3D CT Soft Tissue Craniofacial Analysis and Lip Morphology

ABSTRACT Objctive: To assess the soft tissue characteristics of Bangladeshi adults to formulate soft tissue 3D CT standards using Holdaway's (HA) and lip morphology (LM) analyses. Another aim of this study was to assess the gender dimorphism of Bangladeshi population. Material and Methods: One hundred and seventeen (Eighty-five men and Thirty-two women) Bangladeshi adults have obtained their computed tomography (CT) scan at the Radiology Department for normal diagnosis. Craniofacial deformities were undetected in all cases. The CT images were prepared by a 3D imaging programming software (Mimics 11.02 Materialise). Parameters from the identified landmark points were measured in 3D through this software. Results: Upper lip thickness (ULT) (vermillion UL-A point) measurement was significant in HA and in LM analyses, upper lip protrusion (ULP) (Ls to Sn-SPog) measurement has demonstrated significant difference among both genders, where p-value was less than 0.05. Mean measurements of Bangladeshi adults were relatively comparable except the face convexity (FC) when compared with the HA cephalometric soft tissue values. Conclusion: By using HA and LM analyses, 3D CT soft tissue standards were established for Bangladeshi adults. Measurements for all parameters have remained equivalent with the HA standard data apart from the FC measurement. This consequently may demonstrate that the Bangladeshi population retains a convex shape with a slight protrusive lip or retruded chin.

Type-2 Diabetes Mellitus Individuals Carry Different Periodontal Bacteria

ABSTRACT Objective: To identify etiologic microbiota associated periodontal diseases among diabetes patients and the factors related to the most commonly identified bacteria species. Material and Methods: Periodontal plaque samples from 11 diabetic participants and 13 non-diabetic controls were collected to assess their aerobic and anaerobic bacterial growth. Different distinct colonies were identified by microscopic and 16srDNA sequencing. Pearson's chi-square tests were conducted to examine any association between categorical variables. Results: The diabetic subjects revealed a more intense plaque formation with a mean plaque index of 2.4 compared to 1.8 in non-diabetics. A total of 86 bacteria were isolated from 24 plaque samples, 44 were aerobic, and 42 were anaerobic. Only aerobic isolates, 22 from diabetic patients and 22 from non-diabetic patients, were evaluated in these analyses. Bacillus spp. (B. cereus mainly) and Klebsiella spp. (K. pneumoniae, K. aerogenes, K. oxytoca) were detected markedly higher in non-diabetic individuals than in diabetic subjects (p=0.026 and p=0.021, respectively). Some bacteria were only identified in the dental plaque of diabetic individuals, namely, Bacillus mojavensis, Enterobacter cloacae, Proteus mirabilis, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus pasteuri, Streptococcus mutans, and Streptococcus pasteurianus. The presence of acid reflux and jaundice were significantly associated with the most common bacterial isolate, namely Bacillus spp., with the p-values of 0.007 and 0.001, respectively. Conclusion: Type-2 diabetes mellitus is associated with a higher amount of dental plaques. Periodontal plaque samples from diabetic and non-diabetic subjects possess differential microbial communities. Diabetic plaques contain more versatile microbes predominated by gram-positive streptococci and staphylococci.

Association between order of birth and chronic malnutrition of children: a study of nationally representative Bangladeshi sample / Associação entre ordem de nascimento e desnutrição crônica em crianças: estudo de uma amostra nacional representativa em Bangladesh / Asociación entre el orden de nacimiento y la desnutrición crónica infantil: un estudio de una muestra representativa Bangladesí a nivel nacional

Abstract This paper examines the net effect of birth order on child nutritional status in Bangladesh using data from the Bangladesh Demographic Health Survey, 2011 (BDHS). Analyses were restricted to 4,120 surviving, lastborn singleton children who were younger than 36 months at the time of the survey. Logistic regression was used to assess the association between birth order and child nutritional status. Results indicate 38.1% children are stunted and 8.2% children are fifth or higher order birth. Order of birth is one of the significant predictors of child being stunted. Third order, fourth order, and fifth or higher order children are 24%, 30%, and 72%, respectively, more likely to be stunted after adjusting for all other variables. Besides birth order, results also indicate that child age, size at birth, birth intention, maternal education, maternal body mass index, wealth index, place of residence and mass media access exert strong influences over child malnutrition. Reducing birth rates which limit number of births and birth order as well may reduce child malnutrition in Bangladesh.

Resumo O estudo analisa o efeito ajustado da ordem de nascimento sobre estado nutricional em crianças de Bangladesh, com base em dados do Inquérito Nacional de Demografia e Saúde daquele país (BDHS) em 2011. As análises se limitaram a 4.120 nascidos vivos de parto único, últimos na ordem de nascimento e vivos e com menos de 36 meses de idade no momento do inquérito. A regressão logística foi utilizada para avaliar a associação entre ordem de nascimento e estado nutricional. Segundo os resultados, 38,1% das crianças apresentavam baixa estatura para a idade e 8,2% ocupavam quinto lugar ou mais na ordem de nascimento. A ordem de nascimento é preditor significativo de baixa estatura para a idade em crianças de Bangladesh. A terceira, quarta ou quinta posição ou mais na ordem de nascimento mostrou um aumento de probabilidade de 24%, 30% e 72%, respectivamente, de baixa estatura para a idade, depois de ajustar para todas as outras variáveis. Além da ordem de nascimento, os resultados indicam que a idade da criança, comprimento cabeça-nádega ao nascer, intenção da gravidez, escolaridade materna, índice de massa corporal materna, índice de riqueza familiar, lugar de residência e acesso aos meios de comunicação de massa têm forte influência sobre a desnutrição infantil. A redução da taxa de natalidade e consequente limitação do número de nascimentos e da ordem de nascimento podem também reduzir a desnutrição infantil em Bangladesh.

Resumen Este trabajo analiza el efecto neto del orden de nacimiento en el status nutricional infantil en Bangladés, utilizando datos de la Encuesta Demográfica Bangladesí sobre la Salud, 2011 (BDHS). Los análisis se restringieron a los últimos 4,120 bebés nacidos vivos, procedentes de un embarazo único, y que fueran menores de 36 meses en el momento de la realización de la encuesta. Se usó la regresión logística para evaluar la asociación entre el orden de nacimiento y el estado nutricional infantil. Los resultados indican que un 38.1% de los niños sufren retraso en su crecimiento y un 8.2% de los niños ocupan el quinto o un orden más elevado de nacimiento. El orden de nacimiento es uno de los predictores significativos del retraso en el crecimiento en los niños. Quienes ocupan el tercer, cuarto, quinto o puestos más elevados en este orden son niños que en un 24%, 30% y un 72%, respectivamente, tienen más probabilidad de sufrir retraso en su crecimiento tras ajustar para todos otras variables. Asimismo, los resultados en el orden del nacimiento también indicaban que la edad y tamaño del niño tras el parto, así como el carácter del nacimiento, la educación materna, el índice de masa corporal materna, de riqueza, el lugar de residencia y el acceso a medios de comunicación ejercen fuertes influencias sobre la desnutrición infantil. Reduciendo la tasa de natalidad que limita el número de nacimientos y el orden de nacimientos se podría llegar a reducir la desnutrición infantil en Bangladés.

International Medical Mission Facing Global Increase of Chronic Disease: 2-Year Experience in Bangladesh

Specialists of developing countries are facing the epidemic growth of noncommunicable diseases (NCDs). From 2011 to 2013, I, as a Korean volunteer doctor, had been working in a local primary healthcare center in Bangladesh, assessing rates of NCDs. Proportion of patients with NCDs was increased from 74.96% in 1999 to 83.05% in 2012, particularly due to the spreading of diabetes mellitus, cardiovascular diseases, and tuberculosis. To succeed in medical mission in developing countries, volunteer doctors have to take measures for preventing chronic diseases along with proper treatment.

Establishment of Blastocystis hominis in-vitro Culture Using Fecal Samples from Infants in Slum Area of Mirpur, Dhaka, Bangladesh.

Introduction: Blastocystis hominis (B. hominis) is an obligate anaerobic protozoan found in the human large intestine, and is the most common eukaryotic organism reported in human fecal samples. Method: Multiple stool samples from 460 children (53.9% male and 46.07% female) were collected and examined for the presence of Blastocystis hominis in Parasitology Laboratory of International Centre for Diarrhoeal Diseases Research, Bangladesh during the period of 9th January to 28th December, 2011. Among them, 255 were diarrheal patients (56.47% male and 43.53% female). Direct microscopy was done for each of the samples and each sample was cultured in vitro for 48 hours and observed again for the presence of the pathogen. Th e aim of the study was to develop a sustainable technique to identify the pathogen. Results: In culture, several morphological forms were observed. Th rough microscopy, various morphological forms were clearly observed. Within 5679 tested samples, 795 samples (0.14%) were positive for B. hominis. As multiple forms were observed in the same sample, the most prevalent was cyst (0.125%) whereas least prevalent was granular (0.0072%). Th e highest percentage for all the morphological forms was observed in age group 25-36 months. In direct microscopy from fresh samples, children from 37-48 months showed the highest percentage (22.9%) of infection (p=0.000). In culture, the same age group showed the most infection rate (p=0.000). Among the diff erent morphological forms observed in culture, the highest prevalence of cyst was in age group 37-48 months (p=0.000). Th e highest prevalence of vacuolar form(5.7%) was observed in the same age group (p=0.015). In contrast, the amoeboid forms were mostly observed in children of 25-36 months (p=0.002).Th e children aged in between 37 to 48 months are at the most risk of the infection. Conclusion: Th e sensitivity of direct microscopy was found only 38.46% in respect to in-vitro culture which strongly suggests that in-vitro culture is the gold standard for the diagnosis of this parasite.

Predictors of tobacco smoking and smokeless tobacco use among adults in Bangladesh.

Introduction: To examine predictors of current tobacco smoking and smokeless tobacco use among the adult population in Bangladesh. Materials and Methods: We used data from the 2009 Global Adult Tobacco Survey (GATS) in Bangladesh consisting of 9,629 adults aged ΃15 years. Differences in and predictors of prevalence for both smoking and smokeless tobacco use were analyzed using selected socioeconomic and demographic characteristics that included gender, age, place of residence, education, occupation, and an index of wealth. Results: The prevalence of smoking is high among males (44.7%, 95% confidence interval [CI]: 42.5-47.0) as compared to females (1.5%, 95% CI: 1.1-2.1), whereas the prevalence of smokeless tobacco is almost similar among both males (26.4%, 95% CI: 24.2-28.6) and females (27.9%, 95% CI: 25.9-30.0). Correlates of current smoking are male gender (odds ratio [OR] = 41.46, CI = 23.8-73.4), and adults in older age (ORs range from 1.99 in 24-35 years age to 5.49 in 55-64 years age), less education (ORs range from 1.47 in less than secondary to 3.25 in no formal education), and lower socioeconomic status (ORs range from 1.56 in high wealth index to 2.48 in lowest wealth index. Predictors of smokeless tobacco use are older age (ORs range from 2.54in 24-35 years age to 12.31 in 55-64 years age), less education (ORs range from 1.44 in less than secondary to 2.70 in no formal education), and the low (OR = 1.34, CI = 1.0-1.7) or lowest (OR = 1.43, CI = 1.1-1.9) socioeconomic status. Conclusion: Implementation of tobacco control strategies needs to bring special attention on disadvantaged group and cover all types of tobacco product as outlined in the WHO Framework Convention on Tobacco Control (FCTC) and WHO MPOWER to protect people's health and prevent premature death.

Climatic factors influencing dengue cases in Dhaka city: a model for dengue prediction.

Background & objectives: Transmission of dengue virus depends on the presence of Aedes mosquito. Mosquito generation and development is known to be influenced by the climate. This study was carried out to examine whether the climatic factors data can be used to predict yearly dengue cases of Dhaka city, Bangladesh. Methods: Monthly reported dengue cases and climate data for the years 2000–2008 were obtained from the Directorate General of Health Services (DGHS) and Meteorological Department of Dhaka, Bangladesh, respectively. Data for the period 2000 to 2007 were used for development of a model through multiple linear regressions. Retrospective validation of the model was done with 2001, 2003, 2005 and 2008 data. Log transformation of the dependent variable was done to normalize data for linear regression. Average monthly humidity, rainfall, minimum and maximum temperature were used as independent variables and number of dengue cases reported monthly was used as dependent variable. Accuracy of the model for predicting outbreak was assessed through receiver operative characteristics (ROC) curve. Results: Climatic factors, i.e. rainfall, maximum temperature and relative humidity were significantly correlated with monthly reported dengue cases. The model incorporating climatic data of two-lag month explained 61 per cent of variation in number of reported dengue cases and this model was found to predict dengue outbreak (≥ 200 cases) with considerable accuracy [area under ROC curve = 0.89, 95%CI = (0.89-0.98)]. Interpretation & conclusions: Our results showed that the climate had a major effect on the occurrence of dengue infection in Dhaka city. Though the prediction model had some limitations in predicting the monthly number of dengue cases, it could forecast possible outbreak two months in advance with considerable accuracy.

Vector control interventions for visceral leishmaniasis elimination initiative in South Asia, 2005-2010.

The Visceral Leishmaniasis (VL) Elimination Initiative in the Indian subcontinent was launched in 2005 as a joint effort between the governments in the Region (India, Nepal and Bangladesh) and the World Health Organization (WHO). The objective is to reduce the annual VL incidence below 1/10,000 inhabitants by 2015 based on detection and treatment of VL cases and vector control. We present here a review of studies published in the period 2005-2010 on the efficacy of different tools to control Phlebotomus argentipes. The review indicates that the current indoor residual spraying (IRS) and novel vector control methods mainly insecticide treated nets (ITN) have low effectiveness for several reasons. Efforts to improve quality of IRS operations and further research on alternative and integrated vector control methods need to be promoted to reach the VL elimination target by 2015.

How do health care providers deal with kala-azar in the Indian subcontinent.

Background & objectives: Three countries, Bangladesh, India and Nepal, set out to eliminate kala-azar by 2015. This study was aimed to document the knowledge and practices in kala-azar case management of public and private health providers in these three countries. Methods: A health care provider survey was conducted in 2007 at 4 study sites, viz., Muzaffarpur and Vaishali districts in India, Mahottari district in Nepal, and Rajshahi district in Bangladesh. Interviews were conducted with formal and informal health care providers at their home or practice. Results: About half of the providers in India and Nepal knew the rapid diagnostic test rK39 recommended by the elimination initiative, but this was not in Bangladesh. Knowledge of the recommended first-line drug, miltefosine, was good in India and Nepal but less so in Bangladesh. Interpretation & conclusions: Innovative tools for VL care have not yet been fully taken up by private for profit care providers in the three countries that launched a VL elimination initiative. The elimination initiative needs to address these gaps in private providers’ knowledge, given their substantial share in the care of VL patients.

Malaria incidence among paramilitary personnel in an endemic area of Tripura.

Background & objectives: Paramilitary operations along the Indo-Bangladesh border are adversely affected by malaria induced morbidity and mortality. Villages surrounding the paramilitary installations often serve as disease reservoirs. Malaria incidence in Tripura State Rifles (TSR) units in Dhalai District of Tripura was studied and the role of the village population in disease transmission was also assessed. Methods: Mass blood surveys were carried out among TSR personnel and villagers during 2007 to 2009. Malaria diagnosis through blood smear examination and rapid detection kits was done, and percentage parasitaemia was determined. Activity of malaria vectors was monitored using CDC light traps. Results: Slide positivity rates (SPR) in the neighbouring villages (51.4%) was significantly higher than that in TSR (27.7%) (P<0.0001). Malaria incidence in villages did not show seasonal variability while it was lowest during post-monsoon season in TSR (P<0.325; OR = 0.74). Per cent Pf parasitaemia was high in TSR (0.29) as compared to villagers (0.20) (P<0.0001). Anopheles minimus and An. dirus were the major malaria vectors observed. Interpretation & conclusions: Paramilitary and public health authorities should adopt targeted measures to reduce the malaria incidence in the villages surrounding the paramilitary installations as the village populations play a major role in disease transmission.

Antibiotic sensitivity pattern of causative organisms of neonatal septicemia in an urban hospital of Bangladesh.

Background: The information of the sensitivity pattern of the causative organisms is very important for effective control of septicemia in neonates. OBJECTIVE: To determine the proportion and profile of pathogenic bacteria in the blood cultures of the neonates with clinically suspected septicemia and their susceptibility pattern to antimicrobial agents for developing a unified antibiotic treatment protocol. Materials and Methods: A cross-sectional retrospective study was conducted over a period of 3 year and 4 months (39 months). The study included 1000 patients admitted in the selected hospital in Bangladesh. Blood samples for culture were taken aseptically before starting antibiotic therapy. Microorganisms were isolated and identified by standard microbiological processes which include colony morphology, Gram stain, and biochemical profiles. Antimicrobial sensitivity patterns were performed by Kirby-Bauer's disc diffusion method against imipenem, ciprofloxacin, ceftazidime, chloramphenicol, netilmicin, gentamicin, ceftriaxone, aztreonam, cefotaxime, cephalexin, and ampicillin. Results: Among the patients, 633 (63.3%) were males and 367 (36.7%) were females. Blood cultures were found positive in 194 (19.4%) neonates. The organisms isolated were Pseudomonas spp. (31.4%), Klebsiella pneumoniae (23.2%), Staphylococcus aureus (12.4%), Escherichia coli (7.2%), Acinatobactor (5.7%), Gram-negative Bacilli (4.1%), Flavobacterium spp. (3.6%), Serratia spp. (5.7%), Citrobacter fruendi (3.1%), Streptococcus species (2.6%), and Enterobacter spp. (1.0%). A majority of the bacterial isolates in neonatal sepsis were found sensitive to imipenem (91.8%) and ciprofloxacin (57.2%) and resistant to commonly used antibiotics, eg. ampicillin (96.4%) and cephalexin (89.2%). Conclusion : The problem can be mitigated by careful selection and prudent use of available antibiotics.

Risk factors of bronchial asthma in two contrasting settings–metropolitan and coastal areas of Bangladesh: A case control study.

Background. Seven million people are suffering from bronchial asthma in Bangladesh. But scanty data is available to explain the risk factors for asthma in Bangladesh. Methods. This population-based, age, sex, and economic status matched case-control study was conducted to identify the risk factors responsible for the development of bronchial asthma in two contrasting settings, the metropolitan capital city and coastal area of Bangladesh. A structured pre-tested questionnaire was filled up by face-to-face interviews with the patients or parents of patients with bronchial asthma and the normal controls after a respiratory physician confirmed the diagnosis on the basis of history, physical examination and spirometry. Results. Presence of allergic problems was recognised as risk factors for the development of bronchial asthma. Concomitant existence of atopic diseases, like allergic rhinitis, eczema and allergic conjunctivitis were found to be significant risk factors in both the settings. History of early childhood lung infections, like pneumonia, bronchiolitis and intake of antibiotics and paracetamol in last 12 months were also observed to be the risk factors in both the areas. Though most of the so-called allergic foods were statistically found to be a protective factor in both the settings [odds ratio (OR) 0.48, 95% confidence intervals (CI) 0.37-0.63 in city area and OR 0.80, 95% CI 0.66-0.96 in coastal area], this was considered to be an artifact. Conclusions. Several common risk factors for the development of bronchial asthma were identified in both city and coastal areas of Bangladesh. Bronchial asthma prevention campaign in Bangladesh may focus on sensitising the people on these risk factors.

HEV infection as an aetiologic factor for acute hepatitis: experience from a tertiary hospital in Bangladesh.

Acute hepatitis is seen sporadically round the year in Bangladesh. The incidence of acute viral hepatitis E increases after floods as this allows sewerage contamination of piped and groundwater. The aim of this retrospective study was to assess the burden of hepatitis E virus (HEV infection) in Bangladesh. Patients attending the Hepatology Unit III of the Bangabandhu Sheikh Mujib Medical University, during June 2004-December 2006, were included in the study. All viral markers were tested by enzyme-linked immunosorbent assay. The study population was divided in four groups. Group 1 included 144 patients with acute viral hepatitis. The inclusion criteria were: nausea and/or vomiting, loss of appetite, serum bilirubin >200 micromol/L, raised serum transaminases, and prothrombin time >3 seconds prolonged beyond control value. In Group 2, there were 31 pregnant women with acute viral hepatitis. All the patients had prodrome, icterus, raised serum bilirubin and raised serum transaminase levels. Group 3 included 23 patients presenting with fulminant hepatic failure. In Group 4, 69 patients with cirrhosis of liver were included. They presented with features of decompensation for the first time. The inclusion criteria were: patients with established cirrhosis with jaundice and/or ascites and/or hepatic encephalopathy. In Group 1, 58.33% of the 144 patients had acute viral hepatitis E. In Group 2, 45.16% of the pregnant women also had acute viral hepatitis E. HEV was responsible for 56.52% cases of fulminant hepatic failure in Group 3. In 21.7% cases in Group 4, decompensation of cirrhosis was due to HEV. Acute viral hepatitis E in the third trimester of pregnancy and HEV-induced fulminant hepatic failure were associated with 80% of mortality despite the best possible care. In this clinical context, acute viral hepatitis E is the leading cause of wide spectrum of liver disease ranging from severe acute viral hepatitis, fulminant hepatic failure, to decompensation of liver in cirrhotics in Bangladesh. Sewerage contamination of piped water following floods may contribute to the higher incidence of HEV infection.

High prevalence of hepatitis A virus antibody among Bangladeshi children and young adults warrants pre-immunization screening of antibody in HAV vaccination strategy.

Serum samples from 465 subjects aged between 1 and 25 years were tested for antibody against hepatitis A virus (HAV) [anti-HAV IgG and IgM] to determine the seroprevalence of HAV antibody and do a cost-benefit analysis for decision making about vaccination against HAV among the general population of Bangladesh. A high prevalence of anti-HAV (74.8%) was observed in the study population; the whole study population was found positive for anti-HAV by the age of 25 years. On performing the cost-benefit analysis, it was found that the cost for vaccination with screening for anti-HAV was almost three times cheaper than vaccination without screening. Thus, in the present socioeconomic condition of Bangladesh, a policy based on screening for HAV antibody before vaccination is recommended.

HIV and AIDS in Bangladesh.

Bangladesh initiated an early response to the HIV epidemic starting in the mid-1980s. Since then, the response has been enhanced considerably, and many HIV-prevention interventions among the most at-risk populations and the general youth are being undertaken. Alongside prevention activities, gathering of data has been a key activity fostered by both the Government and individual development partners. This paper reviews available sources of data, including routine surveillance (HIV and behavioural among most at-risk populations), general population surveys, and various research studies with the aim to understand the dynamics of the HIV epidemic in Bangladesh. Available data show that the HIV epidemic is still at relatively low levels and is concentrated mainly among injecting drug users (IDUs) in Dhaka city. In addition, when the passively-reported cases were analyzed, another population group that appears to be especially vulnerable is migrant workers who leave their families and travel abroad for work. However, all sources of data confirm that risk behaviours that make individuals vulnerable to HIV are high--this is apparent within most at-risk populations and the general population (adult males and youth males and females). Based on the current activities and the sources of data, modelling exercises of the future of the HIV epidemic in Dhaka suggest that, if interventions are not enhanced further, Bangladesh is likely to start with an IDU-driven epidemic, similar to other neighbouring countries, which will then move to other population groups, including sex workers, males who have sex with males, clients of sex workers, and ultimately their families. This review reiterates the often repeated message that if Bangladesh wants to be an example of how to avert an HIV epidemic, it needs to act now using evidence-based programming.

Nutrition: basis for healthy children and mothers in Bangladesh.

Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. It has been estimated that nearly 50.6 million under-five children are malnourished, and almost 90% of these children are from developing countries. Bangladesh is one of the countries with the highest rate of malnutrition. The recent baseline survey by the National Nutrition Programme (NNP) showed high rates of stunting, underweight, and wasting. However, data from the nutrition surveillance at the ICDDR,B hospital showed that the proportion of children with stunting, underweight, and wasting has actually reduced during 1984-2005. Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. In Bangladesh, although the median duration of breastfeeding is about 30 months, the rate of exclusive breastfeeding until the first six months of life is low, and practice of appropriate complementary feeding is not satisfactory. Different surveys done by the Bangladesh Demographic and Health Survey, United Nations Children's Fund (UNICEF), and Bangladesh Breastfeeding Foundation (BBF) showed a rate of exclusive breastfeeding to be around 32-52%, which have actually remained same or declined over time. The NNP baseline survey using a strict definition of exclusive breastfeeding showed a rate of exclusive breastfeeding (12.8%) until six months of age. Another study from the Abhoynagar field site of ICDDR,B reported the prevalence of exclusive breastfeeding to be 15% only. Considerable efforts have been made to improve the rates of exclusive breastfeeding. Nationally, initiation of breastfeeding within one hour of birth, feeding colostrum, and exclusive breastfeeding have been promoted through the Baby-Friendly Hospital Initiative (BFHI) implemented and supported by BBF and UNICEF respectively. Since most (87-91%) deliveries take place in home, the BFHI has a limited impact on the breastfeeding practices. Results of a few studies done at ICDDR,B and elsewhere in developing countries showed that the breastfeeding peer-counselling method could substantially increase the rates of exclusive breastfeeding. Results of a study in urban Dhaka showed that the rate of exclusive breastfeeding was 70% among mothers who were counselled compared to only 6% who were not counselled. Results of another study in rural Bangladesh showed that peer-counselling given either individually or in a group improved the rate of exclusive breastfeeding from 89% to 81% compared to those mothers who received regular health messages only. This implies that scaling up peer-counselling methods and incorporation of breastfeeding counselling in the existing maternal and child heath programme is needed to achieve the Millennium Development Goal of improving child survival. The recent data showed that the prevalence of starting complementary food among infants aged 6-9 months had increased substantially with 76% in the current dataset. However, the adequacy, frequency, and energy density of the complementary food are in question. Remarkable advances have been made in the hospital management of severely-malnourished children. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR,B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR,B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management. Although the community nutrition centres of the NNP have been providing food supplementation and performing growth monitoring of children with protein-energy malnutrition, the referral system and management of complicated severely-malnourished children are still not in place.

Infectious diseases and vaccine sciences: strategic directions.

Despite substantial progress, infectious diseases remain important causes of ill-health and premature deaths in Bangladesh. Bangladesh has experienced a > 90% reduction in the incidence of deaths due to childhood diarrhoea over the last 25 years. Further reductions can be achieved through the introduction of effective vaccines against rotavirus and improvements in home hygiene, quality of drinking-water, and clinical case management, including appropriate use of oral rehydration solution and zinc. Pneumonia is now the leading cause of childhood deaths in Bangladesh, and the pneumonia-specific child mortality is largely unchanged over the last 25 years. Reductions in mortality due to pneumonia can be achieved through the introduction of protein conjugate vaccines against Haemophilus influenza type b and Streptococcus pneumoniae, improvements in case management, including efforts to prevent delays in providing appropriate treatment, and the wider use of zinc. Tuberculosis is responsible for an estimated 70,000 deaths each year in Bangladesh. Although services for directly-observed therapy have expanded markedly, improved case finding and involvement of private practitioners will be important to reduce the burden of disease.