Be-Nazir Ahmed

Foodborne Transmission of Nipah Virus, Bangladesh

TOC summary line: Nipah virus was likely transmitted from fruit bats to humans by drinking fresh date palm sap.

Recurrent Zoonotic Transmission of Nipah Virus into Humans, Bangladesh, 2001-2007

More than half of identified cases result from person-to-person transmission.

Nipah virus outbreak with person-to-person transmission in a district of Bangladesh, 2007

In February 2007 an outbreak of Nipah virus (NiV) encephalitis in Thakurgaon District of northwest Bangladesh affected seven people, three of whom died. All subsequent cases developed illness 7-14 days after close physical contact with the index case while he was ill. Cases were more likely than controls to have been in the same room (100% vs. 9.5%, OR undefined, P<0.001) and to have touched him (83% vs. 0%, OR undefined, P<0.001). Although the source of infection for the index case was not identified, 50% of Pteropus bats sampled from near the outbreak area 1 month after the outbreak had antibodies to NiV confirming the presence of the virus in the area. The outbreak was spread by person-to-person transmission. Risk of NiV infection in family caregivers highlights the need for infection control practices to limit transmission of potentially infectious body secretions.

Anthrax Outbreaks in Bangladesh, 2009–2010

During August 2009-October 2010, a multidisciplinary team investigated 14 outbreaks of animal and human anthrax in Bangladesh to identify the etiology, pathway of transmission, and social, behavioral, and cultural factors that led to these outbreaks. The team identified 140 animal cases of anthrax and 273 human cases of cutaneous anthrax. Ninety one percent of persons in whom cutaneous anthrax developed had history of butchering sick animals, handling raw meat, contact with animal skin, or were present at slaughtering sites. Each year, Bacillus anthracis of identical genotypes were isolated from animal and human cases. Inadequate livestock vaccination coverage, lack of awareness of the risk of anthrax transmission from animal to humans, social norms and poverty contributed to these outbreaks. Addressing these challenges and adopting a joint animal and human health approach could contribute to detecting and preventing such outbreaks in the future.

Fatal outbreak from consuming Xanthium strumarium seedlings during time of food scarcity in northeastern Bangladesh.

Background An outbreak characterized by vomiting and rapid progression to unconsciousness and death was reported in Sylhet Distrct in northeastern Bangladesh following destructive monsoon floods in November 2007. Methods and Findings We identified cases presenting to local hospitals and described their clinical signs and symptoms. We interviewed patients and their families to collect illness histories and generate hypotheses about exposures associated with disease. An epidemiological study was conducted in two outbreak villages to investigate risk factors for developing illness. 76 patients were identified from 9 villages; 25% (19/76) died. Common presenting symptoms included vomiting, elevated liver enzymes, and altered mental status. In-depth interviews with 33 cases revealed that 31 (94%) had consumed ghagra shak, an uncultivated plant, in the hours before illness onset. Ghagra shak was consumed as a main meal by villagers due to inaccessibility of other foods following destructive monsoon flooding and rises in global food prices. Persons who ate this plant were 34.2 times more likely (95% CI 10.2 to 115.8, p-value<0.000) than others to develop vomiting and unconsciousness during the outbreak in our multivariate model. Ghagra shak is the local name for Xanthium strumarium, or common cocklebur. Conclusions The consumption of Xanthium strumarium seedlings in large quantities, due to inaccessibility of other foods, caused this outbreak. The toxic chemical in the plant, carboxyatratyloside, has been previously described and eating X. strumarium seeds and seedlings has been associated with fatalities in humans and livestock. Unless people are able to meet their nutritional requirements with safe foods, they will continue to be at risk for poor health outcomes beyond undernutrition.

Kala-azar (Visceral Leishmaniasis) Elimination in Bangladesh: Successes and Challenges

Visceral leishmaniasis (VL) also known as kala-azar is a major public health problem in Bangladesh. A national VL elimination program was initiated in 2008 in Bangladesh after the signing of a memorandum of understanding between the Government of Bangladesh, India, and Nepal in 2005 for the elimination of VL from these three countries by 2015. Following the strategic plan of the VL elimination program of the three countries, the national program in Bangladesh was established in 2008. Based on information in the directorate general of health services, expert opinions in a recently held advocacy meeting in Dhaka and on available scientific literature, we report here the successes and challenges of the national VL elimination program in Bangladesh. The program prepared the national kala-azar elimination guidelines and strategic plan for VL elimination in consultation with the technical working group for VL elimination and VL experts in Bangladesh and abroad, including the World Health Organization-The Special Programme for Research and Training in Tropical Diseases (TDR). The program trained health staff from all VL endemic hospitals in proper diagnosis and treatment, stratified the country according to VL burden, and introduced the rapid diagnostic test and oral treatment with miltefosine at no cost for patients. Integrated vector control management with indoor residual spraying and the distribution of commercial, long-lasting, insecticide-treated bed-nets were also studied and then implemented. VL burden has declined, but is still far from the target of VL elimination. Thus, the program must continue to maintain these activities and also introduce new activities to involve community participation in the program. The program is facing challenges regarding the shortage of human resources and logistics because of a scarcity of resources. To maintain the success of the program, support from national and international donor agencies and policy makers will be necessary. Other options for the treatment of VL patients as well as for vector control must also be considered.

Strongyloidiasis in a high risk community of Dhaka, Bangladesh

Residents of a slum community of Dhaka city, Bangladesh were tested by serological and faecal examination for evidence of Strongyloides stercoralis infection. In stool specimens from a total of 147 participants Strongyloides larvae were found in 34 (23.1%) by Harada-Mori culture, 15 (10.2%) by agar plate culture (APC) and one (0.7%) by microscopy. Strongyloides IgG, IgG1 and IgG4 antibodies were found in 90 (61.2%), 46 (31.3%) and 53 (36.1%) of participants, respectively. A positive correlation was observed between total IgG levels and the presence of isotypes IgG1 and IgG4 (p<0.001). Six sera (4.0%) reacted to the recombinant filaria antigen Bm 14, three of which were Strongyloides IgG positive. This indicates either there is cross reactivity or some participants are co-infected with lymphatic filariasis. No correlations were found between positive serology and Strongyloides infection in stool, socio- demographic factors or domestic hygienic practices. However, positive stool cultures showed significant associations with irregular nail trimming, walking bare-foot and irregular hand washing after defecation (p<0.05). Other enteric parasites were detected in stools of some participants but their presence showed no correlation with S. stercoralis infection or socio demographic factors. This study confirms that squatters in this slum community in Dhaka have a high prevalence of S. stercoralis infection identified both by serological and coprological methods.

Targeting populations at higher risk for malaria: a survey of national malaria elimination programmes in the Asia Pacific.

BackgroundSignificant progress has been made in reducing the malaria burden in the Asia Pacific region, which is aggressively pursuing a 2030 regional elimination goal. Moving from malaria control to elimination requires National Malaria Control Programmes (NMCPs) to target interventions at populations at higher risk, who are often not reached by health services, highly mobile and difficult to test, treat, and track with routine measures, and if undiagnosed, can maintain parasite reservoirs and contribute to ongoing transmission.MethodsA qualitative, free-text questionnaire was developed and disseminated among 17 of the 18 partner countries of the Asia Pacific Malaria Elimination Network (APMEN).ResultsAll 14 countries that responded to the survey identified key populations at higher risk of malaria in their respective countries. Thirteen countries engage in the dissemination of malaria-related Information, Education, and Communication (IEC) materials. Eight countries engage in diagnostic screening, including of mobile and migrant workers, military staff, and/or overseas workers. Ten countries reported distributing or recommending the use of long-lasting insecticide-treated nets (LLINs) among populations at higher risk with fewer countries engaging in other prevention measures such as indoor residual spraying (IRS) (two countries), spatial repellents (four countries), chemoprophylaxis (five countries), and mass drug administration (MDA) (three countries). Though not specifically tailored to populations at higher risk, 11 countries reported using mass blood surveys as a surveillance tool and ten countries map case data. Most NMCPs lack a monitoring and evaluation structure.ConclusionCountries in the Asia Pacific have identified populations at higher risk and targeted interventions to these groups but there is limited information on the effectiveness of these interventions. Platforms like APMEN offer the opportunity for the sharing of protocols and lessons learned related to finding, targeting and successfully clearing malaria from populations at higher risk. The sharing of programme data across borders may further strengthen national and regional efforts to eliminate malaria. This exchange of real-life experience is invaluable to NMCPs when scarce scientific evidence on the topic exists to aid decision-making and can further support NMCPs to develop strategies that will deliver a malaria-free Asia Pacific by 2030.

Detection of Leishmania donovani in peripheral blood of asymptomatic individuals in contact with patients with visceral leishmaniasis.

BACKGROUND The majority of individuals infected with Leishmania donovani complex remain asymptomatic. They may act as transmission reservoirs for visceral leishmaniasis (VL). We investigated sero-prevalence of L. donovani complex amongst those closely associated with patients with VL and whether these sero-reactive individuals had Leishmania parasites in their peripheral blood. Other risk factors were also investigated. METHODS A total of 257 individuals in contact with patients with VL were tested for anti-Leishmania antibodies by rK39 immunochromatographic test (rK39 ICT), ELISA using promastigote antigen (p-ELISA) and indirect fluorescent antibody test (IFAT). Buffy coats of rK39 ICT positive individuals were cultured; sero-reactive buffy coats were tested for Leishmania DNA by ITS1 PCR. DNA obtained from culture was sequenced to confirm Leishmania species. Risk factors were evaluated for each sero-positive sample. RESULTS The results showed 29.2% (75/257) prevalence by serological tests: 14.4% (37/257) were positive by rK39 ICT, 25.3% (65/257) by p-ELISA, 18.3% (47/257) by IFAT and 10.9% (28/257) by all three serological methods. Ten percent (3/30) of cultures were positive for Leishmania promastigotes. Only 3% (2/74) sero-reactive buffy coats were positive for DNA; sequence analysis revealed L. donovani species. Significant risk factors were age, working as farmers, domestic animals in household and proximity to animal shelters. CONCLUSIONS Asymptomatic family members of patients with VL can carry live L. donovani in peripheral blood and may act as potential reservoirs. GENBANK ACCESSION NUMBER BankIt1863680 Leishmania KT921417 (DNA sequences of the ribosomal ITS1 region of L. donovani).

A Study on Health Seeking Behaviors of Patients of Post-Kala-Azar Dermal Leishmaniasis

Post-Kala-Azar Dermal Leishmaniasis (PKDL) remains a major public health threat in Bangladesh. A cross-sectional study was carried out in Surya Kanta Kala azar Research Centre (SKKRC), Mymensingh, from January 2012 to July 2013 to evaluate the health seeking behaviour and the length of delay of PKDL management. The consecutive 200 diagnosed PKDL cases that got treatment in SKKRC hospital were subjected to evaluation. Most (98%) of the patients were not aware and had no knowledge about PKDL, though 87.5% had a history of history of Kala-azar treatment. Many patients reported first to village doctor (15.5%), the pharmacy shop (10%), or traditional health provider (7.5%) upon recognition of symptom. The time between the initial symptom recognition and first medical consultation (patient delay) ranged from 10 days to 4745 days (13 years) with a median of 373 days (mean: 696; IQR: 138 to 900 days). The time between first medical consultations to definite treatment (system delay) ranged from 0 days to 1971 days (5.4 years), with a median delay of 14 days (mean: 46.48; IQR: 7 to 44 days) that was reported in this study. Age, education, occupation, and residential status had significant association with patient delay (P < 0.05). Educational status, occupation, number of treatment providers, and first health care provider had a significant association with system delay (P < 0.05). Success in PKDL diagnosis and treatment requires specific behavior from patients and health care providers which facilitate those practices.