Acute febrile illness among outpatients seeking health care in Bangladeshi hospitals prior to the COVID-19 pandemic.

Understanding the distribution of pathogens causing acute febrile illness (AFI) is important for clinical management of patients in resource-poor settings. We evaluated the proportion of AFI caused by specific pathogens among outpatients in Bangladesh. During May 2019-March 2020, physicians screened patients aged ≥2 years in outpatient departments of four tertiary level public hospitals. We randomly enrolled patients having measured fever (≥100.4°F) during assessment with onset within the past 14 days. Blood and urine samples were tested at icddr,b through rapid diagnostic tests, bacterial culture, and polymerase chain reaction (PCR). Acute and convalescent samples were sent to the Centers for Disease Control and Prevention (USA) for Rickettsia and Orientia (R/O) and Leptospira tests. Among 690 patients, 69 (10%) had enteric fever (Salmonella enterica serotype Typhi orSalmonella enterica serotype Paratyphi), 51 (7.4%) Escherichia coli, and 28 (4.1%) dengue detected. Of the 441 patients tested for R/O, 39 (8.8%) had rickettsioses. We found 7 (2%) Leptospira cases among the 403 AFI patients tested. Nine patients (1%) were hospitalized, and none died. The highest proportion of enteric fever (15%, 36/231) and rickettsioses (14%, 25/182) was in Rajshahi. Dhaka had the most dengue cases (68%, 19/28). R/O affected older children and young adults (IQR 8-23 years) and was detected more frequently in the 21-25 years age-group (17%, 12/70). R/O was more likely to be found in patients in Rajshahi region than in Sylhet (aOR 2.49, 95% CI 0.85-7.32) between July and December (aOR 2.01, 1.01-5.23), and who had a history of recent animal entry inside their house than not (aOR 2.0, 0.93-4.3). Gram-negative Enterobacteriaceae were the most common bacterial infections, and dengue was the most common viral infection among AFI patients in Bangladeshi hospitals, though there was geographic variability. These results can help guide empiric outpatient AFI management.

Establishing a sentinel surveillance system for the novel COVID-19 in a resource-limited country: methods, system attributes and early findings.

OBJECTIVES: To establish a hospital-based platform to explore the epidemiological and clinical characteristics of patients screened for COVID-19. DESIGN: Hospital-based surveillance. SETTING: This study was conducted in four selected hospitals in Bangladesh during 10 June-31 August 2020. PARTICIPANTS: In total, 2345 patients of all age (68% male) attending the outpatient and inpatient departments of surveillance hospitals with any one or more of the following symptoms within last 7 days: fever, cough, sore throat and respiratory distress. OUTCOME MEASURES: The outcome measures were COVID-19 positivity and mortality rate among enrolled patients. Pearson's χ2 test was used to compare the categorical variables (sign/symptoms, comorbidities, admission status and COVID-19 test results). Regression analysis was performed to determine the association between potential risk factors and death. RESULTS: COVID-19 was detected among 922 (39%) enrolled patients. It was more common in outpatients with a peak positivity in second week of July (112, 54%). The median age of the confirmed COVID-19 cases was 38 years (IQR: 30-50), 654 (71%) were male and 83 (9%) were healthcare workers. Cough (615, 67%) was the most common symptom, followed by fever (493, 53%). Patients with diabetes were more likely to get COVID-19 than patients without diabetes (48% vs 38%; OR: 1.5; 95% CI: 1.2 to 1.9). The death rate among COVID-19 positive was 2.3%, n=21. Death was associated with age ≥60 years (adjusted OR (AOR): 13.9; 95% CI: 5.5 to 34), shortness of breath (AOR: 9.7; 95% CI: 3.0 to 30), comorbidity (AOR: 4.8; 95% CI: 1.1 to 21.7), smoking history (AOR: 2.2, 95% CI: 0.7 to 7.1), attending the hospital in <2 days of symptom onset due to critical illness (AOR: 4.7; 95% CI: 1.2 to 17.8) and hospital admission (AOR: 3.4; 95% CI: 1.2 to 9.8). CONCLUSIONS: COVID-19 positivity was observed in more than one-third of patients with suspected COVID-19 attending selected hospitals. While managing such patients, the risk factors identified for higher death rates should be considered.

Use of Antimicrobials among Suspected COVID-19 Patients at Selected Hospitals, Bangladesh: Findings from the First Wave of COVID-19 Pandemic.

Antimicrobials are empirically used in COVID-19 patients resulting in increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients. From March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis. Among 1188 suspected COVID-19 patients, 69% were male, 40% had comorbidities, and 53% required oxygen. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral (1%) and antiparasitic drugs (3%). Third-generation cephalosporin use was the highest (708; 60%), followed by macrolide (481; 40%), and the majority (853; 78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7; 95% CI: 4.5-30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6; 95% CI: 1.0-2.5). Antimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with third-generation cephalosporin among mild to moderately ill patients was common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.

A Case Series Describing the Recurrence of COVID-19 in Patients Who Recovered from Initial Illness in Bangladesh.

To date, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has infected over 80 million people globally. We report a case series of five clinically and laboratory confirmed COVID-19 patients from Bangladesh who suffered a second episode of COVID-19 illness after 70 symptom-free days. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), is a leading public health research institution in South Asia. icddr, b staff were actively tested, treated and followed-up for COVID-19 by an experienced team of clinicians, epidemiologists, and virologists. From 21 March to 30 September 2020, 1370 icddr,b employees working at either the Dhaka (urban) or Matlab (rural) clinical sites were tested for COVID-19. In total, 522 (38%) were positive; 38% from urban Dhaka (483/1261) and 36% from the rural clinical site Matlab (39/109). Five patients (60% male with a mean age of 41 years) had real-time reverse transcription-polymerase chain reaction (rRT-PCR) diagnosed recurrence (reinfection) of SARS-CoV-2. All had mild symptoms except for one who was hospitalized. Though all cases reported fair risk perceptions towards COVID-19, all had potential exposure sources for reinfection. After a second course of treatment and home isolation, all patients fully recovered. Our findings suggest the need for COVID-19 vaccination and continuing other preventive measures to further mitigate the pandemic. An optimal post-recovery follow-up strategy to allow the safe return of COVID-19 patients to the workforce may be considered.