Chikungunya outbreak (2017) in Bangladesh: Clinical profile, economic impact and quality of life during the acute phase of the disease

Background

Chikungunya virus causes mosquito-transmitted infection that leads to extensive morbidity affecting substantial quality of life. Disease associated morbidity, quality of life, and financial loss are seldom reported in resources limited countries, such as Bangladesh. We reported the acute clinical profile, quality of life and consequent economic burden of the affected individuals in the recent chikungunya outbreak (May to September 2017) in Dhaka city, Bangladesh.

Methods

We conducted a cross-sectional study during the peak of chikungunya outbreak (July 24 to August 5, 2017) to document the clinical profiles of confirmed cases (laboratory test positive) and probable cases diagnosed by medical practitioners. Data related to clinical symptoms, treatment cost, loss of productivity due to missing work days, and quality of life during their first two-weeks of symptom onset were collected via face to face interview using a structured questionnaire. World Health Organization endorsed questionnaire was used to assess the quality of life.

Results

A total of 1,326 chikungunya cases were investigated. Multivariate analysis of major clinical variables showed no statistically significant differences between confirmed and probable cases. All the patients reported joint pain and fever. Other more frequently reported symptoms include headache, loss of appetite, rash, myalgia, and itching. Arthralgia was polyarticular in 56.3% of the patients. Notably, more than 70% patients reported joint pain as the first presenting symptom. About 83% of the patients reported low to very low overall quality of life. Nearly 30% of the patients lost more than 10 days of productivity due to severe arthropathy.

Conclusions

This study represents one of the largest samples studied so far around the world describing the clinical profile of chikungunya infection. Our findings would contribute to establish an effective syndromic surveillance system for early detection and timely public health intervention of future chikungunya outbreaks in resource-limited settings like Bangladesh.

A major outbreak of chikungunya virus occurred for the first time in Dhaka, Bangladesh between May and September 2017. In this study, a face-to-face interview with a structured questionnaire was conducted to collect data to investigate the clinical symptoms, quality of life, and economic aspects of 1,326 chikungunya patients during the first two weeks of infection. The severity of the disease was similar to previously reported severe outbreaks elsewhere but joint pain prior to fever emerged as a unique symptom in the Dhaka outbreak. This unique clinical feature was consistent across age and sex of the patients. Some clinical symptoms varied with age. For instance, a higher proportion of skin rash were found among children (under 15) while morning stiffness, severity, and duration of pain were proportionally higher among other age groups. Joint swelling was most commonly noted in elderly patients (60+ years). About 83% of the patients reported low to very low overall quality of life (QoL) during first two weeks of chikungunya infection. Elderly patients reported lower average QoL scores compared to <60 years. Interestingly, housewives reported higher QoL score compared to those of businessmen and service holders. In particular, patients in the highest monthly income category bracket (BDT 50,000 per month; >$606 per month) reported the lowest average overall score. Nearly 95% of the patients have mostly confined to sickbed and approximately 30% of them lost more than 10 days of productivity due to severe arthropathy. Our study would contribute to establishing an effective syndromic surveillance system for early detection and timely public health intervention of future chikungunya outbreaks in resource-limited countries like Bangladesh.

Impaired acylcarnitine profile in transfusion-dependent beta-thalassemia major patients in Bangladesh

Patients with beta-thalassemia major (BTM) suffer from fatigue, poor physical fitness, muscle weakness, lethargy, and cardiac complications which are related to an energy crisis. Carnitine and acylcarnitine derivatives play important roles in fatty acid oxidation, and deregulation of carnitine and acylcarnitine metabolism may lead to an energy crisis. The present study aimed to investigate carnitine and acylcarnitine metabolites to gain an insight into the pathophysiology of BTM. Dried blood spots of 45 patients with BTM and 96 age-matched healthy controls were analyzed for free carnitine and 24 acylcarnitines by using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Although medium chain acylcarnitine levels were similar in the patients with BTM and healthy controls, free carnitine, short chain acylcarnitines, long chain acylcarnitines, and total acylcarnitine levels were significantly lower in patients with BTM than in the healthy controls (P < 0.05). Moreover, an impaired fatty acid oxidation rate was observed in the patients with BTM, as manifested by decreased fatty acid oxidation indicator ratios, namely C2/C0 and (C2 + C3)/C0. Furthermore, an increase in the C0/(C16 + C18) ratio indicated reduced carnitine palmitoyltransferase-1 (CPT-1) activity in the patients with BTM compared with that in the healthy controls. Thus, a low level of free carnitine and acylcarnitines together with impaired CPT-1 activity contribute to energy crisis-related complications in the patients with BTM.

Evaluation of Bcr-Abl Gene Rearrangement among Bangladeshi Chronic Myeloid Leukaemia Patients

Chronic Myeloid Leukaemia (CML) is a clonal myeloproloferative disorder. Presence of molecular translocation t (9; 22) in CML patients can be confirmed by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Among haematological malignancies CML is the commonest leukaemia of adults in Asia. Despite this, there are very few studies published from Bangladesh, documenting the frequency of bcr-abl fusion transcripts. So, we would like to perform this observational study to evaluate bcr-abl fusion transcripts and demographic status among RT-PCR positive chronic phase CML patients at BIRDEM & other two centers of Dhaka city, Bangladesh where patients admitted from different districts of Bangladesh in the period of January 2010 to June 2012. Twenty patients from three centers willing to perform RT-PCR test and showed positive PCR result, were enrolled under written consent before starting treatment with targeted molecular therapy. The age range of the sample was 18 to 52 years, with mean age of 34.80 and male - female ratio of 4:1. This study showed among chronic phase CML patients bcr-abl transcript rearrangement frequency was b3a2 (e14a 2) 45% while b2a2 (e13a2) was 55% by RT-PCR testing method. Cytogenetic and molecular analysis has become mandatory in order to make a correct diagnosis and monitoring response to newer molecular targeted treatment modalities. So our health sector should be enriched with laboratories with modern technology to diagnose haemato-oncological diseases as per WHO guideline.

Disseminated intravascular coagulation in acute promyelocytic leukaemia and its impact on the induction failure: a single centre study

Life-threatening coagulopathy associated with acute promyelocytic leukemia (APL) has been the defining clinical characteristic and is an important risk factor for fatal haemorrhage and early death. Pathogenesis of coagulopathy in APL is complex and mainly includes disseminated intravascular coagulation (DIC). The study was done to see the status of DIC and its impact on the outcome of APL in our setting. Among the total 60 patients, induction mortality rate was 30% and remission rate was 70%. The main cause of induction mortality was bleeding that accounts for 66.7% of mortality. DIC was present among 32 out of 60 patients (53.33%). Induction mortality has significant relationship to DIC as the induction mortality rate is 47% in patients with DIC and 11% in patient without DIC (P value 0.0009). Induction motality rate in low, intermediate and high risk group is 6.70%, 24% and 58% respectively (p value < 0.0001). Finally, risk group subclassification revealed presence of DIC in high risk group has the highest early mortality rate.

Diagnosed hematological malignancies in Bangladesh - a retrospective analysis of over 5000 cases from 10 specialized hospitals

Background

The global burden from cancer is rising, especially as low-income countries like Bangladesh observe rapid aging. So far, there are no comprehensive descriptions reporting diagnosed cancer group that include hematological malignancies in Bangladesh.

Methods

This was a multi-center hospital-based retrospective descriptive study of over 5000 confirmed hematological cancer cases in between January 2008 to December 2012. Morphological typing was carried out using the “French American British” classification system.

Results

A total of 5013 patients aged between 2 to 90 years had been diagnosed with malignant hematological disorders. A 69.2% were males (n = 3468) and 30.8% females (n = 1545), with a male to female ratio of 2.2:1. The overall median age at diagnosis was 42 years. Acute myeloid leukemia was most frequent (28.3%) with a median age of 35 years, followed by chronic myeloid leukemia with 18.2% (median age 40 years), non-Hodgkin lymphoma (16.9%; median age 48 years), acute lymphoblastic leukemia (14.1%; median age 27 years), multiple myeloma (10.5%; median age 55 years), myelodysplastic syndromes (4.5%; median age 57 years) and Hodgkin’s lymphoma (3.9%; median age 36 years). The least common was chronic lymphocytic leukemia (3.7%; median age 60 years). Below the age of 20 years, acute lymphoblastic leukemia was predominant (37.3%), followed by acute myeloid leukemia (34%). Chronic lymphocytic leukemia and multiple myeloma had mostly occurred among older patients, aged 50-over.

Conclusions

For the first time, our study presents the pattern and distribution of diagnosed hematological cancers in Bangladesh. It shows differences in population distributions as compared to other settings with possibly a lower presence of non-Hodgkin lymphoma. There might be under-reporting of affected women. Further studies are necessary on the epidemiology, genetics and potential environmental risk factors within this rapidly aging country.

Auto-analyzer based screening of microcytic hypochromic ratio to differentiate thalassaemia and non thalassemic microcytosis

DOI: http://dx.doi.org/10.3329/bmrcb.v39i3.20317 Bangladesh Med Res Counc Bull 2013; 39: 146-147

Response of vincristine, melphalan, cyclophosphamide and prednisolone in refractory multiple myeloma

In refractory and relapsing multiple, myeloma good complete response rates may be achieved by Vincristine, Melphalan, Cyclophosphamide and Prednisolone (VMCP) like regimen which is effective alternative and less expensive in developing country like Bangladesh. The study was conducted to see the response of VMCP as an alternative in relapsing or refractory multiple myeloma. The study has been carried out in the department of Haematology, Bangabandhu Sheikh Mujib Medical University from July 2004 to June, 2005. This study was conducted on refractory case of multiple myeloma, having aged between 45 to 70 years. A total of ten patients had been taken for this study group. Newly diagnosed multiple myeloma is not included in this study. All of the 10 patients were treated according to the following VMCP protocol, Vincristine 1mg IV, d1, Melphalan 6mg/m2/d p.o. d1-d7, Cyclophosphamide 120mg/m2/d p.o. d1-d7 Prednisolone 60mg/m2/d p.o. d1-d7. Cycles were repeated every 28 days for 6 cycle. Six out of ten patients with refractory multiple myeloma displayed minimal response (60%) after treatment with 6 cycle of VMCP protocol, three patients entered partial remission (30%), and one (10%) showed complete response.

The Bombay blood group: are we out of risk?

The Bombay blood group is a rare blood group, phenotypes of this group lacking H antigen on the red cell membrane and have anti-H in the serum. It fails to express any A, B or H antigen on their red cells or other tissues. The existence of a human H/h genetic polymorphism was first established by Bhende et al. As first discovery in Bombay (Mumbai), in India in 1952, so the name of this rare blood group is known as Bombay blood group. People having Bombay phenotype are mostly confined to the Southeast Asia. Around 179 persons in India with a frequency of 1 in 10,000 have "Bombay Blood group". A high level of consanguinity present among the parents of the Bombay phenotype. The classic Bombay phenotype has been reported in those of Indian descendent. It is quite rare in Caucasian with an incidence of 1 in 250,000. As because in our country there is routine practice of "only forward or cell type grouping" using finger prick method by voluntary blood donors organization and various blood banks; so there is tremendous chance of misinterpretation or unexploration of this Bombay blood group. When misdiagnosed, this Bombay group can cause fatal haemolytic transfusion reaction. For this reason our suggestion is to incorporate "routine serum typing or reverse grouping confirmation" along with 'O' cell control in reverse grouping procedure in every Transfusion Medicine Department or Blood Bank or Blood Donor Centers and this practice should be mandatory to reduce the risk of fatal haemolytic transfusion reaction. In this view we will highlight the incidence, molecular biology and clinical significance of this rare and fatal blood group.