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Akpan E, Hossain SJ, Devine A, Braat S, Hasan MI, Tipu SMMU, Bhuiyan MSA, Hamadani JD, Biggs BA, Pasricha SR, Carvalho N. Cost-effectiveness of universal iron supplementation and iron-containing micronutrient powders for anemia among young children in rural Bangladesh: analysis of a randomized, placebo-controlled trial. Am J Clin Nutr 2022; 116:1303-1313. [PMID: 36192508 PMCID: PMC9630870 DOI: 10.1093/ajcn/nqac225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC (Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh. OBJECTIVES We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh. METHODS We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results. RESULTS Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 [half of gross domestic product (GDP) per capita] per DALY averted. Scenario and sensitivity analyses supported the base case findings. CONCLUSIONS These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh.This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.
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Affiliation(s)
- Edifofon Akpan
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sheikh J Hossain
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Angela Devine
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia,Division of Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia,Department of Medicine at the Peter Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Mohammed I Hasan
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - S M Mulk Uddin Tipu
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Saiful Alam Bhuiyan
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jena D Hamadani
- International Centre for Diarrhoeal Disease Research, Maternal and Child Health Division, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Beverley-Ann Biggs
- Department of Medicine at the Peter Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia,Diagnostic Hematology, The Royal Melbourne Hospital, Parkville, Victoria, Australia,Clinical Hematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Victoria, Australia,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
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Uddin MF, Molyneux S, Muraya K, Jemutai J, Berkley JA, Walson JL, Hossain MA, Islam MA, Zakayo SM, Njeru RW, Ahmed T, Chisti MJ, Sarma H. Treatment-seeking and recovery among young undernourished children post-hospital discharge in Bangladesh: A qualitative study. PLoS One 2022; 17:e0274996. [PMID: 36149880 PMCID: PMC9506605 DOI: 10.1371/journal.pone.0274996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Post-hospital discharge mortality is high among undernourished children in many low and middle-income countries. Although a number of quantitative studies have highlighted a range of potential socio-cultural, economic and health system factors influencing paediatric post-discharge treatment-seeking and recovery, few studies have explored family and provider perspectives of the post-discharge period in-depth. METHODS This work was part of a large, multi-country prospective cohort study, the Childhood Acute Illness and Nutrition (CHAIN) Network. We conducted a qualitative sub-study to understand the post-discharge treatment-seeking and recovery experiences of families of undernourished children aged 2-23 months admitted in a rural and urban icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) hospital. Methods included repeat in-depth interviews (73 interviews in total) with 29 family members of 17 purposively selected children. These data were supplemented by interviews with 33 health workers, and by observations in hospitals and homes. RESULTS Important drivers of treatment-seeking perceived to support recovery included advice provided to family members while in hospital, media campaigns on hygiene practice, availability of free treatment, and social and financial support from family members, relatives and neighbours. Key perceived challenges included low household incomes, mothers having to juggle multiple responsibilities in addition to caring for the sick child, lack of support (sometimes violence) from the child's father, and family members' preference for relatively accessible drug shops, physicians or healers over hospital admission. CONCLUSION Development of interventions that address the challenges that families face is essential to support post-discharge adherence to medical advice and recovery. Potential interventions include strengthening information giving during hospitalization on what post-discharge care is needed and why, reducing direct and indirect costs associated with hospital visits, engaging fathers and other 'significant others' in post-discharge advice, and building mobile phone-based support for follow-up care.
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Affiliation(s)
- Md. Fakhar Uddin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sassy Molyneux
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Julie Jemutai
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James A. Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Judd L. Walson
- Department of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Md. Alamgir Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Aminul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Haribondhu Sarma
- National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
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Sarmin M, Hossain MI, Islam SB, Alam NH, Sarker SA, Islam MM, Chisti MJ, Islam SMR, Mahfuz M, Ahmed T. Efficacy of a Green Banana-Mixed Diet in the Management of Persistent Diarrhea: Protocol for an Open-Labeled, Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e15759. [PMID: 32224490 PMCID: PMC7154927 DOI: 10.2196/15759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 12/15/2019] [Indexed: 12/17/2022] Open
Abstract
Background Diarrhea is the second-leading cause of death in children under 5 years of age. In low- and middle-income countries, 3%-20% of acute diarrheal episodes become persistent diarrhea (PD) (ie, duration ≥14 days), which results in 36%-56% of all diarrheal deaths. In Bangladesh, PD causes >25% of diarrhea-related deaths. Commensal gut microbiota dysbiosis is increasingly recognized in the pathogenesis of PD. Hospital-based management of PD requires a hospital stay, which increases the risk of infection and hospital costs. The higher cost of treatment and high case-fatality rates reiterate PD as an important public health problem. At the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the last two decades, a consensus-based guideline has been followed for PD. Observation has revealed that green banana helps in the resolution of diarrhea. However, no larger prospective study has been conducted to evaluate the efficacy of green banana in the management of PD among children older than 6 months of age. Objective Our objective is to assess the efficacy of full-strength rice suji (semolina) with and without green banana compared to three-quarter-strength rice suji in the management of PD in children aged 6-36 months at the Dhaka Hospital of the icddr,b. Methods This open-labeled, randomized controlled study aims to enroll a total of 145 children with PD who have not been improving on a diet of milk suji. Children will be randomized into three different diet-specific groups: full-strength rice suji containing green banana, full-strength rice suji alone, and three-quarter-strength rice suji. The primary outcome is the percentage of children who recovered from diarrhea by day 5. Results Recruitment and data collection began in December 2017 and were completed in November 2019. Results are expected by April 2020. Conclusions This study is expected to provide insights into the incorporation of green banana into the dietary management of PD. This would be the first study to investigate the role of microbiota and metabolomics in the pathogenesis of PD. Trial Registration ClinicalTrials.gov NCT03366740; https://clinicaltrials.gov/ct2/show/NCT03366740 International Registered Report Identifier (IRRID) DERR1-10.2196/15759
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Affiliation(s)
- Monira Sarmin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Shoeb Bin Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Nur Haque Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - S M Rafiqul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital, Dhaka, Bangladesh
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Abstract
BACKGROUND Persistent diarrhoea (PD), defined as diarrhoeal symptoms for longer than 2 weeks, still forms a substantial disease burden in children under 5 years of age. This article provides an overview of the current knowledge of PD and discusses novel concepts. METHODS A literature search on PD was performed which focused on evidence on epidemiology, pathophysiology and management of the disease. RESULTS The prevalence of PD has potentially decreased over the last decades. Debate remains around the role of specific bacterial, viral and parasitic infections with PD. PD is associated with malnutrition and a compromised immune system, including that caused by HIV infection. Management includes fluid resuscitation and improving nutritional status. There is a lack of evidence on the use of antibiotic therapy for PD. There is increasing interest in nutrient-based interventions, including pre- and/or probiotics that can modify the microbiome and thereby potentially prevent or improve the outcome of PD in children. CONCLUSION As PD remains a significant health burden, multicentre clinical trials are needed to inform future treatment guidelines. ABBREVIATIONS PD, persistent diarrhoea; EED, environmental enteric dysfunction; IBD, inflammatory bowel disease; WHO, World Health Organization.
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Affiliation(s)
- Robert H J Bandsma
- a Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children , Toronto , Canada.,b Translational Medicine Program, Hospital for Sick Children , Toronto , Canada.,c Centre for Global Child Health, Hospital for Sick Children , Toronto , Canada.,d Department of Nutrition Sciences , University of Toronto , Toronto , Canada
| | - Kamran Sadiq
- e Department of Paediatrics and Child Health , Aga Khan University , Karachi , Pakistan
| | - Zulfiqar A Bhutta
- c Centre for Global Child Health, Hospital for Sick Children , Toronto , Canada.,d Department of Nutrition Sciences , University of Toronto , Toronto , Canada.,e Department of Paediatrics and Child Health , Aga Khan University , Karachi , Pakistan
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Persistent diarrhoea in a 5-month-old baby carrying Vibrio cholerae nonO1/nonO139 producing Haitian cholera toxin. New Microbes New Infect 2017; 21:72-74. [PMID: 29234496 PMCID: PMC5721208 DOI: 10.1016/j.nmni.2017.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/12/2017] [Accepted: 10/18/2017] [Indexed: 12/17/2022] Open
Abstract
Cholera toxin (CT) is the principal virulence factor of Vibrio cholerae for fatal cholera diarrhoea. Serogroups O1 and O139 harbour CT and are known to be epidemic strains. The remaining serogroups (nonO1/nonO139) are non-toxigenic and may be associated with mild disease. O1 serogroup emerged with a variant of CT known as Haitian cholera toxin (HCT). The HCT strains are hypervirulent and have been associated with severe cholera outbreaks in India, Western Africa and Haiti. Here, we report the presence of HCT (ctxB7) in a nonO1/nonO139 isolate causing persistent diarrhoea.
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