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Gary L Darmstadt,
Abdullah H Baqui,
Yoonjoung Choi, Sanwarul Bari,
Syed M Rahman,
Ishtiaq Mannan,
A S M Nawshad Uddin Ahmed,
Samir K Saha,
Habibur Rahman Seraji,
Radwanur Rahman,
Peter J Winch,
Stephanie Chang,
Nazma Begum,
Robert E Black,
Mathuram Santosham,
Shams El Arifeen
[show abstract]
[hide abstract]
ABSTRACT: To validate a clinical algorithm for community health workers (CHWs) during routine household surveillance for neonatal illness in rural Bangladesh.
Surveillance was conducted in the intervention arm of a trial of newborn interventions. CHWs assessed 7587 neonates on postnatal days 0, 2, 5 and 8 and identified neonates with very severe disease (VSD) using an 11-sign algorithm. A nested prospective study was conducted to validate the algorithm (n=395). Physicians evaluated neonates to determine whether newborns with VSD needed referral. The authors calculated algorithm sensitivity and specificity in identifying (1) neonates needing referral and (2) mortality during the first 10 days of life.
The 11-sign algorithm had sensitivity of 50.0% (95% CI 24.7% to 75.3%) and specificity of 98.4% (96.6% to 99.4%) for identifying neonates needing referral-level care. A simplified 6-sign algorithm had sensitivity of 81.3% (54.4% to 96.0%) and specificity of 96.0% (93.6% to 97.8%) for identifying referral need and sensitivity of 58.0% (45.5% to 69.8%) and specificity of 93.2% (92.5% to 93.7%) for screening mortality. Compared to our 6-sign algorithm, the Young Infant Study 7-sign (YIS7) algorithm with minor modifications had similar sensitivity and specificity.
Community-based surveillance for neonatal illness by CHWs using a simple 6-sign clinical algorithm is a promising strategy to effectively identify neonates at risk of mortality and needing referral to hospital. The YIS7 algorithm was also validated with high sensitivity and specificity at community level, and is recommended for routine household surveillance for newborn illness. ClinicalTrials.gov no. NCT00198627.
Archives of Disease in Childhood 09/2011; 96(12):1140-6. · 2.88 Impact Factor
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Ishtiaq Mannan,
Yoonjoung Choi,
Anastasia J Coutinho,
Atique I Chowdhury,
Syed Moshfiqur Rahman,
Habib R Seraji, Sanwarul Bari,
Rasheduzzaman Shah,
Peter J Winch,
Shams El Arifeen,
Gary L Darmstadt,
Abdullah H Baqui
[show abstract]
[hide abstract]
ABSTRACT: Infection is the major cause of neonatal deaths. Home born newborns in rural Bangladeshi communities are exposed to environmental factors increasing their vulnerability to a number of disease agents that may compromise their health. The current analysis was conducted to assess the association of very severe disease (VSD) in newborns in rural communities with temperature, rainfall, and humidity. A total of 12,836 newborns from rural Sylhet and Mirzapur communities were assessed by trained community health workers using a sign based algorithm. Records of temperature, humidity, and rainfall were collected from the nearest meteorological stations. Associations between VSD and environmental factors were estimated. Incidence of VSD was found to be associated with higher temperatures (odds ratios: 1.14, 95% CI: 1.08 to 1.21 in Sylhet and 1.06, 95% CI: 1.04 to 1.07 in Mirzapur) and heat humidity index (odds ratios: 1.06, 95% CI: 1.04 to 1.08 in Sylhet and, 1.03, 95% CI: 1.01 to 1.04 in Mirzapur). Four months (June-September) in Sylhet, and six months in Mirzapur (April-September) had higher odds ratios of incidence of VSD as compared to the remainder of the year (odds ratios: 1.72, 95% CI: 1.32 to 2.23 in Sylhet and, 1.62, 95% CI: 1.33 to 1.96 in Mirzapur). Prevention of VSD in neonates can be enhanced if these interactions are considered in health intervention strategies.
International Journal of Environmental Research and Public Health 08/2011; 8(8):3437-52. · 1.61 Impact Factor
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Gary L Darmstadt,
Yoonjoung Choi,
Shams E Arifeen, Sanwarul Bari,
Syed M Rahman,
Ishtiaq Mannan,
Habibur Rahman Seraji,
Peter J Winch,
Samir K Saha,
A S M Nawshad Uddin Ahmed,
Saifuddin Ahmed,
Nazma Begum,
Anne C C Lee,
Robert E Black,
Mathuram Santosham,
Derrick Crook,
Abdullah H Baqui
[show abstract]
[hide abstract]
ABSTRACT: To evaluate a delivery strategy for newborn interventions in rural Bangladesh.
A cluster-randomized controlled trial was conducted in Mirzapur, Bangladesh. Twelve unions were randomized to intervention or comparison arm. All women of reproductive age were eligible to participate. In the intervention arm, community health workers identified pregnant women; made two antenatal home visits to promote birth and newborn care preparedness; made four postnatal home visits to negotiate preventive care practices and to assess newborns for illness; and referred sick neonates to a hospital and facilitated compliance. Primary outcome measures were antenatal and immediate newborn care behaviours, knowledge of danger signs, care seeking for neonatal complications, and neonatal mortality.
A total of 4616 and 5241 live births were recorded from 9987 and 11153 participants in the intervention and comparison arm, respectively. High coverage of antenatal (91% visited twice) and postnatal (69% visited on days 0 or 1) home visitations was achieved. Indicators of care practices and knowledge of maternal and neonatal danger signs improved. Adjusted mortality hazard ratio in the intervention arm, compared to the comparison arm, was 1.02 (95% CI: 0.80-1.30) at baseline and 0.87 (95% CI: 0.68-1.12) at endline. Primary causes of death were birth asphyxia (49%) and prematurity (26%). No adverse events associated with interventions were reported.
Lack of evidence for mortality impact despite high program coverage and quality assurance of implementation, and improvements in targeted newborn care practices suggests the intervention did not adequately address risk factors for mortality. The level and cause-structure of neonatal mortality in the local population must be considered in developing interventions. Programs must ensure skilled care during childbirth, including management of birth asphyxia and prematurity, and curative postnatal care during the first two days of life, in addition to essential newborn care and infection prevention and management.
Clinicaltrials.gov NCT00198627.
PLoS ONE 01/2010; 5(3):e9696. · 4.09 Impact Factor
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Syed Rahman,
Nabeel Ali,
Larissa Jennings,
Seraji M Habibur,
Ishtiaq Mannan,
Rasheduzzaman Shah,
Arif Al-Mahmud, Sanwarul Bari,
Daniel Hossain,
Milan Das,
Abdullah Baqui,
El Arifeen Shams,
Peter Winch
[show abstract]
[hide abstract]
ABSTRACT: Abstract
Background
Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.
Methods
Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.
Results
Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.
Conclusions
The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.
Human Resources for Health. 01/2010;
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Syed Moshfiqur Rahman,
Nabeel Ashraf Ali,
Larissa Jennings,
M Habibur R Seraji,
Ishtiaq Mannan,
Rasheduzzaman Shah,
Arif Billah Al-Mahmud, Sanwarul Bari,
Daniel Hossain,
Milan Krishna Das,
Abdullah H Baqui,
Shams El Arifeen,
Peter J Winch
[show abstract]
[hide abstract]
ABSTRACT: Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.
Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.
Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.
The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.
Human Resources for Health 01/2010; 8:12. · 1.83 Impact Factor
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Gary L Darmstadt,
Shams El Arifeen,
Yoonjoung Choi, Sanwarul Bari,
Syed M Rahman,
Ishtiaq Mannan,
Peter J Winch,
A S M Nawshad Uddin Ahmed,
Habibur Rahman Seraji,
Nazma Begum,
Robert E Black,
Mathuram Santosham,
Abdullah H Baqui
[show abstract]
[hide abstract]
ABSTRACT: Effective and scalable community-based strategies are needed for identification and management of serious neonatal illness.
As part of a community-based, cluster-randomized controlled trial of the impact of a package of maternal-neonatal health care, community health workers (CHWs) were trained to conduct household surveillance and to identify and refer sick newborns according to a clinical algorithm. Assessments of newborns by CHWs at home were linked to hospital-based assessments by physicians, and factors impacting referral, referral compliance and outcome were evaluated.
Seventy-three per cent (7310/10,006) of live-born neonates enrolled in the study were assessed by CHWs at least once; 54% were assessed within 2 days of birth, but only 15% were attended at delivery. Among assessments for which referral was recommended, compliance was verified in 54% (495/919). Referrals recommended to young neonates 0-6 days old were 30% less likely to be complied with compared to older neonates. Compliance was positively associated with having very severe disease and selected clinical signs, including respiratory rate > or = 70/minute; weak, abnormal or absent cry; lethargic or less than normal movement; and feeding problem. Among 239 neonates who died, only 38% were assessed by a CHW before death.
Despite rigorous programmatic effort, reaching neonates within the first 2 days after birth remained a challenge, and parental compliance with referral recommendation was limited, particularly among young neonates. To optimize potential impact, community postnatal surveillance must be coupled with skilled attendance at delivery, and/or a worker skilled in recognition of neonatal illness must be placed in close proximity to the community to allow for rapid case management to avert early deaths.
Health Policy and Planning 11/2009; 25(2):112-24. · 2.65 Impact Factor
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Gary L Darmstadt,
Samir K Saha,
Yoonjoung Choi,
Shams El Arifeen,
Nawshad Uddin Ahmed, Sanwarul Bari,
Syed M Rahman,
Ishtiaq Mannan,
Derrick Crook,
Kaniz Fatima,
Peter J Winch,
Habibur Rahman Seraji,
Nazma Begum,
Radwanur Rahman,
Maksuda Islam,
Anisur Rahman,
Robert E Black,
Mathuram Santosham,
Emma Sacks,
Abdullah H Baqui
[show abstract]
[hide abstract]
ABSTRACT: To devise treatment strategies for neonatal infections, the population-level incidence and antibiotic susceptibility of pathogens must be defined.
Surveillance for suspected neonatal sepsis was conducted in Mirzapur, Bangladesh, from February 2004 through November 2006. Community health workers assessed neonates on postnatal days 0, 2, 5, and 8 and referred sick neonates to a hospital, where blood was collected for culture from neonates with suspected sepsis. We estimated the incidence and pattern of community-acquired neonatal bacteremia and determined the antibiotic susceptibility profile of pathogens.
The incidence rate of community-acquired neonatal bacteremia was 3.0 per 1000 person-neonatal periods. Among the 30 pathogens identified, the most common was Staphylococcus aureus (n = 10); half of all isolates were gram positive. Nine were resistant to ampicillin and gentamicin or to ceftiaxone, and 13 were resistant to cotrimoxazole.
S. aureus was the most common pathogen to cause community-acquired neonatal bacteremia. Nearly 40% of infections were identified on days 0-3, emphasizing the need to address maternal and environmental sources of infection. The combination of parenteral procaine benzyl penicillin and an aminoglycoside is recommended for the first-line treatment of serious community-acquired neonatal infections in rural Bangladesh, which has a moderate level of neonatal mortality. Additional population-based data are needed to further guide national and global strategies.
The Journal of Infectious Diseases 09/2009; 200(6):906-15. · 6.41 Impact Factor
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Shams E Arifeen,
Samir K Saha,
Sayedur Rahman,
Kazi Mizanur Rahman,
Syed Moshfiqur Rahman, Sanwarul Bari,
Aliya Naheed,
Ishtiaq Mannan,
M Habibur R Seraji,
Nawshad U Ahmed, [......],
Ashraf Uddin Siddik,
Iftekhar Quasem,
Maksuda Islam,
Kaniz Fatima,
Hassan Al-Emran,
W Abdullah Brooks,
Abdullah H Baqui,
Robert F Breiman,
David Sack,
Stephen P Luby
[show abstract]
[hide abstract]
ABSTRACT: Streptococcus pneumoniae infection is recognized as a global priority public health problem, and conjugate vaccines have been shown to prevent vaccine-type invasive pneumococcal disease (IPD) in children. However, better estimates of the disease burden and reliable population-based data on serotype composition are needed for vaccine development and implementation in developing countries.
We initiated a population-based surveillance in the rural Bangladesh community of Mirzapur, covering a population of approximately 144,000. Village health care workers made weekly visits to approximately 12,000 children 1-59 months of age in the study area. Children with reported fever, cough, or difficulty breathing were assessed by the village health care workers using a clinical algorithm and were referred to the hospital if required. Children from the study area who were seen in the hospital underwent clinical examination and laboratory testing if they met standardized case definitions. IPD was confirmed by blood and/or cerebrospinal fluid culture results. Isolates were identified, tested for susceptibility to antibiotics, and serotyped in accordance with standard laboratory methods. We present here the results from the first 3 years of the surveillance (July 2004-June 2007).
Village health care workers identified 5020 cases of possible severe pneumonia and/or very severe disease (165 cases per 1000 child-years)and 9411 cases of possible pneumonia (310 cases per 1000 child-years) as well as 2029 cases of suspected meningitis and/or very severe disease (67 cases per 1000 child-years) and 8967 cases of high fever and/or possible bacteremia (295 cases per 1000 child-years). Pneumonia was the single most common form of illness observed among 2596 hospitalizations (found in 977 [38%] of cases). We recovered 26 S. pneumoniae isolates (25 isolates from 6925 blood cultures and 1 isolate from 41 cerebrospinal fluid cultures), which gave an overall IPD incidence of 86 cases per 100,000 child-years. Invasive pneumococcal infection was common during infancy (with infants accounting for 23 of the 26 cases), and 50% of the total isolates were obtained from nonhospitalized patients who received a diagnosis of upper respiratory tract infection and fever. The most prevalent pneumococcal serotypes were serotypes 1, 5, 14, 18C, 19A, and 38. Ten of the 26 isolates were completely resistant to trimethoprim-sulfamethoxazole, and another 10 isolates had intermediate resistance.
IPD contributes substantially to childhood morbidity in rural Bangladesh. S. pneumoniae can cause invasive but nonsevere disease in children, and IPD incidence can be seriously under reported if such cases are overlooked. The emerging high resistance to trimethoprim-sulfamethoxazole should be addressed. Data on serotype distribution would help to guide appropriate pneumococcal conjugate vaccine formulation.
Clinical Infectious Diseases 04/2009; 48 Suppl 2:S103-13. · 9.15 Impact Factor
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Gary L Darmstadt,
Abdullah H Baqui,
Yoonjoung Choi, Sanwarul Bari,
Syed M Rahman,
Ishtiaq Mannan,
A S M Nawshad Uddin Ahmed,
Samir K Saha,
Radwanur Rahman,
Stephanie Chang,
Peter J Winch,
Robert E Black,
Mathuram Santosham,
Shams El Arifeen
[show abstract]
[hide abstract]
ABSTRACT: To estimate the validity (sensitivity, specificity, and positive and negative predictive values) of a clinical algorithm as used by community health workers (CHWs) to detect and classify neonatal illness during routine household visits in rural Bangladesh.
CHWs evaluated breastfeeding and symptoms and signs of illness in 395 neonates selected randomly from neonatal illness surveillance during household visits on postnatal days 0, 2, 5 and 8. Neonates classified with very severe disease (VSD) were referred to a community-based hospital. Within 12 hours of CHW assessments, physicians independently evaluated all neonates seen in a given day by one CHW, randomly chosen from among 36 project CHWs. Physicians recorded symptoms and signs of illness, classified the illness, and determined whether the newborn needed referral-level care at the hospital. Physicians' identification and classification were used as the gold standard in determining the validity of CHWs' identification of symptoms and signs of illness and its classification.
CHWs' classification of VSD showed a sensitivity of 73%, a specificity of 98%, a positive predictive value of 57% and a negative predictive value of 99%. A maternal report of any feeding problem as ascertained by physician questioning was significantly associated (P < 0.001) with 'not sucking at all' and 'not attached at all' or 'not well attached' as determined clinically by CHWs during feeding assessment.
CHWs identified with high validity the neonates with severe illness needing referral-level care. Home-based illness recognition and management, including referral of neonates with severe illness by CHWs, is a promising strategy for improving neonatal health and survival in low-resource developing country settings.
Bulletin of the World Health Organisation 01/2009; 87(1):12-9. · 4.64 Impact Factor
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Sanwarul Bari,
Ishtiaq Mannan,
Mohammed Anisur Rahman,
Gary L Darmstadt,
M Habibur R Serajil,
Abdullah H Baqui,
Shams El Arifeen,
Syed Moshfiqur Rahman,
Samir K Saha,
A S M Nawshad Uddin Ahmed,
Saifuddin Ahmed,
Mathuram Santosham,
Robert E Black,
Peter J Winch
[show abstract]
[hide abstract]
ABSTRACT: The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.
Journal of Health Population and Nutrition 01/2007; 24(4):519-29. · 0.95 Impact Factor
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Sanwarul Bari,
Ishtiaq Mannan,
Mohammed Anisur Rahman,
Gary L Darmstadt,
M. Habibur,
R. Seraji,
Abdullah H Baqui,
Shams El Arifeen,
Syed Moshfiqur Rahman,
Samir K Saha, [......],
Nabeel Ashraf Ali,
Tariq Anwar,
Nazma Begum,
Atique Iqbal Chowdhury,
Sameena Chowdhury,
A.K.M. Fazlul Haque,
Quamrul Hasan,
Dulal Poddar,
Qazi Sadequr Rahman,
Ashrafuddin Siddik
[show abstract]
[hide abstract]
ABSTRACT: The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.
The Journal of Health, Population and Nutrition (ISSN: 1606-0997) Vol 24 Num 4.
