ObjectiveTo estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh.DesignAn incidence-based COI study was performed for one episode of childhood severe pneumonia ...from a household perspective. Face-to-face interviews collected data on socioeconomic, resource use and cost from caregivers. A micro-costing bottom-up approach was applied to calculate medical, non-medical and time costs. Multiple regression analysis was applied to explore the factors associated with COI. Sensitivity analysis explored the robustness of cost parameters.SettingFour urban and rural study sites from two districts in Bangladesh.PatientsChildren aged 2–59 months with severe pneumonia.Results1472 children with severe pneumonia were enrolled between November 2015 and March 2019. The mean age of children was 12 months (SD ±10.2) and 64% were male. The mean household cost per episode was US$147 (95% CI 141.1 to 152.7). Indirect costs were the main cost drivers (65%, US$96). Household costs for the poorest income quintile were lower in absolute terms, but formed a higher proportion of monthly income. COI was significantly higher if treatment was received from urban health facilities compared with rural health facilities (difference US$84.9, 95% CI 73.3 to 96.3). Child age, household income, healthcare facility and hospital length of stay (LoS) were significant predictors of household COI. Costs were most sensitive to hospital LoS and productivity loss.ConclusionsSevere pneumonia in young children is associated with high household economic burden and cost varies significantly across socioeconomic parameters. Management strategies with improved accessibility are needed particularly for the poor to make treatment affordable in order to reduce household economic burden.
ObjectiveTo estimate inpatient care costs of childhood severe pneumonia and its urban–rural cost variation, and to predict cost drivers.DesignThe study was nested within a cluster randomised trial of ...childhood severe pneumonia management. Cost per episode of severe pneumonia was estimated from a healthcare provider perspective for children who received care from public inpatient facilities. A bottom-up micro-costing approach was applied and data collected using structured questionnaire and review of the patient record. Multivariate regression analysis determined cost predictors and sensitivity analysis explored robustness of cost parameters.SettingEight public inpatient care facilities from two districts of Bangladesh covering urban and rural areas.PatientsChildren aged 2–59 months with WHO-classified severe pneumonia.ResultsData on 1252 enrolled children were analysed; 795 (64%) were male, 787 (63%) were infants and 59% from urban areas. Average length of stay (LoS) was 4.8 days (SD ±2.5) and mean cost per patient was US$48 (95% CI: US$46, US$49). Mean cost per patient was significantly greater for urban tertiary-level facilities compared with rural primary–secondary facilities (mean difference US$43; 95% CI: US$40, US$45). No cost variation was found relative to age, sex, malnutrition or hypoxaemia. Type of facility was the most important cost predictor. LoS and personnel costs were the most sensitive cost parameters.ConclusionHealthcare provider cost of childhood severe pneumonia was substantial for urban located public health facilities that provided tertiary-level care. Thus, treatment availability at a lower-level facility at a rural location may help to reduce overall treatment costs.
Background: Recent evidence suggests that the vitamin A equivalency of beta-carotene from plant sources is lower than previously estimated. Objective: We assessed the effect of 60 d of daily ...supplementation with 750 microgram retinol equivalents (RE) of either cooked, pureed sweet potatoes; cooked, pureed Indian spinach (Basella alba); or synthetic sources of vitamin A or beta-carotene on total-body vitamin A stores in Bangladeshi men. Design: Total-body vitamin A stores in Bangladeshi men (n = 14/group) were estimated by using the deuterated-retinol-dilution technique before and after 60 d of supplementation with either 0 microgram RE/d (white vegetables) or 750 microgram RE/d as sweet potatoes, Indian spinach, retinyl palmitate, or beta-carotene (RE = 1 microgram retinol or 6 microgram beta-carotene) in addition to a low-vitamin A diet providing approximately equal to 200 microgram RE/d. Mean changes in vitamin A stores in the vegetable and beta-carotene groups were compared with the mean change in the retinyl palmitate group to estimate the relative equivalency of these vitamin A sources. Results: Overall geometric mean (±SD) initial vitamin A stores were 0.108 ± 0.067 mmol. Relative to the low-vitamin A control group, the estimated mean changes in vitamin A stores were 0.029 mmol for sweet potato (P = 0.21), 0.041 mmol for Indian spinach (P = 0.033), 0.065 mmol for retinyl palmitate (P < 0.001), and 0.062 mmol for beta-carotene (P < 0.002). Vitamin A equivalency factors (beta-carotene:retinol, wt:wt) were estimated as approximately equal to 13:1 for sweet potato, approximately equal to 10:1 for Indian spinach, and approximately equal to 6:1 for synthetic beta-carotene. Conclusion: Daily consumption of cooked, pureed green leafy vegetables or sweet potatoes has a positive effect on vitamin A stores in populations at risk of vitamin A deficiency.
ObjectiveDelays in seeking medical attention for childhood pneumonia may lead to increased morbidity and mortality. This study aimed at identifying the drivers of delayed seeking of treatment for ...severe childhood pneumonia in rural Bangladesh.MethodsWe conducted a formative study from June to September 2015 in one northern district of Bangladesh. In-depth interviews were conducted with 20 rural mothers of children under 5 years with moderate or severe pneumonia. We analysed the data thematically.ResultsWe found that mothers often failed to assess severity of pneumonia accurately due to lack of knowledge or misperception about symptoms of pneumonia. Several factors delayed timely steps that could lead to initiation of appropriate treatment. They included time lost in consultation with non-formal practitioners, social norms that required mothers to seek permission from male household heads (eg, husbands) before they could seek healthcare for their children, avoiding community-based public health centres due to their irregular schedules, lack of medical supplies, shortage of hospital beds and long distance of secondary or tertiary hospitals from households. Financial hardships and inability to identify a substitute caregiver for other children at home while the mother accompanied the sick child in hospital were other factors.ConclusionsThis study identified key social, economic and infrastructural factors that lead to delayed treatment for childhood pneumonia in the study district in rural Bangladesh. Interventions that inform mothers and empower women in the decision to seek healthcare, as well as improvement of infrastructure at the facility level could lead to improved behaviour in seeking and getting treatment of childhood pneumonia in rural Bangladesh.
Depot medroxyprogesterone acetate (DMPA) is a widely used contraceptive method. HIV pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil fumarate (F/TDF) is highly effective in ...reducing HIV acquisition in women. We sought to determine the impact of DMPA on F/TDF pharmacokinetics and pharmacodynamics.
Twelve healthy premenopausal cisgender women were enrolled and each completed 4 sequential conditions: (1) baseline, (2) steady-state F/TDF alone, (3) steady-state F/TDF + DMPA, and (4) DMPA alone. Assessments included clinical, pharmacokinetic, viral infectivity (ex vivo challenge of peripheral blood mononuclear cells by X4- and R5-tropic green fluorescent protein pseudoviruses and cervical tissue by HIV BaL ), endocrine, immune cell phenotyping, and renal function.
Compared with baseline, F/TDF (± DMPA) significantly decreased both %R5- and X4-infected CD4 T cells and F/TDF + DMPA decreased cervical explant p24 (all P < 0.05). The %R5- and X4-infected CD4 T cells were higher during DMPA alone than during F/TDF periods and lower than baseline (not statistically significant). Cervical explant p24 fell between baseline and F/TDF values (not statistically significant). There were neither statistically significant differences in F/TDF pharmacokinetics, including total or renal clearance of either antiviral drug, nor changes in glomerular filtration rate with the addition of DMPA. There were few immune cell phenotypic differences across conditions.
F/TDF decreased HIV infection in both challenge assays, whereas DMPA alone did not enhance HIV infection in either challenge assay. DMPA did not alter F/TDF pharmacokinetics or renal function.
Diarrheal disease is a leading cause of childhood morbidity and mortality worldwide, but particularly in low-income countries in sub-Saharan Africa and South Asia. The Global Enteric Multicenter ...Study (GEMS) examined the infectious etiologies as well as associated demographics, socioeconomic markers, health-care-seeking behaviors, and handwashing practices of the households of children with diarrhea and their age- and gender-matched controls in seven countries over a 3-year period (December 2007-December 2010). Stool studies to determine diarrheal etiologies and anthropometry were performed at baseline and at 60-day follow-up visits, along with surveys to record demographics and living conditions of the children. We performed secondary analyses of the GEMS data derived from the Bangladesh portion of the study in children with diarrhea associated with viral enteropathogens and explored pathogen-specific features of disease burden. Rotavirus and norovirus were the most prevalent pathogens (39.3% and 35%, respectively). Disease due to rotavirus and adenovirus was more common in infants than in older children (
< 0.001 and
= 0.001, respectively). Height for age decreased from baseline to follow-up in children with diarrhea associated with rotavirus, norovirus, and adenovirus (
< 0.001). Based on these analyses, preventive measures targeted at rotavirus, norovirus, and adenovirus will be expected to have meaningful clinical impact. Cost of treatment was highest for rotavirus as well, making it an obvious target for intervention. Association of specific viruses with stunting is particularly notable, as stunting is an attributable risk factor for poor cognitive development and future productivity and economic potential.
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