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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 47-51  

The effect of a newly established urban diarrhea treatment facility in Bangladesh: Changing patient characteristics and etiologies


1 Research Assistant, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
2 Epidemiologist, Menzies School of Health Research, Darwin, Brisbane, Australia
3 Assistant Scientist, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
4 Scientist, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
5 Consultant, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
6 Associate Scientist, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh (icddr,b); PhD Candidature, Institute for Social Science Research, The University of Queensland, Brisbane, Australia

Date of Web Publication6-Mar-2018

Correspondence Address:
Sumon Kumar Das
Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka 1212

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_374_16

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   Abstract 


Background: Mirpur treatment centre (MTC), Dhaka of the International Centre for Diarrhoeal Disease Research, Bangladesh, was established as a consequence of an outbreak of diarrheal disease during the summer month of April 2007 in Mirpur area. Objective: The present study aimed to evaluate the impact of this new facility on patient load, common etiology, and other characteristics of patient population who sought treatment at Dhaka Hospital. Methods: As part of the Diarrheal Disease Surveillance System (DDSS), 10% patients (every 10th) seeking care irrespective of age, sex, sociodemographic background, and severity of disease were enrolled at MTC as opposed to 2% (every 50th) at Dhaka Hospital following identical methodology from 2010 to 2013. Moreover, enrolled DDSS patients from 2005 to 2009 at Dhaka Hospital were also included in analysis to further examine the impact of MTC on Dhaka Hospital. Results: Patient load from Mirpur area attending the Dhaka Hospital reduced from 13% during epidemic in 2010 to 6% in 2013 (53% reduction), whereas attendance in MTC increased substantially by 33%. This changing trend was also observed among children <5 years old. A significant reduction of patients presenting with moderately severe disease from Mirpur area at Dhaka Hospital was observed (69% reduction); however, attendance at MTC increased by 26% during same period. Conclusion: The number of patients from Mirpur area in Dhaka Hospital reduced but increased at MTC explaining the need for establishment of a set up for early treatment and control of diarrheal disease when consistent increase in annual number of cases or at the time of upsurge of cases is observed.

Keywords: Bangladesh, diarrhea, surveillance


How to cite this article:
Das J, Shamsir Ahmed A M, Ahmed S, Chisti MJ, Golam FaruqueSyed AS, Das SK. The effect of a newly established urban diarrhea treatment facility in Bangladesh: Changing patient characteristics and etiologies. Indian J Public Health 2018;62:47-51

How to cite this URL:
Das J, Shamsir Ahmed A M, Ahmed S, Chisti MJ, Golam FaruqueSyed AS, Das SK. The effect of a newly established urban diarrhea treatment facility in Bangladesh: Changing patient characteristics and etiologies. Indian J Public Health [serial online] 2018 [cited 2019 Aug 20];62:47-51. Available from: http://www.ijph.in/text.asp?2018/62/1/47/226624




   Introduction Top


During summer month of April 2007, the population of the Dhaka city experienced the routine summer (premonsoon) outbreak of diarrheal diseases that continued till early July.[1] The large-scale flooding of 2007 started in the later part of July was thought to have contributed to large diarrhea outbreak with high burden in health-care delivery at the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b).[1] The hospital noted a 3 to 4-fold increase in the number of patient visits and received highest number of patients in its history, 1045 on August 14, 2007. The patient number remained higher than the usual patient visits of the Dhaka Hospital of icddr’b until the end of September 2007 placing profound burden on hospital resources and capacities to meet needs for excess supplies including intravenous saline, oral rehydration salt (ORS) and antimicrobials, and hiring of additional trained medical personnel and auxiliaries for their prompt and appropriate delivery of care. The Diarrheal Disease Surveillance System (DDSS)[2] of Dhaka Hospital revealed that increasing number of people were coming from one particular area known to be Mirpur, a suburb in the north of the city. Loss of some valuable lives was reported during travelling while many of the patients arrived late in life-threatening conditions such as severe dehydration with hypovolemic shock. In March 2009, following another sharp surge in cases of diarrheal illnesses, icddr’b responded to a request made by the Ministry of Health and Family Planning, Government of the People’s Republic of Bangladesh (GoB) by opening a treatment center in Mirpur named as Mirpur Treatment Centre (MTC).[3] The 60-bed facility began to operate right after 1 month in the vacant place of an existing health facility. The present study aimed to evaluate the effect of the new facility on patient load, and characteristics of patient population including common etiology of those individuals seeking treatment for diarrheal illness at Dhaka Hospital.


   Materials and Methods Top


Catchment area1

During the flood in 2007 and onward postflood years, especially the years of 2008 and 2009, a large proportion of patients who attended the Dhaka Hospital of icddr’b were from Mirpur area which consisted of three thanas: Mirpur, Pallabi, and Kafrul. These three areas were located to the North-west of Dhaka, the capital city where water sanitation and sewerage system are known to be less organized because of hurriedly expanding number of housing infrastructures.[4] The situation further deteriorated due to rapidly developing or expanding slums. Moreover, the area was close to the river Turag, and during monsoon each year, the low lands by the side of the river are inundated due to flash flooding. Family members of this area often share toilets. Over 98% of patients use tap water and around 1% use tube-well water for bathing or drinking purposes. About 33% of the patient population was familiar with nontreated water drinking.[4] As a result, the residents were vulnerable to diarrhea.

Diarrhoeal Disease Surveillance System

The DDSS of icddr, b started in the Dhaka Hospital to provide valuable information to clinicians in their clinical decision-making processes and monitors changes in patients’ characteristics which has been reported elsewhere.[2],[5] In Dhaka Hospital, it systematically enrolls 2% (every 50th) of the patients seeking care at the hospital irrespective of age, sex, sociodemographic background, and severity of disease. The large facility provides treatment free of charge that allows the poor and disadvantaged population to receive optimal care. From 2010, soon after the establishment of the MTC, the DDSS also expanded its activities by systematically enrolling 10% patients (every 10th) following identical methodology followed in Dhaka Hospital. Clinical, epidemiological, and laboratory information were collected from enrolled patients using a structured questionnaire which included fecal culture for isolation and identification of common enteric pathogens, for example, Shigella spp., Vibrio cholerae, Salmonella, and rotavirus; however, enterotoxigenic Escherichia coli was detected only among Dhaka Hospital patient population following standard laboratory methods.[6],[7]

Data extraction

Relevant information was extracted from the data archive of DDSS for 2010–2013 with the aim to evaluate the impact of newly established MTC. In addition to that, corresponding data for Dhaka Hospital from 2005 to 2013 was also analyzed to see changes in patient load, their clinical features, and other characteristics of those seeking treatment at the Dhaka Hospital from Mirpur area.

Assessment of diarrheal disease severity

Diarrheal disease severity was scored using a 17-point numerical scale based on the following clinical features: duration of diarrhea, number of stools passed in last 24 h, number of occasions of vomiting in last 24 h, fever (°C), dehydration status, and treatment received (described elsewhere by Ruuska et al.).[8] Disease severity was then classified as mild (≤6), moderately severe, and severe-to-very severe (≥10). Duration of vomiting was not used for scoring because of absence of data.

Data analysis

Data from Dhaka Hospital (during 2005–2013) was analyzed in two ways. One, overall and second, among enrolled patients form Mirpur catchment area with the aim to determine any changes in characteristics of patient population presenting at Dhaka Hospital from Mirpur catchment area after the establishment of MTC. Moreover, such impact was also assessed for MTC patients, especially number of patients visited (including children under-5), their disease severity, use of intravenous saline for rehydration, and common etiologies (Shigella spp., V. cholerae, and rotavirus) for 2010–2013. Chi-square for trend was computed to test statistical significance of changing trend.[9] The estimated number of patients attended the Dhaka Hospital and MTC was equated by number of patients enrolled in the DDSS multiplied by 50 (2% enrolment) and 10 (10% enrolment), respectively. In addition, principal component analysis (factor analysis) was performed to determine wealth quintiles (using household assets). Variables included were construction material of the wall, roof, and floor of the house, and household assets, for example, radio, television, table, cupboard, local motorized vehicle, animal-drawn cart, refrigerator, motor boat, rickshaw, sanitary toilet (sanitary), and nonsanitary toilet (semi-sanitary, dug hole [with ring], open pit, hanging, and no fixed place). The households were classified into quintiles of socioeconomic status based on the wealth index quintile 1 = poor, 2 = lower middle, 3 = middle, 4 = upper middle, and 5 = rich.[10] Moreover, annual inflation rate of $US was used to estimate the monthly family income. Chi-square test was performed, and a probability value of < 0.05 was considered statistically significant with their odds ratios and their 95% confidence intervals.

Percent changes between different time points (year) were estimated by subtracting 1st point from 2nd point dividing by 1st point and multiplying by 100. Finally, a comparative analysis of patient characteristics such as sociodemographic, clinical, and etiologies were done between patient population other than Mirpur and from Mirpur catchment area attending at Dhaka hospital and MTC. Comparison was performed between 2005 and 2009 first for patients attended at Dhaka hospital from other areas versus Mirpur area and then between 2010 and 2013 in Dhaka hospital as well as in MTC.

Ethical statement

DDSS of icddr, b is a routine ongoing activity which has been approved by the Research Review Committee and Ethical Review Committee of icddr, b.


   Results Top


An estimated 38,650 and 65,700 patients from Mirpur catchment area attended Dhaka Hospital and MTC during 2010–2013. Their characteristics were identical with regard to age, sex, and educational status; however, significant differences were observed for different wealth quintiles [Table 1]. Among individuals who attended at Dhaka Hospital, a higher proportion of them had a duration of illness more than 24 h prior coming to hospital (P < 0.001) and used more often antimicrobials at home (P = 0.012), they also had severe-to-very severe disease, stayed for longer period at hospital (>24 h) and were infected more often with V. cholerae [Table 1] compared to those attended in MTC. Among individuals attending Dhaka Hospital, 11% of them used sanitary toilet; however, only 4% of patient population used sanitary toilet who attended in MTC (data not shown).
Table 1: Comparison of patient characteristics, disease severity, and etiology of diarrhea between Dhaka hospital and Mirpur Treatment Centre who resided in Mirpur area during 2010-2013

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An overall increase in patient load from Mirpur area at Dhaka Hospital during 2005 and 2009 (a 22% increase) was noted; however, significant reduction of diarrheal patients with moderately severe disease at Dhaka Hospital was reported from 2010 to 2013 (69% reduction). Compared to that, MTC noted increase in number of patients by 26% from 2010 to 2013. Moreover, patients who received intravenous saline and number of children under 5-years-old were significantly reduced between 2010 and 2013 (54% and 45%, respectively) in Dhaka Hospital [Table 2].
Table 2: Distribution of patients with disease severity and use of intravenous saline attended Dhaka hospital from Mirpur and other areas, and Mirpur Treatment Centre over the study period

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   Discussion Top


Lack of coordination, resources mobilization, strong program management, and advocacy are the thematic bottlenecks and barriers for reduction of burden of diarrheal illnesses reported by Gill et al.[11] With this framework, the present paper is an example of collaboration between Government of Bangladesh and icddr, b that describes proper and efficient utilization of resources in a meaningful way.

The most important observations were reduction of patient population at Dhaka Hospital from Mirpur catchment area (53% reduction) in 2013 compared to the patient load of 2010, with a gradual increasing in number of patients in the MTC from 2010 to 2013. This supports the rationale for setting up a facility in a community known to be highly prevalent for diarrheal illness including cholera requiring hospitalization. On the other hand, there was a significant reduction of patients with moderately severe or severe-to-very severe diarrheal disease coming from Mirpur catchment area to Dhaka Hospital.

Free of charge treatment, highly skilled professionals in providing services (doctors, nurses, and administrative personnel), easy access to the facility for the community people because of the setup located in a highly endemic area, and availability of the services round the clock are the likely explanations for such a success. However, some patients from Mirpur catchment area kept on attending Dhaka Hospital. These patients were supposed to go to the MTC, their reporting to Dhaka Hospital could be because they were living at the edge of the catchment area which was close by the Dhaka Hospital or they were the patients significantly different from those patients reporting at MTC. They presented with longer duration of illness, had severe-to-very severe disease,[4] received more intravenous saline, and stayed for longer period in the Dhaka Hospital compared to MTC patient population. A significant proportion of these patients at Dhaka Hospital received antimicrobials before coming to the hospital compared to MTC; this proportion was alarming for MTC patients as well (59%), but use of ORS at home was close to 100%. Alternatively, individuals from Mirpur catchment area who attended Dhaka Hospital received antimicrobials at home which correlated with delayed care-seeking behavior (duration of diarrhea 24 h and more) with moderately severe or severe-to-very severe disease compared to patients reporting to MTC.

The efforts of newly established MTC in a small scale not only strengthened the framework of health system at policy level but also provided a good number of important information related to diarrheal disease epidemiology including changing etiology and presenting clinical features of patient population which also reported elsewhere.[4],[12],[13],[14],[15]

The experiences gathered from MTC could be translated into action to the other newer places all over the country, especially at subdistrict levels and MTC might be a good example for addressing sensibly any global emergencies. Availability of essential supplies, periodic monitoring, provision of quality care, and overall resources coordination may be the top determinants of success. Moreover, public–private partnership between medical and nonmedical organizations would be crucial for sustainability of such efforts. In addition, it is essential to know the current knowledge, attitudes, and practices related to hygienic behavior at community level.


   Conclusion Top


The DDSS of MTC provided many important messages within this shortest period. Such findings clearly demonstrate the time demanding necessity of establishment of MTC. Monitoring of changes in characteristics of diarrheal patient population, their etiologies, and socioeconomic background should be continued for better understanding and planning for public health interventions for control and prevention of diarrheal disease.

Acknowledgments

Hospital surveillance was funded by icddr’b and the Government of the People’s Republic of Bangladesh through IHP-HNPRP. icddr’b, is also thankful to the Governments of Australia, Bangladesh, Canada, Sweden, and the UK for providing core/unrestricted support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Harris AM, Chowdhury F, Begum YA, Khan AI, Faruque AS, Svennerholm AM, et al. Shifting prevalence of major diarrheal pathogens in patients seeking hospital care during floods in 1998, 2004, and 2007 in Dhaka, Bangladesh. Am J Trop Med Hyg 2008;79:708-14.  Back to cited text no. 1
    
2.
Stoll BJ, Glass RI, Huq MI, Khan MU, Holt JE, Banu H, et al. Surveillance of patients attending a diarrhoeal disease hospital in Bangladesh. Br Med J (Clin Res Ed) 1982;285:1185-8.  Back to cited text no. 2
    
3.
ICDDR, B. ICDDR, B Opens a New Urban Treatment Centre to Cope With Ongoing Diarrhoeal Disease Demand; 2009. Available from: http://www.icddrb.org/news_detail.cfm?ID=297. [Last accessed on 2010 Feb 22].  Back to cited text no. 3
    
4.
Chowdhury F, Rahman MA, Begum YA, Khan AI, Faruque AS, Saha NC, et al. Impact of rapid urbanization on the rates of infection by Vibrio cholerae O1 and enterotoxigenic Escherichia Coli in Dhaka, Bangladesh. PLoS Negl Trop Dis 2011;5:e999.  Back to cited text no. 4
    
5.
Das SK, Begum D, Ahmed S, Ferdous F, Farzana FD, Chisti MJ, et al. Geographical diversity in seasonality of major diarrhoeal pathogens in Bangladesh observed between 2010 and 2012. Epidemiol Infect 2014;142:2530-41.  Back to cited text no. 5
    
6.
Programme for Control of Diarrhoeal Diseases. In: Manual for Laboratory Investigation of Acute Enteric Infections. Geneva: World Health Organization; 1987. p. 9-20.  Back to cited text no. 6
    
7.
Rahman M, Sultana R, Ahmed G, Nahar S, Hassan ZM, Saiada F, et al. Prevalence of G2P[4] and G12P[6] rotavirus, Bangladesh. Emerg Infect Dis 2007;13:18-24.  Back to cited text no. 7
    
8.
Ruuska T, Vesikari T. Rotavirus disease in Finnish children: Use of numerical scores for clinical severity of diarrhoeal episodes. Scand J Infect Dis 1990;22:259-67.  Back to cited text no. 8
    
9.
Available from: http://www.statsdirect.com/help/chi_square_tests/2k.htm. [Last assessed on 2017 Oct 23].  Back to cited text no. 9
    
10.
Vyas S, Kumaranayake L. Constructing socio-economic status indices: How to use principal components analysis. Health Policy Plan 2006;21:459-68.  Back to cited text no. 10
    
11.
Gill CJ, Young M, Schroder K, Carvajal-Velez L, McNabb M, Aboubaker S, et al. Bottlenecks, barriers, and solutions: Results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths. Lancet 2013;381:1487-98.  Back to cited text no. 11
    
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Zaman K, Yunus M, El Arifeen S, Azim T, Faruque AS, Huq E, et al. Methodology and lessons-learned from the efficacy clinical trial of the pentavalent rotavirus vaccine in Bangladesh. Vaccine 2012;30 Suppl 1:A94-100.  Back to cited text no. 12
    
13.
Sow SO, Tapia M, Haidara FC, Ciarlet M, Diallo F, Kodio M, et al. Efficacy of the oral pentavalent rotavirus vaccine in Mali. Vaccine 2012;30 Suppl 1:A71-8.  Back to cited text no. 13
    
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Shin S, Anh DD, Zaman K, Yunus M, Mai le TP, Thiem VD, et al. Immunogenicity of the pentavalent rotavirus vaccine among infants in two developing countries in Asia, Bangladesh and Vietnam. Vaccine 2012;30 Suppl 1:A106-13.  Back to cited text no. 14
    
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Das SK, Ahmed S, Ferdous F, Farzana FD, Chisti MJ, Leung DT, et al. Changing emergence of Shigella sero-groups in Bangladesh: Observation from four different diarrheal disease hospitals. PLoS One 2013;8:e62029.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2]



 

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