We assessed 188 children diagnosed with extrapulmonary tuberculosis in Bangladesh. Over half were aged 10-14 years old. Common symptoms included fever (91.5%), weight loss (88.3%), and decreased appetite (72.9%). Four children died prior to treatment; of 176 children on treatment, 4.0% had unsuccessful outcomes, potentially influenced by age and low weight. Findings highlight the need for improved diagnosis and management in children.

Despite the crucial role of private healthcare facilities globally, little research compares pediatric tuberculosis (TB) services across public and private sectors. Public facilities generally adhere to national TB guidelines, while private clinicians may tailor care more flexibly, resulting in variable service quality. Cascade analysis is well-suited to comparing care delivery across providers and sectors but has not been used to compare pediatric TB care between public and private facilities. We applied cascade analysis to evaluate and compare pediatric TB services – including screening, diagnosis, and treatment – across facilities in Mymensingh Division, Bangladesh. Between 2018 and 2021, an intensified pediatric TB screening initiative was conducted in Mymensingh Division, Bangladesh. In this retrospective cohort analysis, we compared completion of the care cascade, consisting of screening, evaluation, diagnosis, treatment initiation, and treatment success, across public and private facilities, and by facility level (primary vs. tertiary). Of 842,203 children screened, 670,833 were in 79 public facilities and 171,370 in 47 private facilities. Private facilities had higher percentages of children screening positive (3.4

Pediatric extrapulmonary tuberculosis (EPTB) remains under-recognized due to biological, diagnostic, and systemic barriers. This Perspective outlines pragmatic, multilevel strategies-spanning frontline clinics to national systems-to strengthen diagnosis, reporting, and visibility of pediatric EPTB across diverse health settings.

Background Programmatic interventions to increase the detection of children with tuberculosis (TB) are rarely evaluated to understand age- and sex-specific completion rates. We applied modified TB screening and treatment cascade frameworks to assess indicators of effective implementation by age and sex of a TB screening program for children (zero to 14 years) in Bangladesh. Methods We implemented an intensified screening program for paediatric TB detection in 119 health care facilities (2018-21). We followed systematic verbal screening by referral for full evaluation for children who reported symptoms or contact history with a patient with TB. Further, we linked children to treatment if diagnosed and followed for outcomes. We calculated the percentage of children, by age and sex, progressing through each step of the care cascade and compared the frequency of step completion by sex using chi(2) tests. Results In total, we screened 552 182 males and 461 419 females for TB. 2.8% of males and 2.6% of females screened positive (P < 0.001). 74.2% of males and 73.9% of females underwent appropriate evaluation (P = 0.560). 10.3% of males and 11.5% of females were diagnosed with TB (P = 0.008). 100% of children initiated treatment, and 97.6% of males and 97.1% of females achieved a successful treatment outcome (P = 0.428). The percent of children screening positive on verbal screen, who were clinically evaluated for TB, and who were diagnosed with TB generally increased with age, with some variability throughout (ranges: 1.2-9.1%, 59.8-88.5%, 6.5-21.9%, respectively). Conclusions The largest gap observed for both sexes and among all ages was children who were not appropriately evaluated for TB despite screening positive. In our research, we highlight the value of identifying gaps in paediatric TB care to inform innovative, age- and sex-tailored interventions to improve future care in children.

Abstract Background Bangladesh has a high tuberculosis (TB) burden, accounting for 4% of pediatric patients estimated to have TB globally. Obtaining microbiological confirmation of disease in children is challenging; in lieu of this, diagnosis often relies on the presence of symptoms, exposure history, physical examination, and a variety of other test results, such as chest x-rays and tuberculin skin tests (TST). We evaluate the contribution of TST to pediatric TB diagnoses. Methods An enhanced patient-finding initiative was implemented across 109 facilities in Mymensingh division, Bangladesh (2018-2021) to improve pediatric TB detection. Among children who screened positive on systematic verbal symptom screening and whose subsequent evaluation for TB disease included TST, we report the discriminatory properties of TST for TB diagnosis. We compare patient characteristics between children with positive and negative TST results using chi-squared/Fisher’s exact test. Results Of 20,209 children who screened positive on verbal symptom assessment and were further evaluated for disease, 7,318 (36.2%) patients had TST, of which 1598 (21.8%) were diagnosed with TB disease. Discriminatory properties of TST were: sensitivity of 42.2% (95% Confidence Interval: 39.8-44.7%), specificity of 92.4% (91.7-93.1%), PPV of 60.9% (58.3-63.4%), and NPV of 85.1% (84.6-85.7%) (Table 1). A total of 648 (40.6%) children with TB and 364 (6.4%) children without TB had an induration diameter of >10mm (Table 2). Among children diagnosed with TB, fewer males (p=0.01) and children aged 5-9 years (p< 0.01), and more children aged 10-14 years (p< 0.01), underweight (p< 0.01), presenting with night sweats (p=0.02) and decreased appetite (p=0.04), and had a chest x-ray (p< 0.01) or smear (p=0.01) suggestive of TB disease had a positive-TST result compared to children with negative-TST results. Among children with a negative TST result, those who were underweight were diagnosed with TB more often than those not underweight (p< 0.01) (Table 3). Conclusion TST can be a clinically helpful part of diagnostic algorithms for children. Given its high specificity and NPV, TST can be combined with an evaluation of clinical symptoms and diagnostic studies to help diagnose or rule out disease in children at risk of TB. Disclosures Amyn Malik, MBBS, MPH, PhD, Analysis Group, Inc: Former Employee. Worked as a consultant with Pharma and Biotech for research studies

Background: The United Nations high-level meeting (UNHLM) pledged to enroll 30 million in tuberculosis preventive treatment (TPT) by 2022, necessitating TPT expansion to all at tuberculosis (TB) risk. We assessed the uptake and completion of a 12-dose, weekly isoniazid–rifapentine (3HP) TPT regimen. Methods: Between February 2018 and March 2019 in Dhaka, community-based TPT using 3HP targeted household contacts of 883 confirmed drug-sensitive pulmonary TB patients. Adhering to World Health Organization guidelines, contacts underwent active TB screening before TPT initiation. Results: Of 3193 contacts who were advised health facility visits for screening, 67% (n = 2149) complied. Among these, 1804 (84%) received chest X-rays. Active TB was diagnosed in 39 (2%) contacts; they commenced TB treatment. Over 97% of 1216 contacts began TPT, with completion rates higher among females, those with more education and income, non-slum residents, and those without 3HP-related adverse events. Adverse events, mainly mild, occurred in 5% of participants. Conclusions: The 3HP regimen, with its short duration, self-administered option, and minimal side effects, achieved satisfactory completion rates. A community-focused TPT approach is feasible, scalable nationally, and aligns with UNHLM targets.

BACKGROUND:Bangladesh has a shortfall of health professionals. The World Health Organization states that improving education will increase recruitment and retention of health workers. Traditional learning approaches, in medical education particularly, focus on didactic teaching, teaching of subjects and knowledge testing. These approaches have been superseded in some programmes, with a greater focus on active learning, integrated teaching and learning of knowledge, application, skills and attitudes or values and associated testing of competencies as educational outcomes. In addition, some regions do not have continuous professional development or clinical placements for health worker students, contributing to difficulties in retention of health workers. This study aims to explore the experiences of health professional education in Bangladesh, focusing on what is through observation of health professional education sessions and experiences of educators.METHODS:This mixed method study included 22 observations of teaching sessions in clinical and educational settings, detailed analysis of 8 national curricula documents mapped to Global Competency and Outcomes Framework for Universal Health Coverage and 15 interviews of professionals responsible for health education. An observational checklist was created based on previous literature which assessed training of within dimensions of basic clinical skills; diagnosis and management; professionalism; professional development; and effective communication. Interviews explored current practices within health education in Bangladesh, as well as barriers and facilitators to incorporating different approaches to learning.RESULTS:Observations revealed a variety of approaches and frameworks followed across institutions. Only one observation included all sub-competencies of the checklist. National curricula documents varied in their coverage of the Global Competency and Outcomes Framework domains. Three key themes were generated from a thematic analysis of interview transcripts: (1) education across the career span; (2) challenges for health professional education; (3) contextual factors and health professional education. Opportunities for progression and development post qualification are limited and certain professions are favoured over others.CONCLUSION:Traditional approaches seem to predominate but there is some enthusiasm for a more clinical focus to education and for more competency based approaches to teaching, learning and assessment.

Background: The UNHLM pledged to enroll 30 million in TB preventive treatment (TPT) by 2022, necessitating TPT expansion to all at TB risk. We assessed uptake and completion of a 12-dose, weekly isoniazid-rifapentine (3HP) TPT regimen. Methods: Between February 2018 - March 2019 in Dhaka, community-based TPT using 3HP targeted household contacts of 883 confirmed drug-sensitive pulmonary TB patients. Adhering to WHO guidelines, contacts underwent active TB screening before TPT initiation. Results: Of 3,193 contacts who advised health facility visits for screening, 67% (n=2,149) complied. Among these, 1,804 (84%) received chest X-rays. Active TB was diagnosed in 39 (2%) contacts; they commenced TB treatment. Over 97% of 1,216 contacts began 3HP TPT, with completion rates higher among females, those with more education and income, non-slum residents, and those without 3HP-related adverse events. Adverse events, mainly mild, occurred in 5% of participants. Conclusions: The 3HP weekly regimen, with its short duration, self-administered option, and minimal side effects, achieved satisfactory completion rates. A community-focused 3HP TPT approach is feasible, scalable nationally, and aligns with UNHLM targets.

Objectives. Decades of targeted violence, statelessness, and persecution have caused more than a million Rohingyas to flee their homes to Bangladesh. Although basic assistance is being provided, these refugees are living in highly challenging circumstances. The burden of mental health among these refugees is believed to be widespread; however, the extent of these problems is yet to be fully ascertained. We, therefore, conducted a qualitative study to explore the mental health status and psychosocial support among the Rohingya refugees. Methods. A participatory, qualitative research was conducted among the Rohingya refugees, guided by a multidisciplinary team of experts. A mix of purposive sampling, snowball sampling, and random sampling techniques was applied. The participants were randomly selected to ensure the representation of vulnerable groups and physically disabled people. Data were collected by using pretested semi-structured questionnaire and a health facility assessment checklist. The data were analysed using SPSS (version 24) and thematic content analysis techniques. Results. There is a high prevalence of mental health and psychological problems among the Rohingya refugees, but most of the problems are hidden or remained unnoticed. Daily stressors were found to be widespread and associated with social insecurity, lack of livelihood opportunities, and past trauma history of the participants. Conclusions. Stigma and cultural interpretation of mental health among Rohingya are unique and are different from the host population of Bangladesh. To address such huge and challenging problems, all partners working in the humanitarian assistance and development programs in Bangladesh need to provide integrated, effective, and culturally appropriate services to the Rohingya population.

Background Missed opportunities for vaccination (MOVs), that is, when children interact with the health system but fail to receive age-eligible vaccines, pose a crucial challenge for equitable and universal immunization coverage. Inaccurate interpretations of complex catch-up schedules by health workers contribute to MOVs. Objective We assessed the feasibility of a mobile-based immunization decision support system (iDSS) to automatically construct age-appropriate vaccination schedules for children and to prevent MOVs. Methods A sequential exploratory mixed methods study was conducted at 6 immunization centers in Pakistan and Bangladesh. An android-based iDSS that is packaged in the form of an application programming interface constructed age-appropriate immunization schedules for eligible children. The diagnostic accuracy of the iDSS was measured by comparing the schedules constructed by the iDSS with the gold standard of evaluation (World Health Organization–recommended Expanded Programme on Immunization schedule constructed by a vaccines expert). Preliminary estimates were collected on the number of MOVs among visiting children (caused by inaccurate vaccination scheduling by vaccinators) that could be reduced through iDSS by comparing the manual schedules constructed by vaccinators with the gold standard. Finally, the vaccinators’ understanding, perceived usability, and acceptability of the iDSS were determined through interviews with key informants. Results From July 5, 2019, to April 11, 2020, a total of 6241 immunization visits were recorded from 4613 eligible children. Data were collected for 17,961 immunization doses for all antigens. The iDSS correctly scheduled 99.8% (17,932/17,961) of all age-appropriate immunization doses compared with the gold standard. In comparison, vaccinators correctly scheduled 96.8% (17,378/17,961) of all immunization doses. A total of 3.2% (583/17,961) of all due doses (across antigens) were missed in age-eligible children by the vaccinators across both countries. Vaccinators reported positively on the usefulness of iDSS, as well as the understanding and benefits of the technology. Conclusions This study demonstrated the feasibility of a mobile-based iDSS to accurately construct age-appropriate vaccination schedules for children aged 0 to 23 months across multicountry and low- and middle-income country settings, and underscores its potential to increase immunization coverage and timeliness by eliminating MOVs.

Background: Bangladesh is being the commissioner for oaths to vision 2020, a global campaign for elimination of avoidable blindness by 2020, formulated a national eye care plan. This report illustrates the present status of Bangladesh eye health care service using eye care service assessment tool (ECSAT) that assesses an eye health system across six ‘building blocks’ of a health system.Methods: The study followed a mixed method to collect data. World health organization (WHO) standard ECSAT was used to gather information on eye care service. A purposive sampling method was used. Data from the assessment were extracted and all the information was cross-checked with leading stakeholders of ministry of health.Results: Eye care planning is led by the national eye care. There is a national eye health action plan and a national eye health coordination office under the ministry of health. The health delivery system includes primarily government and non-profit facilities with eight hospitals delivering specialist eye care services across the country. A significant proportion of eye care is provided through community outreach camps and a network of primary and community health workers. The national cataract surgical rate (CSR) is estimated at 2600 per million populations per year.Conclusions: This assessment suggests that although Bangladesh has made some progress towards elimination of avoidable blindness, it would be difficult to retain without further significant investment with a transparent accountability framework in eye health considering all limitation and contemporary challenges.

The global fight against tuberculosis (TB) has gained momentum since the adoption of the ‘End TB Strategy’ in 2014 [...]

Abstract We developed a novel method to align two data sources (TB notifications and the Demographic Health Survey, DHS) captured at different geographic scales. We used this method to identify sociodemographic indicators – specifically population density – that were ecologically correlated with elevated TB notification rates across wards (~100 000 people) in Dhaka, Bangladesh. We found population density was the variable most closely correlated with ward-level TB notification rates (Spearman's rank correlation 0.45). Our approach can be useful, as publicly available data (e.g. DHS data) could help identify factors that are ecologically associated with disease burden when more granular data (e.g. ward-level TB notifications) are not available. Use of this approach might help in designing spatially targeted interventions for TB and other diseases in settings of weak existing data on disease burden at the subdistrict level.

Purpose: Tuberculosis (TB) is geographically heterogeneous, and geographic targeting can improve the impact of TB interventions. However, standard TB notification data may not sufficiently capture this heterogeneity. Better understanding of patient reporting patterns (discrepancies between residence and place of presentation) may improve our ability to use notifications to appropriately target interventions. Methods: Using demographic data and TB reports from Dhaka North City Corporation and Dhaka South City Corporation, we identified wards of high TB incidence and developed a TB transmission model. We calibrated the model to patient-level data from selected wards under four different reporting pattern assumptions and estimated the relative impact of targeted versus untargeted active case finding. Results: The impact of geographically targeted interventions varied substantially depending on reporting pattern assumptions. The relative reduction in TB incidence, comparing targeted with untargeted active case finding in Dhaka North City Corporation, was 1.20, assuming weak correlation between reporting and residence, versus 2.45, assuming perfect correlation. Similar patterns were observed in Dhaka South City Corporation (1.03 vs. 2.08). Conclusions: Movement of individuals seeking TB diagnoses may substantially affect ward-level TB transmission. Better understanding of patient reporting patterns can improve estimates of the impact of targeted interventions in reducing TB incidence. Incorporating high-quality patient-level data is critical to optimizing TB interventions. (C) 2020 Elsevier Inc. All rights reserved.

In rapidly growing and high-burden urban centres, identifying tuberculosis (TB) transmission hotspots and understanding the potential impact of interventions can inform future control and prevention strategies. Using data on local demography, TB reports and patient reporting patterns in Dhaka South City Corporation (DSCC) and Dhaka North City Corporation (DNCC), Bangladesh, between 2010 and 2017, we developed maps of TB reporting rates across wards in DSCC and DNCC and identified wards with high rates of reported TB (i.e. 'hotspots') in DSCC and DNCC. We developed ward-level transmission models and estimated the potential epidemiological impact of three TB interventions: active case finding (ACF), mass preventive therapy (PT) and a combination of ACF and PT, implemented either citywide or targeted to high-incidence hotspots. There was substantial geographic heterogeneity in the estimated TB incidence in both DSCC and DNCC: incidence in the highest-incidence wards was over ten times higher than in the lowest-incidence wards in each city corporation. ACF, PT and combined ACF plus PT delivered to 10% of the population reduced TB incidence by a projected 7%-9%, 13%-15% and 19%-23% over five years, respectively. Targeting TB hotspots increased the projected reduction in TB incidence achieved by each intervention 1.4- to 1.8-fold. The geographical pattern of TB notifications suggests high levels of ongoing TB transmission in DSCC and DNCC, with substantial heterogeneity at the ward level. Interventions that reduce transmission are likely to be highly effective and incorporating notification data at the local level can further improve intervention efficiency.

Globally, eye diseases are considered as one of the major contributors of nonfatal disabling conditions. In Bangladesh, 1.5% of adults are blind and 21.6% have low vision. Therefore, this paper aimed to identify the community-based prevalence and associated risk factors of eye diseases among slum dwellers of Dhaka city. The study was carried out in two phases. In the first phase, a survey was conducted using multistage cluster sampling among 1320 households of three purposively selected slums in Dhaka city. From each household, one family member (≥ 18 years old) was randomly interviewed by trained data collectors using a structured questionnaire. After that, each of the participants was requested to take part in the second phase of the study. Following the request, 432 participants out of 1320 participants came into the tertiary care hospitals where they were clinically assessed by ophthalmologist for presence of eye diseases. A number of descriptive and inferential statistics were performed using Stata 13. The majority of total 432 study participants were female (68.6%), married (82.6%) and Muslim (98.8%). Among them almost all (92.8%) were clinically diagnosed with eye disease. The most prevalent eye diseases were refractive error (63.2%), conjunctivitis (17.1%), visual impairment (16.4%) and cataract (7.2%). Refractive error was found significantly associated with older age, female gender and income generating work. Cataract was found negatively associated with the level of education, however, opposite relationship was found between cataract and visual impairment. Our study provides epidemiologic data on the prevalence of eye diseases among adult population in low-income urban community of Dhaka city. The high prevalence of refractive error, allergic conjunctivitis, visual impairment, and cataract among this group of people suggests the importance of increasing access to eye care services.

Objectives: To test a model of integrated pediatric eye care delivery and examine the prevalence and factors associated with childhood ocular morbidity in a peri-urban setting in Bangladesh. Study design: Cross-sectional, population-based study. Methods: The study was conducted in three phases among children aged <= 15 years. Trained community health workers (CHWs) conducted awareness intervention and identified children with ocular problems. These children were then referred to the base hospital for examination and treatment by ophthalmologists. A pediatric ophthalmologist further examined the children with complicated eye diseases and ensured treatment at a tertiary public eye hospital. Awareness, referral patterns, and health-seeking behavior were also examined. All data were analyzed statistically using Statistical Package for Social Sciences. Results: CHWs screened 33,549 eligible children and identified 1887 cases with ocular morbidity. The prevalence of ocular morbidity and childhood blindness were 5.63% (95% confidence interval [CI] = 5.27-6.16) and 0.060% (95% CI = 0.03-0.11), respectively. The most commonly observed ocular morbidities were refractive error (3.24%; 95% CI = 3.11 -3.45), allergic eye conditions (1.2%; 95% = CI 0.74-1.27), and nasolacrimal duct obstruction (0.52%; 95% CI = 0.25-0.74). Blindness was more frequently seen in children aged <5 years than in those aged 5-15 years (chi(2) = 7.25; P = 0.007). The causes of blindness were corneal opacity, congenital eye anomaly, cataract, retinopathy of prematurity, and retinoblastoma. The prevalence of ocular morbidity was higher among older children, boys, children with low parental education and income, and children from households dwelling in slums. Conclusions: This study demonstrated that in a setting where screening and treatment for vision problems remain low, ocular morbidity among children could be easily identified through well-designed community-based screening programs involving appropriately trained CHWs. Community mobilization, awareness, and early detection of childhood eye diseases, with effective referral mechanisms for accessing appropriate care, are crucially important to improve service delivery. (C) 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Background: As the proportion of deliveries in health institutions increases in low- and middle-income countries, so do the challenges of maintaining standards of hygiene and preventing healthcare-associated infections (HCAIs) in mothers and babies. Adequate water, sanitation, and hygiene (WASH) and infection prevention and control (IPC) in these settings should be seen as integral parts of the broader domain of quality care. Assessment approaches are needed which capture standards for both WASH and IPC, and so inform quality improvement processes. Design: A needs assessment was conducted in seven maternity units in Gujarat, India, and eight in Dhaka Division, Bangladesh in 2014. The WASH & CLEAN study developed and applied a suite of tools – a ‘walkthrough checklist’ which included the collection of swab samples, a facility needs assessment tool and document review, and qualitative interviews with staff and recently delivered women – to establish the state of hygiene as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual determinants or drivers. Results: No clear relationship was found between visually assessed cleanliness and the presence of pathogens; findings from qualitative interviews and the facility questionnaire found inadequacies in IPC training for healthcare providers and no formal training at all for ward cleaners. Lack of written policies and protocols, and poor monitoring and supervision also contributed to suboptimal IPC standards. Conclusions: Visual assessment of cleanliness and hygiene is an inadequate marker for ‘safety’ in terms of the presence of potential pathogens and associated risk of infection. Routine environmental screening of high-risk touch sites using simple microbiology could improve detection and control of pathogens. IPC training for both healthcare providers and ward cleaners represents an important opportunity for quality improvement. This should occur in conjunction with broader systems changes, including the establishment of functioning IPC committees, implementing standard policies and protocols, and improving health management information systems to capture information on maternal and newborn HCAIs.