, Mymensingh Medical College, Bangladesh from March 2021 to February 2022. Venous blood was collected from clinically suspected patients admitted at ICU, Neonatal Intensive Care Unit (NICU), Mymensingh Medical College Hospital, Bangladesh. Primary blood culture was performed by automated method followed by sub-culture in Saboraud's Dextrose Agar (SDA) and blood agar media. Candida species were recognized by phenotypic and genotypic methods. Antifungal susceptibility testing was done by disk diffusion and broth microdilution method (BMD). Out of 125 blood specimens collected, Candida species were isolated from 39(31.0%) blood samples of which NAC species were 35(89.0%) whereas C. albicans was only 4(10.2%). Eight (8) different Candida species were identified of which C. parapsilosis was predominant 16(41.0%). Rare and emerging drug resistant species of C. ciferrii 23.0%, C. auris 7.7%, C. rugosa 10.3%, C. lusitaniae 2.6% were also isolated. Candidemia was highest in neonate 33(84.61%) with male predominance 24(61.54%). Use of broad-spectrum antibiotics, prolonged hospital stay, pre-maturity and low birth weight (LBW) were found to be important risk factors. In candidemia the highest resistance was to Fluconazole-33% and lowest to Voriconazole-5%. The study showed that NAC species were more common with emergence of rare and multidrug resistant species.

Pressure sore is an important post-stroke complication that results in increased morbidity, mortality and poor prognosis of the patients. The objective of the present study was to find out the prevalence and the factors associated with pressure sore among stroke patients. This prospective cross-sectional study includes 50 stroke patients admitted in the Department of Neurology of Dhaka Medical College Hospital, Bangladesh from July to December 2018. Data were collected from the by direct interview of the patients or their relatives or caregiver using a structured case report form. Descriptive statistics were used to represent patients' characteristics and the chi-square test was used to determine the difference between patients' groups. The mean ±SD age of the stroke patients was 59.16±11.53 years and half of them were male. Fifty percent of the patients had been suffering from ischemic stroke and the rest from hemorrhagic stroke. Of all, one-fourth of the patients (24.0%) developed post-stroke pressure sore during the hospital stay and type-specific prevalence was 20.0% in ischemic stroke and 30.0% in hemorrhagic stroke. Common sites of the pressure sore were sacrum (50.0%), buttock (25.0%), heels (17.0%), and greater trochanter (8.0%). Only 8.0% of the patients developed grade IV wounds. Pressure sores of 42.0% of patients healed spontaneously, 25.0% needed conservative management and 25.0% needed a skin graft. This study found that a large portion of stroke patients develop a pressure sore during hospital stay which can deteriorate clinical outcomes and compromise the quality of life of the patients. Adequate preventive measures and proper rehabilitation should be encouraged for better stroke management and to reduce long-term complications.

The study aimed to assess the level of potentially toxic elements (As, Cd, Pb, Zn, Cu, Cr, Mn, and Ni) and associated health implications through commonly consumed rice cultivars of Bangladesh available in Capital city, Dhaka. The range of As, Cd, Pb, Zn, Cu, Cr, Mn, and Ni in rice grains were 0.04-0.35, 0.01-0.15, 0.01-1.18, 10.74-34.35, 1.98-13.42, 0.18-1.43, 2.51-22.08, and 0.21-5.96 mg/kg fresh weight (FW), respectively. The principal component analysis (PCA) identified substantial anthropogenic activities to be responsible for these elements in rice grains. The estimated daily intake (EDI) of the elements was below the maximum tolerable daily intake (MTDI) level. The hazard index (HI) was above the threshold level, stating non-carcinogenic health hazards from consuming these rice cultivars. The mean target cancer risk (TCR) of As and Pb exceeded the USEPA acceptable level (10-6), revealing carcinogenic health risks from the rice grains., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Shaheen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Chronic respiratory diseases (CRDs) require holistic management which considers patients' preferences, appropriate pharmacotherapy, pulmonary rehabilitation, and integrated care. We aimed to understand the perceptions of people with CRDs about their condition and pulmonary rehabilitation in Bangladesh., Methods: We conducted semi-structured interviews with a maximum variation sample of people with CRDs who had participated in a feasibility study of pulmonary rehabilitation in 2021/2022. A multidisciplinary team transcribed the interviews verbatim and analysed them in Bengali using a grounded theory approach., Results: We interviewed 15 participants with chronic obstructive pulmonary disease, asthma, or post-tuberculosis. The analysis revealed three themes. The first encompassed understanding CRDs: Patients characterised their condition by the symptoms (e.g. 'Hapani' meaning 'breathlessness') rather than describing a disease entity. Some believed occupation, previous infection, or family history to be a cause. The second theme included perceptions of pulmonary rehabilitation: Exercise was counterintuitive, as it exacerbated the breathlessness symptom that defined their disease. Views varied, though many acknowledged the benefits after a few sessions. Even with home-based programmes, participants described practical barriers to finding time for the sessions and adopted strategies to overcome the challenges. The third theme focused on implementation: Participants highlighted the need for raising awareness of CRDs and the potential of pulmonary rehabilitation in the community, adapting to the local context, and establishing an accessible resourced service., Conclusions: Understanding how patients and their communities perceive their condition and the barriers (both conceptual and logistical) to acceptance is the first step to embedding this highly effective intervention into routine health care services in Bangladesh with potential benefits for the increasing number of people living with CRDs in low- and middle-income countries., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose the following activities and/or relationships: MH owns the pulmonary rehabilitation clinic in Khulna. HP and MH are co-investigators in the RESPIRE Global Health Unit., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

This cross-sectional descriptive purposive study was done on 150 (70 right and 80 left) fully ossified dry human scapulae of Bangladeshi people to find out the variation in length of acromiocoracoid and acromioglenoid distance. Sample collection was carried out in the Department of Anatomy, Mymensingh Medical College, Bangladesh from January to December 2019. Any kind of damaged or broken scapulae were excluded to maintain standard measurement. Length of these distances was measured with the help of digital Vernier slide calipers. The mean±SD acromiocoracoid distance were 35.8±4.64 mm and 36.32±5.55 mm on right and left sided scapulae respectively and the mean±SD acromioglenoid distance were 27.69±3.43 mm on right sided scapulae and 28.18±3.26 mm on left sided scapulae. These data are important to compare Bangladeshi scapulae to those from various other races that could contribute to demographic studies of shoulder disease probability and management in Bangladeshi population.

Background: Cholera can result in the expulsion of important microbiota from the gut and result in death if left untreated. The disease transmits mainly via drinking water carrying Vibrio cholerae; and household contacts (HHC) of cholera patients are at elevated risk during the first week of infection. The gut microbiota profiles of HHC-children of cholera patients at Dhaka city slums were investigated before (day 0) and after (day 8) delivery of chlorinated water as part of the major study 'CHoBI7 trial (cholera-hospital-based intervention for 7 days)'., Result: Results of sequencing and analysis of bacterial community DNA revealed the predominance of two bacterial phyla: Bacteroidetes and Firmicutes at day 0 with a relative abundance of 62 ± 6 (mean ± SEM%) and 32 ± 7, respectively. The pattern reversed at day 8 with a decreased relative abundance of Bacteroidetes (39 ± 12; p = 0.034) and an increased abundance of Firmicutes (49 ± 12; p = 0.057). Of 65 bacterial families confirmed at day 0, six belonging to Proteobacteria including Vibrionaceae disappeared at day 8. Interestingly, the relative abundance of four Firmicutes families-Lachnospiraceae, Bifidobacteriaceae, Clostridiaceae, and Ruminococcaceae was increased in all five study children at day 8., Conclusion: The observed exclusion of pathogenic Proteobacteria and enhancement of beneficial Firmicutes in the gut of children delivered with chlorinated water as part of WASH intervention reflect a great promise of the CHoBI7 program in preventing cholera and improving child health., (© 2023. The Author(s).)

Background: Evaluating the effects of cancer diagnosis and treatment on a patient's overall well-being is crucial and health-related quality of life (HRQoL) is a reliable metric for assessing this impact. Little is known about HRQoL among cancer survivors across various stages and treatments. The study examined individual and clinical factors influencing HRQoL among cancer survivors., Methods: A cross-sectional study was conducted in two specialised cancer care hospitals in Dhaka, Bangladesh. Cancer-diagnosed adults receiving treatment at selected hospitals from January to May 2022 were enrolled. The 5-level EuroQol-5 Dimensions version (EQ-5D-5L) instrument was used to collect HRQoL data. HRQoL scores were derived using UK value sets. The investigation used a multivariable Tobit regression model to determine the association between independent variables and HRQoL scores., Results: A total of 607 adult patients were enrolled, with 55% being females and 66% aged 36 to 64 years. Reported health problems in five EQ-5D domains include mobility (11%), self-care (11%), usual daily activities (19%), pain/discomfort (21%), and anxiety/depression (46%). Patients with throat, brain, lung, blood, and liver cancer had lower utility scores. Advanced-stage cancer survivors had lower utility scores (β = -49 units, 95% codfidence interval [CI]: -0.75 to -0.22) compared to early-stage survivors. Physically inactive survivors had lower utility scores by 0.41 units (95% CI: -0.51 to -0.30) compared to their counterparts. Private hospital patients had higher utility scores, whereas patients belonged to poor socioeconomic groups scored worse than wealthier ones., Conclusions: This study highlights the impact of clinical and individual characteristics on HRQoL among cancer survivors. These findings advocate for an enhanced Bangladeshi cancer patient care model through timely interventions or programs, early detection or diagnosis, tailored treatments, and the promotion of physical activity to bolster HRQoL outcomes., (© 2023. The Author(s).)

Background: In Bangladesh, dengue has been prevalent since its resurgence in 2018, and the dominant causative virus in 2019 was considered dengue virus serotype 3 (DENV-3). However, limited information is available for DENV serotype/genotype circulating after 2020. Materials and Methods: Viral RNA was extracted from NS1 antigen-positive blood samples of febrile patients in Dhaka, in 2021. DENV gene was detected by semi-nested RT-PCR, and sequences of envelope (E) gene and C-prM gene were determined by direct sequencing of RT-PCR products for genetic analysis. Results: Among 172 NS1-positive samples collected, 91 samples were assigned to DENV-3 and DENV-2 (88 and 3 samples, respectively) by RT-PCR targeting the C-prM gene. Phylogenetic analysis of the E gene for the 17 representative DENV-3 samples showed that all the viruses belonged to genotype I, forming a cluster (B-cluster) with those of DENV-3 reported in Bangladesh in 2017. Analysis of the deduced amino acid sequences of E protein revealed 16 amino acid substitutions, including two novel ones (G221W, L285P), and a substitution T223I that was specifically found in DENV-3 B-cluster. Conclusion: This study showed the persistent predominance of DENV-3 genotype I in Bangladesh having unique genetic traits in the E gene. (Approval number: MMC/IRB/2022/468).

Background: The distribution of healthcare services should be based on the needs of the population, regardless of their ability to pay. Achieving universal health coverage implies first ensuring that people of all income levels have access to quality healthcare, and then allocating resources reasonably considering individual need. Hence, this study aims to understand how public benefits in Bangladesh are currently distributed among wealth quintiles considering different layers of healthcare facilities and to assess the distributional impact of public benefits., Methods: To conduct this study, data were extracted from the recent Bangladesh Demographic and Health Survey 2017-18. We performed benefit incidence analysis to determine the distribution of maternal and child healthcare utilization in relation to wealth quintiles. Disaggregated and national-level public benefit incidence analysis was conducted by the types of healthcare services, levels of healthcare facilities, and overall utilization. Concentration curves and concentration indices were estimated to measure the equity in benefits distribution., Results: An unequal utilization of public benefits observed among the wealth quintiles for maternal and child healthcare services across the different levels of healthcare facilities in Bangladesh. Overall, upper two quintiles (richest 19.8% and richer 21.7%) utilized more benefits from public facilities compared to the lower two quintiles (poorest 18.9% and poorer 20.1%). Benefits utilization from secondary level of health facilities was highly pro-rich, while benefit utilization found pro-poor at primary levels. The public benefits in Bangladesh were also not distributed according to the needs of the population; nevertheless, poorest 20% household cannot access 20% share of public benefits in most of the maternal and child healthcare services even if we ignore their needs., Conclusions: Benefit incidence analysis in public health spending demonstrates the efficacy with which the government allocates constrained health resources to satisfy the needs of the poor. Public health spending in Bangladesh on maternal and child healthcare services were not equally distributed among wealth quintiles. Overall health benefits were more utilized by the rich relative to the poor. Hence, policymakers should prioritize redistribution of resources by targeting the socioeconomically vulnerable segments of the population to increase their access to health services to meet their health needs., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Resistance to multiple drugs in Klebsiella pneumoniae (KPN) is an important issue in human and animal medicine. KPN phenotypic and genotypic aspects in poultry samples have not been comprehensively explored in Bangladesh., Methods: This research focused on the prevalence of antibiotic resistance and the characterization of KPN in Bangladeshi poultry isolates using both phenotypic and genotypic approaches., Results: A total of 32 poultry samples were randomly obtained from a commercial poultry farm in Narsingdi, Bangladesh, and 43.90% (18/41) of the isolates were confirmed to be KPN, whereas all isolates were biofilm producers. The antibiotic sensitivity test revealed the most remarkable (100%) antibiotic resistance level against Ampicillin, Doxycycline and Tetracycline while remaining susceptible to Doripenem, Meropenem, Cefoxitin and Polymyxin B. Resistance to Nalidixic acid, Nitrofurantoin, Trimethoprim, Levofloxacin, Ciprofloxacin, Cefuroxime and Chloramphenicol ranges from 18% to 70%. Minimum inhibitory concentrations for carbapenem-resistant KPN ranged from 128 to 512 mg/mL for Meropenem, Imipenem, Gentamycin and Ciprofloxacin, respectively. [Correction added on 15 June 2023, after first online publication: 512 g/mL was corrected to 512 mg/mL in the preceding sentence]. Carbapenemase-producing KPN isolates harboured a single or multiple β-lactamase genes, bla SIM-1 , bla IMP-4 and bla OXA-48 as well as one ESBL gene (bla TEM ) and plasmid-mediated quinolone resistance gene (qnrB). Furthermore, Cr and Co outperformed Cu and Zn in antibacterial effectiveness., Conclusions: The results of this investigation showed that the high prevalence of multidrug-resistant pathogenic KPN in our chosen geographic location had displayed sensitivity to FOX/PB/Cr/Co, which might be regarded as an alternate treatment to reduce pressure of use on carbapenems., (© 2023 The Authors. Veterinary Medicine and Science published by John Wiley & Sons Ltd.)

Foot-and-Mouth Disease (FMD) hinders the growth of the livestock industry in endemic countries like Bangladesh. The management and prevention of FMD are severely impacted by the high mutation rate and subsequent frequent generation of newer genotypes of the causative agent, Foot-and-Mouth Disease Virus (FMDV). The current study was conducted in nine districts of Bangladesh during 2019-21 to characterize the circulating FMDV strains based on the VP1 sequence analysis, the major antigenic recognition site providing serotype specificity and high variability of FMDV. This study detected the first emergence of the SA-2018 lineage in Bangladesh along with the predominance of Ind-2001e (or Ind-2001BD1) sublineage of ME-SA topotype under serotype O during 2019-21. The mutational spectrum, evolutionary divergence analysis and multidimensional plotting confirmed the isolates collected from Mymensingh districts, designated as MYMBD21 as a novel sublineage under the SA-2018 lineage. Analysis of the amino acid sequence revealed several changes in the G-H loop, B-C loop and C-terminal region of VP1, revealing a 12-13% divergence from the existing vaccine strains and a 95% VP1 protein homology, with most of the mutations potentially considerable as vaccine escape mutations, evidenced by three-dimensional structural analysis. This is the first report on the emergence of the SA-2018 lineage of ME-SA topotype of FMDV serotype O in Bangladesh, as well as a possible mutational trend towards the emergence of a distinct sublineage under SA-2018 lineage, which calls for in-depth genome-wide analysis and monitoring of the FMD situation in the country to implement a strategic vaccination and effective FMD control program., (© 2023. The Author(s).)

In 2022, one of its worst cholera outbreaks began in Bangladesh and the icddr,b Dhaka hospital treated more than 1300 patients and ca. 42,000 diarrheal cases from March-1 to April-10, 2022 1 . Here, we present genomic attributes of V. cholerae O1 responsible for the 2022 Dhaka outbreak and 960 7th pandemic El Tor (7PET) strains from 88 countries. Results show strains isolated during the Dhaka outbreak cluster with 7PET wave-3 global clade strains, but comprise subclade BD-1.2, for which the most recent common ancestor appears to be that responsible for recent endemic cholera in India. BD-1.2 strains are present in Bangladesh since 2016, but not establishing dominance over BD-2 lineage strains 2 until 2018 and predominantly associated with endemic cholera. In conclusion, the recent shift in lineage and genetic attributes, including serotype switching of BD-1.2 from Ogawa to Inaba, may explain the increasing number of cholera cases in Bangladesh., (© 2023. The Author(s).)

In this prospective cohort study, we explored individual- and household-level risk factors associated with diarrheal diseases among 251 children younger than 5 years in slum areas of urban Dhaka, Bangladesh. During the 3-month study period, diarrhea surveillance was conducted monthly, and spot checks of the household compound were performed at baseline to assess the presence of feces (animal or human) in the household compound and in cooking and food storage areas, and to assess whether cooked food was covered and refrigerated. We also collected caregiver reports on child mouthing behaviors. Children living in households with feces within 10 steps of cooking and food storage areas (odds ratio [OR], 8.43; 95% CI, 1.01-70.18), those with visible feces found on the ground of the household compound (OR, 4.05; 95% CI, 1.24-13.22), and those in households found to keep cooked food uncovered and without refrigeration (OR, 6.16; 95% CI, 1.11-34.25) during spot checks had a significantly greater odds of diarrhea. There was no significant association between pediatric diarrhea and caregiver-reported child mouthing behaviors or presence of animals in the cooking area. These study findings demonstrate that presence of visible feces in the household compound and near cooking and food storage areas, and poor household food hygiene practices, were significant risk factors for diarrheal disease among young children in Dhaka, Bangladesh. Health communication programs are needed to target these exposure pathways to fecal pathogens.

Background: Low- and middle-income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh., Methods: The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016-2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service-related factors with patients' preferences for healthcare services., Results: The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56-0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80-9.86) or affordability of healthcare services (RRR = 3.13; 2.25-4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15-1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70-5.04) than the quality of treatment in the health facility, when compared with private service providers., Conclusions: Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management., Patient or Public Contribution: Our research team includes four researchers (co-authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases., (© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Objectives: Pseudomonas aeruginosa is a key opportunistic pathogen causing a wide range of community- and hospital-acquired infections in immunocompromised or catheterized patients. Here, we report the complete genome sequence of a multidrug-resistant (MDR) P. aeruginosa DMC30b to elucidate the genetic diversity, molecular epidemiology, and underlying mechanisms for antimicrobial resistance and virulence., Methods: P. aeruginosa DMC30b was isolated from septic wound swab of a severe burn patient. Whole-genome sequencing was performed under Ion Torrent platform. The genome was assembled using the SPAdes v. 3.12.01 in an integrated Genome Analysis Platform for Ion Torrent sequence data. The genome was annotated using the National Center for Biotechnology Information (NCBI) Prokaryotic Genome Annotation Pipeline. In-silico predictions of antimicrobial resistance genes, virulence factor genes, and metabolic functional potentials were performed using different curated bioinformatics tools., Results: P. aeruginosa DMC30b was found as a MDR strain and belonged to sequence type 244 (ST244). The complete genome size is 6 994 756 bp with a coverage of 76.76x, guanine-cytosine content of 65.7% and a Benchmarking Universal Single-Copy Orthologs score of 100. The genome of P. aeruginosa DMC30b harboured two predicted plasmid replicons (e,g. IncP-6; 78 007 bp and ColRNAI; 9359 bp), 35 resistomes (antimicrobial resistance genes) conferring resistance to 18 different antibiotics (including four beta-lactam classes), and 214 virulence factor genes. It was identified as the 167 th ST244 strain among ∼ 5800 whole-genome sequences of P. aeruginosa available in the NCBI database., Conclusion: The MDR P. aeruginosa DMC30b was identified as the 167 th ST244 complete genome to be submitted to the NCBI, and the first ST244 isolate sequenced from Bangladesh. The complete genome data with high genetic diversity and underlying mechanisms for antimicrobial resistance and virulence of P. aeruginosa DMC30b will aid in understanding the evolution and phylogeny of such high-risk clones and provide a solid basis for further research on MDR or extensively drug resistant strains., Competing Interests: Competing interests None declared., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Non-communicable diseases have overtaken communicable diseases as the most common cause of death worldwide, with the majority of these deaths in low-income and middle-income countries. Hypertension alone causes over nine million deaths per year.Since 2017, around 750 000 Rohingya refugees have fled violence in Myanmar into Cox's Bazar District in Bangladesh. We describe a quality improvement project focused on the management of hypertension in Rohingya refugees in three primary health facilities within the Rohingya refugee camps. The aim of the project was to create a sustainable hypertension service within existing primary care services.A number of plan-do-study-act cycles were performed to improve care, with methods including: creating a specialised clinic, writing a treatment algorithm, training of pharmacists, engaging community health workers and educational programmes for staff and patients.In 2020, 554 patients were engaged in the new hypertension service. Of these, 358 (64.6%) returned for follow-up at least once. Mean systolic blood pressure (BP) was 141.7 (SD 60.0) mm Hg and mean diastolic BP was 88.1 (SD 11.1) mm Hg. Patients engaged in treatment had a significant reduction of BP of 8.2 (95% CI 5.4 to 11.0)/6.0 (95% CI 4.1 to 7.9) mm Hg (p<0.0001).Our project shows that it is possible to create a hypertension service in a challenging humanitarian crisis, which can successfully improve the control of hypertension, although retention in care can be difficult., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate adolescents' attitudes towards soft drinks and identify the underlying factors that are associated with their consumption of such drinks., Method: A cross-sectional study was conducted among 213 adolescents aged between 10 and 19years living in Dhaka, Bangladesh. A structured questionnaire was used to assess their socio-demographic and soft drinks consumption-related characteristics, and their attitudes towards soft drinks. Structural equation modelling was employed to identify the potential factors associated with soft drink consumption among adolescents., Results: More than 80% of the adolescents consumed soft drinks at least once a week. Overall, adolescents had a positive attitude toward soft drinks. Results revealed that adolescent's attitudes, gender, accessibility of soft drinks at school/college, distance from home to shop, outside food intake habit and parents' soft drinks consumption were the factors associated with their consumption of soft drinks., Conclusion: High proportion of adolescents consumed soft drinks. Thus, a community and individual level nutrition education programme with targeted behaviour change might be helpful to reduce the consumption of sweetened beverages among adolescents., (Copyright © 2022 Elsevier España, S.L.U. All rights reserved.)

Vibrio cholerae O1 El Tor, causative agent of the ongoing seventh cholera pandemic, is native to the aquatic environment of the Ganges Delta, Bay of Bengal (GDBB). Recent studies traced pandemic strains to the GDBB and proposed global spread of cholera had occurred via intercontinental transmission. In the research presented here, NotI-digested genomic DNA extracted from V. cholerae O1 clinical and environmental strains isolated in Bangladesh during 20042014 was analyzed by pulsed-field gel electrophoresis (PFGE). Results of cluster analysis showed 94.67% of the V. cholerae strains belonged to clade A and included the majority of clinical strains of spatio-temporal origin and representing different cholera endemic foci. The rest of the strains were estuarine, all environmental strains from Mathbaria, Bangladesh, and occurred as singletons, clustered in clades B and C, or in the small clades D and E. Cluster analysis of the Bangladeshi strains and including 157 El Tor strains from thirteen countries in Asia, Africa, and the Americas revealed 85% of the total set of strains belonged to clade A, indicating all were related, yet did not form an homogeneous cluster. Overall, 15% of the global strains comprised multiple small clades or segregated as singletons. Three sub-clades could be discerned within the major clade A, reflecting distinct lineages of V. cholerae O1 El Tor associated with cholera in Asia, Africa, and the Americas. The presence in Asia and the Americas of non-pandemic V. cholerae O1 El Tor populations differing by PFGE and from strains associated with cholera globally suggests different ecotypes are resident in distant geographies., Competing Interests: Declaration of Competing Interest The research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022. Published by Elsevier B.V.)

Cholera has been endemic to the Ganges Delta for centuries. Although the causative agent, Vibrio cholerae, is autochthonous to coastal and brackish water, cholera occurs continually in Dhaka, the inland capital city of Bangladesh which is surrounded by fresh water. Despite the persistence of this problem, little is known about the environmental abundance and distribution of lineages of V. cholerae, the most important being the pandemic generating (PG) lineage consisting mostly of serogroup O1 strains. To understand spatial and temporal dynamics of PG lineage and other lineages belonging to the V. cholerae species in surface water in and around Dhaka City, we used qPCR and high-throughput amplicon sequencing. Seven different freshwater sites across Dhaka were investigated for six consecutive months, and physiochemical parameters were measured in situ. Total abundance of V. cholerae was found to be relatively stable throughout the 6-month sampling period, with 2 × 10 5 to 4 × 10 5  genome copies/L at six sites and around 5 × 10 5  genome copies/L at the site located in the most densely populated part of Dhaka City. PG O1 V. cholerae was present in high abundance during the entire sampling period and composed between 24 and 92% of the total V. cholerae population, only showing occasional but sudden reductions in abundance. In instances where PG O1 lost its dominance, other lineages underwent a rapid expansion while the size of the total V. cholerae population remained almost unchanged. Intraspecies richness of V. cholerae was positively correlated with salinity, conductivity, and total dissolved solids (TDS), while it was negatively correlated with dissolved oxygen (DO) concentration in water. Interestingly, negative correlation was observed specifically between PG O1 and salinity, even though the changes in this variable were minor (0-0.8 ppt). Observations in this study suggest that at the subspecies level, population composition of naturally occurring V. cholerae can be influenced by fluctuations in environmental factors, which can lead to altered competition dynamics among the lineages., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Financial risk protection and equity are two fundamental components of the global commitment to achieve Universal Health Coverage (UHC), which mandates health system reform based on population needs, disease incidence, and economic burden to ensure that everyone has access to health services without any financial hardship. We estimated disease-specific incidences of catastrophic out-of-pocket health expenditure and distress financing to investigate progress toward UHC financial risk indicators and investigated inequalities in financial risk protection indicators by wealth quintiles. In addition, we explored the determinants of financial hardship indicators as a result of hospitalization costs., Methods: In order to conduct this research, data were extracted from the latest Bangladesh Household Income and Expenditure Survey (HIES), conducted by the Bangladesh Bureau of Statistics in 2016-2017. Financial hardship indicators in UHC were measured by catastrophic health expenditure and distress financing (sale/mortgage, borrowing, and family support). Concentration curves (CC) and indices (CI) were estimated to measure the pattern and severity of inequalities across socio-economic classes. Binary logistic regression models were used to assess the determinants of catastrophic health expenditure and distress financing., Results: We found that about 26% of households incurred catastrophic health expenditure (CHE) and 58% faced distress financing on hospitalization in Bangladesh. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%). The financial hardship indicators in terms of CHE (CI = -0.109) and distress financing (CI = -0.087) were more concentrated among low-income households. Hospital admission to private health facilities, non-communicable diseases, and the presence of chronic patients in households significantly increases the likelihood of higher UHC financial hardship indicators., Conclusions: The study findings strongly suggest the need for national-level social health security schemes with a particular focus on low-income households, since we identified greater inequalities between low- and high-income households in UHC financial hardship indicators. Regulating the private sector and implementing subsidized healthcare programmes for diseases with high treatment costs, such as cancer, heart disease, liver disease, and kidney disease are also expected to be effective to protect households from financial hardship. Finally, in order to reduce reliance on OOPE, the government should consider increasing its allocations to the health sector., (© 2022. The Author(s).)

Background: Road traffic injuries (RTI) are the leading cause of death worldwide in children over 5 and adults aged 18-29. Nonfatal RTIs result in 20-50 million annual injuries. In Bangladesh, a new mechanism of RTI has emerged over the past decade known as a 'scarf injury.' Scarf injuries occur when scarves, part of traditional female dress, are caught in the driveshaft of an autorickshaw. The mechanism of injury results in novel, strangulation-like cervical spine trauma. This study aimed to understand the immediate emergency response, acute care pathway, and subsequent functional and health outcomes for survivors of scarf injuries., Methods: Key informant interviews were conducted with female scarf injury survivors (n = 12), caregivers (n = 6), and health care workers (n = 15). Themes and subthemes were identified via inductive content analysis, then applied to the three-delay model to examine specific breakdowns in pre-hospital care and provide a basis for future interventions., Findings: Over half of the scarf injury patients were between the ages of 10 and 15. All but two were tetraplegic. Participants emphasized less than optimal patient outcomes were due to unawareness of scarf injuries and spinal cord injuries among the general public and health professionals; unsafe and inefficient bystander first aid and transportation; and high cost of acute health care., Conclusions: Females in Bangladesh are at significant risk of sustaining serious and life-threatening trauma through scarf injuries in autorickshaws, further worsened through inadequate care along the trauma care pathway. Interventions designed to increase awareness and knowledge of basic SCI care at the community and provider level would likely improve health and functional outcomes., (© 2022. The Author(s).)

This article puts critical disability studies and global health into conversation around the phenomenon of scarf injury in Bangladesh. Scarf injury occurs when a woman wearing a long, traditional scarf called an orna rides in a recently introduced autorickshaw with a design flaw that allows the orna to become entangled in the vehicle's driveshaft. Caught in the engine, the orna pulls the woman's neck into hyperextension, causing a debilitating high cervical spinal cord injury and quadriplegia. The circumstances of the scarf injury reveal the need for more critical cultural analysis than the fields of global health and rehabilitation typically offer. First, the fatal design flaw of the vehicle reflects different norms of gender and dress in China, where the vehicle is manufactured, versus Bangladesh, where the vehicle is purchased at a low price and assembled on-site-a situation that calls transnational capitalist modes of production and exchange into question. Second, the experiences of women with scarf injuries entail many challenges beyond the injury itself: the transition to life with disability following the rehabilitation period is made more difficult by negative perceptions of disability, lack of resources and accessible infrastructure, and cultural norms of gender and class in Bangladesh. Our cross-disciplinary conversation about women with scarf injuries, involving critical disability studies, global health and rehabilitation experts, exposes the shortcomings of each of these fields but also illustrates the urgent need for deeper and more purposeful collaborations. We, therefore, argue that the developing subfield of global health humanities should include purposeful integration of a humanities-based critical disability studies methodology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Comparative genomic analysis of Vibrio cholerae El Tor associated with endemic cholera in Asia revealed two distinct lineages, one dominant in Bangladesh and the other in India. An in-depth whole-genome study of V. cholerae El Tor strains isolated during endemic cholera in Bangladesh (1991 to 2017) included reference genome sequence data obtained online. Core genome phylogeny established using single nucleotide polymorphisms (SNPs) showed V. cholerae El Tor strains comprised two lineages, BD-1 and BD-2, which, according to Bayesian phylodynamic analysis, originated from paraphyletic group BD-0 around 1981. BD-1 and BD-2 lineages overlapped temporally but were negatively associated as causative agents of cholera during 2004 to 2017. Genome-wide association study (GWAS) revealed 140 SNPs and 31 indels, resulting in gene alleles unique to BD-1 and BD-2. Regression analysis of root to tip distance and year of isolation indicated early BD-0 strains at the base, whereas BD-1 and BD-2 subsequently emerged and progressed by accumulating SNPs. Pangenome analysis provided evidence of gene acquisition by both BD-1 and BD-2, of which six crucial proteins of known function were predominant in BD-2. BD-1 and BD-2 diverged and have distinctively different genomic traits, namely, heterogeneity in VSP-2, VPI-1, mobile elements, toxin encoding elements, and total gene abundance. In addition, the observed phage-inducible chromosomal island-like element (PLE1), and SXT ICE elements (ICE TET ) in BD-2 presumably provided a fitness advantage for the lineage to outcompete BD-1 as the etiological agent of endemic cholera in Bangladesh, with implications for global cholera epidemiology. IMPORTANCE Cholera is a global disease with specific reference to the Bay of Bengal Ganges Delta where Vibrio cholerae O1 El Tor, the causative agent of the disease showed two circulating lineages, one dominant in Bangladesh and the other in India. Results of an in-depth genomic study of V. cholerae associated with endemic cholera during the past 27 years (1991 to 2017) indicate emergence and succession of the two lineages, BD-1 and BD-2, arising from a common ancestral paraphyletic group, BD-0, comprising the early strains and short-term evolution of the bacterium in Bangladesh. Among the two V. cholerae lineages, BD-2 supersedes BD-1 and is predominant in the most recent endemic cholera in Bangladesh. The BD-2 lineage contained significantly more SNPs and indels, and showed richness in gene abundance, including antimicrobial resistance genes, gene cassettes, and PLE to fight against bacteriophage infection, acquired over time. These findings have important epidemic implications on a global scale.

Background: Pneumonia is the leading cause of death in children globally with the majority of these deaths observed in resource-limited settings. Globally, the annual incidence of clinical pneumonia in under-five children is approximately 152 million, mostly in the low- and middle-income countries. Of these, 8.7% progressed to severe pneumonia requiring hospitalization. However, data to predict children at the greatest risk to develop severe pneumonia from pneumonia are limited., Method: Secondary data analysis was performed after extracting relevant data from a prospective cluster randomized controlled clinical trial; children of either sex, aged two months to five years with pneumonia or severe pneumonia acquired in the community were enrolled over a period of three years in 16 clusters in urban Dhaka city., Results: The analysis comprised of 2,597 children aged 2-59 months. Of these, 904 and 1693 were categorized as pneumonia (controls) and severe pneumonia (cases), respectively based on WHO criteria. The median age of children was 9.2 months (inter quartile range, 5.1-17.1) and 1,576 (60%) were male. After adjustment for covariates, children with temperature ≥38°C, duration of illness ≥3 days, male sex, received prior medical care and severe stunting showed a significantly increased likelihood of developing severe pneumonia compared to those with pneumonia. Severe pneumonia in children occurred more often in older children who presented commonly from wealthy quintile families, and who often sought care from private facilities in urban settings., Conclusion and Recommendation: Male sex, longer duration of illness, fever, received prior medical care, and severe stunting were significantly associated with development of WHO-defined severe childhood pneumonia in our population. The results of this study may help to develop interventions target to reduce childhood morbidity and mortality of children suffering from severe pneumonia., Competing Interests: The authors have declared that no competing interests exist.

Aim: The study aims to explore the current knowledge and skills of healthcare providers already trained by SIMESON (simulation for essential skills for obstetrical and neonatal care), in reviewing perinatal health situations including current status of healthcare facilities and cost estimation., Design: It was an observational study., Methods: Cost estimation following both quantitative and qualitative approaches was also attempted., Result: Knowledge and skills of 88 healthcare providers about the provision of normal delivery and immediate postpartum care, management of postpartum haemorrhage (PPH), retained placenta and use of bag and mask ventilation to help a baby breathe were found to be considerably strengthened following SIMESON training. During the 6 months after training, there were 477 PPH cases managed successfully with only one death; neonatal deaths observed were 6.6/1,000 live births; twice the number of facility deliveries; and 80% use rate of Ambu bag for helping baby breathe. The estimated cost per trainee was 395.68 USD, and 5.85 USD per beneficiary., (© 2021 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Bangladesh is one of the major labour-exporting countries in the world, with large-scale labour migration flows occurring both internationally and domestically. Spousal separation due to migration has the potential to disrupt women's ability to use contraception in line with their reproductive goals. This qualitative study complements the 2014 Bangladesh Demographic and Health Survey (BDHS) data; we conducted in-depth interviews with a sub-sample of 23 BDHS respondents whose husbands stayed elsewhere but returned at least once a year to Barisal Division, Bangladesh. The study explores how husbands' migration patterns influence couples' fertility intentions, contraceptive decision-making and behaviour, and unintended pregnancies. Results showed that contraceptive use was high among the study participants, with nearly all couples using some method to avoid pregnancy - usually pills and condoms. However, the use was episodic and inconsistent, reducing effectiveness. Experiences of side effects were commonplace, which contributed to this pattern of inconsistent use: women used pills only during the duration of their husband's visits. Half of the informants experienced unintended pregnancies either due to the inconsistent use of pills or other method failures. The study findings indicate that women with migrant husbands need family planning education related to their particular circumstances and access to a wider range of family planning choices. Quality counselling should respect women's experiences with side effects and include thorough discussion of viable alternatives.

Background: Female undergraduate students may undergo many health implications due to the transition from secondary to undergraduate level., Aim: The study was aimed to assess molar ratios of phytate to minerals (calcium, zinc, and iron) in the diets, and to measure the iron status of resident female students at Dhaka University., Methods: In total, 180 female students between 18-26 years of age from 3 dormitories of Dhaka University were selected for the study. Dietary intake information was collected over three consecutive days. Multiple-Pass 24-hour recall. Blood hemoglobin and serum ferritin levels were analyzed for sub-sample (20 participants from each dormitory)., Results: The mean dietary intake of phytate, calcium, zinc, and iron were estimated at 347.11, 181.04, 6.59, and 7.14 mg/day, and hemoglobin and serum ferritin at 11.34 g/dl, and 18.48 ng/ml, respectively. The respective molar ratios of phytate: calcium, phytate: zinc, phytate: iron and phytate × calcium: zinc were 0.13, 5.27, 4.20, and 21.26 in the diet of the respondents. The prevalence of anemia, iron deficiency and iron deficiency anemia among the respondents was found to be 51.7%, 48.4%, and 28.3%, respectively. Linear regression analysis showed that only zinc intake had positive association with hemoglobin, while iron and zinc intake had a significant positive, and phytate:iron molar ratio had a significant negative association with serum ferritin concentration ( p < 0.05). After adjusting all significant determinants of serum ferritin, no predictors have found significant., Conclusions: Larger and more specific research is needed to clearly understand the mechanism behind anemia and iron deficiency among female residential students.

Salmonella is one of the most important foodborne zoonotic pathogens, and becoming multidrug-resistant (MDR), which represents a serious public health concern worldwide. This study aimed to identify the circulating MDR strains of Salmonella through cutting edge molecular techniques including gene specific PCR, RAPD-PCR, ribosomal gene sequencing, and multilocus sequence types (MLST) in the poultry industry of Bangladesh. Two hundred Salmonella isolates were retrieved from 154 samples comprising droppings (n = 60), cloacal swabs (n = 60), feeds (n = 14), feeding water (n = 14), and handler's swab (n = 6) from 14 commercial layer farms of Bangladesh. The isolates were confirmed as Salmonella through invA gene specific PCR, and further genotyping was done by RAPD-PCR, and 16S rRNA sequencing. The isolates were distributed into 18 different genotypes according to RAPD typing. The phylogenetic analysis identified three diverging phylogroups such as S. enterica Litchfield, S. enterica Enteritidis and S. enterica Kentucky with 11, 8, and 6 strains, respectively. The in vitro antibiogram profiling the Salmonella isolates through disc diffusion method using 13 commercially available antibiotics revealed highest resistance against doxycycline (91.5%) followed by tetracycline and ampicillin (86.0%, in each), and 72.0% isolates as MDR, being resistant to ≥ 5 antibiotics. The MLST typing was carried out based on the PCR amplification of seven housekeeping genes (aroC, hisD, hemD, purE, secA, thrA, and dnaN). MLST typing also revealed three sequence types (STs) such as ST11, ST198, and ST214 in these isolates, and eBURST analysis showed ST11 as the founder genotype. The three STs were highly resistant to tetracyclines and quinolone group of antibiotics, and all of the isolates harboring S. enterica Litchfield showed the highest resistance. Circulating common MLSTs with MDR properties in different farms confirmed the possibility of a common route of intra-farm transmission. We report for the first time of the association serovar Litchfield (ST11) in avian salmonellosis with MDR properties which is an urgent public health concern in Bangladesh., (© 2021. Sociedade Brasileira de Microbiologia.)

Background: Rotavirus is a common cause of severe acute gastroenteritis among young children. Estimation of the economic burden would provide informed decision about investment on prevention strategies (e.g., vaccine and/or behavior change), which has been a potential policy discussion in Bangladesh for several years., Methods: We estimated the societal costs of children <5 years for hospitalization from rotavirus gastroenteritis (RVGE) and incidences of catastrophic health expenditure. A total of 360 children with stool specimens positive for rotavirus were included in this study from 6 tertiary hospitals (3 public and 3 private). We interviewed the caregiver of the patient and hospital staff to collect cost from patient and health facility perspectives. We estimated the economic cost considering 2015 as the reference year., Results: The total societal per-patient costs to treat RVGE in the public hospital were 126 USD (95% CI: 116-136) and total household costs were 161 USD (95% CI: 145-177) in private facilities. Direct costs constituted 38.1% of total household costs. The out-of-pocket payments for RVGE hospitalization was 23% of monthly income and 76% of households faced catastrophic healthcare expenditures due to this expense. The estimated total annual household treatment cost for the country was 10 million USD., Conclusions: A substantial economic burden of RVGE in Bangladesh was observed in this study. Any prevention of RVGE through cost-effective vaccination or/and behavioural change would contribute to substantial economic benefits to Bangladesh., Competing Interests: Declaration of Competing Interest James D. Heffelfinger reported that he was involved with GlaxoSmithKline PLC and Merck & Co. Inc. during the study outside the submitted work. All other authors had no conflict of interests to declare., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh., Methods: Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat., Results: Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61-.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69-.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31-.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31-.96]) compared with children in the standard message arm., Conclusions: The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households., Clinical Trials Registration: NCT04008134., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Despite improvements in many health indicators, providing access to affordable healthcare remains a considerable challenge in Bangladesh. Financing incidence analysis will enable an evaluation of how well the healthcare system performs to achieve equity in health financing. The objective of this study is to assess the burden of out-of-pocket (OOP) cost on different socio-economic groups by assessing the health financing incidence because OOP cost dominates household expenditure on health in Bangladesh., Methods: The study was conducted using latest Household Income and Expenditure Survey (HIES) 2016. We focused mainly on four specific indicators: level of monthly household OOP cost on in-patient care, urban-rural differences in OOP cost, socio-economic status differences in different payment mechanisms and the Kakwani index. Descriptive statistics were employed to analyse and summarise the selected variables based on the SES and location of residence (e.g., rural and urban)., Results: The study showed the overall OOP healthcare expenditure was 7.7% of the household monthly income while the poorer income group suffered more and spent up to 35% of their household income on healthcare. The Kakwani index indicated that the poorest quintile spends a greater share of their income on healthcare services than the richest quintile., Conclusions: This study observed that OOP cost in Bangladesh is regressive, that is, poorer members of society contribute a greater share of their income. Therefore, policymakers should initiate health reforms for developing and implementing risk-pooling financing mechanisms such as social health insurance to achieve the Universal Health Coverage in Bangladesh., (© 2021 John Wiley & Sons Ltd.)

Aeromonads are aquatic bacteria associated with frequent outbreaks of diarrhea in coastal Bangladesh, but their potential risks from environmental sources have remained largely unexplored. This study, over 2 years, examined homestead pond waters in the region for monthly dynamics and diversity of Aeromonas spp. The bacterial counts showed bi-modal annual growth peak, pre- and post-monsoon, strongly correlating ( p < 0.0005) with temperature. Of 200 isolates characterized, Aeromonas veronii bv. sobria (27%) was predominant among co-existent Aeromonas schubertii (20%), Aeromonas hydrophila (17%), Aeromonas caviae (13%), and three more. PCR screening of virulence-related genes identified 15 genotypes (I to XV), however, enterotoxigenicity in animal model was observed for five genotypes, ca. 18% (nine of 50) strains, prevalent in A. veronii bv. sobria, A. hydrophila , and A. caviae . Pathogenic strains were distinguishable by possessing at least three of the major virulence genes: ascV, hlyA, ela, ast , and alt , together with accessory virulence factors. PFGE of Xba I-digested genomic DNA revealed high genetic diversity and distant lineage of potentially toxigenic clones. Therefore, along with increased global warming, Aeromonas spp. having multi-factorial virulence potential in coastal ponds that serve as drinking water sources pose a potential health risk, and underscores the need for routine monitoring., Competing Interests: NH and RC are employees of EzBiome Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sadique, Neogi, Bashar, Sultana, Johura, Islam, Hasan, Huq, Colwell and Alam.)

We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.

Objective: To estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh., Design: An incidence-based COI study was performed for one episode of childhood severe pneumonia from a household perspective. Face-to-face interviews collected data on socioeconomic, resource use and cost from caregivers. A micro-costing bottom-up approach was applied to calculate medical, non-medical and time costs. Multiple regression analysis was applied to explore the factors associated with COI. Sensitivity analysis explored the robustness of cost parameters., Setting: Four urban and rural study sites from two districts in Bangladesh., Patients: Children aged 2-59 months with severe pneumonia., Results: 1472 children with severe pneumonia were enrolled between November 2015 and March 2019. The mean age of children was 12 months (SD ±10.2) and 64% were male. The mean household cost per episode was US$147 (95% CI 141.1 to 152.7). Indirect costs were the main cost drivers (65%, US$96). Household costs for the poorest income quintile were lower in absolute terms, but formed a higher proportion of monthly income. COI was significantly higher if treatment was received from urban health facilities compared with rural health facilities (difference US$84.9, 95% CI 73.3 to 96.3). Child age, household income, healthcare facility and hospital length of stay (LoS) were significant predictors of household COI. Costs were most sensitive to hospital LoS and productivity loss., Conclusions: Severe pneumonia in young children is associated with high household economic burden and cost varies significantly across socioeconomic parameters. Management strategies with improved accessibility are needed particularly for the poor to make treatment affordable in order to reduce household economic burden., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Global injury research and policy too often fail to acknowledge the need for gender-sensitive approaches in their efforts to effectively reduce the detrimental burden of traumatic road injuries. A case example from Bangladesh demonstrates the distinct challenges females face and how addressing those are critical to achieving global health equity., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Foot-and-mouth disease virus (FMDV) serotype A exhibits a higher degree of genetic and antigenic diversity resulting in frequent vaccine failure due to serological mismatch between the vaccine and heterologous strains. Currently, knowledge on the molecular basis of antigenic relationships among the FMDVs is limited; nevertheless, intratype antigenic variation due to mutation(s) is widely considered as the main hurdle to appropriate FMD vaccine development. Here, we studied genetic and antigenic variations of four FMDV serotype A isolates, BAN/GA/Sa-197/2013 (BAN-197), BAN/CH/Sa-304/2016 (BAN-304), BAN/DH/Sa-307/2016 (BAN-307) and BAN/DH/Sa-310/2017 (BAN-310) circulating in Bangladesh during 2013-2017. Initially, antigenic relationships (r 1 -values) of the field isolates were evaluated by the two-dimensional microneutralization test (2D-MNT) using the hyperimmune antisera raised in cattle against the vaccine strain, BAN-304. Interesingly, the results showed protective serological cross-reactivity (r 1 -values > 0.4) between the vaccine strain and the field isolates, BAN-307 and BAN-310, except BAN-197 that substantially mismatched (r 1  = 0.129 ± 0.043) with the BAN-304. Although VP1-based phylogeny grouped all the isolates within the same sublineage C (a subgroup of VP3 Δ59 variant) under the lineage A/ASIA/G-VII, strikingly, computational analyses of the viral capsid proteins demonstrated significant deviation at the VP1 G-H loop of BAN-197 from the vaccine strain, while VP(2-4) of both isolates were structurally conserved. To bridge the gap of how the distortion of the G-H loop and consequent antigenic hetergeneity occurred in BAN-197, we performed in silico combinatorial substitutions of the VP1 mutant amino acids (aa) of BAN-197 with the respective residues in BAN-304. Remarkably, our analyses revealed that two substitutions of distantly located aa at B-C (T48I:threonine → isoleucine) and G-H (A143V:alanine → valine) loops, in combination, distorted the VP1 G-H loop. Overall, this work contributes to understanding the molecular basis of antigenic relationships operating in serotype A FMDVs and the selection of suitable vaccine strain(s) for effective prophylaxis of FMD based on VP1-based analyses., (© 2020 Blackwell Verlag GmbH.)

This study investigates the influence of household socioeconomic status and maternal risk factors and health-care service availability on changes in the under-five mortality rate (U5MR) in Bangladesh. Potential risk factors that influence U5MRs were investigated using multilevel logistic regression analysis and 29,697 data points from the Bangladesh Demographic and Health Surveys, 2004-2014. Maternal and child health parameters such as childhood morbidity, low vaccination coverage, poor utilization of perinatal care, and malnutrition were found to be more concentrated in poorer households. Pooled estimates indicated that the aggregate odds of U5MR risk declined by 18% to 2007 to 38% to 2014 compared to 2004. However, inadequate antenatal care, short birth interval, primiparity, illiteracy, delayed conception, and low socioeconomic status were significantly associated with a higher risk of under-five mortality. The magnitude of inequality using these measures were significantly associated with large variations in U5MR changes. Although a significant reduction in U5MR in Bangladesh was found in this study, substantial socioeconomic variations still persist. The analysis suggests that decreasing inequality in society is required for further reductions in child mortality. This will help to achieve a more equitable distribution of child and neonatal outcomes and assist the achievement of Sustainable Development Goals 3.2 by 2030.

Poor food hygiene practices, child feces not being disposed of in a latrine, child mouthing of contaminated fomites, and poor hand hygiene of caregivers have been associated with diarrheal diseases, environmental enteropathy, and impaired growth in young children. Mobile health (mHealth) programs present a low-cost approach to delivering water, sanitation, and hygiene (WASH) programs. We conducted a theory-driven and evidence-based approach to formative research and intervention development to design and pilot test a Baby WASH mHealth program targeting food hygiene, child mouthing, and child feces disposal behaviors in urban Dhaka, Bangladesh. Formative research activities included 31 semi-structured interviews, five group discussions, six mHealth workshops, and a three-phase iterative pilot study among 102 households. Findings from semi-structured interviews and group discussions indicate that caregivers of young children have relatively high awareness of the need for safer food hygiene, child mouthing, and child feces disposal practices, but are limited by existing household responsibilities and restricted access to enabling technology that would facilitate practicing recommended behaviors. The piloted Baby WASH mHealth program was well-received by households. This study presents a theory-driven and evidence-based approach for intervention development that can be implemented for the development of future WASH mHealth programs in low-resource settings.

Vibrio cholerae serogroup O1 is responsible for epidemic and pandemic cholera and remains a global public health threat. This organism has been well established as a resident flora of the aquatic environment that alters its phenotypic and genotypic attributes for better adaptation to the environment. To reveal the diversity of clinical isolates of V. cholerae O1 in the Bay of Bengal, we performed whole-genome sequencing of isolates from Kolkata, India, and Dhaka, Bangladesh, collected between 2009 and 2016. Comparison with global isolates by phylogenetic analysis placed the current isolates in two Asian lineages, with lineages 1 and 2 predominant in Dhaka and Kolkata, respectively. Each lineage possessed different genetic traits in the cholera toxin B subunit gene, Vibrio seventh pandemic island II, integrative and conjugative element, and antibiotic-resistant genes. Thus, although recent global transmission of V. cholerae O1 from South Asia has been attributed only to isolates of lineage 2, another distinct lineage exists in Bengal. IMPORTANCE Cholera continues to be a global concern, as large epidemics have occurred recently in Haiti, Yemen, and countries of sub-Saharan Africa. A single lineage of Vibrio cholerae O1 has been considered to be introduced into these regions from South Asia and to cause the spread of cholera. Using genomic epidemiology, we showed that two distinct lineages exist in Bengal, one of which is linked to the global lineage. The other lineage was found only in Iran, Iraq, and countries in Asia and differed from the global lineage regarding cholera toxin variant and drug resistance profile. Therefore, the potential transmission of this lineage to other regions would likely cause worldwide cholera spread and may result in this lineage replacing the current global lineage., (Copyright © 2020 Morita et al.)

One of the six sublineages of the dominant O/ME-SA/Ind2001 lineage of foot-and-mouth disease virus (FMDV), Ind2001BD1 has already spread throughout 14 countries, including Bangladesh. Here, we report the complete genome sequence of the potential serotype O vaccine strain BAN/TA/Dh-301/2016, which has been shown to provide protection against all the circulating serotype O viruses in Bangladesh. The viral genome is 8,211 nucleotide (nt) long with an open reading frame (ORF) of 6999 nt. The ORF is flanked by a 1098-nt-long 5'-UTR and a 114-nt-long 3'-UTR. Compared to the Indian FMDV serotype O vaccine strain O/India/R2/75 (AF204276), ten mutations were identified in the major antigenic sites of BAN/TA/Dh-301/2016 (MK088170.1).

Objective: The objective of the study was to investigate potential risk factors for growth faltering among children under 5 years of age., Method: We conducted a prospective cohort study of 553 children under 5 years from diarrhoea patient households in urban Dhaka, Bangladesh. Height and weight measurements were obtained at baseline and at a 12-month follow-up. Caregivers of young children were administered a monthly questionnaire on household sociodemographic characteristics and hygiene practices., Results: Children with caregiver reports of mouthing soil at the majority of household visits had a significant reduction in their height-for-age z-scores (HAZ) from baseline to the 12-month follow-up (ΔHAZ: -0.28 (95% confidence interval (CI): -0.51, -0.05)). A significant reduction in HAZ was also observed for children in households with animals in their sleeping space (ΔHAZ: -0.37 (95% CI: -0.71, -0.04))., Conclusion: These findings provide further evidence to support the hypothesis that child mouthing of soil and the presence of animals in the child's sleeping space are potential risk factors for growth faltering among young children. Interventions are urgently needed to provide clean play and sleeping spaces for young children to reduce exposure to faecal pathogens through child mouthing., (© 2020 John Wiley & Sons Ltd.)

Objective: To characterise childhood mouthing and handling behaviours and to assess the association between hand-to-object and object-to-mouth contacts and diarrhoea prevalence in young children in urban Dhaka, Bangladesh., Methods: A prospective cohort study was conducted among 494 children under 5 years of age in Dhaka, Bangladesh. This study was nested within the randomised controlled trial of the Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program. The CHoBI7 mHealth program focuses on promoting handwashing with soap and water treatment to diarrhoea patients and their household members through mobile messages and a single in person visit. Mouthing and handling of faeces and fomites among young children was measured by five-hour structured observation and caregiver reports. Diarrhoea surveillance data was collected monthly for 12 months., Results: Fifty five percent of caregivers reported that their child put a visibly dirty fomite (object or soil) in their mouth in the past week. Caregivers reported that 50% of children had mouthed visibly dirty objects, 26% had mouthed dirt, and 2% had mouthed faeces. Forty five percent of children were observed mouthing a visibly dirty fomite during structured observation, 40% of children were observed mouthing a visibly dirty object, 10% were observed mouthing soil, and one child (0.2%) was observed mouthing faeces. Mouthing of visibly dirty fomites was highest for children 12-18 months of age with 69% of these children having caregiver reports and 54% having observed events. Children with caregiver reports of mouthing faeces had a significantly higher odds of diarrhoea over the subsequent month (Odds Ratio: 4.54; 95% Confidence Interval: 1.06, 19.48)., Conclusion: These findings demonstrate that mouthing of contaminated fomites among young children is frequent in urban environments in Bangladesh, and that mouthing faeces is associated with a significantly higher odds of diarrhoea. Interventions are urgently needed to protect young children from faecal pathogens in their play spaces., (© 2020 John Wiley & Sons Ltd.)

Foot-and-mouth disease (FMD) is a highly contagious disease of cloven-hoofed animals throughout the world. The endemicity of this disease in Bangladesh has been causing high economic loss and an impediment to the full potential surge of livestock industries. In Bangladesh, vaccination using imported or locally produced FMD vaccines is the existing practice of controlling the disease, although vaccine failure cases are very common. Hence, to address the problem, the present study was envisaged to develop an effective FMD vaccine tailored to the circulating indigenous foot-and-mouth disease virus (FMDV) strains. Three local circulating FMDVs O/BAN/TA/Dh-301/2016 (MK088170.1), A/BAN/CH/Sa-304/2016 (MK088171.1) and Asia1/BAN/DH/Sa-318/2018 (MH457186.1) isolates were selected as vaccine strains based on recent epidemiology, genetic and antigenic analyses. These serotype O, A and Asia1 vaccine strains showed strong antigenic relationship (r1 > 0.3) with 100% to 75% of the respective circulating viruses. The candidate viruses were successfully inactivated by 3.0 mM binary ethylenimine within 7-10 h after the onset of inactivation. Extrapolation of inactivation kinetics confirmed < 1 log 10 TCID 50 in a 10000-liter batch liquid preparation after 24 h inactivation cycle. The inactivated virus particles were significantly (p < 0.05) concentrated and the trivalent vaccine was formulated using 6 µg per dose per serotype antigen payload. The trivalent vaccine was administered in divided doses in different groups of cattle. All doses of the vaccine elicited significantly (p < 0.05) higher levels of antibodies as early as 14-day post-vaccination (dpv) and peak antibody titers were achieved in 28 dpv. The 'full dose' (6.0 µg per dose per serotype) vaccine elicited antibody titers expected to confer protection in 100% cattle of the respective group and maintained such level of antibodies beyond 180 dpv. Thus, the trivalent FMD vaccine prepared with 6.0 µg antigen per dose per serotype of the selected candidate viruses will confer protection against circulating FMDVs of Bangladesh and its neighboring countries., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh., Methods: A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates., Results: The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones., Conclusions: The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage., (© The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

The aim of this study was to explore the association of Infant and Young Child Feeding (IYCF) practices with health and nutritional status among children aged 0-23 months and to investigate the predictors of minimum acceptable diets (MADs) using Bangladesh Demographic and Health Survey (BDHS) data. Binary logistic regression models were performed to assess the association between IYCF and child health and to determine the influential predictors for MAD. About 55% mothers reported exclusive breastfeeding; 65% introduced solid, semisolid, or soft foods for their child; and 27% maintained minimum dietary diversity (MDD). About 64% children received recommended minimum meal frequency (MMF) and 23% received recommended MAD. The likelihood of having wasting was .22 times lower for the child who received MDD and MMF, respectively. MDD and MAD were associated with lower probability of experiencing underweight among children (Adjusted odds ratio [AOR] = .73 and AOR= .81, respectively). Early initiation and continuation of breastfeeding were significantly associated with reduction in diarrhea prevalence among young children. The findings of the study generated imperative evidence related to dietary diversity, associated factors, and child health outcomes. Policy should focus on the improvement of IYCF practices and complimentary food diversity by taking initiatives for designing and implementing effective interventions to tackle childhood morbidity.

Introduction: Bangladesh has a history of endemic malaria transmission, with 17.5 million people at risk. The objective of this study was to assess the cost-effectiveness of universal childhood malaria vaccination in Chittagong Hill Tracts (CHT) of Bangladesh with newly developed RTS,S/AS01 malaria vaccines., Methods: A decision model was been developed using Microsoft® Excel to examine the potential impact of future vaccination in Bangladesh. We estimated the economic and health burden due to malaria and the cost-effectiveness of malaria vaccination from the health system and societal perspective. The primary outcomes include the incremental cost per Disability-Adjusted Life Year (DALY) averted, incremental cost per case averted, and the incremental cost per death averted., Results: Introducing childhood malaria vaccination in CHT in Bangladesh for a single birth cohort could prevent approximately 500 malaria cases and at least 30 deaths from malaria during the first year of vaccination. The cost per DALY averted of introducing the malaria vaccine compared to status quo is US$ 2,629 and US$ 2,583 from the health system and societal perspective, respectively., Conclusions: Introduction of malaria vaccination in CHT region is estimated to be a cost-effective preventive intervention and would offer substantial future benefits particularly for young children vaccinated today. Policies should, thus, consider the operational advantages of targeting these populations, particularly in the CHT area, with the vaccine along with other malaria control initiatives., Competing Interests: The authors have declared that no competing interests exist.