Background This paper estimates the impact on childhood drowning rates of community-based introduction of crèches or playpens or both in rural Bangladesh for children aged 0–47 months. Methods A baseline census of the whole population of 270,387 households in 51 unions, 451 villages from 7 rural sub-districts in Bangladesh was conducted in 2013. The baseline census determined retrospective, age-specific, and cumulative drowning incidence rates (IR) experienced in the target households in the 12 months prior to the intervention. Beginning in late 2013, creches for drowning prevention were established across the study area. Acceptance into creches was provided and written assent to attend a creche was obtained for all children aged 9–47 months in all participating unions. Playpens were provided to 45,460 of these children, of which 5981 children received only the playpens. All children were followed-up until their 48-month birthday or administrative censoring (fixed timepoint to stop observing the drowning deaths), after a two-year implementation period (2014–2016). Drowning IR were estimated for children and compared to corresponding baseline rates from 2012. Age-specific drowning IR under different “as treated” categories (playpen-only, creche-only, and playpen-plus-creche) were compared to the baseline rates experienced by the categorized households prior to intervention. Results A total of 3205 creches (average of 7 creches per village) were established, and 116,054 children aged 9–47 months were exposed to the intervention packages. Aggregated drowning IRs between age 0 and 47 were estimated per 100,000 population per year at 86.73 (95% CI: 69.67–107.97) and 43.03 (95% CI: 35.55–52.10) in the baseline and post implementation period, respectively. Risk ratios were 0.40 (95% CI: 0.28–0.57) overall, and 0.34 (95% CI: 0.13–0.90), 0.09 (95% CI: 0.02–0.36), and 0.04 (95% CI: 0.002–0.60) in children under the creche-only, aged, 1, 2, and 3 years old respectively. Inexplicably, drowning rates were statistically significantly higher post-intervention in children 0-11 months. There was no mortality reduction with playpen use (alone or in combination), and this group may actually have had a higher risk of drowning. Conclusions Creches are effective for preventing childhood drowning in rural Bangladesh for children above age 1-year, and should be considered for further scale-up.

Background Drowning is the leading cause of death among children 12–59 months old in rural Bangladesh. This study evaluated the cost-effectiveness of a large-scale crèche (daycare) intervention in preventing child drowning. Methods The cost of the crèches intervention was evaluated using an ingredients-based approach and monthly expenditure data collected prospectively throughout the study period from two agencies implementing the intervention in different study areas. The estimate of the effectiveness of the crèches intervention was based on a previous study. The study evaluated the cost-effectiveness from both a program and societal perspective. Results From the program perspective the annual operating cost of a crèche was $416.35 (95% CI: $221 to $576), the annual cost per child was $16 (95% CI: $8 to $23), and the incremental-cost-effectiveness ratio (ICER) per life saved with the crèches was $17,008 (95% CI: $8817 to $24,619). From the societal perspective (including parents time valued) the ICER per life saved was − $166,833 (95% CI: − $197,421 to − $141,341)—meaning crèches generated net economic benefits per child enrolled. Based on the ICER per disability-adjusted-life years averted from the societal perspective (excluding parents time), $1978, the crèche intervention was cost-effective even when the societal economic benefits were ignored. Conclusions Based on the evidence, the crèche intervention has great potential for generating net societal economic gains by reducing child drowning at a program cost that is reasonable.

Background Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. Methods Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever ≥38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. Results The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported “lower abdominal pain without fever” (K = 0.39-0.57). Conclusion In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.

Globally, drowning is a major cause of injury-related deaths among under-five children. Nearly, 90% of these deaths occur in low- and middle-income countries. However, there is limited evidence on effectiveness of childhood drowning prevention interventions from LMICs. Some of the interventions for child drowning prevention have been tested. These include barriers (fencing, door barriers, playpen), crèches, swimming lessons, rescue and resuscitation and personal flotation device.While removing or covering water hazard and isolation fencing around pools have been found to be effective in preventing childhood drowning, there is insufficient evidence for effectiveness of playpens and door barriers. Crèches/day care centers provide supervision of children especially when caregivers are busy. These have been found to be effective for childhood drowning. Swimming may reduce the risk of drowning among children. However, there is insufficient evidence whether this can be effective for very young children.In event of drowning, safe rescue and immediate resuscitation can save life. However, personal flotation device although effective may not be practical in a LMIC setting where most drowning occurs closer to home and in natural bodies of water.To generate evidence on large scale effectiveness of playpens and crèches, the the Johns Hopkins International Injury Research Unit in collaboration with the Centre for Injury Prevention and Research, Bangladesh and International Centre for Diarrheal Disease Research, Bangladesh with the support from Bloomberg Philanthropies, implemented the ‘Saving of Lives from Drowning’ (2012 – 2015) study in seven rural sub-districts of Bangladesh. Nearly, 1.2 million people were covered in the SoLiD baseline injury survey and surveillance, and about 70 000 children received SoLiD interventions.

Human Milk Oligosaccharides (HMO), complex glycans highly abundant in human milk, are thought to protect the breast‐fed infant from infectious diseases and diarrhea. For example, the concentration of alpha1‐2‐fucosylated HMO in human milk is inversely correlated to the incidence of infant diarrhea. Diarrhea poses a particular threat to infants in developing countries, where mothers are also often malnourished. Here, we studied whether a low body mass index (BMI) in mothers had any effect on the HMO concentration in their milk. As part of the MINIMat project, milk samples from mothers in rural Bangladesh with a BMI of either 14–18 (n=8) or 24–28 (n=8) were collected at 8 weeks post‐partum. All milk samples were spiked with raffinose as internal standard. Oligosaccharides were isolated as described before, tagged with 2‐aminobenzamide, and analyzed by HPLC with fluorescence detection. Milk from mothers with a BMI of 14–18 contained 42.4% less total HMO than milk from mothers with a BMI of 24–28 (P<0.001), which may put the infant at higher risk of developing infectious diseases and diarrhea. Most intriguingly, 50% of all Bangladeshi samples were from Secretor‐negative mothers (lacking alpha1–2‐fucosylated HMO), which exceeds the 23% average reported for American/European mothers. This study is the first to show a correlation between the mother's nutritional status and the oligosaccharide concentration in her milk.