Showing papers by "International Centre for Diarrhoeal Disease Research, Bangladesh published in 1998"

Epidemiology, Genetics, and Ecology of Toxigenic Vibrio cholerae

Abstract: Cholera caused by toxigenic Vibrio cholerae is a major public health problem confronting developing countries, where outbreaks occur in a regular seasonal pattern and are particularly associated with poverty and poor sanitation. The disease is characterized by a devastating watery diarrhea which leads to rapid dehydration, and death occurs in 50 to 70% of untreated patients. Cholera is a waterborne disease, and the importance of water ecology is suggested by the close association of V. cholerae with surface water and the population interacting with the water. Cholera toxin (CT), which is responsible for the profuse diarrhea, is encoded by a lysogenic bacteriophage designated CTXΦ. Although the mechanism by which CT causes diarrhea is known, it is not clear why V. cholerae should infect and elaborate the lethal toxin in the host. Molecular epidemiological surveillance has revealed clonal diversity among toxigenic V. cholerae strains and a continual emergence of new epidemic clones. In view of lysogenic conversion by CTXΦ as a possible mechanism of origination of new toxigenic clones of V. cholerae, it appears that the continual emergence of new toxigenic strains and their selective enrichment during cholera outbreaks constitute an essential component of the natural ecosystem for the evolution of epidemic V. cholerae strains and genetic elements that mediate the transfer of virulence genes. The ecosystem comprising V. cholerae, CTXΦ, the aquatic environment, and the mammalian host offers an understanding of the complex relationship between pathogenesis and the natural selection of a pathogen.

Causes of childhood deaths in Bangladesh : results of a nationwide verbal autopsy study

Abstract: While knowledge of causes of deaths is important for health sector planning, little is known from conventional sources about the causes of deaths in Bangladesh This is partly due to deficiencies in the registration system and partly because few deaths are attended by qualified physicians The present study was undertaken to update the information available on causes of deaths among under-5-year-olds, taking advantage of advances in verbal autopsy methodology and of the national Bangladesh Demographic and Health Survey conducted in 1993-94 About 25% of the deaths were associated with acute lower respiratory infections (ALRI) and about 20% with diarrhoea Neonatal tetanus and measles remained important causes of death, and drowning was a major cause for 1-4-year-olds Research and programmes to enable mothers to identify ALRI cases, particularly pneumonia, and to encourage timely and appropriate care-seeking and strengthening of ALRI case management at the primary care facilities are important priorities While promotion of oral rehydration for watery diarrhoea and antibiotic treatment for dysentery should continue, broader preventive interventions including provision of safe water and sanitation, and improvements in personal hygiene require more attention Further intensification of immunization programmes and innovative experimental interventions to reduce childhood from drowning should be designed and tested

Successful treatment of rotavirus diarrhea in children with immunoglobulin from immunized bovine colostrum.

Abstract: Background.Oral ingestion of immunoglobulins in humans has been shown to be effective as prophylaxis against enteric infections. However, its therapeutic effect in children with infectious diarrhea has hitherto not been proven. We treated children with rotavirus diarrhea with immunoglobulins extract

Analysis of Clinical and Environmental Strains of Nontoxigenic Vibrio cholerae for Susceptibility to CTXΦ: Molecular Basis for Origination of New Strains with Epidemic Potential

Abstract: Toxigenic Vibrio cholerae strains are lysogens of CTXΦ, a filamentous phage which encodes cholera toxin. The receptor for CTXΦ for invading V. cholerae cells is the toxin-coregulated pilus (TCP), the genes for which reside in a larger genetic element, the TCP pathogenicity island. We analyzed 146 CTX-negative strains of V. cholerae O1 or non-O1 isolated from patients or surface waters in five different countries for the presence of the TCP pathogenicity island, the regulatory gene toxR, and the CTXΦ attachment sequence attRS, as well as for susceptibility of the strains to CTXΦ, to investigate the molecular basis for the emergence of new clones of toxigenic V. cholerae. DNA probe or PCR assays for tcpA, tcpI, acfB, toxR, and attRS revealed that 6.85% of the strains, all of which belonged to the O1 serogroup, carried the TCP pathogenicity island, toxR, and multiple copies of attRS, whereas the remaining 93.15% of the strains were negative for TCP but positive for either one or both or neither of toxR and attRS. An analysis of the strains for susceptibility to CTXΦ, using a genetically marked derivative of the phage CTX-KmΦ, showed that all TCP-positive CTX-negative strains and 1 of 136 TCP-negative strains were infected by the phage either in vitro or in the intestines of infant mice. The phage genome integrated into the chromosome of infected V. cholerae O1 cells forming stable lysogens. Comparative analysis of rRNA gene restriction patterns revealed that the lysogens derived from nontoxigenic progenitors were either closely related to or distinctly different from previously described clones of toxigenic V. cholerae. To our knowledge, this is the first demonstration of lysogenic conversion of naturally occurring nontoxigenic V. cholerae strains by CTXΦ. The results of this study further indicated that strains belonging to the O1 serogroup of V. cholerae are more likely to possess the TCP pathogenicity island and hence to be infected by CTXΦ, leading to the origination of potential new epidemic clones.

Induction of the Lysogenic Phage Encoding Cholera Toxin in Naturally Occurring Strains of Toxigenic Vibrio cholerae O1 and O139

Abstract: In toxigenic Vibrio cholerae, the CTX genetic element which carries the genes for cholera toxin (CT) is the genome of a lysogenic bacteriophage (CTXPhi). Clinical and environmental strains of V. cholerae O1 or O139 and stools that were culture positive for cholera were analyzed to study the induction and transmission of CTXPhi. To our knowledge, this is the first report of the examination of CTXPhi in clinical materials and in naturally occurring strains. DNA probe analysis revealed that 4.25% (6 of 141) of the isolated V. cholerae strains spontaneously produced a detectable level of extracellular CTXPhi particles in the culture supernatants whereas another 34.04% (48 of 141) produced CTXPhi particles when induced with mitomycin C. CTXPhi isolated from 10 clinical or environmental strains infected a CT-negative recipient strain, CVD103, both inside the intestines of infant mice and under laboratory conditions. All culture-positive stools analyzed were negative for the presence of CTXPhi both in the DNA probe assay and by in vivo assay for the infection of the recipient strain in infant mice. These results suggested that naturally occurring strains of toxigenic V. cholerae are inducible lysogens of CTXPhi but that cholera pathogenesis in humans is not associated with the excretion of CTXPhi particles in stools, indicating that induction of the phage may not occur efficiently inside the human intestine. However, in view of the efficient transmission of the phage under conditions conducive to the expression of toxin-coregulated pili, it appears that propagation of CTXPhi in the natural habitat may involve both environmental and host factors.

Astrovirus infection in association with acute, persistent and nosocomial diarrhea in Bangladesh.

Abstract: Background. Diarrhea is an important public health concern in developing countries such as Bangladesh. Diarrhea in children that persists for 14 days or more occurs in 7% of patients in Bangladesh and frequently results in death. Astrovirus has been demonstrated as a cause of acute and nosocomial diarrhea and can be excreted for prolonged periods, yet its importance as a cause of diarrhea among children in a developing country like Bangladesh has not been investigated. Methods. We tested 629 stool specimens from patients with acute diarrhea, 153 from patients with persistent diarrhea, 175 specimens from 76 patients hospitalized for diarrhea who were sampled repeatedly to detect nosocomial infection and 428 from nonhospitalized healthy children (controls). All children enrolled in the study were <5 years of age. Astrovirus was detected by enzyme immunoassay and other enteropathogens were detected by standard techniques. Results. The detection of astrovirus increased significantly with the duration of diarrhea. Astrovirus was found in 23 (15%) specimens from patients with persistent diarrhea, 26 (4%) patients with acute diarrhea, but only 8 (2%) healthy controls. This trend remained when we limited our analysis to infants <12 months of age and to episodes in which astrovirus was the sole pathogen. Among patients with nosocomial diarrhea, 16% of postadmission specimens were positive for astrovirus when the admission specimen was negative. Conclusion. The observation that astrovirus is detected more frequently with diarrhea of increasing duration suggests the need for further studies to determine whether astrovirus plays a causative role in persistent diarrhea or is a secondary agent.

Single dose vitamin A treatment in acute shigellosis in Bangladeshi children: randomised double blind controlled trial

Abstract: OBJECTIVE: To evaluate the efficacy of a single large oral dose of vitamin A in treating acute shigellosis in children in Bangladesh. DESIGN: Randomised double blind controlled clinical trial. SETTING: Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh. SUBJECTS: 83 children aged 1-7 years with bacteriologically proved shigellosis but no clinical signs of vitamin A deficiency; 42 were randomised to treatment with vitamin A and 41 formed a control group. INTERVENTION: Children were given a single oral dose of 200,000 IU of vitamin A plus 25 IU vitamin E or a control preparation of 25 IU vitamin E. MAIN OUTCOME MEASURES: Clinical cure on study day 5 and bacteriological cure. RESULTS: Baseline characteristics of the subjects in the two treatment groups were similar. Significantly more children in the vitamin A group than in the control group achieved clinical cure (19/42 (45%) v 8/14 (20%); chi 2 = 5.14, 1 df, P = 0.02; risk ratio = 0.68 (95% confidence interval; 0.50 to 0.93)). When cure was determined bacteriologically, the groups had similar rates (16/42 (38%) v 16/41 (39%); chi 2 = 0.02, 1 df, P = 0.89; risk ratio = 0.98 (0.70 to 1.39)). CONCLUSIONS: Vitamin A reduces the severity of acute shigellosis in children living in areas where vitamin A deficiency is a major public health problem.

Chronic energy deficiency in women from rural Bangladesh: some socioeconomic determinants

Abstract: This paper explores a number of socioeconomic factors thought to explain the wide prevalence of undernutrition among rural Bangladeshi women. The 1992 baseline survey data of the BRAC-ICDDR,B Joint Research Project at Matlab were used. Anthropometry was performed on a random sub-sample of 1462 currently married, non-pregnant women between 15 and 49 years of age. Women's nutritional status was defined in terms of Body Mass Index (BMI = wt in kg/ht in m2). Compared with women from better-off households, the mean weight (41.2 vs 43.0 kg; p < 0.0001), mid-upper arm circumference (MUAC) (22.1 vs 22.7; p < 0.0001), and BMI (18.5 vs 19.1; p < 0.0001) of poor women were consistently lower. However, no significant difference in mean height was found between the two groups. The results showed that women aged more than 35 years are twice as likely to have a BMI < 18.5 compared with younger women. Both years of schooling received and socioeconomic status are found to be important predictors of women's BMI. Women who have received one or more years of formal education are nearly half as likely to suffer chronic energy deficiency (BMI < 18.5) than women with no schooling. Again, better-off women are found to be 0.77 times less likely to have chronic energy deficiency than women from poor households. The implications of these findings in improving the nutritional status of rural Bangladeshi women are discussed.

Treatment of Helicobacter pylori infection in infants in rural Bangladesh with oral immunoglobulins from hyperimmune bovine colostrum

Abstract: Background: Antibodies from hyperimmune bovine colostrum have been shown to be effective in treatment against a variety of microorganisms, including Helicobacter pylori in adults. Aim: To test this form of treatment in a small group of H. pylori infected children in a periurban community in Bangladesh. Methods: Twenty-four infants, 4–29 months old (mean age 16.5 ± 7.7 months) and infected with H. pylori, were treated with purified immunoglobulins from hyperimmune bovine colostrum for 1 month, in a placebo-controlled, double-blind pilot study. Diagnosis was established with 13C-urea breath test (UBT) before and after the treatment period and at a 1-month follow-up. Results: None of the hyperimmune bovine colostrum-treated children became UBT negative. Five children initially positive in the UBT screening spontaneously became negative by the start of the study with hyperimmune bovine colostrum/placebo. At the end of the 1-month study period, three had became positive again. Conclusion: Hyperimmune bovine colostrum does not eradicate H. pylori infection in infants. Transient H. pylori infection is common among infants in high endemic areas, as is reinfection after clearance. This presents obstacles to evaluation of therapeutic investigations in young children in areas where H. pylori is prevalent.

The Census-Based, Impact-Oriented Approach: Its Effectiveness in Promoting Child Health in Bolivia

Abstract: This paper describes the effectiveness for child health of a primary health care approach developed in Bolivia by Andean Rural Health Care and its colleagues, the census-based, impact-oriented (CBIO) approach. Here, we describe selected achievements, including child survival service coverage, mortality impact, and the level of resources required to attain these results. As a result of first identifying the entire programme population through visits at least biannually to all homes and then targeting selected high-impact services to those at highest risk of death, the mortality levels of children under five years of age in the established programme areas was one-third to one-half of mortality levels in comparison areas. Card-documented coverage for the complete series of all the standard six childhood immunizations among children 12-23 months of age was 78%, and card-documented coverage for three nutritional monitorings during the previous 12 months among the same group of children was 80%. Coverage rates in comparison areas for similar services was less than 21%. The local annual recurring cost of this approach was US $8.57 for each person (of all ages) in the programme population. This cost includes the provision of primary care services for all age groups as well as targeted child survival services. This cost is well within the affordable range for many, if not most, developing countries. Manpower costs for field staff in Bolivia are relatively high, so in countries with lower salary scales, the overall recurring cost could be substantially less. An Expert Review Panel reviewed the CBIO approach and found it to be worthy of replication, particularly if stronger community involvement and greater reliance on volunteer or minimally paid staff could be attained. The results of this approach are sufficiently promising to merit implementation and evaluation in other sites, including sites beyond Bolivia.

Why Include Men? Establishing Sexual Health Clinics for Men in Rural Bangladesh

Abstract: Subsequent to recommendations from the 1994 United Nations International Conference on Population and Development, and given recent findings outlining the links between control of sexually transmitted infections (STIs) and a reduction in HIV incidence, many countries are now seeking to establish STI control programmes. In many cases this is through a policy of providing comprehensive reproductive health care through the maternal and child health/family planning (MCH-FP) system. This involves management of all reproductive tract infections including STIs. This paper demonstrates how such an approach may miss one of the largest target groups--men. In general, men are at higher risk of initially contracting STIs, but, once infected, their clinical management is usually simpler than treating equivalent infections in women. It is argued that these two factors alone make the inclusion of men in STI control programmes critical. The paper outlines the experiences of one programme in rural Bangladesh in establishing sexual health clinics for men within the existing service structure. In response to client demand, the clinics moved beyond simple STI care towards provision of comprehensive sexual health services. Finally, the paper argues that whilst including men in sexual health programmes should never be at the expense of providing services for women, excluding them from service provision may make the objectives of STI control programmes unattainable.

Increasing frequency of mecillinam-resistant shigella isolates in urban Dhaka and rural Matlab, Bangladesh: a 6 year observation.

Abstract: A total of 14915 shigella isolates obtained in 1991–1996 from patients attending the Dhaka (urban) and Matlab (rural) treatment centres of the International Centre for Diarrhoeal Disease Research Bangladesh were examined for susceptibility to ampicillin co-trimoxazole nalidixic acid mecillinam and ciprofloxacin by a disc diffusion method. There were no ciprofloxacinresistant shigella isolates. The prevalence of resistance to ampicillin co-trimoxazole and nalidixic acid varied between isolates. It increased to similar degrees in isolates from both Matlab and Dhaka. However resistance to mecillinam was more prevalent among isolates from Matlab than from Dhaka. The increase in mecillinam-resistant shigellae in the community may have grave implications for the empirical treatment of shigellosis in Bangladesh and other developing countries. (authors)

Detection of Shigellae from stools of dysentery patients by culture and polymerase chain reaction techniques.

Abstract: In Bangladesh, the isolation rates of Shigella spp. range from 11% to 12% by the conventional culture technique. Since the sensitivity of this technique is low, the polymerase chain reaction (PCR) technique was used for detecting small number of Shigellae from patients' stools. Sensitivity and specificity of the two techniques were also compared. Stool samples were collected from 41 patients with dysentery who attended the Clinical Research and Service Centre of the ICDDR,B: Centre for Health and Population Research. All stool specimens were directly plated onto MacConkey, Salmonella-Shigella, Xylose lysin deoxycholate and Hectoen enteric agar media, and Shigellae were detected following standard procedures. DNA was extracted from the stool samples, and the target sequence of invasive plasmid antigen (ipa)H locus was amplified by PCR with 130 ng each of two primers (primer H8 [5'-GTTCCTTGACCGCCTTTCCGATAC-3'] and primer H15 [5'-GCCGGTCAGCCACCCTA-3']) following standard procedures. The amplified product was hybridized using an ipaH probe. The isolation rates of Shigella dysenteriae type 1, S.flexneri, S. sonnei, and S. boydii were, respectively, 17.1%, 19.5%, 4.9% and 2.4% by the conventional method. The results of the PCR technique showed that 700 bp fragment was generated in 18 of the 18 culture-positive and in 7 of the 23 culture-negative stools. One hundred twenty-three strains of Escherichia coli were also tested by PCR for identifying the enteroinvasive E. coti, but none of them yielded any positive result This study showed that the sensitivity of the culture technique is 72% and specificity is 100%, when the PCR technique was considered as gold standard. Therefore, the PCR may be considered a more sensitive and specific technique than the conventional culture technique and has the potential to be employed in routine diagnosis of dysentery in clinical centres as well as in epidemiologic studies.

Helicobacter pylori colonization in infants and young children is not necessarily associated with diarrhoea

Abstract: A cohort of 151 infants and young children aged 1-23 months from a poor peri-urban community of Bangladesh was studied to determine the relationship between Helicobacter pylori colonization and morbidity due to diarrhoea. A 13C urea breath test was performed to detect the presence of H. pylori. Children were followed up at home every alternate day for 6 months and diarrhoeal morbidity data were collected. Diarrhoeal morbidity was compared between H. pylori-positive and H. pylori-negative children. Sixty-eight (45 per cent) children were H. pylori positive and 83 (55 per cent) were H. pylori negative. During the first 1-month period following the breath test, three (4.4 per cent) H. pylori-positive and four (4.8 per cent) H. pylori-negative children had diarrhoea. Thirty-two (47 per cent) of the children in the positive group and 43 (52 per cent) in the negative group had one or more episodes of diarrhoea during the 6-month follow-up period. Median number of diarrhoeal episodes was 1.0 (range 1.0-4.0) in the H. pylori-positive children and 2.0 (range 1.0-5.0) in the H. pylori-negative children (p = 0.19). No significant difference was observed in the cumulative days with diarrhoea. The results of this study suggest that H. pylori colonization is not associated with diarrhoeal morbidity in infants and young children.

Association of Providencia alcalifaciens with diarrhea in children.

Abstract: It has been demonstrated in previous studies that Providencia alcalifaciens can produce diarrhea by an invasive mechanism. In the present study, P. alcalifaciens was isolated from the stool specimens of 17 of 814 diarrheal children younger than 5 years of age (2.1%) and from those of 4 of 814 matched controls (0.49%) (P = 0.004), indicating that the organism is significantly associated with diarrhea. However, 71% of P. alcalifaciens-positive diarrheal children had simultaneous infections with other recognized enteric pathogens.

Increased Height Gain of Children Fed a High-Protein Diet during Convalescence from Shigellosis: A Six-Month Follow-Up Study

Abstract: The impact of dietary supplementation on catch-up growth was evaluated in 69 malnourished children ages 24–60 mo after recovery from shigellosis. They were fed either a high-protein (HP) diet with 15% of energy as protein or a standard-protein (SP) diet with 7.5% energy as protein for 3 wk in a metabolic study ward. Children were followed up bi-weekly for 6 mo by trained health assistants when anthropometric measurements and information of any illness were collected. Thirty-one children in the HP group and 28 children in the SP group completed 6-mo follow-up. The increase in height (mean ± SD) was 5.3 ± 1.0 cm vs. 4.1 ± 1.1 cm for HP and SP groups respectively (P < 0.001) whereas increase in body weight was 1.39 ± 0.58 and 1.29 ± 0.72 kg for children fed HP and SP respectively (P = 0.59). The proportion of children who were severely stunted (< 02 SD height-for-age) decreased from 45 to 29% in the HP group compared to 50 to 46% in the SP group (P < 0.05) at 6-mo follow-up. The number of diarrheal episodes per child tended to be lower in the HP vs. SP than in the SP group (1.9 vs. 2.3 P = 0.41). These results demonstrate that feeding an HP diet to the malnourished children during recovery from shigellosis enhanced linear growth with a modest reduction in diarrheal morbidity during the 6-mo follow-up period. (authors)

Enteric Infections in an Endemic Area Induce a Circulating Antibody-Secreting Cell Response with Homing Potentials to Both Mucosal and Systemic Tissues

Abstract: Enteric infections induce a response of circulating pathogen-specific antibody-secreting cells (ASC). The expression of homing receptors (HRs) on these cells was studied in patients with diarrhea caused by Vibrio cholerae in Bangladesh, an area in which cholera is endemic. The gut HR, alpha4beta7, was expressed by approximately 80% of the ASC, indicating mucosal homing of these cells. However, the peripheral lymph node HR, L-selectin, was also expressed by approximately 80% of the ASC specific to either cholera toxin or O antigen. In earlier findings after oral immunization in nonendemic areas, alpha4beta7 has been expressed by approximately 100% and L-selectin by approximately 50% of the ASC. In comparison, the present data speak for a more systemic targeting of the immune response associated with long-lasting immunity in an endemic area. The results thus provide insight for the continued development and evaluation of vaccines.

A randomized clinical trial to compare the efficacy of erythromycin, ampicillin and tetracycline for the treatment of cholera in children

Abstract: To compare the clinical outcome of treatment of cholera in children with ampicillin, erythromycin or tetracycline, a double-'blind' randomized four-cell trial was carried out in Bangladesh. Ampicillin was chosen as additional therapy for acute respiratory tract infection, present in many subjects with diarrhoea. One hundred and eighty-four children aged 1-5 years who were not wasted, with diarrhoea of duration 4 mL/kg/h over 6 h were enrolled in the study. Ampicillin, tetracycline, erythromycin or placebo were given orally every 6 h for 3 d. After 3 d of antibiotic treatment, diarrhoeal stool volume was significantly reduced in all antibiotic groups, with mean volumes per kg body weight as follows: tetracycline, 318 mL (SEM = 50), ampicillin, 335 mL (SEM = 30); erythromycin, 323 mL (SEM = 25); placebo, 498 mL (SEM = 37). Compared to tetracycline, the clinical recovery rates by 96 h were 75% with placebo, 91.3% with ampicillin, and 95.7% with eythromycin. Compared to tetracycline, the total mean times to recovery were increased by 66% with placebo (P < 0.001), 25% with ampicillin (P < 0.017), and 9% with erythromycin (P = 0.37). These results indicated comparable clinical efficacy of tetracycline, ampicillin and erythromycin. We therefore recommend that, unless V. cholerae is resistant, ampicillin should be used as a cost-effective alternative to erythromycin for paediatric cholera, especially in children with concomitant acute respiratory infection.

The Effect of Child Mortality on Fertility Regulation in Rural Bangladesh

Abstract: This study analyzes longitudinal data from Matlab, Bangladesh, to examine the impact of child mortality on subsequent contraceptive acceptance and continuation. The strong negative impact isfound to attenuate withfamily size, indicating a "replacement effect." An "insurance effect" is observed as contraceptive acceptance and continuation were negatively associated with the number of previous deaths of children. Couples seem tofind contraceptive use acceptable if the child who dies is one of a largefamily. Potentially, contraceptive use could be acceptablefor spacing after a child in a small family dies. Family planning programs can help to reducefertility and maternal and child health risks substantially by supplying appropriate methods to those couples who have experienced a young child's death; to be most effective, methods should be supplied immediately after the child's death. (STUDIES IN FAMILY PLANNING 1998; 29,3: 268-281)

Antibody responses in humans against coli surface antigen 6 of enterotoxigenic Escherichia coli.

Abstract: Enterotoxigenic Escherichia coli (ETEC) strains expressing only coli surface antigen 6 (CS6) have previously been isolated from patients with diarrhea, but the immunogenicity of CS6 has not been established in humans. We have detected CS6-specific immunoglobulin A responses in the feces and blood of patients convalescing from natural ETEC disease and of volunteers given an oral ETEC vaccine.

Shigellosis in children: a clinico-epidemiological comparison between Shigella dysenteriae type I and Shigella flexneri.

Abstract: We reviewed the clinical and epidemiological features of 390 children under 5 years of age infected with either Shigella dysenteriae type I or Shigella flexneri attending a diarrhoea treatment centre from 1993 to 1995 in Dhaka, Bangladesh. Older age (24 months or more), underweight and wasting but not stunting were the host factors significantly more associated with Shigella dysenteriae type I infection than in Shigella flexneri-infected children. Moreover, use of antibiotics at home, use of water from tubewells or pipe-water for drinking and lack of sanitary facilities for defaecation were the behavioural and environmental factors strongly associated with S. dysenteriae type I infection. Children with diarrhoea due to S. flexneri presented with more watery/liquid stools and had a shorter duration of illness. Duration of diarrhoea for 4 or more days was typical of S. dysenteriae type I infection. Interventions to address malnutrition and to promote environmental hygiene would be predicted to offer greater protection against shigellosis due to S. dysenteriae than S. flexneri.

Women's health priorities: cultural perspectives on illness in rural Bangladesh:

Abstract: This article reports on a study of womens perceptions of illness in rural Bangladesh. The introduction notes that until recently international research efforts have neglected womens reproductive and sexual health issues and that qualitative methods are appropriate for determining the explanatory models of illness and health operating in a particular culture. This study therefore sought to let women themselves identify salient illness categories illness severity health priorities and health care preferences. After describing the Bangladeshi setting the research methodology is detailed. Data were gathered from a sample of 35 women from a "comparison" (nontreatment) community of the International Centre for Diarrhoeal Disease Research via a variety of qualitative methods including free listing pile sorting and severity ratings (all analyzed using the ANTHROPAC computer program) as well as in-depth interviews. Free listing revealed the prominence of reproductive health-related problems to women and multidimensional scaling of pile sorting results revealed that reproductive health problems are believed to occupy a discrete illness domain. Severity ratings showed that reproductive health problems are among the most serious health problems facing women. Thus the women were proactive about seeking treatment as illustrated in a case study of a 24-year-old women with a reproductive tract infection. It is concluded that contrary to stereotypes reproductive health problems are a major concern for rural Bangladeshi women who require new public health initiatives to meet their needs.

A comprehensive assessment of the quality of immunization services in one major area of Dhaka City, Bangladesh.

Abstract: This report assesses the quality of service inputs, service processes and service outcomes (with the exception of coverage and effectiveness) for immunization services in Zone 3 of Dhaka City. The results indicate that in general, the providers of immunization services are knowledgeable, friendly and give technically appropriate immunizations. Client ratings of the quality of services are quite good. Access is 90% for childhood immunizations and 89% for tetanus toxoid (TT) immunizations for women with a child < 1 year old. Three areas were identified as needing attention: frequently missed opportunities for the promotion or provision of immunizations; uneven distribution and utilization of immunization sites, and some fundamental weaknesses of the TT immunization programme (lack of awareness among women of reproductive age about the importance of TT immunization, low access to it among women of reproductive age who do not have a child < 1 year of age, and confusion among women and service providers about the purpose of TT immunization and the dosage schedule). Efforts to monitor and strengthen the quality of EPI activities will facilitate further decline in the numbers of deaths and illnesses from vaccine-preventable diseases. The approaches used in this study and the typology for quality assessment are widely applicable elsewhere.

Determinants of contraceptive use among married teenage women and newlywed couples.

Abstract: This study examines the sociodemographic and programmatic determinants of contraceptive use and nonuse among married teenage women and newly wed couples in Bangladesh. Data collected from surveys were conducted from September to December 1993 and from October 1994 to June 1995 among 13515 rural married women of reproductive age in six rural thanas of Bangladesh. The association between contraceptive use and the demographic socioeconomic and programmatic variables with emphasis on contraceptive use behavior of the newlyweds (couples married less than 3 years) and married teenage women less than 20 years old were assessed using cross-tabulations and logistic regression. Findings revealed that fieldworker contact rates were substantially lower for teenage married women and newlyweds compared to other age groups. Most of the teenage and newlywed women who have yet to give birth are highly unlikely to use contraception because most of them would want to have children immediately. Furthermore current nonusers intention to use modern contraceptives in the future was significantly higher among teenage married women than older nonusing women. Moreover once teenage women and newlyweds have a child contraceptive use prevalence increases to a level comparable to women in their 20s. This study recommends that family planning workers should pay more attention to newlyweds and teenage married women. Teenage and newlywed women need counseling on appropriate contraceptive methods and on the social and health advantages of delayed childbearing.

Antimicrobial Therapy for Shigellosis: Issues on Antimicrobial Resistance

Abstract: Shigellosis is an infectious disease of global importance, and also an important cause of traveler's diarrhea (1). Although improved public health measures have greatly reduced its incidence in the developed countries where the disease is now sporadic, it continues to be a major cause of childhood morbidity, deaths and growth-faltering in the developing world where epidemic form of the disease is associated with increased morbidity and deaths (1-5). S. dysenteriae, S. flexneri, S. boydii and S. sonnei are the four species of Shigella which together have over 45 serotypes. S. dysenteriae type 1, the epidemic serotype in the developing countries, causes the most severe form of the disease as well as more complications, and is also the most efficient in acquiring antimicrobial resistance (1, 6, 7). S. flexneri, endemic in many developing countries, causes a disease of intermediate severity, and S. sonnei, prevalent in the developed countries, generally causes a milder, non-dysenteric form of illness, however, is also efficient in acquiring antimicrobial resistance (1, 8, 9).