Monitoring and evaluating progress towards Universal Health Coverage in Bangladesh

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Tanvir Mahmudul Huda and colleagues illustrate progress towards UHC and its monitoring and evaluation in Bangladesh. Please see later in the article for the Editors' Summary

Hypoglycaemic, hypolipidemic and antioxidant properties of tulsi (Ocimum sanctum linn) on streptozotocin induced diabetes in rats

Effect of oral administration of 200 mg/Kg body weight of the aqueous extract ofOcimum sanctum (Tulsi) mixed with diet for eight weeks to diabetic (streptozotocin induced) rats was studied. There was significant reduction in fasting blood glucose, serum lipid profile, lipid peroxidation products, (LPO) and improvement in glucose tolerance. The aqueous extract also decreased LPO formation (thiobarbituric acid reactive substances TBARS) and increased antioxidant enzymes superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), glutathione transferase (GT) and one antioxidant reduced glutathione (GSH) in plasma and rat liver, lung, kidney and brain. The decrease in TBARS and increase in GSH, SOD, CAT, GPX, and GT clearly shows the antioxidant property ofOcimum sanctum.

Preliminary studies on the hypoglycaemic effect ofAbroma augusta in alloxan diabetic rats

The hypoglycemic effect of the aqueous extract ofAbroma augusta (Family: Steculiceae) was studied in normal as well as alloxan diabetic rats. Treatement of diabetic rats with 4 ml (4gm dry weight) of agueous extract ofA. augusta for 16 weeks resulted in gradual but significant fall in fasting blood glucose and improvement in glucose tolerance. Serum total and LDL cholesterol and triacylglycerol which increased in diabetic rats showed improvement. These results show that the water extract ofA. augusta has both hypoglycemic and hypocholesterolemic effects.

Phylogenetic analysis of ALAD and MGP genes related to lead toxicity

Experimental studies in our laboratory have established the role of delta-aminolevulinic acid dehydratase (ALAD) and matrix gamma-carboxyglutamic acid (MGP) gene polymorphisms in the etiology of lead toxicity. Polymorphisms in these genes influenced the levels of lead in subjects exposed to this metal. In extension to our studies, we aimed to investigate the possible role of these proteins in evolution by studying the phylogenetic relationship and divergence of ALAD and MGP genes using computational phylogenetic methods. The human ALAD and MGP protein sequences from various species were retrieved from Swiss-Prot database and were compared using Basic Local Alignment Search Tool. Multiple sequence alignment was carried out using ClustalW with defaults, and phylogenetic trees for both the genes were built using neighbor-joining method as in Mega software. Our study indicated that ALAD is a highly conserved protein with the same metal binding site distributed in all the phyla (from archaea to chordates). Phylogenetic analysis of MGP gene revealed that it had an important role in the evolution of endogenous skeleton in contrast to exoskeleton of insects. Occurrence of these genes in evolution with conserved metal binding sites strengthens the role of ALAD and MGP genes in regulating heme biosynthesis and mineralization, respectively, in evolution and helps in better understanding of lead poisoning.

Genotoxicity induced by pesticide mixtures: in-vitro studies on human peripheral blood lymphocytes

To assess the damage caused by pesticides and their mixtures on humans, we designed in-vitro experiments to evaluate their cytotoxicity and genotoxicity. Three equimolar pesticide mixtures were investigated for their capability to affect cultured human peripheral blood lymphocytes. The LC50 values for cytotoxicity, using standard trypan blue dye exclusion and calculated by probit analysis, were 4.18, 5.76, and 7.5 microM for endosulfan, carbofuran, and monocrotophos, respectively. When combined in equimolar concentrations, the LC50 values for cytotoxicity were 0.7, 0.9, and 1.0 microM for monocrotophos + carbofuran, endosulfan + monocrotophos, and endosulfan + carbofuran, respectively, using the method. DNA damage was estimated using chromosomal aberrations (chromatid breaks, fragments, gaps, aneuploidy, and satellite association) and comet assays using 1/10 of the LC50 concentrations. Using a standard alkaline comet assay procedure, high concentrations of individual pesticides (0.5-4.0 microM) caused significant DNA damage as indicated by visible tail lengths. Lower concentrations (0.05-0.5 microM) of their binary mixtures could cause the same effect. The results suggest that analysis of genotoxicity may serve as an important biomarker for occupational and household exposure to pesticides, especially mixtures of pesticides, with different modes of action.

A study on the ALAD gene polymorphisms associated with lead exposure

δ-aminolevulinic acid dehydratase (ALAD) plays an important role in lead poisoning, and polymorphisms in this gene may affect the response of individuals to lead toxicity symptoms. This study was carried out to examine the effects of ALAD gene polymorphism (G177C) on blood lead levels (BLL) and hematological parameters. In all, 113 battery manufacturing unit workers and 102 occupationally unexposed controls from Hyderabad, A.P, India formed the study group. Genotypes for the ALAD G177C polymorphism were determined by Polymerase chain reaction and restriction fragment length digestion. BLL were determined by anode stripping voltammetry using ESA Model 3010B Lead analyzer. Complete blood picture was analyzed using ADVIA cell counter for each sample. The frequencies for ALAD1 and ALAD2 alleles were 0.98 and 0.01, respectively. ALAD 1-2 and ALAD 2-2 genotypes together were considered as a single group and compared with the ALAD 1-1 genotype group. BLL did not differ significantly among ALAD1-1, 1-2, and 2-2 genotypes; however, subjects from the ALAD 1-2/2-2 genotype group showed higher BLL concentrations of 80.51 μg/dL when compared with subjects from the ALAD 1-1 genotype group (50.4 μg/dL). Approximately 29.2% volunteers ( n = 33) from the occupationally exposed group had hemoglobin levels below 10.0 g/dL. There was no significant difference in total white cell count and platelet count between occupational and non-exposed lead-exposed groups. BLL of occupationally exposed individuals were significantly high compared with the unexposed group. ALAD G177C polymorphism along with BLL and assessment of hematological parameters may play an important role in evaluation and better understanding of the consequences of lead exposure.

Maternal health and care-seeking behavior in Bangladesh: findings from a national survey

CONTEXT

Although the reduction of maternal mortality levels is a key Millennium Development Goal, community-based evidence on obstetric complications and maternal care-seeking behavior remains limited in low-resource countries.

METHODS

This study presents an overview of key findings from the 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey of ever-married women aged 13-49. The survey collected data on the prevalence of obstetric complications, women's knowledge of life-threatening complications, treatment-seeking behavior and reasons for delay in seeking medical care.

RESULTS

Bangladeshi women report low but increasing use of antenatal care, as well as low rates of delivery in a health facility or with the assistance of a skilled provider. Although almost half of women reported having one or more complications during pregnancy that they perceived as life threatening, only one in three sought treatment from a qualified provider. More than three-fourths of women with the time-sensitive complications of convulsions or excessive bleeding either failed to seek any treatment or sought treatment from an unqualified provider. The principal reason cited for failing to seek care for life-threatening complications was concern over medical costs, and pronounced socioeconomic disparities were found for maternal care-seeking behavior in both urban and rural Bangladesh.

CONCLUSIONS

Despite these gaps in access to skilled delivery and effective emergency obstetric care, some progress has been made in reducing maternal mortality levels. Improved obstetric care and declining levels of fertility and unwanted pregnancy may have played critical roles in addressing the maternal health care needs of Bangladeshi women.

How should we measure maternal mortality in the developing world? A comparison of household deaths and sibling history approaches

OBJECTIVE

A reduction in the maternal mortality ratio (MMR) is one of six health-related Millennium Development Goals (MDGs). However, there is no consensus about how to measure MMR in the many countries that do not have complete registration of deaths and accurate ascertainment of cause of death. In this study, we compared estimates of pregnancy-related deaths and maternal mortality in a developing country from three different household survey measurement approaches: a module collecting information on deaths of respondents' sisters; collection of information about recent household deaths with a time-of-death definition of maternal deaths; and a verbal autopsy instrument to identify maternal deaths.

METHODS

We used data from a very large nationally-representative household sample survey conducted in Bangladesh in 2001. A total of 104 323 households were selected for participation, and 99 202 households (95.1% of selected households, 98.8% of contacted households) were successfully interviewed.

FINDINGS

The sisterhood and household death approaches gave very similar estimates of all-cause and pregnancy-related mortality; verbal autopsy gave an estimate of maternal deaths that was about 15% lower than the pregnancy-related deaths. Even with a very large sample size, however, confidence intervals around mortality estimates were similar for all approaches and exceeded +/- 15%.

CONCLUSION

Our findings suggest that with improved training for survey data collectors, both the sisterhood and household deaths methods are viable approaches for measuring pregnancy-related mortality. However, wide confidence intervals around the estimates indicate that routine sample surveys cannot provide the information needed to monitor progress towards the MDG target. Other approaches, such as inclusion of questions about household deaths in population censuses, should be considered.

Activity Concentration of 137Cs in soil samples from Punjab province (Pakistan) and estimation of gamma-ray dose rate for external exposure

Punjab is one of the most populated provinces of Pakistan having 34 districts. There is always a need to have baseline background level information about 137Cs and the corresponding gamma-ray doses to the population. In this respect, soil samples were collected to a depth of 30-50 cm from all 34 district headquarters of the Punjab province of Pakistan and 137Cs activity concentrations were measured. 137Cs activity concentration was found to be in the range from 1.1 +/- 1.0 to 5.3 +/- 2.5 Bq kg(-1). The average value of estimated external gamma-ray dose rate from all 34 districts of Punjab province was computed to be 0.18 +/- 0.07 nSv h(-1) from 137Cs in soil samples. The measured 137Cs activity concentration range was compared with the reported ranges in the literature from some of the other locations in the world. Results obtained in this study show that 137Cs concentration is of a lower level in the investigated area. The average value of estimated external effective dose rate is found far below the dose rate limit of 1.0 mSv y(-1) for members of the general public recommended by the International Commission on Radiological Protection (ICRP) as well as the external gamma radiation dose of 0.48 mSv y(-1) received per head from the natural sources of radiation assessed by UNSCEAR (2000). It is concluded that 137Cs soil contamination does not pose radiation hazards to the population in the investigated areas.

Measurements of activity concentrations of naturally occurring radionuclides in soil samples from Punjab province of Pakistan and assessment of radiological hazards

The natural level of radioactivity in soil is one of the major causes of external gamma rays exposure. It was considered imperative to measure gamma-ray activity concentrations due to naturally occurring, potentially hazardous radionuclides from 232Th, 226Ra and 40K in soil samples from Punjab, the most populated province of Pakistan. The activity concentrations were measured in soil samples collected from all 34 district headquarters of Punjab province using a P-type coaxial high purity germanium (HPGe)-based gamma-ray spectrometer having a relative efficiency of 60%. The mean activity concentrations for 232Th, 226Ra and 40K were found to be 41 +/- 8, 35 +/- 7 and 615 +/- 143 Bq kg(-1), respectively in soil samples from all 34 district headquarters of Punjab. The mean values of radium equivalent index (Ra(eq)) and total annual external gamma radiation dose were found to be 141 +/- 27 Bq kg(-1)and 0.38 mSv, respectively. Since these estimated radiological impact assessment factors are lower than the recommended values there seems to be no potential radiological health hazard associated with the soils from the district headquarters in the Punjab province of Pakistan. Geological studies show that most of the soils in Punjab have developed on the extensive fluviatile deposits of five rivers and a stable ratio of natural activity concentrations is observed in soil samples of the areas under study.

Experimental and Monte Carlo simulation studies of open cylindrical radon monitoring device using CR-39 detector

There are several methods of measuring radon concentrations but nuclear track detector cylindrical dosimeters are widely employed. In this investigation, the consequence of effective volumes of the dosimeters on the registration of alpha tracks in a CR-39 detector was studied. In a series of experiments an optimum radius for a CR-39-based open cylindrical radon dosimeter was found to be about 3 cm. Monte Carlo simulation techniques have been employed to verify the experimental results. In this context, a computer code Monte Carlo simulation dosimetry (MOCSID) was developed. Monte Carlo simulation experiments gave the optimum radius of the dosimeters as 3.0 cm. The experimental results are in good agreement with those obtained by Monte Carlo design calculations. In addition to this, plate-out effects of radon progeny were also studied. It was observed that the contribution of radon progeny (218Po and 214Po) plated-out on the wall of the dosimeters increases with an increase of dosimeter radii and then decrease to 0 at a radius of about 3 cm if a point detector has been installed at the center of the dosimeter base. In the code MOCSID different types of random number generators were employed. The results of this research are very useful for designing an optimum size of radon dosimeters.

In vivo genotoxic effect of cadmium chloride in mice leukocytes using comet assay

The alkaline single cell gel electrophoresis (SCGE) or "comet" assay under alkaline conditions was used to measure DNA damage in the leukocytes of Swiss Albino male mice exposed to cadmium chloride (CdCl(2)). The effect of CdCl(2) was studied after a single acute oral administration of a range of doses starting from 0.5 to 128.0 mg/kg b.wt of CdCl(2). The samples of whole blood were collected from each mouse at 24, 48, 72, and 96 h post-treatment to study single/double strand breaks in DNA. A significant increase in mean comet tail length indicating DNA damage was observed with CdCl(2) at 24 h post-treatment (P<0.05) with CdCl(2) when compared to controls. A gradual decrease in the mean tail length was observed at 48 h post-treatment indicating repair of the damaged DNA. The mean tail length showed a dose-related increase and time-dependent decrease after treatment with CdCl(2) when compared to controls. The study also confirms that the comet assay is a sensitive and rapid method to detect DNA damage caused by heavy metal like Cadmium (Cd).

In vivo genotoxic effect of potassium dichromate in mice leukocytes using comet assay

Hexavalent chromium is a well-known mutagen and carcinogen. In the present investigation, single-/double-stranded DNA breaks by potassium dichromate (K2Cr2O7) in mice, a sensitive model for genotoxic effects, have been studied in vivo using alkaline single-cell gel electrophoresis (SCGE)/comet assay. Mice were administered orally with a range of doses starting from 0.59 to 76.0 mg/kg body weight of K2Cr2O7 and samples of whole blood were collected at 24, 48, 72, 96 h, week 1 and week 2 post-treatment for alkaline SCGE assay to study DNA damage. The rationale for using leukocytes was to reflect biomarker analysis in humans. Significant increase in mean comet tail length (5.7-24.25 microM) indicating DNA damage was observed at all the doses with K2Cr2O7 when compared with controls (3.26 microM). Maximum increase in mean comet tail length was observed at 9.5 mg/kg body weight at 48 h post-treatment (24.25 microM). The mean comet tail length showed a clear dose-dependent increase from 0.59 to 9.5 mg/kg body weight and a dose-dependent decrease in higher doses (19.0-76.0 mg/kg body weight). A gradual decrease in the tail lengths from 72 h post-treatment was observed by the second week, and values had returned to control levels at all doses, indicating repair of the damaged DNA and/or loss of heavily damaged cells. The study also reveals that comet assay is a sensitive and rapid method for detecting DNA damage caused by heavy metals such as chromium (Cr).

Effects of phosphorothionate on the reproductive system of male rats

Acute and Sub-acute toxic effects of a new pesticide phosphorothionate coded as RPR-V on testis of albino rat were studied. For the acute study, rats received a single dose of 30 mg/kg of RPR-V and sacrificed after 24 hours. For the Subacute study, 1.42 mg/kg/day was administered orally to rats for 10 days and 21 days. Acute exposure of rats to RPR-V brought no change either in the Gonadosomatic Index (GSI) or in the structure of testis or in the serum levels of Testosterone. Similarly, no significant change was observed in the Glutathione S-transferase (GST) activity. But, in testis there was significant increased in the reduced Glutathione (GSH) and Acid Phosphatase (AcP), whereas Alkaline Phosphatase (AkP) levels decreased significantly at 24hr post treatment. On 7th day (withdrawal period) after the cessation of the treatment the GSH, AcP, and AkP levels reached to near control. The sub-acute study revealed a significant post treatment. Due to RPR-V treatment the testis AcP levels increased significantly at 21st day of medication but AkP levels decreased both at 10th and 21st day of post treatment. Histopathological studies showed that after 10th day testis showed considerable loss of spermatozoids and at 21st day complete derangement of cellular organization was observed. Testosterone levels decreased significantly after 10th day and remained significantly low at 21st day. However, withdrawal studies showed a recovery in testis of rat treated with RPR-V. GST, GSH, GSI, AcP and AkP values were recovered, testosterone levels were also recovered but recovery in testis structure remained at a low profile.

In vivo genotoxic effect of arsenic trioxide in mice using comet assay

Although arsenic has been the subject of toxicological research, acute in vivo genotoxic studies using relevant animal models and uniform methodology are lacking. Hence, the present study aims to study DNA damage caused by arsenic trioxide in mice in in vivo using alkaline single cell gel electrophoresis (Comet) assay. Mice were administered orally 0,0.13,0.27,0.54,1.08,2.15,4.3 and 6.45 mg/kg body weight of arsenic trioxide dissolved in distilled water. The samples of whole blood were collected at 24,48,72 h, first and second week post-treatment and the assay was carried out to determine DNA damage as represented by comet tail-length. All the doses induced significant increase in comet tail-length at 24 h post-treatment (P<0.05) showing a clear dose dependent increase from 0.13 to 2.15 mg/kg b.wt. and a dose dependent decrease in higher doses (4.3-6.45 mg/kg b.wt). At 48 h post-treatment all the doses showed a significant increase (P<0.05) in comet tail-length when compared to 24 h post-treatment. A gradual decrease in the comet tail-length was observed for all the doses from 72 h post-treatment onwards indicating a gradual repair in DNA damage. This indicates a non-linear dose and time response between DNA damage and different doses of arsenic trioxide at different time-intervals. A significant increase in comet tail-length at all the doses clearly gives evidence that arsenic trioxide cause DNA damage effectively. The study indicates that the alkaline comet assay is a reliable and effective method to detect DNA damage caused by metals.

Effects of Vepacide (Azadirachta indica) on aspartate and alanine aminotransferase profiles in a subchronic study with rats

The aim of this study was to ascertain the long-term effects of Vepacide, a neem-based pesticide on biochemical profiles. Albino Wistar rats were treated orally with 80 (low), 160 (medium) and 320 mg/kg (high) doses of Vepacide in coconut oil for 90 days. Control rats received the same volume of the vehicle. Vepacide caused increase of aspartate and alanine aminotransferase in serum, kidney and lung, and these enzymes decreased in liver in both male and female rats when measured after 45 and 90 days of treatment. The two-way analysis of variance (ANOVA) showed that the alterations in these enzymes were dose- and time-dependent. Sexual dimorphism was observed when male rats were compared with female rats (Student t-test at P< 0.05). Positive correlation was observed with regard to these enzymes between serum, kidney and lung, whereas in the case of serum and liver, a negative correlation was recorded. These enzyme profiles elucidate that they increased in serum with simultaneous decrease in liver, indicating necrosis of liver, whereas in other tissues, the level of enzymes increased, showing an adaptive mechanism due to the chemical stress. The affected enzymes were recovered to normal conditions after 28 days of post-treatment (withdrawal study). Due to the Vepacide treatment, lung was more affected followed by liver and kidney. This study has indicated that these enzymes could be useful as biomarkers for the insult of any toxicant. Besides, they can also help in predictive toxicology.

In vivo genotoxic effect of zinc sulfate in mouse peripheral blood leukocytes using Comet assay

Single stranded DNA breaks induced by Zinc sulfate in mice has been studied in vivo using Alkaline Single Cell Gel Electrophoresis (Comet assay). Mice were administered orally with doses of 5.70, 8.55, 11.40, 14.25, 17.10 and 19.95 mg/kg body weight of zinc sulfate respectively. The samples of whole blood were collected at 24, 48, 72, 96 hr and first week post-treatment and the assay was carried out to determine single strand DNA breaks as represented by comet tail-lengths. Results indicated a significant DNA damage at all the doses after treatment with zinc sulfate when compared to controls showing a clear dose-dependent response (p < 0.05). A gradual decrease in the tail-lengths from 48 hr post-treatment onwards was observed indicating a time dependent decrease in the DNA damage. The study confirms that zinc sulfate causes significant DNA damage at the doses used as revealed by comet assay.

Estimation of radon concentrations in coal mines using a hybrid technique calibration curve

The results of epidemiological studies in various countries show that radon and its progeny cause carcinogenic effects on mine workers. Therefore, it becomes of paramount importance to monitor radon concentrations and consequently determine the radon dose rates in coal mines for the protection of coal miners. A new calibration curve was obtained for radon concentration estimation using hybrid techniques. A calibration curve was generated using 226Ra activity concentration measured by a HPGe detector-based gamma-ray spectrometer versus alpha-track-density rate due to radon and its progeny on CR-39 track detector. Using the slope of the experimentally determined curve in the units of Becqueral per kilogram (Bq kg-1) per unit alpha-track-density per hour (cm-2 h-1), radon concentrations (Bq m-3) were estimated using coal samples from various coal mines in two provinces of Pakistan, Punjab and Balochistan. Consequently, radon dose rates were computed in the simulated environment of the coal mines. Results of these computations may be considered with a caveat that the method developed in this paper provides only a screening method to indicate the radon dose in coal mines. It has been shown that the actual measurements of radon concentrations in the coal mines are in agreement with the estimated radon concentrations using the hybrid-technique calibration curve.

Subacute effects of a phosphorothionate pesticide on mixed function oxidases of Wistar rats

Subacute oral toxicity of a newly developed phosphorothionate insecticide (2-butenoic acid-3-(diethoxy-phosphinothioyl) methyl ester), coded as RPR-2, was studied in male rats by oral (multiple) intubation of low (0.014 mg kg(-1) day(-1)), medium (0.028 mg kg(-1) day(-1)), and high (0.042 mg kg(-1) day(-1)) dose for 90 days. The medium and high dose produced toxic symptoms along-with some mortality (20%) occurred in the high dose treated rats. The medium and high doses caused significant inhibition in cytochrome P-450 activity in liver, lung, kidney and brain tissues at 45 and 90 days. The high dose caused significant decrease in cyt.b5 activity of all the four tissues at 45 and 90 days. Whereas, medium dose brought such effect in liver and lung at 45 and 90 days. Kidney and brain cyt.b5 activity decreased significantly at 90th day due to medium dose. Low dose also caused inhibition in cyt.b5 activity in brain at 90th day. Cytochrome P-450 reductase activity was decreased significantly in liver,

Inhibition of acetylcholinesterase and different ATPases by a novel phosphorothionate (RPR-II) in rat brain

A novel phosphorothionate (2-butenoic acid-3-(diethoxy phosphinothioyl)-methyl ester (RPR-II), synthesized at the Indian Institute of Chemical Technology, Hyderabad, targets its effect on rat brain acetylcholinesterase (AChE) and Na(+)-K(+), Mg(2+), and Ca(2+) ATPases, as evident in this investigation. Three subchronic doses 0.014 (low), 0.028 (medium), and 0.042 (high) mg kg(-1) were administered to rats daily for a period of 90 days RPR-II caused statistically significant dose- and time-dependent inhibition in brain AChE and also in Na(+)-K(+), Mg(2+), and Ca(2+) ATPases in both male and female rats after 45 and 90 days of treatment. The low dose was generally insignificant while the medium and high doses were significantly effective. Females were more susceptible than males with regard to brain AChE, Na(+)-K(+), and Mg(2+) ATPases, which indicates sexual dimorphism in the treated rats. Interestingly, after 28 days post-treatment, recovery of these enzymes was observed. The relative sensitivities of these enzymes indicated that brain AChE was more sensitive than any of the ATPases, but among the ATPases Na(+)-K(+) ATPase was more susceptible than Ca(2+) or Mg(2+) ATPases. This compound, besides inhibiting the target of organophosphates, AChE, also inhibited different ATPases, suggesting both synaptic transmission and nerve conduction were affected.