Strengthening government health and family planning programs: findings from an action research project in rural Bangladesh

An ongoing study at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) is based on the premise that public sector health and family planning programs can be improved through an assessment of the dysfunctional aspects of their operations, the development of problem-solving capabilities, and the transfer of strategies successfully tested in a small-scale pilot project. This paper reports findings from a field trial implemented in a subunit of the project area at an early stage of the project. Operational barriers to public sector program implementation are discussed with regard to the quantity of work, the quality of work, supplies and facilities, integration of health and family planning, and leadership, supervision, and decision making. Initial results of the ICDDR,B intervention on these managerial processes are also indicated.

Activities of two aminoglycosides and five newer beta-lactam antibiotics: safer alternatives to aminoglycosides?

Five newer beta-lactam antibiotics and two aminoglycosides were tested on 400 freshly isolated clinically significant organisms from specimens at a district general hospital. All the antibiotics had very broad-spectrum activities but none could cover against all probable pathogens. Latamoxef was the best of all against Bacteroides spp. Aminoglycosides, followed by cefotaxime and ceftizoxime, were best against staphylococci. Tobramycin, followed by ceftazidine and netilmicin, had the best activity against Pseudomonas aeruginosa. Of all 7 antibiotics tested only piperacillin demonstrated activity against Streptococcus faecalis. Cefotaxime and ceftizoxime were the best against Escherichia coli, Klebsiella spp. and most of streptococci. The study demonstrated that safer alternatives to aminoglycosides are now available.

Preliminary experience with continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD) was employed in seven patients of endstage renal failure (ESRF). All the patients had symptom-free ambulant life during CAPD. Blood pressure was well controlled and the haemoglobin level improved significantly. Blood urea and serum creatinine levels were maintained near normal levels. Metabolic acidosis was corrected. Recurrent peritonitis, heavy protein loss and catheter failure were the main complications of CAPD. It appears from these observations that CAPD may be helpful in patients with ESRF.

A diarrhea clinic in rural Bangladesh: influence of distance, age, and sex on attendance and diarrheal mortality

Attendance rates at a diarrhea clinic were monitored in a defined population in rural Bangladesh. Weekly home visits were also carried out to determine diarrheal attacks in communities within six miles of the clinic. Within the first one mile radius, 90 per cent of diarrheal cases came to the clinic for treatment. At two miles the attendance fell to 70 per cent for males and 40 per cent for females. On an average, the greater the distance to the clinic, the more severe was the degree of dehydration on presentation, requiring more frequent use of intravenous fluid. Mortality secondary to diarrhea was significantly reduced only within a two-mile radius of the clinic.

The demographic impact of the contraceptive distribution project in Matlab, Bangladesh

This paper evaluates a study fielded in Bangladesh in 1975 to test the hypothesis that ubiquitous availability of pills and condoms in a rural, traditional, noncontracepting population would increase contraceptive use and reduce fertility. Treatment and comparison areas were designated in Matlab, an area with accurate and complete demographic data. Use prevalence peaked at 18 percent in the first three months of the project and declined thereafter. Project activities continued until 1977. Results show that between-treatment fertility differentials were 10 percent in the first year of program impact, but that effects dissipated with time.

The demographic impact of the family planning--health services project in Matlab, Bangladesh

This paper evaluates the demographic impact of the Family Planning-Health Services Project in Matlab Thana of rural Bangladesh. The project was begun by the International Centre for Diarrhoeal Disease Research, Bangladesh in October 1977. Contraceptive services--including pills, condoms, IUDs, sterilization, and injectables--are supplemented by oral rehydration, tetanus toxoid, and other services. About 33 percent of eligible couples are using contraception. Impact is evaluated by direct measurement of birth rates in the treatment and comparison areas. An overall fertility decline of about 25 percent is observed, concentrated among older women. The impact is two-to-three times that of an earlier project that included fewer methods and used lesser trained workers. The study shows that intensive family planning efforts can affect fertility in the absence of socioeconomic changes.

Penicillin sensitivities of gonoccocci, in 1977-80 from a peripheral health district, and their clinical correlation

Penicillin sensitivities of gonococci isolated from a peripheral health district were observed during 1977-80 by determining the minimum inhibitory concentrations (MIC) of penicillin. During the same period, outcome of penicillin treatment in patients with gonorrhoea was also observed and recorded. Penicillin resistance, as defined, was found in 19·3% strains in these years, but there were year-to-year variations. None of the strains was a penicillinase producer. Association of higher MICs of penicillin with therapeutic failures was not observed in this study until the MICs were greater than 1·0 mg/l. The findings are discussed together with reviews from other published works.

DDT-susceptibility status of malaria vector Anopheles balabacensis balabacensis Baisas (Diptera : Culicidae) in Bangladesh

DDT-susceptibility tests on Anopheles balabacensis balabacensis Baisas carried out during several years especially during 1979 and 1980 in Sylhet district have been reported. The LC50 value for 1980 was found to be 0.88 +/- S.E. 0.02 showing 2.38 fold increase of tolerance from 1970 (LC50 = 0.37 +/- S.E. 0.07). The species is still found to be susceptible to DDT in Bangladesh. The implication of the use of DDT in controlling malaria due to this species is also discussed.

Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic E. coli, and V. cholerae in children

One hundred twenty children below 5 years of age with diarrhea caused by Vibrio cholerae, enterotoxigenic Escherichia coli, or rotavirus were studied for stool electrolyte composition and purging rates. The mean purging rate in cholera was 60.1 ml, in ETEC 39.2 ml, and in rotavirus infection 31.4 ml/kg/8 hour. The mean stool sodium concentration in cholera was 88.9 mMol/L, in ETEC 53.7 mMol/L, and in rotavirus infection 37.2 mMol/L. Stool potassium concentration did not show much variation, Mean CO2 concentration in rotavirus infection was 6 mMol/L, significantly lower than in cholera and in ETEC diarrhea. In cholera, stool sodium concentration increased significantly with increase in purging rates; the same was not true in rotavirus and ETEC diarrhea. These differences are considered important factors in formulating replacement therapy in diarrhea.

Outbreak of Streptococcus pyogenes infections in a geriatric hospital and control by mass treatment

Two outbreaks of Streptococcus pyogenes infection occurred in a geriatric hospital, the first involving one ward only, the second a few weeks later, affecting two. Altogether 17 patients and 6 members of staff were carriers or were infected. All strains were indistinguishable.Extensive investigation of the environment and screening of 120 staff and patients did not reveal a common source. The usual methods of isolation and treatment of cases or carriers and swabbing of contacts failed to stop the outbreak, but 'mass treatment' of all 32 patients in those wards was successful.

Smallpox surveillance in Bangladesh: I - Development of surveillance containment strategy

A major epidemic of Variola major with an estimated 90 000 cases and 18 000 deaths occurred in Bangladesh in 1972. During a 3-year period methods of active surveillance (market search, outbreak investigation, and house-to-house search) were developed to supplement the passive reporting system. The percentage of smallpox cases detected increased from 11.8% in 1972 to 83% in 1975. Together with the implementation of improved methods of outbreak control, smallpox transmission was interrupted in October 1975.

Oral contraceptives and family health in rural Bangladesh

A case-control survey of mothers was undertaken in rural Bangladesh to assess the health problems of oral contraceptive users compared with two groups of nonusers. The complaint most often reported was weakness--more than 80% of all women surveyed. Significantly more pill users than nonusers reported experiencing dizziness and eye problems. However, only one fifth of dizziness complaints among pill users could be attributed to the pill. Although more pill users reported a decrease in lactation, a greater problem among the control group was total cessation of lactation related to a subsequent pregnancy. Therefore, in this context the pill may postpone weaning more often than it reduces lactation. That few women choose to use oral contraceptives in the early postpartum period, when a reduction in breast milk would be most hazardous to the child, contributes to this favorable balance. The attitude toward early termination of pregnancy was positive for 61% of pill users and 34% of nonusers. It is likely that abortion services would be favorably received in this traditional society.

Epidemiology and causes of death among children in a rural area of Bangladesh

From a longitudinal surveillance programme among a rural Bangladesh population of 260,000, the epidemiology and causes of child death (under age 5) over 3 years (1975-1977) were analyzed. The most significant causes of death were diarrhoea (watery and dysentery), tetanus, measles, fever, respiratory disease, drowning, skin disease, and other causes. Of an infant mortality rate of 142.6/1000 live births, neonatal tetanus (37.4/1000), diarrhoea (19.6/1000), and respiratory disease (10.4/1000) were the most significant identifiable causes. Many infant deaths (62.2/1000) were unidentified, taking place during the neonatal (1-28 days) period. The 1-4 year mortality averaged 34.3/1 000. Diarrhoea (15.1/1 000), measles (4.5/1 000), fever (2.9/1 000) and respiratory disease (1.6/1 000) accounted for most 1-4 year deaths. Mortality trends over the past 10 years showed sharp temporary fluctuations in response to 2 disasters but no definitive long-term trend. Most causes of death displayed seasonal fluctuation, and sex differentials were marked with female deaths exceeding male deaths for all ages after the neonatal period. Malnourished children from low socioeconomic status families had higher mortality rates than their better nourished and wealthier counterparts. Overall, the data suggest that the delivery of a few basic health measures (oral hydration and immunization) could result in substantial reduction of under 5 mortality.

The catabolism of arginine by Pseudomonas aeruginosa

Mutants isolated from Pseudomonas aeruginosa strain PAO1632 (Hut-Ami) were unable to utilize L-arginine or L-ornithine as the carbon source for growth. Arginine deiminase (AD), catabolic ornithine carbamoyltransferase (cOTC) and N2-acetylornithine 5-aminotransferase (ACOAT) were present in the mutants but these enzymes were not induced to higher levels by exogenous L-arginine. One group of mutants could utilize L-ornithine but not L-arginine and in these strains L-arginine induced the synthesis of ACOAT but not AD or cOTC. The mutations of the arginine utilization-negative mutants were all in genes of the same transductional linkage group and mapped in the 45 to 50 min region of the chromosome. Revertants isolated on L-arginine or L-ornithine plates were derepressed for the synthesis of ACOAT. It is suggested that L-arginine is normally catabolized by the wild-type strain via the arginine deiminase pathway and requires a threshold level of ACOAT. The regulatory factors controlling the functioning of the divergent arginine deiminase and arginine carboxylase pathways are discussed.

Genes and enzymes of lysine catabolism in Pseudomonas aeruginosa

Pseudomonas aeruginosa strain PAO1 cannot utilize L-lysine effectively as a carbon source for growth but grows on cadaverine and glutarate. Strains PAO1 and PAO1632 (Hut-Ami-) have low activities for L-lysine uptake and for L-lysine decarboxylase but both strains gave rise to mutants that grew well on L-lysine. Strain PAO2087, isolated from PAO1, had an active L-lysine uptake system and an inducible L-lysine decarboxylase. Strain PAO2070, isolated from strain PAO1632, had an active L-lysine uptake system and a constitutive L-lysine decarboxylase. We suggest that the genetic defect of strain PAO1 (and PAO1632) that prevents growth of L-lysine is in a regulatory gene controlling the expression of linked genes for L-lysine permease and L-lysine decarboxylase. Mutants unable to utilize L-lysine as a carbon source, isolated from strain PAO2070, exhibited four distinct growth phenotypes. Transductional analysis showed that the genetic defects of these mutants could be distinguished from each other and from that of strain PAO1. Group I mutants, unable to utilize glutarate, formed a single transduction linkage group and were mapped at about 20 min on the chromosome. The mutations of groups II, III and IV appeared to be in separate but linked genes. The group II mutants had no detectable L-lysine decarboxylase activity and the gene locus was mapped by interrupted mating in the 50 to 60 min region of the chromosome. The group III mutants possessed all the early enzymes of the L-lysine decarboxylase pathway and lacked only an active L-lysine uptake system.

Sensitivities of clinically significant organisms to four cephalosporins, ampicillin and mecillinam

Specimens received at a district laboratory over a period of 4 months were investigated for determination of the sensitivities of common pathogens to 4 cephalosporins, ampicillin and mecillinam. A total of 1035 freshly isolated clinically significant organisms was studied. When sensitivities of all pathogens were considered, the majority were found to be resistant to ampicillin and mecillinam and sensitive to the cephalosporins. Sensitivity figures changed considerably when individual groups of organisms were considered. The great majority of urinary pathogens were sensitive to mecillinam, but not to ampicillin. This pattern was reversed when respiratory pathogens were considered. Only a few pathogens from wound swabs were sensitive to either ampicillin or mecillinam. All the cephalosporins tested showed much wider spectrum of activities. Of all antibiotics tested, only cefoxitin was active against the vast majority of Bacteroides spp. These findings are discussed in relation to the clinical uses of these antibiotics.

Pseudo-leptospires in blood culture

Spiral filaments seen in the blood cultures of two patients with fever and jaundice were initially thought to be leptospires; these were later proved to be artefacts. An investigation was carried out to exclude the possibility of laboratory contamination of the culture media and to find out how these objects were produced. The significance of the findings is discussed in relation to the possibility of a mistaken diagnosis in routine laboratories which have a limited experience of leptospires.

Quality of specimens and sputum culture results: a retrospective study

A retrospective study of laboratory reports of sputums examined in the first 3 months of 1977 and of 1978 showed some interesting findings, which were similar in these 2 years. Analysis of the findings demonstrated that information from a proportion of sputum cultures were not helpful to the clinicians. Probable causes of such unhelpful results and some ways to overcome these problems were discussed, along with reviews of relevant literature. A conclusion drawn at the end of the discussion was that, under present circumstances, it was not expected that sputum cultures would produce totally reliable aetiological agents, unless attempts were made to obtain a better quality of specimen, e.g. those obtained by transtracheal or bronchoscopic aspirations.

Free-sporing Cl. welchii in ordinary laboratory media and conditions

A strain of Clostridium welchii produced spores in ordinary blood agar plates. Investigations confirmed that it was the character of this particular strain and that the laboratory media were not inducing sporulation. During a period of 12 months a total of 100 strains of Cl. welchii were studied. None of them produced spores in ordinary laboratory media and conditions when examined microscopically.

Nephrotic syndrome

The nephrotic syndrome is clinical entity having multiple etiology. In the present study, 70 cases of nephrotic syndrome both in children and adults have been studied. The condition appears to be more common than thought of. The histological classification is helpful both in management and forecasting the prognosis. Steorid and cytotoxic drugs have been used in light negative glomerulonephritis and lupus nephritis producing nephrotic syndrome with good results. The other forms of of glomerulonephritis needs further study to be able to offer any specific therapy.