Clinico-Epidemiological Characteristics of Pediatric COVID-19 Patients in Bangladesh
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Brief description: Background To delineate the clinico-epidemiological characteristics of pediatric coronavirus disease-2019 (COVID-19) patients was the objective of the study. Method This observational study included 290 pediatric patients with a definite diagnosis of COVID-19 admitted to Dhaka Shishu Hospital, Bangladesh, from April 2021 to October 2021. Clinical and epidemiological characteristics were analyzed based on demographic data, medical history, laboratory tests, and outcome information. Data analysis was performed with SPSS 26. Ethical measures were taken in compliance with the current declaration of Helsinki, and final analysis was performed using SPSS 26. Result Of all, 42 (14.5%) were neonates (< 28 days), 88 (30.3%) were infants (28 days to < 1 year) and 160 (55.2%) were children (1–17 years). The median age of the children was 18 (0.3–204) months, 58.3% were male, 62% had malnutrition, and presented with various clinical presentations. The main symptoms were fever (5.7%) and breathlessness (20%). Approximately 22% of children were asymptomatic, and 57% had at least one comorbidity. Fever and abdominal pain were predominant presenting symptoms in children compared with neonates and infants (p < .01 for both), while cough and breathlessness were more frequent in infants (p < .01 for both). The infants suffered significantly from neutropenia and lymphocytosis than neonates and children (p < .001 for both). The discharge and death rates were 77.8% with 6.9%. Overall case fatality was higher among neonates than others. Conclusion Compared to other pediatric groups, neonatal case fatality was higher, and COVID-19 in neonates, infants, and children has similar epidemiological and clinical manifestations. The findings from this study might help to guide the development of measures to prevent and treat this ongoing global pandemic of these particular age groups.
Open Label Randomized Controlled Comparison of Three Alternative Regimes of Ciprofloxacin, Azithromycin and Cefixime for Treatment of Uncomplicated Typhoid Fever in Bangladesh
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Brief description: Multi-drug resistant Typhoid fever (resistant to previously used chloramphenicol, ampicillin, amoxicillin, and trimethoprim-sulfamethoxazole) has been commonly described in the South East Asia region and a recent report suggests that the salmonella typhi have reduced response to fluoroquinolones (nalidixic acid-resistant). The optimum treatment protocol for this type of serovar has not been established. This study compared different antimicrobial regimens for the treatment of uncomplicated typhoid fever which was conducted in the medicine ward of Dhaka Medical College Hospital (DMCH) and outdoor setting in private practice in Dhaka metropolitan city, Mymensingh and Sylhet town from January 2017 to December 2017. Bangladeshi adults with uncomplicated typhoid fever were included in this an open-label randomized controlled trial. Ciprofloxacin (20mg/kg of body weight/day for 14 days), azithromycin (20mg/kg/day for 14 days), and Cefixime (16mg/kg/day for 14 days) were compared. Of the 81 enrolled patients, 62 were eligible for analysis (61 S. enterica serovar Typhi, 1 Salmonella enterica serovar paratyphi A). Of the S enterica serovar Typhi isolates, 88.7% (55/62) were MDR and 93.5% (58/62) were nalidixic acid resistant (NAR). The clinical cure rate was 62% (13/21) with ciprofloxacin, 71% (15/21) with Cefixime, and 85% (17/20) with azithromycin (p=0.053). The mean (95% confidence interval [CI]) fever clearance time for patients treated with azithromycin (5.8 days [5.1 to 6.5 days]) was shorter than that for patients treated with cefixime (7.1 days [6.2 to 8.1 days]) and ciprofloxacin (8.2 days [7.2 to 9.2 days]) (p<0.001). All three antibiotics were well tolerated. A 7-day course of azithromycin can be successfully used in uncomplicated typhoid fever due to isolates of MDR S enterica serovar Typhi.
Virucidal effect of povidone iodine on COVID-19 in the nasopharynx: an open-label randomized clinical trial
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Brief description: Povidone-iodine (PVP-I) is a time-tested antiseptic agent with excellent virucidal (99.99%) properties. Repurposing it against coronavirus disease-19 (COVID-19) is a relatively newer concept and has been sparsely tested in vivo. The most common route of entry of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is the nasopharynx. Averting colonization of the virus could be one of the best options to reduce the incidence of infection. PVP-I gargle and mouthwash were found to be effective in vitro rapid inactivation against SARS-CoV-2 on a smaller scale (Hassandarvish et al. in BDJ 1–4, 2020, Pelletier et al. in ENTJ 1–5, 2020). However, efficacy in humans is lacking. To assess the virucidal effect of PVP-I against SARS-CoV-2 located in the nasopharynx was the objective of this parallel armed randomized clinical trial. We screened all RT-PCR-confirmed COVID-19 cases aged 18 years and above with symptoms. Written informed consent was obtained before randomization. Nasopharyngeal clearance of SARS-CoV-2 was tested after single time application of PVP-I nasal irrigation (NI) at diluted concentrations of .4%, .5% and .6% and PVP-I nasal spray (NS) at diluted concentrations of .5% and .6%. All groups were compared to the corresponding controls (distilled water). The primary outcome was viral clearance in a repeat RT-PCR (qualitative), and the secondary outcome was the number of adverse events. Final data analysis was performed using the statistical software SPSS (Version 20). A total of 189 confirmed COVID-19 cases were randomized into seven groups: 27 patients in each group. Of all, 159 (84.1%) were male, and 30 (15.9%) were female. We observed a statistically significant proportion of nasopharyngeal clearance with all strengths of PVP-I NI and PVP-I NS compared to the corresponding controls. Additionally, 0.5% NI was significantly better than 0.5% NS for viral clearance (p = 0.018) and had the highest nasopharyngeal clearance among all strengths (n = 25, 92.6%). 0.6% NS is better than CNS and 0.5%NS in viral clearance. The only adverse event was nasal irritation recorded in two patients each in the 0.4% and 0.6% PVP-I NI groups (Tables 1 and 2). PVP-I NI and NS are proved as effective virucidal agent against SARS-CoV-2 in human body. Our recommendation is to use PVP-I in naopharynx (as well as oropharynx) to prevent COVID-19.
Introduction
Leishmaniasis in Dhaka Medical College-experience of three years
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Brief description: The People’s Republic of Bangladesh has been working to eliminate visceral leishmaniasis or Kala-azar cases since there was a memorandum of understanding signed between neighboring countries in 2005. As a part of the elimination activity, 44 cases of Kala-azar were diagnosed and treated in the regional referral center Dhaka Medical College Hospital (DMCH) during the last three years, which is reported here. Confirmed leishmaniasis cases were included. Patients attending this specialized center with different demographic characteristics and varied presentations with laboratory findings were reviewed and recorded in a structured case record form. Ethical clearance was obtained prior to starting the study. A total of 44 patients with leishmaniasis were reviewed. Approximately 89% (n = 39) were New Kala-azar (NKA), 7% (n = 3) were Relapse Kala-azar (Relapse KA), only one case (2%) was Kala-azar Treatment Failure (KATF) and Post Kala-azar Dermal Leishmaniasis (PKDL) for both. The mean age of presentation was 32 years. Forty percent of patients had houses made by mud, 26% by tin shed, and the rest lived in buildings and semi-buildings. The predominant clinical features were fever (90.9%), pallor (88.6%), splenomegaly (81.8%) and hepatomegaly (68.2%). rK39 was positive in 90.7% of cases, and 94.4% of cases were positive for LD bodies on splenic aspirate. Of all, 90.90% were treated with Inj. Liposomal amphotericin B and 9.10% with the combination of Inj. Liposomal Amphotericin B and Inj. Miltefosine. Moving forward to the elimination of leishmaniasis from Bangladesh, the study highlights the status, characteristics and treatment of the disease in the country.
Virucidal effect of povidone iodine on COVID-19 in the nasopharynx: A structured summary of a study protocol for an open-label randomized clinical trial
Project started: 20th January, 2020
Project End: 03th May, 2021
Publication status: Published
Brief description: General: To assess the virucidal efficacy of povidone iodine (PVP-I) on COVID-19 virus located in the nasopharynx Specific: i. To evaluate the efficacy of povidone iodine (PVP-I) to removeCOVID-19 virus located in the nasopharynx ii. To assess the adverse events of PVP-I TRIAL DESIGN: This is a single-center, open-label randomized clinical trial with a 7-arm parallel-group design. The study will be conducted at Dhaka Medical College Hospital, Dhaka, Bangladesh. All RT-PCR-confirmed COVID-19 cases aged between 15-90 years with symptoms for the past 4 days will be screened. Those who give informed consent, are willing to participate, and accept being randomized to any assigned group will also be considered for final inclusion. Patients with known sensitivity to PVP-I aqueous antiseptic solution or any of its listed excipients or previously diagnosed thyroid disease or who had a history of chronic renal failure: stage ≥3 by estimated glomerular filtration rate (eGFR) Modification of Diet in Renal Disease (MDRD) or had acute renal failure (KDIGO ≥stage 2: creatinine ≥2 times from the baseline) or patients who required invasive or noninvasive ventilation or planned within the next 6 hours were considered for exclusion. Moreover, lactating or pregnant women will also be restricted to include here. This RCT consist of seven arms: Arm-1 (intervention group): will receive povidone iodine (PVP-I) nasal irrigation (NI) at a concentration of 0.4% Arm-2 (intervention group): will receive PVP-I nasal irrigation at a concentration of 0.5% Arm-3 (intervention group): will receive PVP-I nasal irrigation at a concentration of 0.6%. Arm-4 (intervention group): will receive PVP-I nasal spray (NS) at a concentration of 0.5%. Arm-5 (intervention group): will receive PVP-I nasal spray at a concentration of 0.6%. Arm-6 (placebo comparator group): will receive distilled water through NI Arm-7 (Placebo comparator group): will receive distilled water through NS The intervention arms will be compared to the placebo comparator arms. Other supportive and routine care will be the same in both groups. The primary outcome is the proportion of cases that remain COVID-19 positive following the intervention. It will be assessed from 1 minutes to 15 minutes after the intervention. Any occurrence of adverse effects following the intervention will be documented as a secondary outcome. The assignment to the study (intervention) or control (comparator) group will be allocated in equal numbers through randomization using random number generation in Microsoft Excel by a statistician who is not involved in the trial. The allocation scheme will be made by an independent statistician using a sealed envelope. The participants will be allocated immediately after the eligibility assessment and consenting procedures. This is an open-label clinical trial, and no blinding or masking will be performed. A total of 189 confirmed cases of COVID-19 will be randomized into seven groups. In each arm, a total of 27 participants will be recruited. The current trial protocol is Version 1.5 from September 10, 2020. Recruitment began September 30, 2020 and is anticipated to be completed, including data analysis by February 28, 2021. The trial protocol has been registered in the ClinicalTrials.gov on September 16, 2020. NCT Identifier number: NCT04549376 . The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting the dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.
Efficacy and safety of single-dose liposomal amphotericin B in patients with visceral leishmaniasis in Bangladesh: a real-life experience
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Brief description:Liposomal amphotericin B (LAmB) is the drug of choice in Bangladesh to eliminate the burden of visceral leishmaniasis, also known as kala-azar, a fatal protozoan parasitic disease if left untreated. We aimed to assess efficacy and safety of a single-dose (10 mg/kg) LAmB in visceral leishmaniasis (VL) treatment among the visiting children and adults in a tertiary care setting. This prospective study includes 11 children and 19 adults with a confirmed diagnosis of kala-azar (total 30 cases). Intravenous infusion of LAmB (10 mg/kg body weight) was given to all of the patients. Clinical assessments were conducted during treatment, before hospital discharge, and on days 30 and 180 after treatment. Efficacy was estimated in terms of initial cure (at day 30) and the final cure (at 180 days). All information was recorded in a preformed case record form and analysis was performed in SPSS 22. The mean age was 27.13 ± 18.04 years (3–65) with male predominance (60%). Significant regression of spleen size was found following treatment with LAmB at 30 days and 180 days follow up visit (p < 0.05 for all). Overall, rate of initial cure was 90% (n = 27) (child 90.9% vs 89.47% adult) and final cure was 96.66% (n = 29) (child 100% vs 94.73% adult). Fourteen adverse events were recorded mostly including fever and/or shivering (85.71%). No case relapsed or were referred either due to management or Severe Adverse Event (SAE). In real-life experience, the LAmB treatment for visceral leishmaniasis is as safe and effective for treatment of kala-azar patients.
Comparison of clinical manifestation of dengue fever in Bangladesh: an observation over a decade
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Brief description: The clinical presentation of dengue fever had been observed to change with time since its first outbreak in 2000 in Bangladesh. This report showed the clinical presentation of the 2019 outbreak in Bangladesh along with its comparison to previous outbreaks witnessed in this region. This hospital-based cross-sectional study was conducted in one of the largest tertiary care hospitals in Dhaka city. A total of 553 laboratory-confirmed and 194 probable dengue cases were interviewed. The clinical manifestation of the confirmed cases of the current outbreak was compared with three of the outbreak reports retrieved from the databases. R version 3.6.3 was used for data analysis. Among the confirmed cases, two-thirds were male (63.2%) and the average age was 27(± 11) years. Positive tests for NS1 and IgM were present in 99.6% (n = 525/527) and 82.6% (n = 38/46) of the cases, respectively. Thrombocytopenia was present in 66.1% of cases. Fever (100%) was common for all. Gastrointestinal (GIT) features, including abdominal pain (86.5%), anorexia and/or vomiting (69.6%), and Diarrhea (> 3 motions/day) (26.2%) were more frequent than typical rash and other pain symptoms. Hypotension was present in approximately a quarter of patients (25%). GIT features (anorexia, nausea, and/or vomiting) and hypotension were more common among adult participants while bleeding manifestation (melena and vaginal bleeding, p = 0.009 & 0.032) was more frequent in pediatric patients. Compared to outbreaks of 2008, 2016, and 2018, increasing trends in GIT symptoms e.g. anorexia, abdominal pain, and diarrhea were observed. While a negative trend in hemorrhagic manifestations (skin rash, melena, and conjunctival hemorrhage/hemorrhagic sclera) and arthralgia/joint pain were found. The present outbreak was noticeably characterized by GIT symptoms and hypotension in addition to the typical clinical features like rash and pain symptoms. An increasing trend in GIT features and decreasing trend in hemorrhagic manifestations was noted over the last decade of dengue outbreaks.
Clinico-epidemiological characteristics of a symptomatic and symptomatic COVID-19-positive patients in Bangladesh
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Brief description: As of August 15, 2020, Bangladesh lost 3591 lives since the first Coronavirus disease 2019 (COVID-19) case announced on March 8. The objective of the study was to report the clinical manifestation of both symptomatic and asymptomatic COVID-19-positive patients. A online-based cross-sectional survey was conducted for initial recruitment of participants with subsequent telephone interview by the three trained physicians in 237 adults with confirmed COVID-19 infection in Bangladesh. The study period was between 27 April to 26th May, 2020. Consent was ensured before commencing the interview. Collected data were entered in a predesigned case report form and subsequently analyzed by SPSS 20. The mean age at presentation was 41.59±13.73 (SD) years and most of the cases were male (73%). A total of 90.29% of patients reside in urban areas. Among the positive cases, 13.1% (n = 31) were asymptomatic. Asymptomatic cases were significantly more common in households with 2 to 4 members (p = .008). Both symptomatic and asymptomatic patients shared similar ages of presentation (p = 0.23), gender differences (p = 0.30), and comorbidities (p = 0.11). Only 5.3% of patients received ICU care during their treatment. The most frequent presentation was fever (88.3%), followed by cough (69.9%), chest pain (34.5%), body ache (31.1%), and sore throat (30.1%). Thirty-nine percent (n = 92) of the patients had comorbidities, with diabetes and hypertension being the most frequently observed. There has been an upsurge in COVID-19 cases in Bangladesh. Patients were mostly middle-aged and male. Typical presentations were fever and cough. Maintenance of social distancing and increased testing are required to meet the current public health challenge.
Clinico-epidemiologic characteristics of the 2019 dengue outbreak in Bangladesh
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Brief description: Dengue fever shows a broad range of clinical presentations worldwide. Here we report on our clinical findings during the 2019 dengue outbreak in one of the largest tertiary care hospitals in Dhaka, the capital of Bangladesh. A total of 747 suspected dengue cases (553 confirmed and 194 probable) were interviewed with a pro forma case record form. Statistical analyses were conducted using SPSS 20.0. Ethical clearance was obtained from the Dhaka Medical College. The mean age of the dengue cases was 27 y and approximately two-thirds were male. Positive tests for NS1 and anti-dengue immunoglobulin M antibody were present in 91.9% and 59.4% of the cases, respectively. Thrombocytopenia was present in 69% of cases and fever was present in 99.1% of cases. Gastrointestinal (GI) features, including anorexia and/or vomiting (69.4%), abdominal pain (39.8%) and diarrhoea (25.6%), were more prevalent than typical rash and pain symptoms. Hypotension was present in approximately one-quarter of patients (25.4%). Probable and confirmed dengue cases have shown similar clinical characteristics and laboratory findings. The 2019 outbreak of dengue fever in Bangladesh was characterized by increased presentation with GI features. Recognition of this trend would permit early diagnosis and proper management of patients.
Syndemic of Tuberculosis and COVID-19 in Bangladesh
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Brief Description: Bangladesh ranks seventh among the 30 countries with a high burden of tuberculosis (TB) and a considerable annual incidence of multidrug-resistant TB. Before the pan- demic, on average, 70 000 cases remained undiagnosed, and 40% of drug-resistant TB cases were enrolled each year. Despite actions taken, the TB care system of the country is riddled with limitations, including delay in diagnosis, lack of adequate diagnostic amenities, complex care pathways, and improper referral practices. These were markedly enhanced due to the ongoing coronavirus disease 2019 (COVID-19) pandemic and had a negative impact on the number of people seeking and receiving health care due to TB. The countrywide lockdown strategy and closure of public transport during the initial stages of the pandemic had put immense pressure on the national TB control pro- gram. Closure of routine care in many hospitals to facilitate COVID-19 management led to difficulty accessing directly observed treatment short course (DOTS) corners, interruption in the drug supply chain, and shutdown of essential laboratory services. Even the remaining open centers were hard to reach at that time, mostly due to the complete closure of private and public transports. Thus, a significant disruption occurred in the prevention, monitor ing, and treatment of TB. A drop in TB notifications, delayed treatment initiations, reduced treatment adherence, and, in general, a significant reduction in TB services was obvious. The number of persons admitted for inpatient treatment also fell significantly than that in the previous year. Data on the actual disruption of the TB care system as well as potential medium- and long-term consequences of such disruption are currently lacking. However, a national dedicated TB hospital statistic suggested a significant decline in the admission rate and outpatient visits during the crisis (Figure 1 and Supplementary Figure 1). Overall reporting system of the country went down as well. Mathematical models suggest that disruption of TB services might substantially increase TB mortality and incidence in the near future. One model indicated that a 50% drop in TB case detection over 3 months could increase the number of TB deaths worldwide by nearly 400 000 in 2020
alone. The TB burden will also increase several-fold due to the syndemic effects of COVID-19 with social inequalities, pushing the people to extreme poverty. Although we are facing a more significant challenge of managing COVID-19 cases at this moment, the burden of TB may bounce back and exceed previous levels in the coming years unless proper strategic steps are taken immediately. There is an urgent need for a recovery plan to obtain TB responses back on track.
Extensive catch-up works and ramped-up essential service packages, particularly routine immunization, enhanced diagnosis and treatment, advocacy, and funding, are needed as immediate measures. Prompt identification of missing TB patients is required. Some approaches for this purpose might include concomitant TB-COVID-19 screening and intensified case finding through reinforcement of sputum smear microscopy with rapid molecular testing and homebased sample collection. Treatment could be ensured through TB medicine delivery at home and by modification of the DOTS approach to include digital adherence technologies, call centers, and family members to provide treatment support. Additionally, repurposing a corona tracer (a mobile application used for COVID-19 contact tracing in Bangladesh) for contact tracing, reporting, and establishing a national TB helpline can also strengthen the overall TB care system. A long-term targeted investment is crucial for strengthening community responses to both COVID-19 and TB and addressing poverty, malnutrition (by food rationing), overcrowding, poor housing, and unemployment. Coordinated dissemination and sharing of knowledge and a community-centered approach to mitigate the burden of TB could be other essential steps. Commitment from high-level.
