Background and ObjectivesAlthough Bangladesh has made significant progress in reducing maternal and child mortality in the last decade, childbirth assisted by skilled attendants has not increased as much as expected. An objective of the Bangladesh National Strategy for Maternal Health 2014–2024 is to reduce maternal mortality to 50/100,000 live births. It also aims to increase deliveries with skilled birth attendants to more than 80% which remains a great challenge, especially in rural areas. This study explores the underlying factors for the major reliance on home delivery with Traditional Birth Attendants (TBA) in rural areas of Bangladesh.MethodsThis was a qualitative cross-sectional study. Data were collected between December 2012 and February 2013 in Sunamganj district of Sylhet division and data collection methods included key informant interviews (KII) with stakeholders; formal and informal health service providers and health managers; and in-depth interviews (IDI) with community women to capture a range of information. Key questions were asked of all the study participants to explore the question of why women and their families prefer home delivery by TBA and to identify the factors associated with this practice in the local community.ResultsThe study shows that home delivery by TBAs remain the first preference for pregnant women. Poverty is the most frequently cited reason for preferring home delivery with a TBA. Other major reasons include; traditional views, religious fallacy, poor road conditions, limited access of women to decision making in the family, lack of transportation to reach the nearest health facility. Apart from these, community people also prefer home delivery due to lack of knowledge and awareness about service delivery points, fear of increased chance of having a caesarean delivery at hospital, and lack of female doctors in the health care facilities.ConclusionsThe study findings provide us a better understanding of the reasons for preference for home delivery with TBA among this population. These identified factors can inform policy makers and program implementers to adopt socially and culturally appropriate interventions that can improve deliveries with skilled attendants and thus contribute to the reduction of maternal and neonatal mortality and morbidity in rural Bangladesh.

BackgroundUnsafe water supplies continue to raise public health concerns, especially in urban areas in low resource countries. To understand the extent of public health risk attributed to supply water in Dhaka city, Bangladesh, Escherichia coli isolated from tap water samples collected from different locations of the city were characterized for their antibiotic resistance, pathogenic properties and genetic diversity.Methodology/Principal FindingsA total of 233 E. coli isolates obtained from 175 tap water samples were analysed for susceptibility to 16 different antibiotics and for the presence of genes associated with virulence and antibiotic resistance. Nearly 36% (n = 84) of the isolates were multi-drug(≥3 classes of antibiotics) resistant (MDR) and 26% (n = 22) of these were positive for extended spectrum β-lactamase (ESBL). Of the 22 ESBL-producers, 20 were positive for bla CTX-M-15, 7 for bla OXA-1-group (all had bla OXA-47) and 2 for bla CMY-2. Quinolone resistance genes, qnrS and qnrB were detected in 6 and 2 isolates, respectively. Around 7% (n = 16) of the isolates carried virulence gene(s) characteristic of pathogenic E. coli; 11 of these contained lt and/or st and thus belonged to enterotoxigenic E. coli and 5 contained bfp and eae and thus belonged to enteropathogenic E. coli. All MDR isolates carried multiple plasmids (2 to 8) of varying sizes ranging from 1.2 to >120 MDa. Ampicillin and ceftriaxone resistance were co-transferred in conjugative plasmids of 70 to 100 MDa in size, while ampicillin, trimethoprim-sulfamethoxazole and tetracycline resistance were co-transferred in conjugative plasmids of 50 to 90 MDa. Pulsed-field gel electrophoresis analysis revealed diverse genetic fingerprints of pathogenic isolates.SignificanceMulti-drug resistant E. coli are wide spread in public water supply in Dhaka city, Bangladesh. Transmission of resistant bacteria and plasmids through supply water pose serious threats to public health in urban areas.

A total of 21 isolates were included randomly on the basis of their initial identification by the appearance of metallic sheen and from the biochemical traits to detect virulent markers of diarrhoeagenic E. Coli isolated from surface water. The antibiotic susceptibility pattern of the isolates were determined against six most commonly used antibiotics. About 52% of the isolates showed resistance to at least one of the antibiotics. About 38% of the isolates were resistant to more than one antibiotics. However, all the isolates were sensitive to gentamicin (CN). Among the 21 isolates, a total of 5 randomly selected isolates were examined for the detection of virulent genes (elt, est and stx) by PCR based method. Among the 5 tested isolates, 3 harbored the gene stx encoding Shiga toxin (Stx) and 2 to elt encoding heat-labile enterotoxin (LT). None of the isolates contained est encoding heat-stable enterotoxin (ST). Data revealed that as the virulent marker genes were detected, diarrhoeagenic E. coli strains present in the surface water would become a major public health concern.

BackgroundUrinary tract infection (UTI) in pregnancy, including asymptomatic bacteriuria, is associated with maternal morbidity and adverse pregnancy outcomes, including preterm birth and low birthweight. In low-middle income countries (LMICs), the capacity for screening and treatment of UTIs is limited. The objective of this study was to describe the population-based prevalence, risk factors, etiology and antimicrobial resistance patterns of UTIs in pregnancy in Bangladesh.MethodsIn a community-based cohort in Sylhet district, Bangladesh, urine specimens were collected at the household level in 4242 pregnant women (< 20 weeks gestation) for culture and antibiotic susceptibility testing. Basic descriptive analysis was performed, as well as logistic regression to calculate adjusted odds ratios (aOR) for UTI risk factors.ResultsThe prevalence of UTI was 8.9% (4.4% symptomatic UTI, 4.5% asymptomatic bacteriuria). Risk factors for UTI in this population included maternal undernutrition (mid-upper arm circumference <23 cm: aOR= 1.29, 95% CI: 1.03–1.61), primiparity (aOR= 1.45, 95% CI: 1.15–1.84), and low paternal education (no education: aOR= 1.56, 95% CI: 1.09–2.22). The predominant uro-pathogens were E. coli (38% of isolates), Klebsiella (12%), and staphyloccocal species (23%). Group B streptococcus accounted for 5.3% of uro-pathogens. Rates of antibiotic resistance were high, with only two-thirds of E. coli susceptible to 3rd generation cephalosporins.ConclusionsIn Sylhet, Bangladesh, one in 11 women had a UTI in pregnancy, and approximately half of cases were asymptomatic. There is a need for low-cost and accurate methods for UTI screening in pregnancy and efforts to address increasing rates of antibiotic resistance in LMIC.

Resistance to carbapenem antibiotics through the production of New Delhi metallo-␤-lactamase-1 (NDM-1) constitutes an emerging challenge in the treatment of bacterial infections. To monitor the possible source of the spread of these organisms in Dhaka, Bangladesh, we conducted a comparative analysis of wastewater samples from hospital-adjacent areas (HAR) and from community areas (COM), as well as public tap water samples, for the occurrence and characteristics of NDM-1-producing bacteria. Of 72 HAR samples tested, 51 (71%) samples were positive for NDM-1-producing bacteria, as evidenced by phenotypic tests and the presence of the bla NDM-1 gene, compared to 5 of 41 (12.1%) samples from COM samples (P Ͻ 0.001). All tap water samples were negative for NDM-1-producing bacteria. Klebsiella pneumoniae (44%) was the predominant bacterial species among bla NDM-1 -positive isolates, followed by Escherichia coli (29%), Acinetobacter spp. (15%), and Enterobacter spp. (9%). These bacteria were also positive for one or more other antibiotic resistance genes, including bla CTX-M-1 (80%), bla CTX-M-15 (63%), bla TEM (76%), bla SHV (33%), bla CMY-2 (16%), bla OXA-48-like (2%), bla OXA-1 (53%), and bla OXA-47-like (60%) genes. Around 40% of the isolates contained a qnr gene, while 50% had 16S rRNA methylase genes. The majority of isolates hosted multiple plasmids, and plasmids of 30 to 50 MDa carrying bla NDM-1 were self-transmissible. Our results highlight a number of issues related to the characteristics and source of spread of multidrug-resistant bacteria as a potential public health threat. In view of the existing practice of discharging untreated liquid waste into the environment, hospitals in Dhaka city contribute to the potential dissemination of NDM-1-producing bacteria into the community.IMPORTANCE Infections caused by carbapenemase-producing Enterobacteriaceae are extremely difficult to manage due to their marked resistance to a wide range of antibiotics. NDM-1 is the most recently described carbapenemase, and the bla NDM-1 gene, which encodes NDM-1, is located on self-transmissible plasmids that also carry a considerable number of other antibiotic resistance genes. The present study shows a high prevalence of NDM-1-producing organisms in the wastewater samples from hospitaladjacent areas as a potential source for the spread of these organisms to community areas in Dhaka, Bangladesh. The study also examines the characteristics of the isolates and their potential to horizontally transmit the resistance determinants. The significance of our research is in identifying the mode of spread of multiple-antibiotic-resistant organisms, which will allow the development of containment measures, leading to broader impacts in reducing their spread to the community.

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Infections by methicillin-resistant Staphylococcus aureus (MRSA) are gradually increasing in the community. In this study, we investigated a total of 162 food samples including 112 ready-to-eat (RTE) foods and 40 processed raw meat and fish samples collected from retail vendors in Dhaka, Bangladesh and determined the occurrence of toxigenic S. aureus and MRSA. Around 22% of samples were positive for S. aureus, RTE foods being more positive (23%) than the processed raw meat/fish samples (18%). Among 35 S. aureus isolates, 74% were resistant to erythromycin, 49% to ciprofloxacin and around 30% to oxacillin and cefoxitin. Around 37% of isolates were resistant to ≥3 classes of antibiotics and 26% of isolates (n = 9) were identified as MRSA. Majority of the isolates were positive for enterotoxin genes (74%), followed by pvl gene (71%), toxic shock syndrome toxin (tsst) gene (17%) and exfoliative toxin genes (11%). Multi locus sequence typing (MLST) of 9 MRSA isolates identified four different types such as ST80 (n = 3), ST6 (n = 2), ST239 (n = 2) and ST361 (n = 2). spa typing of MRSA isolates revealed seven different types including t1198 (n = 2), t315 (n = 2), t037 (n = 1), t275 (n = 1), t304 (n = 1), t8731 (n = 1) and t10546 (n = 1). To our knowledge, this is the first report entailing baseline data on the occurrence of MRSA in RTE foods in Dhaka highlighting a potential public health risk to street food consumers.

Objective There is dearth of information on the timeliness of antenatal care (ANC) uptake. This study aimed to determine the timely ANC uptake by a medically trained provider (MTP) as per the World Health Organization (WHO) recommendations and the country guideline. Methods Cross-sectional survey was done with 2,731 women having livebirth outcome in last one year in Dinajpur, Nilphamari and Rajshahi districts, Bangladesh from August-November,2016. Results About 82%(2,232) women received at least one ANC from a MTP. Overall, 78%(2,142) women received 4 or more ANCs by any provider and 43%(1168) from a MTP. Only 14%(378) women received their first ANC at the 1st trimester by a MTP. As per 4 schedule visits by the WHO FANC model and the country guideline 8%(203) and 20%(543) women respectively received the first 2 timely ANC by a MTP; where only 1%(32) and 3%(72) received the first 3 visits timely and 0.6%(17) and 1%(29) received all the four timely visits. Factors significantly associated with the first two timely visits are: 10 or above years of schooling of women [adj. OR 2.13 (CI: 1.05, 4.30)] and their husbands [adj. OR 2.40 (CI: 1.31, 4.38)], women’s employment [adj. OR 2.32 (CI: 1.43, 3.76)], urban residential status [adj. OR 3.49 (CI: 2.46, 4.95)] and exposure to mass media [adj. OR 1.58 (CI: 1.07, 2.34)] at 95% confidence interval. According to the 2016 WHO ANC model, only 1.5%(40) women could comply with the first two ANC contacts timely by a MTP and no one could comply with all the timely 8 contacts. Conclusion Despite high coverage of ANC utilization, timely ANC visit is low as per both the WHO recommendations and the country guideline. For better understanding, further studies on the timeliness of ANC coverage are required to design feasible intervention for improving maternal and child health.