Search

Introduction: The aims of the study are to: (1) determine the short-term reactogenicity of WHO-approved COVID-19 vaccines (i.e., Pfizer-BioNTech, Moderna, Sinovac, Oxford-AstraZeneca, Johnson and Johnson, Covaxin) amongst lactating women and their children, and 2) evaluate lactation-related outcomes following the same vaccines in Bangladesh. Methods: This was a multi-centre, self-reported, cross-sectional study of lactating woman-child dyads in Bangladesh. Demographics, past medical history, breastfeeding history and clinical outcomes of lactating woman–child dyads at least 7 days after the last dose of vaccine were determined through a structured questionnaire. Results: There were 750 participants from four centres. The mean age of lactating women and children surveyed were 27.6 (SD ± 4.6) years and 10.3 (SD ± 6.7) months, respectively. Majority (81.2%; 608 of 750) received 2 doses of COVID-19 vaccinations while lactating. Almost all (99.9%; 749 of 750) vaccinated lactating women surveyed reported no change in human milk supply. More than half of the participants (56.9%; 373 of 656) reported no symptoms after both doses of COVID-19 vaccines. There were no serious adverse events such as anaphylaxis or hospital admission. Majority of the lactating women (98.9%; 742 of 750) reported that the children whom they breastfed had no symptoms such as fever or cough. Discussion: This large study of lactating woman-child dyads in Bangladesh, who received a diverse range of WHO-approved COVID-19 vaccines, showed no serious short-term adverse effects. Significance: What is Already Known on this Subject?: mRNA COVID-19 vaccination is safe for lactating woman and child dyads in the short term. What this Study adds?: This is the largest known South Asian study on WHO-approved COVID-19 vaccines (both mRNA and non-mRNA) which showed that these vaccines are safe for lactating women and child dyads in the short-term. [ABSTRACT FROM AUTHOR]

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6. Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019. [ABSTRACT FROM AUTHOR]

Background: Typhoid and paratyphoid remain common bloodstream infections in areas with suboptimal water and sanitation infrastructure. Paratyphoid, caused by Salmonella Paratyphi A, is less prevalent than typhoid and its antimicrobial resistance (AMR) trends are less documented. Empirical treatment for paratyphoid is commonly based on the knowledge of susceptibility of Salmonella Typhi, which causes typhoid. Hence, with rising drug resistance in Salmonella Typhi, last-line antibiotics like ceftriaxone and azithromycin are prescribed for both typhoid and paratyphoid. However, unlike for typhoid, there is no vaccine to prevent paratyphoid. Here, we report 23-year AMR trends of Salmonella Paratyphi A in Bangladesh. Methods: From 1999 to 2021, we conducted enteric fever surveillance in two major pediatric hospitals and three clinics in Dhaka, Bangladesh. Blood cultures were performed at the discretion of the treating physicians; cases were confirmed by culture, serological and biochemical tests. Antimicrobial susceptibility was determined following CLSI guidelines. Results: Over 23 years, we identified 2,725 blood culture-confirmed paratyphoid cases. Over 97% of the isolates were susceptible to ampicillin, chloramphenicol, and cotrimoxazole, and no isolate was resistant to all three. No resistance to ceftriaxone was recorded, and >99% of the isolates were sensitive to azithromycin. A slight increase in minimum inhibitory concentration (MIC) is noticed for ceftriaxone but the current average MIC is 32-fold lower than the resistance cut-off. Over 99% of the isolates exhibited decreased susceptibility to ciprofloxacin. Conclusions: Salmonella Paratyphi A has remained susceptible to most antibiotics, unlike Salmonella Typhi, despite widespread usage of many antibiotics in Bangladesh. The data can guide evidence-based policy decisions for empirical treatment of paratyphoid fever, especially in the post typhoid vaccine era, and with the availability of new paratyphoid diagnostics. Author summary: Typhoid and paratyphoid fever, caused by Salmonella Typhi and Paratyphi A respectively, are common in areas lacking safe water and optimum infrastructure. With increasing multidrug resistance in Salmonella Typhi, newer antimicrobials like ceftriaxone and azithromycin are frequently prescribed for the empirical treatment of both typhoid and paratyphoid fever. This is because Salmonella Paratyphi A is less prevalent in most endemic countries, and typhoid and paratyphoid fever are often symptomatically indistinguishable. In this study, we conducted comprehensive surveillance of Salmonella Paratyphi A in Bangladesh over a period of 23 years and identified 2,725 blood culture-confirmed paratyphoid cases. Our findings indicate that Salmonella Paratyphi A remained susceptible to most of the older generation of antibiotics as over 97% of the isolates continue to be susceptible to ampicillin, chloramphenicol and cotrimoxazole, and no isolate detected was resistant to all three drugs. Although 99% of the isolates exhibited reduced fluoroquinolone susceptibility, 99% and 100% were sensitive to azithromycin and ceftriaxone. These findings are important and can guide evidence-based policy decisions for the empirical treatment of paratyphoid fever. While newer antimicrobials such as azithromycin and ceftriaxone remain effective, successful implementation of typhoid conjugate vaccines and rapid diagnostics may re-enable the use of older generation antibiotics for empirical treatment of enteric fever without compromising the treatment efficacy. This approach can contribute to the antimicrobial stewardship efforts by preserving critically important antimicrobials such as ceftriaxone and azithromycin for the treatment of numerous other multidrug-resistant bacterial infections. [ABSTRACT FROM AUTHOR]

Background: Considering the high frequency of respiratory infections among children in low- and middle-income countries (LMICs), the World Health Organization (WHO) developed a pragmatic guideline for managing pneumonia in low-resource settings. The guideline's low specificity leads to many false-positive pneumonia cases receiving antibiotic treatment. Integrating diagnostic technology to incorporate lung sounds into WHO guidelines could improve childhood pneumonia diagnosis and management. This qualitative study aimed to explore the acceptability of a prototype digital stethoscope device among potential end-users in Bangladesh. Methods: We conducted four focus group discussions (FGDs) with beneficiaries and service providers who used a 2018 digital stethoscope prototype. The data collection was conducted in November 2020. The study was carried out at Zakiganj Upazila (sub-district) of Sylhet district of Bangladesh. A total of 34 respondents, including parents of under-5 children, Community Health Care Providers (CHCPs), and community leaders were enrolled. Two researchers (TJ and a research assistant (not a co-author of this manuscript) conducted the FGDs. Verbatim transcripts were prepared, and translations were completed. Coding was executed in Microsoft Excel, and relevant quotes were extracted to ascertain the emerging themes. To ensure validity, two researchers coded the dataset independently and inconsistencies were resolved through discussion. Findings: Mothers were more aware of the digital stethoscope than fathers. Except for the female community leaders, male leaders were unaware of the stethoscopes. Most CHCPs had positive perceptions of the digital stethoscope. They appreciated stethoscope training as they learned about new technology and diagnostic approaches. The users mentioned several technical shortcomings of the prototype device. A few stakeholders expressed dissatisfaction with the level of community involvement and information sharing from the study. The use of the device plummeted during the COVID-19 pandemic for fear of infection, to counteract which the CHCPs cleaned the device with chlorhexidine after every application as a precaution. Conclusion: Overall, device use was supported by stakeholders despite perceptions that the prototype had some technological limitations, community engagement was suboptimal, and the COVID-19 pandemic caused disruptions. Stronger community engagement, addressing technological issues, and further research on its health systems application would improve the acceptability and effective use of the digital stethoscope. [ABSTRACT FROM AUTHOR]

Background: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh. Methods: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs. Results: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers. Conclusion: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0–59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016. Methods: This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance. Results: At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7–57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens. Conclusions: Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context. [ABSTRACT FROM AUTHOR]

Introduction: Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0–59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016). Methods: We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines. Results: Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions—including engaging informal providers in treatment of the infant—to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses. Conclusion: Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines. [ABSTRACT FROM AUTHOR]

Liquid Chromatography tandem mass spectrometry (LC-MS/MS) is used for the diagnosis of more than 30 inborn errors of metabolisms (IEMs). Accurate and reliable diagnosis of IEMs by quantifying amino acids (AAs) and acylcarnitines (ACs) using LC-MS/MS systems depend on the establishment of age-specific cut-offs of the analytes. This study aimed to (1) determine the age-specific cut-off values of AAs and ACs in Bangladesh and (2) validate the LC-MS/MS method for diagnosis of the patients with IEMs. A total of 570 enrolled healthy participants were divided into 3 age groups, namely, (1) newborns (1-7 days), (2) 8 days–7 years, and (3) 8–17 years, to establish the age-specific cut-offs for AAs and ACs. Also, 273 suspected patients with IEMs were enrolled to evaluate the reliability of the established cut-off values. Quantitation of AAs and ACs was performed on an automated LC-MS/MS system using dried blood spot (DBS) cards. Then the specimens of the enrolled clinically suspected patients were analyzed by the established method. Nine patients came out as screening positive for different IEMs, including two borderline positive cases of medium-chain acyl-CoA dehydrogenase deficiency (MCAD). A second-tier test for confirmation of the screening positive cases was conducted by urinary metabolic profiling using gas chromatography- mass spectrometry (GC-MS). Out of 9 cases that came out as screening positive by LC-MS/MS, seven cases were confirmed by urinary GC-MS analysis including 3 cases with phenylketonuria, 1 with citrullinemia type II, 1 with methylmalonic acidemia, 1 with isovaleric acidemia and 1 with carnitine uptake defect. Two borderline positive cases with MCAD were found negative by urinary GC-MS analysis. In conclusion, along with establishment of a validated LC-MS/MS method for quantitation of AAs and ACs from the DBS cards, the study also demonstrates the presence of predominantly available IEMs in Bangladesh. [ABSTRACT FROM AUTHOR]

Objective To describe the implementation, coverage and performance of the national kangaroo mother care programme in Bangladesh. Methods Kangaroo mother care services for clinically stable babies with birth weight under 2000 g were set up in government-run healthcare facilities in rural and urban areas of Bangladesh. Each facility provided counselling on kangaroo mother care, ensured adequate nutrition, and followed up mothers and babies. We studied implementation of the programme from January 2016 to March 2020 using data from the national database. We tracked the number of eligible babies enrolled and their outcomes, mortality and post-discharge follow-up. Findings The numbers of kangaroo mother care facilities increased from 16 in 2016 to 108 in 2020. Over the 4-year period 64 426 babies weighing under 2000 g were born in these facilities, 6410 of whom received kangaroo mother care. The quarterly percentage of eligible babies receiving kangaroo mother care increased from 4.7% (37/792) during the first quarter to 21.7% (917/4226) during the last five quarters of the programme. Deaths of babies receiving kangaroo mother care showed a downward trend over the study period. The overall mortality was 1.2% (77/6410), with large quarterly fluctuations in mortality. Post-discharge follow-up was low and only 15--20% of babies received four follow-up visits. Conclusion Implementation of kangaroo mother care interventions is feasible in low-resource settings. Such care has the potential to reduce mortality among low-birth-weight and premature babies. Challenges include low coverage, expanding the programme to the community and strengthening the monitoring system. [ABSTRACT FROM AUTHOR]

Background: Birth defect is one of the most important causes of neonatal mortality worldwide. In a developing country like Bangladesh many possible factors for birth defects are present which should be identified. This study was performed to determine those risk factors of birth defect and complications associated with it. Materials and Methods: A hospital based matched case-control study was conducted from August 2015 to July 2016 in department of Neonatology along with Obstetrics and Gynecology at BSMMU. A total of 98 mother-infant pair (49 babies with birth defect as cases and 49 healthy babies without any birth defects as controls) was included in the study. For each case, a gestational age, sex and post-natal age matched control was taken. Data was collected by face to face interview. Univariate and multivariate conditional logistic regression models were computed to examine the effect of independent variables on outcome variable using SPSS 23.0. Variables with p-value <0.05 were considered statistically significant. Results: The mean (± SD) birth weight for cases and controls were 2718.37 (±756.9) grams, and 2617.14 (±978.8) grams respectively. Cardiovascular system was the predominant system (21%) involved in birth defects. Maternal age between 20-29 years (AOR: 4.69; 95% CI 1.078, 20.448), less than four antenatal care visits (AOR: 10.07; 95% CI 2.816, 36.0), no multivitamin intake (AOR: 7.38; 95% CI 1.791, 30.365) and presence of maternal diabetes (AOR: 0.194; 95% CI 0.047, 0.799) were significantly associated with birth defects among newborns. Sepsis, asphyxia, hypoglycemia and dyselectrolytemia were the most prevalent problems among these babies. The need of intravenous fluid, thermal care, antibiotics and mechanical ventilation was also high among the cases. Conclusion: Birth defect is an upcoming issue in current newborn health situation which need to be prioritized. Significant risk factors should be addressed timely for early diagnosis and proper management of these babies can help in reduction of mortality. [ABSTRACT FROM AUTHOR]

Background: Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately higher in low- and middle-income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. In LMICs, an estimated half of all newborns are born at home and few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh., Methods: 530 Bangladeshi women in their second or third trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm - home screening and treatment for neonatal hyperbilirubinemia - or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor for clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold, but >15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB ≥15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared., Conclusion: This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia., Competing Interests: No competing interests were disclosed., (Copyright: © 2024 Foote EM et al.)

Background: Bangladesh reported its first COVID-19 case on March 8, 2020. Despite lockdowns and promoting behavioural interventions, as of December 31, 2021, Bangladesh reported 1.5 million confirmed cases and 27 904 COVID-19-related deaths. To understand the course of the pandemic and identify risk factors for SARs-Cov-2 infection, we conducted a cohort study from November 2020 to December 2021 in rural Bangladesh., Methods: After obtaining informed consent and collecting baseline data on COVID-19 knowledge, comorbidities, socioeconomic status, and lifestyle, we collected data on COVID-like illness and care-seeking weekly for 54 weeks for women (n = 2683) and their children (n = 2433). Between March and July 2021, we tested all participants for SARS-CoV-2 antibodies using ROCHE's Elecsys® test kit. We calculated seropositivity rates and 95% confidence intervals (95% CI) separately for women and children. In addition, we calculated unadjusted and adjusted relative risk (RR) and 95% CI of seropositivity for different age and risk groups using log-binomial regression models., Results: Overall, about one-third of women (35.8%, 95% CI = 33.7-37.9) and one-fifth of children (21.3%, 95% CI = 19.2-23.6) were seropositive for SARS-CoV-2 antibodies. The seroprevalence rate doubled for women and tripled for children between March 2021 and July 2021. Compared to women and children with the highest household wealth (HHW) tertile, both women and children from poorer households had a lower risk of infection (RR, 95% CI for lowest HHW tertile women (0.83 (0.71-0.97)) and children (0.75 (0.57-0.98)). Most infections were asymptomatic or mild. In addition, the risk of infection among women was higher if she reported chewing tobacco (RR = 1.19,95% CI = 1.03-1.38) and if her husband had an occupation requiring him to work indoors (RR = 1.16,  95% CI = 1.02-1.32). The risk of infection was higher among children if paternal education was >5 years (RR = 1.37, 95% CI = 1.10-1.71) than in children with a paternal education of ≤5 years., Conclusions: We provided prospectively collected population-based data, which could contribute to designing feasible strategies against COVID-19 tailored to high-risk groups. The most feasible strategy may be promoting preventive care practices; however, collecting data on reported practices is inadequate. More in-depth understanding of the factors related to adoption and adherence to the practices is essential., Competing Interests: Disclosure of interest: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author) and declare no conflicts of interest., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Majority of under-five children with developmental disabilities live in low- and middle-income countries (LMIC). A considerable proportion of disabilities results from perinatal adversities. The neonatal and infant mortality rates in India, Bangladesh, and Sri Lanka have improved over the last two decades, implying survival of infants at risk for developmental impairments. The need to thrive beyond survival is a well-recognized concept and it is imperative to establish high-risk infant follow-up (HRIF) programmes to capture these infants within the first 1000 d of life. Many challenges are present within the LMICs to identify infants at risk and to ensure early intervention (EI) during the window of optimal neural plasticity. However, it is essential to acknowledge the strengths within such systems to understand the impact of these programmes and packages on the activity and participation of these infants and their families. The International Classification of Functioning, Health and Disability for Children and Youth (ICF-CY) version is a holistic framework that will enable the families, clinicians, and policymakers to measure the impact of these interventions. Though all three countries have national policies to reach for high-risk infants, there is lack of published evidence on the successful implementation of such strategies. Therefore, it is timely to establish universally accessible, culturally appropriate and sustainable HRIF programmes. It is also recommended to measure the outcomes of such programmes based on the ICF-CY to understand the impact on the activity and participation of children in South Asia., (© 2021. Dr. K C Chaudhuri Foundation.)

Introduction: The WHO's Integrated Management of Childhood Illnesses (IMCI) algorithm for diagnosis of child pneumonia relies on counting respiratory rate and observing respiratory distress to diagnose childhood pneumonia. IMCI case defination for pneumonia performs with high sensitivity but low specificity, leading to overdiagnosis of child pneumonia and unnecessary antibiotic use. Including lung auscultation in IMCI could improve specificity of pneumonia diagnosis. Our objectives are: (1) assess lung sound recording quality by primary healthcare workers (HCWs) from under-5 children with the Feelix Smart Stethoscope and (2) determine the reliability and performance of recorded lung sound interpretations by an automated algorithm compared with reference paediatrician interpretations., Methods and Analysis: In a cross-sectional design, community HCWs will record lung sounds of ~1000 under-5-year-old children with suspected pneumonia at first-level facilities in Zakiganj subdistrict, Sylhet, Bangladesh. Enrolled children will be evaluated for pneumonia, including oxygen saturation, and have their lung sounds recorded by the Feelix Smart stethoscope at four sequential chest locations: two back and two front positions. A novel sound-filtering algorithm will be applied to recordings to address ambient noise and optimise recording quality. Recorded sounds will be assessed against a predefined quality threshold. A trained paediatric listening panel will classify recordings into one of the following categories: normal, crackles, wheeze, crackles and wheeze or uninterpretable. All sound files will be classified into the same categories by the automated algorithm and compared with panel classifications. Sensitivity, specificity and predictive values, of the automated algorithm will be assessed considering the panel's final interpretation as gold standard., Ethics and Dissemination: The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 09630012018) and Academic and Clinical Central Office for Research and Development Medical Research Ethics Committee, Edinburgh, UK (REC Reference: 18-HV-051). Dissemination will be through conference presentations, peer-reviewed journals and stakeholder engagement meetings in Bangladesh., Trial Registration Number: NCT03959956., Competing Interests: Competing interests: IMM will be paid for developing Feelix Smart Stethoscope and a machine learning algorithm from Sonavi Labs., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: To describe the implementation, coverage and performance of the national kangaroo mother care programme in Bangladesh., Methods: Kangaroo mother care services for clinically stable babies with birth weight under 2000 g were set up in government-run health-care facilities in rural and urban areas of Bangladesh. Each facility provided counselling on kangaroo mother care, ensured adequate nutrition, and followed up mothers and babies. We studied implementation of the programme from January 2016 to March 2020 using data from the national database. We tracked the number of eligible babies enrolled and their outcomes, mortality and post-discharge follow-up., Findings: The numbers of kangaroo mother care facilities increased from 16 in 2016 to 108 in 2020. Over the 4-year period 64 426 babies weighing under 2000 g were born in these facilities,  6410 of whom received kangaroo mother care. The quarterly percentage of eligible babies receiving kangaroo mother care increased from 4.7% (37/792) during the first quarter to 21.7% (917/4226) during the last five quarters of the programme. Deaths of babies receiving kangaroo mother care showed a downward trend over the study period. The overall mortality was 1.2% (77/6410), with large quarterly fluctuations in mortality. Post-discharge follow-up was low and only 15-20% of babies received four follow-up visits., Conclusion: Implementation of kangaroo mother care interventions is feasible in low-resource settings. Such care has the potential to reduce mortality among low-birth-weight and premature babies. Challenges include low coverage, expanding the programme to the community and strengthening the monitoring system., ((c) 2022 The authors; licensee World Health Organization.)

Background: Although therapeutic hypothermia reduces death or disability after neonatal encephalopathy in high-income countries, its safety and efficacy in low-income and middle-income countries is unclear. We aimed to examine whether therapeutic hypothermia alongside optimal supportive intensive care reduces death or moderate or severe disability after neonatal encephalopathy in south Asia., Methods: We did a multicountry open-label, randomised controlled trial in seven tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh. We enrolled infants born at or after 36 weeks of gestation with moderate or severe neonatal encephalopathy and a need for continued resuscitation at 5 min of age or an Apgar score of less than 6 at 5 min of age (for babies born in a hospital), or both, or an absence of crying by 5 min of age (for babies born at home). Using a web-based randomisation system, we allocated infants into a group receiving whole body hypothermia (33·5°C) for 72 h using a servo-controlled cooling device, or to usual care (control group), within 6 h of birth. All recruiting sites had facilities for invasive ventilation, cardiovascular support, and access to 3 Tesla MRI scanners and spectroscopy. Masking of the intervention was not possible, but those involved in the magnetic resonance biomarker analysis and neurodevelopmental outcome assessments were masked to the allocation. The primary outcome was a combined endpoint of death or moderate or severe disability at 18-22 months, assessed by the Bayley Scales of Infant and Toddler Development (third edition) and a detailed neurological examination. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02387385., Findings: We screened 2296 infants between Aug 15, 2015, and Feb 15, 2019, of whom 576 infants were eligible for inclusion. After exclusions, we recruited 408 eligible infants and we assigned 202 to the hypothermia group and 206 to the control group. Primary outcome data were available for 195 (97%) of the 202 infants in the hypothermia group and 199 (97%) of the 206 control group infants. 98 (50%) infants in the hypothermia group and 94 (47%) infants in the control group died or had a moderate or severe disability (risk ratio 1·06; 95% CI 0·87-1·30; p=0·55). 84 infants (42%) in the hypothermia group and 63 (31%; p=0·022) infants in the control group died, of whom 72 (36%) and 49 (24%; p=0·0087) died during neonatal hospitalisation. Five serious adverse events were reported: three in the hypothermia group (one hospital readmission relating to pneumonia, one septic arthritis, and one suspected venous thrombosis), and two in the control group (one related to desaturations during MRI and other because of endotracheal tube displacement during transport for MRI). No adverse events were considered causally related to the study intervention., Interpretation: Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available., Funding: National Institute for Health Research, Garfield Weston Foundation, and Bill & Melinda Gates Foundation., Translations: For the Hindi, Malayalam, Telugu, Kannada, Singhalese, Tamil, Marathi and Bangla translations of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests JW reports a grant from the National Institutes for Health (number 1R21HD093563-01) outside the submitted work. RP reports personal fees from UCB and Kephala outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The impact of SARS-CoV-2 on neonates remains largely unknown in low- and middle-income countries (LMICs). We provide an epidemiologic and clinical report of SARS-CoV-2 infections in neonates hospitalized in Bangladesh., Methods: Outborn neonates admitted to Dhaka Shishu Hospital, a tertiary-care referral hospital, between 29 March and 1 July were screened for SARS-CoV-2. We reviewed clinical data, including chest radiograph and laboratory reports, and conducted SARS-CoV-2 genome sequencing. Patients were followed-up for 27-75 days. A subset of caregivers was also tested., Results: Of 83 neonates tested, 26 were positive (median age 8 days). Most neonates were admitted with diagnosis unrelated to SARS-CoV-2: 11 presented with serious non-communicable diseases, 7 with early-onset sepsis, 5 with late-onset sepsis and 2 with pneumonia. In 3 of 5 chest radiograph, infiltrates and ground-glass or patchy opacities were noted. Two neonates developed metabolic acidosis, one developed disseminated intravascular coagulation. Most SARS-CoV-2 positive neonates were referred to government-designated COVID-19 hospitals, leading to gaps in treatment. Twenty-three neonates could be followed-up: 12 were healthy, 8 died and 3 were still seeking medical care. Of 9 caregivers tested, 8 were positive., Conclusions: SARS-CoV-2 may have serious adverse effects on children born in LMICs. The virus likely contributed directly to two deaths, but the remaining 6 neonates who died had serious comorbidities. Positive SARS-CoV-2 test results led to gaps in immediate clinical care for other morbidities, which likely contributed to adverse outcomes. This case series emphasizes the need to understand COVID-19 in neonates in LMICs and its indirect impacts.

Introduction: There is a set of globally accepted and nationally adapted signal functions for categorising health facilities for maternal services. Newborn resuscitation is the only newborn intervention which is included in the WHO recommended list of emergency obstetric care signal functions. This is not enough to comprehensively assess the readiness of a health facility for providing newborn services. In order to address the major causes of newborn death, the Government of Bangladesh has prioritised a set of newborn interventions for national scale-up, the majority of which are facility-based. Effective delivery of these interventions depends on a core set of functions (skills and services). However, there is no standardised and approved set of newborn signal functions (NSFs) based on which the service availability and readiness of a health facility can be assessed for providing newborn services. Thus, this study will be the first of its kind to identify such NSFs. These NSFs can categorise health facilities and assist policymakers and health managers to appropriately plan and adequately monitor the progress and performance of health facilities delivering newborn healthcare., Methods and Analysis: We will adopt the Delphi technique of consensus building for identification of NSFs and 1-2 indicator for each function while employing expert consultation from relevant experts in Bangladesh. Based on the identified NSFs and signal function indicators, the existing health facility assessment (HFA) tools will be updated, and an HFA survey will be conducted to assess service availability and readiness of public health facilities in relation to the new NSFs. Descriptive statistics (proportion) with a 95% CI will be used to report the level of service availability and readiness of public facilities regarding NSFs., Ethics and Dissemination: Ethical approval was obtained from Research Review and Ethical Review Committee of icddr, b (PR-17089). Results will be disseminated through meetings, seminars, conference presentations and international peer-review journal articles., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Expectant reduction of neonatal mortality and formulation of preventive strategies can only be achieved by analysis of risk factors in a particular setting. This study aimed to document incidence of neonatal death and to analyze the risk factors associated with neonatal death., Methods: This retrospective study was carried out in department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) over a 12-month period from January to December 2015. The newborns that died within 28 d of life were defined as "Cases" and "Control" were the surviving newborn discharged to home as healthy. Two birth weight and gestational age matched controls were taken for each case. Maternal, obstetric, and newborn characteristics were analyzed between both the groups. Data analysis was performed using SPSS version 20.0 (SPSS Inc., Chicago, IL). A probability of < .05 was considered statistically significant. The strength of association was determined by calculating odds ratio and their 95% confidence intervals (CIs)., Results: During the study period, the proportion of death was 9.6% (64/612). Both in Chi-square analysis and in logistic regression analysis, less than four antenatal visits (odds ratio (OR) 2.78; 95% CI: 1.23-6.28, p = .014) and sepsis (OR 2.37; 95% CI: 1.07-5.26, p = .034) were found to be independent risk factors for deaths, whereas LUCS found to be protective for deaths (OR 0.40; 95% CI: 0.19-0.83, p = .015)., Conclusion: In conclusion, less than four antenatal visits and presence of sepsis were found to be independent risk factors whereas LUCS protective of newborn death.

Neural tube defect (NTD) is a multi-factorial disorder in which nutritional, genetic and environmental factors are involved. Among the nutritional factors, low level of serum zinc has been reported from different parts of the world. This hospital-based case-control study was conducted with the objective of finding the relationship between serum zinc level in newborns and their mothers and NTDs in a Bangladeshi population. The study was conducted during August 2006-July 2007 at the Bangabandhu Sheikh Mujib Medical University (BSMMU) in Dhaka. In total, 32 mothers and their newborns with NTDs were included as cases and another 32 mothers with their normal babies were included as controls. Concentration of serum zinc was determined by pyro-coated graphite furnace atomic absorption spectrophotometer (GF-AAS). The mean age of the case and control mothers was 25.28 years and 24.34 years respectively. The mean gestational age of the case newborns was 36.59 weeks and that of the control newborns was 37.75 weeks. The mean serum zinc level of the case and control mothers was 610.2 microg/L and 883.0 microg/L respectively (p < 0.01). The mean serum zinc level of the case and control newborns was 723 microg/L and 1,046 microg/L respectively (p < 0.01). In both case and control groups, the serum zinc level of the newborns positively correlated with that of the mothers. The serum zinc levels of the mothers and newborns negatively correlated with NTDs. Mothers with serum zinc level lower than normal were 7.66 [95% confidence interval (CI) 2.5-23.28] times more likely to have NTDs compared to the normal zinc level of mothers. After adjusting for the zinc level of the newborns, parity, and age of the mothers, this risk reduced 1.61 times [confidence interval (CI) 95% 0.24-8.77]. On the other hand, the low serum zinc level of the newborns was 7.22 times more associated with NTDs compared to the newborns with the normal serum zinc level, which was statistically significant (p = 0.001). After adjusting for other factors, such as maternal age and parity, newborns with the low serum zinc level was found to be 9.186 times more likely to be associated with NTDs compared to newborns with normal serum zinc level. Based on the findings, it may be concluded that the low serum zinc levels of newborns may be associated with NTDs. To confirm these findings, a further study with a larger sample-size is recommended. Moreover, a follow-up study with zinc supplementation to pregnant women and its impact on NTDs is also recommended.