International Centre for Diarrhoeal Disease Research

Dengue cases in Bangladesh have surged in recent years. The existing insecticide-based control program is challenged by issues of insufficient household coverage and high levels of insecticide resistance in the primary dengue virus (DENV) vector, Aedes aegypti. A more sustainable, effective alternative could be the implementation of a Wolbachia-mediated disease management strategy. Hence, we created and characterised a Wolbachia-infected Ae. aegypti strain with a Dhaka wild-type genetic background, and compared its reproductive compatibility, maternal inheritance, fitness, and virus-blocking ability to the parental strains (Dhaka wild-type and wAlbB2-F4). The new Ae. aegypti strain wAlbB2-Dhaka demonstrated complete cytoplasmic incompatibility with the wild-type and complete maternal transmission, retaining levels of pyrethroid resistance of the Dhaka wild-type. No significant fitness costs were detected during laboratory comparison. Compared to the wild-type, wAlbB2-Dhaka mosquitoes demonstrated a significantly reduced genome copies of DENV in the bodies (44.4%, p = 0.0034); a two-fold reduction in dissemination to legs and wings (47.6%, p < 0.0001); and > 13-fold reduction of DENV in saliva expectorates (proxy of transmission potential) (92.7%, p < 0.0001) 14 days after ingesting dengue-infected blood. Our work indicates that the wAlbB2-Dhaka strain could be used for Ae. aegypti suppression or replacement strategies for dengue management in Bangladesh.

Introduction Obsessive-compulsive disorder (OCD) imposes a considerable impact on day-to-day functioning. Many people experience insufficient symptom relief even after taking the optimum dose of OCD medications. Reduced levels of folic acid and vitamin B₁₂, along with elevated homocysteine (HCY), have been suggested as possible factors in the persistence of obsessive-compulsive (OC) symptoms. This study investigated how supplementation of vitamin B₁₂, folic acid, and selective serotonin reuptake inhibitors (SSRIs) affects OC symptoms and related biochemical markers. Methods A comparative study enrolled 72 OCD patients. For eight weeks, the conventional treatment group received SSRIs or other anti-obsessive medication. In contrast, the nutrient-supplemented group received supplements of vitamin B₁₂, folic acid, and SSRIs. Micronutrients HCY, folic acid, and vitamin B₁₂ were measured at baseline and after eight weeks. Besides, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was applied to assess the severity of OCD symptoms at the baseline, four-week, and eight-week visits. Results Group A (conventional treatment with nutrient supplement) showed significant improvements in vitamin B₁₂, blood folic acid, and reductions in HCY levels compared to Group B (conventional treatment). However, no substantial differences in insight levels were observed between the groups. Both groups exhibited decreased Y-BOCS scores, indicating a reduction in OCD symptoms; however, the improvements in Group A (conventional treatment + nutrient supplement) were statistically significant. Conclusions When taken with SSRIs, vitamin B₁₂ and folic acid supplements seem to improve OCD patients’ clinical results. These results imply that this supplementation could be a useful therapeutic adjunct

The whole genome sequence of a dengue virus serotype 2 strain (GenBank accession number PQ657766 ) obtained from a dengue-infected hospitalized patient in Chittagong, Bangladesh, is classified as the cosmopolitan genotype V, with genetic alterations observed in several structural proteins. The genomic data were generated using Oxford Nanopore sequencing technology.

Severe COVID-19 is rare in children suggesting differences in immune response between children and adults. Limited information is available on how cellular immunity is modulated by COVID-19 vaccination and prior infection, and whether it is differentially modulated in children compared to adults. Here, we aimed to compare COVID-19 vaccine-induced functional T cell response between adults and children with and without previous SARS-CoV-2 infection. Adults (18–45 years; n = 45) and children (5–10 years; n = 51;), who received Pfizer-BioNTech COVID-19 vaccine or remained unvaccinated, and previously infected or not with SARS-CoV-2 were selected from two cross-sectional SARS-CoV-2 serosurveillance studies conducted in Bangladesh. Plasma nucleocapsid (N)-specific antibodies were measured by electrochemiluminescence immunoassay; IFN-γ, perforin and granzyme B secreting T cells were assessed using ELISpot assay. Vaccination in adults without previous infection, induced higher frequencies of IFN-γ and granzyme B secreting T lymphocytes compared to unvaccinated adults, while it increased only IFN-γ expression in vaccinated children. Previous infection increased IFN-γ response in unvaccinated adults only. Unvaccinated children showed higher granzyme B expression compared to adults irrespective of infection status. In vaccinated individuals, prior infection induced perforin expression in both adults and children. Children showed slightly different functional T cell response than adults in response to COVID-19 vaccination and infection. mRNA vaccination provided higher IFN-γ response in both adults and children, but induced cytotoxic T lymphocyte (CTL) response in adults only. Future studies may evaluate the impact of other types of COVID-19 vaccines on functional T cell immunity in children to confirm the findings.

Background Social protection programs have played a significant role in ensuring that persons with disabilities (PWD) in low- and middle-income countries have access to basic livelihoods. However, there is a lack of research examining the extent of social protection program coverage for PWD and the factors influencing their inclusion. This study aimed to explore the extent of PWD’s inclusion in social protection programs in Bangladesh and the factors influencing their inclusion in these programs. Methods We analyzed data from the 2021 National Household Survey on Persons with Disabilities in Bangladesh. The outcome variable considered was PWD’s inclusion in social protection programs (yes, no) to receive support, as well as the timing of inclusion in the social protection program (non-inclusion (0), inclusion within 0–6 months of the survey (1), and inclusion more than 6 months before the survey (2)). Explanatory variables included factors at the individual, household, and community levels. A multilevel multinomial logistic regression model was used to explore the associations between the outcome variable and explanatory variables, with respondents categorized into two groups based on age (children (0 to <18) and adults and older (18–95 years)). Results Data from a total of 4,293 PWD were analyzed, with a mean age of 41.4 years; 59% of the respondents were male. Approximately 37.7% (95% CI, 36.0–39.6) of the total respondents reported inclusion in social protection programs within 0–6 months of the survey, rising to 47.4% (95% CI, 45.6–49.2) for support received more than 6 months before the survey. “Disability allowances (69.0%) were the most common type of social protection program that PWD reported being included in, followed by old age allowances (16.3%) and assistance through the VGD/VGF programs (6.8%). Among children aged <18 years, the likelihood of inclusion in social protection programs was higher for those with multiple disabilities. In contrast, for PWD aged 18 years and older, inclusion in social protection programs was lower among those with mental illness, hearing disabilities, and intellectual disabilities. The likelihood of inclusion in social protection programs was higher for older, unmarried, widowed, divorced, or separated PWD. Conversely, PWD from wealthier households and those residing in the Dhaka division had a lower likelihood of being included in social protection programs. Conclusion The findings of this study underscore the urgent need for more comprehensive and inclusive social protection policies and programs to support the well-being of PWD in Bangladesh. Since disability grants are the primary source of social protection for this group, it is crucial to expand coverage and increase the amount of financial support provided.

Rapid and reliable diagnostic tests for tuberculous meningitis (TBM) in children remain limited. This study evaluated the performance of Xpert MTB/RIF Ultra (Ultra), an improved version of Xpert MTB/RIF (Xpert), for detecting TBM in children using cerebrospinal fluid (CSF). Children (0–14 years) presumptive of TBM were enrolled prospectively from three tertiary level hospitals in Dhaka, Bangladesh, from December 2019 to January 2022. CSF was tested by Ultra, Xpert, Lowenstein–Jensen (L–J) culture, and acid-fast bacilli (AFB) microscopy. Diagnostic performance was assessed against clinical case definitions, composite microbiological reference standard (CMRS), and L–J culture. Of 187 children, Ultra detected TBM in 23.4% of cases, significantly higher than the 9.1% detected by Xpert (p < 0.001). Compared to the clinical case definition of probable and definite TBM, Ultra exhibited a sensitivity of 88% (44/50), markedly outperforming Xpert (34%, 17/50) and L-J culture (30%, 15/50) (p < 0.001). Against the CMRS, Ultra’s sensitivity was 100% (44/44), compared to Xpert (38.6%, 17/44) and L-J culture (34.1%, 15/44) (p < 0.001). AFB microscopy showed very low sensitivity (2.3%, 1/44). Negative predictive values for both clinical case definition and CMRS were higher for Ultra (95.8–100%) than Xpert (80.6–84.1%) and L–J culture (79.7–83.1%) (p < 0.001). Compared to gold standard L–J culture, Ultra’s sensitivity (100%, 15/15) was also higher than Xpert (93.3%, 14/15) (p = 0.316), with specificities of 83.1% (143/172) and 98.3% (169/172), respectively. Ultra detected 26 TBM cases missed by other tests, with most (84.6%) in the ‘trace detected’ category. Due to the high performance, Ultra can be used widely at health care settings of high TB burden countries like Bangladesh for rapid and accurate diagnosis of paediatric TBM using CSF samples.

Nipah virus (NiV) is a deadly zoonotic pathogen in Southeast Asia causing severe respiratory and encephalitis symptoms with a high fatality rate. Whole-genome sequencing (WGS) is crucial for tracking transmission, conducting epidemiological analyses, and understanding NiV’s adaptive evolution. WGS is essential for analyzing genomes, particularly in understanding pathogen nature, and pathogenesis and aiding in the development of therapeutics. However, sequencing this highly contagious virus directly from samples is challenging in low- and middle-income countries lacking BSL-4 facilities. This study developed and optimized a culture-independent, high-throughput multiplex PCR-based third-generation sequencing protocol for NiV using the Oxford Nanopore Technology platform and a proposed bioinformatics pipeline to generate consensus genome sequences directly from environmental and clinical specimens. We amplified 12 NiV RT-PCR-positive specimens (11 clinical, one environmental) to produce 60 amplicons, each approximately 400 bp, covering the entire ~18.2 kb genome. Using a two-step reverse transcriptase PCR approach, libraries were prepared with a ligation sequencing kit. Raw sequence data were then analyzed using bioinformatics tools. A minimum of 10,000 total reads per sample provided a nearly complete coverage (>95%) of the NiV genome, even with low virus concentrations (Ct ≤ 32), with an average quality score of 10.2. The WGS of 12 NiV-positive samples achieved coverage between 95.71% (Ct 29.54) and 99.3% (Ct 22.34). The entire process, from RNA extraction to finished sequences, took only 24 h. We developed a portable, culture-independent, high-throughput sequencing workflow suitable for resource-limited settings, aiding in real-time monitoring, outbreak investigation, and detection of new NiV strains and genetic evolution. IMPORTANCE The development of a culture-independent, high-throughput whole-genome sequencing (WGS) protocol for Nipah virus (NiV) using the Oxford Nanopore MinION technology marks a significant advancement in outbreak response, surveillance, and genomic analysis of NiV. NiV is an RG4 category C pathogen; working with the NiV virus is a deep concern of biosafety and biosecurity. It demands the development of biologically safe procedures to get genetic information. This protocol utilizes biologically safe samples that were collected into recommended lysis solution, multiplex PCR, and third-generation sequencing, effectively addressing challenges in sequencing NiV. This optimized workflow achieved over 95% genome coverage without the need for virus culture. It is a cost-effective, rapid, and efficient approach to the WGS of NiV, making it suitable for resource-limited settings like Bangladesh. The method enhances the capacity for outbreak investigations, epidemiological analyses, and monitoring virus, aiding in detecting emerging strains. This work contributes significantly to global pandemic preparedness and response efforts.

Background Hard-to-reach riverine communities of northern Bangladesh face unique challenges in healthcare services. Friendship, an international social purpose organization, implemented a 3-tier healthcare model addressing these unique challenges over the past 20 years. This study evaluated Friendship’s 3-tier healthcare model in the northern riverine area, assessing service-seeking practices, experiences, stakeholders’ perceptions, and cost benefits for beneficiaries. Methods A concurrent mixed-method approach was employed, including desk reviews, a cross-sectional quantitative survey, facility mapping, and qualitative interviews with service recipients, community representatives, healthcare providers, and health managers. Data were collected from five hard-to-reach riverine sub-districts across the Kurigram, Gaibandha, Bogura, Sirajganj, and Jamalpur districts of Bangladesh between April 2022 and July 2023. Data analysis followed major thematic domains for a comprehensive and complementary understanding. Results A significant proportion (43.0%) of survey participants had no formal education, were aged 18–35 (57.5%), and earned less than 1,620 USD yearly (66.6%). Friendship’s healthcare services at the doorstep through satellite clinics and Female Community Medic Aides were widely accepted and preferred within the community for convenience, affordability (0.05–0.09 USD service charges), and superior quality, particularly the specialized treatments available on the hospital ships. Conclusion Friendship’s 3-tier healthcare model made the accessibility and affordability of primary healthcare. Upon implementing a robust referral mechanism, continuing collaboration with the Government of Bangladesh, and expanding community awareness sessions to include topics such as mental health and disaster response, this model has the potential to be effective in similar settings in Bangladesh and other developing countries, as well as during emergency responses.

Introduction Environmental enteric dysfunction (EED), a subclinical intestinal disorder, is characterized by chronic fecal-oral exposure to entero-pathogens and could be diagnosed by measuring non-invasive biomarkers. Escherichia coli is the one of the key bacterial enteric pathogens that drives EED, but there is a lack of information on the E. coli pathotypes in relation to the biomarkers of EED in malnourished adults. Here, we intended to measure the possible association of these pathotypes with EED biomarkers and nutritional status of adults residing in a slum in Bangladesh. Method Fecal samples were collected from 524 malnourished adults (BMI ≤18.5 kg/m²) living in a slum-setting in Dhaka from March 2016 to September 2019 and analyzed by TaqMan Array Card assays to evaluate the presence of E. coli pathotypes and other entero-pathogens. The multivariable linear regression model was used to assess the association. Results In these malnourished adults, the most prevalent pathotype of E. coli was EAEC (61.7%) and the least prevalent was STEC (6.7%). The prevalence of atypical EPEC, ETEC and Shigella/EIEC were 52%, 48.9% and 45.1% respectively. The infection with atypical EPEC had significant positive association with levels of Myeloperoxidase (b = 0.38; 95% CI = 0.11, 0.65; p-value = 0.006). Similarly, a significantly higher concentration of alpha-1-antitrypsin (b = 0.13; 95% CI = 0.03, 0.22; p-value = 0.011) was found in the STEC-infected adults. However, no notable association was found between the E. coli pathotypes and nutritional status of these adult participants. Moreover, Plesiomonas infected adults were more likely to be infected with EAEC (p-value = 0.017), ETEC (p-value <0.001) and STEC (pvalue = 0.002). Significant coinfection was also detected among the pathotypes and other entero-pathogens such as Giardia, Ascaris, Campylobacter, Salmonella, Enterocytozoon bieneusi, and Adenovirus. Discussion The study results imply that there is an influence of particular E. coli pathotypes (EPEC and STEC) on intestinal inflammation and gut permeability of the malnourished Bangladeshi adults, but no association with nutritional status is found. Potential pathogenicity of the E. coli pathotypes is also observed when co-infection with other pathogens exists in these adults.

Hypothermia remains a leading contributing factor to neonatal mortality. This study reports testing of a thermoregulatory device—‘Thermal Jacket’ that includes a reusable chemical warming pad (CWP) and an insulating jacket designed for hypothermia management. The laboratory experiments were conducted in two distinct phases between February’21 and June’22. In phase 1, a ternary composite of Sodium-Acetate-Trihydrate, Glycerol, Paraffin, and water contained in a high-density polyethylene-pouch named ‘CWP’ was finalised, and an insulating jacket was designed for targeted heat retention. In phase 2, the device’s efficacy was evaluated using a mannequin in a controlled setting. The sample size was 81 events. Welch’s t-test, ANOVA, and GEE were used to assess any significant differences between successful and failed events. Among 81 events, approximately 93% events of CWP and 98% events of insulating jacket successfully maintained temperature within 36–38°C for 120 minutes. Moreover, ambient temperature, reuse of CWPs, humidity did not have any significant effect on the success rate of the CWP and insulating jacket. Thermal Jacket had achieved and sustained the temperature range of 36–38°C for 2 hours. While this study used mannequin, clinical trial with preterm or low birthweight neonates is imperative to assess its effectiveness for thermal care management.

Background Intimate partner violence (IPV) remains a significant public health concern in Bangladesh, with societal norms heavily influencing women’s attitudes toward its justification. Education is often linked to reduced IPV justification, as it can empower women to challenge harmful gender norms. However, this relationship is likely moderated by community norms, where entrenched beliefs about IPV may limit the protective effects of education. This study examines the interplay between education and community norms in shaping the attitudes toward IPV among ever-married women aged 15 to 49 in Bangladesh. Methods This study utilized data from the 2022 Bangladesh Demographic and Health Survey (BDHS). A sample of 19,022 ever-married women was analyzed. A composite measure of attitudes toward IPV was developed, assessing agreement with various justifications for IPV. Statistical analyses, including chi-square tests, rank-biserial correlation test, and generalized linear models with binomial link function, were utilized to evaluate associations between IPV justification and sociodemographic factors. The parametric g-formula was employed to estimate potential outcome probabilities of IPV justification under hypothetical scenarios, with bootstrapping used for standard error calculations. Results 13.9% of the ever-married women in Bangladesh aged 15–49 years justified IPV. Women with no formal education had 78% higher odds of justifying IPV compared to higher educated women (AOR 1.78 with 95% CI 1.11 to 2.85). Women from communities with a high prevalence of IPV justification had 3.21 times higher odds of perceiving IPV as justifiable compared to those from low-prevalence community (AOR 3.21 with 95% CI 2.06 to 5.01). Additionally, poor older women with limited household decision-making autonomy, having uneducated husband, and belonged to certain divisions were more prone to justify IPV. Within a fixed level of community norms, the prevalence of IPV justification among women with no formal education is not significantly different from the women with primary or secondary education (all p values > 0.40). On the other hand, if all women from the study population had no formal education and belonged to a community with low IPV justification, they would have been 6% less likely to perceive IPV as justifiable compared to if all of them were to belong to a highly educated community high IPV justification (95% CI: -11% to -2%). Conclusion The findings highlight that education alone is insufficient to combat the norm regarding IPV justification, particularly in communities where such beliefs are entrenched. The results underscore the necessity of targeted, community-level interventions aimed at shifting societal attitudes toward non-violence and gender equality, creating sustainable change, and reducing the normalization of IPV in Bangladesh.

Background Public health professionals are instrumental in shaping evidence-based policies and improving population health by translating research findings into actionable solutions. To sustain this progress, it is essential to understand the research engagement, aspirations, and challenges of public health students, as their active participation in research is critical for their development into successful public health practitioners. Methods This cross-sectional descriptive study surveyed graduate public health students from universities in Bangladesh offering Master of Public Health program, using a questionnaire to collect data on demographics, research engagement, training, future aspirations, and the challenges encountered during research. Results Among the 417 participating students, the mean age was 31.3 ± 5.7 (SD) years, with a majority being female (58.7%). Approximately half of the participants (49.2%) had engaged in research activities prior to pursuing their current degree, while 27.6% had received formal research training. Of all, 87.8% students (n = 366) had an intention to pursue research career in future. Female students (aOR 2.07, 95% CI 1.02–4.19, p = 0.043), students who were ≥ 30 years (aOR 2.51, 95% CI 1.11–5.69, p = 0.027), and studying MPH in public institutions (aOR 0.45, 95% CI 0.22–0.90, p = 0.024) exhibited a higher likelihood of conducting research independently, compared to male students, age < 30 years and studying MPH in private institutions, respectively. Factors such as prior research training (aOR 5.61, 95% CI 2.64–11.9, p < 0.001) and prior education in non-science discipline (aOR 3.40, 95% CI 1.16–9.99, p = 0.026) were positively associated with conducting research independently. Conclusion Graduate public health students have demonstrated a strong interest in research careers, with nearly half reporting prior research experience. Being able to conduct research independently is shaped by factors such as gender, academic background, and the quality of training they receive.

Background Melioidosis, which is caused by Burkholderia pseudomallei, is a disease with a high case fatality rate and a wide variety of disease manifestations causing diagnostic dilemmas for medical professionals. Risk factors such as diabetes contribute to a worse prognosis if not treated with appropriate antibiotics during the course of management. This case report describes a diabetic melioidosis case with a rare presentation of venous thrombosis of the lower limb and a successful course of treatment. Case presentation The patient was a 48-year-old Bangladeshi male who was admitted with gradually increasing left knee pain and intermittent high-grade fever for 7 days. On examination, he had a palpable spleen, high body temperature (102 °F), and pitting edema in the left lower limb during admission. He was treated with empiric meropenem on admission considering his serious illness. Doppler ultrasound of the left lower limb revealed superficial venous thrombosis and thrombophlebitis involving the long saphenous vein and superficial veins of saphenous territory below the knee. The patient was enrolled as an eligible case in a research study called the Acute Febrile Illness study. Blood culture confirmed the diagnosis as melioidosis. Doxycycline was added to his treatment regimen when the research study team informed the treating physician at the hospital about the diagnosis of melioidosis. He was discharged with cotrimoxazole, which was advised to be taken for 3 months. Conclusion This case report shows us the lack of diagnostics to detect melioidosis in hospital settings in Bangladesh. The successful treatment outcome proved the importance of routine surveillance for rare or unusual diseases, in addition to endemic pathogens. In addition, training is essential to improve knowledge and raise awareness among clinicians about the clinical diagnosis and management of melioidosis.

Acute Malnutrition affects 45 million children under five globally, with Bangladesh contributing more than 1.7 million cases. While community‐based management of acute malnutrition (CMAM) guidelines in Bangladesh exist, they primarily emphasise nutritional counselling and face challenges in coverage and implementations. It is important to understand barriers to CMAM uptake and implementation. This study aims to explore the perceptions of acute malnutrition's underlying factors and consequences among parents, healthcare providers, and policymakers, alongside parents' care‐seeking behaviours for under‐five children with acute malnutrition. Conducted in areas with and without CMAM programs, the research follows a phenomenological design with thematic analysis of focus group discussions (FGDs) and key informant interviews (KIIs). Thirty FGDs with parents, 28 KIIs with healthcare providers, and 16 KIIs with policymakers were conducted. Identified causes of acute malnutrition included infections, diseases, lack of awareness about nutritious foods, supernatural beliefs, poverty, and inadequate care and feeding practices. Consequences included stunted growth, impaired mental development, and increased illness risk. Although parents acknowledged the urgency of treating acute malnutrition, they sought care at healthcare facilities regardless of illness. Factors influencing care‐seeking behaviour were inability in problem prioritisation, transportation cost and availability, healthcare access, wage loss, and out‐of‐pocket expenses. Despite awareness of acute malnutrition's underlying factors and consequences, parental care‐seeking remains limited. The study recommends integrating acute malnutrition guidelines with communicable disease programs, implementing targeted social and behavioural change programs, addressing superstitions, fostering collaboration with traditional healers strengthening social safety nets, and empowering women in healthcare decision‐making.

Objective Underweight, wasting, and stunting are crucial malnutrition indicators responsible for morbidities among children. Data regarding coexisting forms of malnutrition (CFM) is scarce. We aimed to investigate the prevalence and associated factors of CFM across two survey years among under-5 Bangladeshi children. Design Cross-sectional study. Setting Data were acquired from two rounds of Multiple Indicator Cluster Survey (MICS), Bangladesh conducted in 2012-13 and 2019. Subjects The analysis included 43,946 (2012-13: 20,885; 2019: 23,061) under-5 children. Results Binomial proportion test, slope index of inequality, and multinomial logistic regression models were used for analysis. The prevalence of CFM was 27.45% and 18.56% in 2012-13 and 2019, respectively. A significant decrease in the prevalence of CFM was seen across the surveys (p-value<0.001). Children from urban residence [( 2012-13 :aOR=0.70, 95% CI:0.64,0.77); ( 2019 :aOR=0.71, 95% CI:0.65,0.78], higher maternal education [( 2012-13 :aOR=0.28, 95% CI:0.24,0.32); ( 2019 :aOR=0.28, 95% CI:0.24,0.32], larger size at birth [( 2012-13 :aOR=0.62, 95% CI:0.52,0.73); ( 2019 :aOR: 0.60, 95% CI:0.50,0.73], richest wealth quintile [( 2012-13 :aOR=0.25, 95% CI:0.22,0.28); ( 2019 :aOR: 0.30, 95% CI:0.27,0.34)] had lower odds of suffering from CFM compared to their counterparts. Children from poorer quintiles were more influenced by CFM than richer quintiles (Coef.:-0.175, 95% CI:-0.192,-0.157, p-value<0.001). Higher percentage of CFM was observed among rich families in 2019 compared to 2012-13 (24.50% and 20.15%, respectively; p-value<0.001) Conclusion The findings of this study should help the researchers and policymakers to understand CFM more clearly and plan prospective studies to explore CFM outcomes. Targeted interventional approaches are needed among parents of rural communities to control the burden of CFM.