RotaFlash, April 2016
Every day, concerned families bring children of all ages to the famous Cholera Hospital run by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). The children are brought to be treated for diarrhoea, but many are suffering from other conditions, including severe acute malnutrition (SAM). Left untreated, SAM has a fatality rate of 30-50%. But researchers and clinicians at icddr,b have developed treatment protocols and interventions that dramatically improve childrens’ chances of survival. My name is Yana and as an icddr,b staff member, I see this scene on a daily basis. I wanted to learn more about SAM and so I went into the Hospital to find out more.
Five and a half month old Alim arrives at Dhaka Hospital and within minutes is admitted by Nurse Khatun for recurring diarrhoea.
The busy hospital entrance is no easy scene to step into. At the triage counter, mothers and fathers comfort their crying children while nurses conduct preliminary assessments and register the children.
Nurse Majeda Khatun, who is on duty this day, tells me that the hospital admission process follows the World Health Organization (WHO) admission guidelines for malnutrition. These involve measuring and weighing children and checking for abnormal swelling in the feet for indicators of malnutrition. A child suspected of acute malnourishment is quickly referred to the hospital’s ‘Short Stay Unit’ for a more in-depth assessment.
The medical staff use a tablet to assess Sameha’s (pictured) z- score (weight x height) where a z-score below -3 indicates SAM as outlined by the WHO growth standards.
As I am escorted through the Short Stay Unit, the doctors tell me that “before treating children with severe malnutrition, we must treat their acute diarrhoea and existing illnesses.” We walk over to eight-month-old Sameha, who was admitted a few hours earlier. At the hospital, doctors use a tablet computer with customised software to measure Sameha’s z-score – a measure of growth - that confirms Sameha is suffering from malnutrition. One of an average 19 children per week that hospital staff diagnose with SAM, she is immediately put on a special liquid diet to increase her caloric intake, while having her diarrhoea treated with oral rehydration solution (ORS).
Azraful receives his zinc tablet from Dr. Mamun. Administration of micronutrients such as zinc in children with diarrhoea has proven to accelerate recovery and decrease chances of recurring diarrhoea in infants up to 5 years of age.
Next stop is the ‘Long Stay Unit’, where I meet Dr. Mamun. He is about to give 26-month-old Ashraful his daily zinc tablet by mixing it with a few drops of water. Dr. Mamun explains that Ashraful has a 47% higher chance of surviving while in the care of the hospital and with treatment administered according to the hospital’s SAM protocol, compared to non-standardised protocols. “Once the acute diarrhoea stops after a week of treatment of diet, antibiotics, slow rehydration, vitamins and minerals,” he says, “we will urge Ashraful’s mother to take him to the ‘Nutrition and Rehabilitation Unit’ to focus on treating his SAM.”
Saifun Nahar (left), a dedicated health worker at the NRU helps Hasan’s mother, Hahina, with feeding.
Stepping into the Nutrition Rehabilitation Unit is completely different from visiting the previous wards. The smiling and playing children in this small, 10-bed ward were clearly no longer experiencing such discomfort or pain. Right away I was drawn to 10-month old Hasan, who was on his road to recovery from malnutrition. As part of his treatment, he was being fed halwa and kitchuri, local inexpensive food items that are rich in calories and easily prepared at home. Through intense feeding over a course of three-four weeks in the hospital, the health workers and Hasan’s mother hope he will recover his lost weight and nutrients.
Hasan plays with a variety of toys as part of a scheduled psycho-social stimulation session at the Nutrition Rehabilitation Unit.
The effects of SAM can have implications well into a child’s later years of development, as malnutrition can lead to growth stunting and delays in cognitive function . At the Dhaka Hospital, nutritional rehabilitation goes beyond feeding to incorporate psycho-social stimulation of the child. For an hour each day, Hasan gets to play with cognitive-focused games, as well as home-made toys, to increase his mental development and cognitive skills. I watch Hasan as he laughs and curiously grabs every toy in sight. His mother has a smile on her face and says that she is determined to see through his recovery.
Mothers at the Nutrition Rehabilitation Unit receive daily counselling from a health worker.
An hour of each day is dedicated to mothers, who get together for a counselling session with one of the hospital’s health workers. A range of topics are covered, including food preparation, nutritional value of local produce, breastfeeding, and child development. In some cases, malnutrition in Bangladesh is not due simply to a lack of food, but due to lack of education or information as to how best to feed children. For many of these mothers, the sessions are the only source of reliable information when it comes to child care, and they are encouraged to share what they learn here with their family and friends when returning home.
Hasan smiling at the NRU ward after feeding and psycho-social stimulation.
Once Hasan achieves a 15% weight gain since admission, or his z-score improves to -2, he will be discharged from the Nutrition Rehabilitation Unit and his mother will be advised to come back for follow-up in a week. Follow-up sessions lasting up to a year are designed to prevent children from relapsing, monitor their ongoing well-being, and answer any questions the parents might have.
Thanks to the protocols developed through the organization’s research, the fight against SAM at the Dhaka Hospital ensures that all children have the opportunity to recover from SAM and go on to lead healthy and happy lives.
Sheema, is one of the hospital’s most memorable children who had SAM. She was admitted in critical condition with diarrhea, malnutrition, and pneumonia, and her successful recovery after 35 days of treatment at icddr,b has been used as a case study since.Read more
On 13 February 2014 in Guinea, a woman holds her son in a sling on her back as he is vaccinated against measles in Conakry, the capital. The immunization was administered as part of a massive emergency vaccination campaign against the disease. The government-led campaign, which aimed to reach over 1.7 million children across the country, in response to an increase in the number of measles deaths and suspected cases of the disease.” Photo credit: UNICEF/NYHQ2014-1923/La Rose.
Measles, a disease that has been all but forgotten by many families in high-income countries, returned as front-page news in America, Canada, and Germany this year. I’ve seen these articles appear on my news feeds on Twitter and Facebook and watched as debates emerged about what role the government has in requiring parents to vaccinate their children. This is an important public health discussion, but absent from these articles and online debates is the story that millions of families around the world are desperate to vaccinate their children against measles but can’t because they lack access to this affordable and effective life-saving vaccine. Because: measles vaccines are life-saving.
Measles is an infection that weakens the immune system, which can lead to other infections such as severe diarrhea, pneumonia, and encephalitis. In low-income countries, where children have limited or no access to medical treatment and are often malnourished, getting measles and then severe diarrhea or pneumonia can be deadly. Between 2 – 15 percent of children who get measles in low-income countries will die from measles-related deaths and in the worst outbreaks up to 25 percent of children can die. That’s why so many families literally refer to measles vaccines as miracles – because they know the toll of not vaccinating.
When communities host measles vaccination campaigns, we see families travel by boat and walk great distances to ensure their children are vaccinated. Despite families demanding vaccines and their willingness to go to great lengths to protect their children against measles, global measles vaccination efforts are facing significant funding challenges. For example, a large-scale vaccination campaign in Ethiopia that aimed at vaccinating roughly 40 million children (9 months to 14 years old) was postponed until next year because of funding shortfalls. And still, there aren’t enough funds to vaccinate over 28 million children in Ethiopia next year. While Ethiopian children wait for the global community to fund this vaccination effort, measles outbreaks rage in their country. As of mid-August, Ethiopia had 16,000 suspected cases of measles. In a country that is facing a drought and more than 28 percent of children are malnourished, these children cannot wait to be vaccinated.
This week, immunization experts from around the world are gathering in DC for the Measles & Rubella Initiative Annual Meeting. In presentations and side conversations, I’ve heard the frustration in the voices of doctors and public health experts who see firsthand parents who are eager to vaccinate their children, but can’t because we lack the resources to reach every child. I find myself hearing questions about why parents aren’t vaccinating their children in high-income countries and I wonder why we aren’t also asking, “How can we let 40 million children not get vaccinated this year when we have an effective vaccine that costs just $1/child and their parents are desperate to protect them from measles?”Read more
A well nourished child is a healthy child. Fighting iron deficiency and the anemia it can cause is a big step toward fighting malnutrition, which weakens a child’s immune system and leaves him/her susceptible to infections, including diarrhea and pneumonia. We invited Dhiraj Agarwal, a researcher participating in our clinical trial of a new rotavirus vaccine, to share his findings from a study evaluating iron fortification among Indian children.
In July 2007, I joined the Vadu Rural Health Program, KEM Hospital Research Centre, Pune as a Junior Research Fellow. My responsibility was to coordinate activities for a study on “Iron intervention in school-going children.”
Anemia is a major public health concern in many parts of India. There are various reasons for anemia among infants and children such as low intake of iron, infections etc. Studies have reported the prevalence of anemia in Indian children to be 60 to 80 percent. To help children in rural India get iron fortification, we conducted three studies between 2004 to 2008.
It was encouraging to see that the solutions we tested had promise. In the first study, through a grant from the Canadian Institutes for Health Research, we tested the efficacy of various forms and doses of iron in form of Sprinkles - a micronutrient powder that provides microencapsulated ferrous fumarate in single serve sachets (procured with support from Heinz India). When caregivers added Sprinkles to cooked food once daily for two months, the powder helped reduce the risk and prevalence of anemia in children. In another study group, caregivers added drops of a measured dose of 1.5 mL (equivalent to 20 mg elemental iron) to food once daily for two months. Field investigators made weekly visits to monitor the study, and these house visits also served to motivate caregivers to give Sprinkles or Drops. The study found Sprinkles to be a more effective iron supplement when compared with drops.
The second study, supported by the HJ Heinz Foundation and Helen Keller International, assessed the effectiveness of micronutrient powder (Sprinkles Plus) supplementation in reducing anemia levels in children aged six months to six years when distributed through India’s Integrated Child Development Services (ICDS) program. This study was conducted in five places in Maharashtra, India, including Vadu. In this study, 60 sachets of micronutrient powder were administered flexibly over four months to 17,124 children at home or at anganwadis (government centers in rural areas that combat hunger and malnutrition and provide basic healthcare for pregnant women and children).
Caregivers added the Sprinkles sachet to a small portion of the child’s cooked meal once daily at the anganwadi or home. The study showed that the initiative was effective in reducing and treating anemia in the selected target population, and this method was later implemented in Tamil Nadu state by ICDS to reduce anemia in preschool children.
Finally, a third study tested the efficacy of NaFeEDTA fortified wheat flour in reducing anemia, improving body iron stores, and improving and cognitive performance in school going Indian children aged 6-15 years. This study was supported by Department of Biotechnology, Ministry of Science and Technology, Government of India and conducted in Vadu schools and Bengaluru. Researchers found that NaFeEDTA-fortified wheat flour improved body iron stores and reduced iron deficiency in iron-depleted children.
As a researcher in public health and looking at these studies, we look forward to this being incorporated into public health policies, ultimately improving health and nutrition of India’s vulnerable children.
-- Dhiraj Agarwal is Health Scientist by training and working as a Laboratory Manager at the Vadu Health and Demographic Surveillance System (Vadu HDSS), Vadu Rural Health Program (VRHP), KEM Hospital Research Centre, Pune.
Soumya fulfills a lifelong dream to travel to Hollywood. Here, he takes on Uma Thurman in a sword fight at Madame Tussauds.
As a member of the operational team of the bovine-human reassortant rotavirus vaccine (BRV) project, I am responsible for developing and implementing plans and procedures for efficient operations and communications among PATH, the Serum Institute, clinical research sites, contract research organizations (CROs), laboratories, and other parties (vendors) when needed.
I am from Amtala, which is in the southern part of Kolkata. I graduated from Calcutta University, and completed my Basic Management in Cerebral Palsy from Jadavpur University and earned an MD in Psychiatry. Although I began my career as a private practitioner, I felt that scope was very limited. I wanted to learn more about clinical research and wished to work with renowned doctors and scientists.
A few years later, I joined NVS Bio Research (a Kolkata-based Indian CRO) as Research Officer. I then moved to Glaxo Smith Kline as a Clinical Research Associate and moved to Gurgaon. My next career move was to Quintiles Research where I learned a lot and made good friends. In December 2012, I moved to PATH’s New Delhi office where I work as a Clinical Research Manager for a Phase 3 rotavirus vaccine study. I now live in Delhi with my wife, Ujjyaini. My younger brother, his wife, and their cute daughter, Gully, continue to live in Kolkata.
My work thus far has allowed me to visit and work with several renowned hospitals, and my parents’ dream became true when as a clinical research professional I travelled to the Netherlands, Uganda, and the United States – covering three different continents. But the most rewarding part of my current work at PATH is training field workers in clinical trials sites in remote villages throughout India.
A Soumya Hazra creation: prawn malai curry and rice.
Since my passions are travelling and cooking, I have travelled to almost all parts of India from its northern tip in Kashmir to it southern seacoast Kanyakumari. During my travel I have savored local cuisines. My passion to cook took me to the third round of the first season of Master Chefs of India! I am always game to cook four to five items for 60-70 people – vegetarian or non-vegetarian!
I enjoy listening Bengali and Hindi music, and l love watching movies in Bengali, Hindi, South Indian, and from Hollywood – especially the James Bond series and the Fast and Furious series.Tom Cruise is my all-time favorite actor, and I also love Arnold Schwarzenegger and Jean Claude Van Damme. Last year, one of my wish was fulfilled when I visited Hollywood and Madame Tussauds. I am also very fond of stage performances like recitation, drama, mimicry, and I have participated in these, too. I have a huge friend circle both in India and abroad.
I began work as a private practitioner with my parents’ blessing and advice to serve poor people. Today I continue to serve. Because the only rotavirus vaccine that is currently available in India is priced at 1,000 Rupees, it is not affordable by poor people. Once this vaccine we are testing is licensed and available in the market, the cost will be affordable to all.Read more
I consider it my life’s mission to catalyze innovations and mentor startups that would help develop a cutting edge biotechnology industry for India and the world. This would simultaneously help solve some of India’s pressing public health impact problems. Part of my motivation is rooted in my personal health circumstances from childhood observing my extended family’s young ones suffer from respiratory disease infections, and part of it is rooted in my analyzing and reflecting on the constellation of risks that infants in India have to face just to reach their fifth birthday.
Rais Akhtar and Andrew Learmonth have documented in their work in medical geography that India has the unique distinction of being on the cusp of two disease ecological patterns, South-West and South-East. As a result of this, the country’s tropical climate tends to be a fertile Petri dish for a bubbling cauldron of mutating viruses and bacteria, to which our little ones are most vulnerable. Since surviving this onslaught is a yearly cyclical problem, many of our children do not have the bodily resources to fight these threats, due to among other issues problems like fetal, child and neonatal malnutrition. Coupled with these risks, is the tendency among service providers to indiscriminately use antibiotics for handling patient volumes, which has resulted in a drug resistance epidemic.
As India hosts the Call to Action Summit 2015, I feel very heartened that some of our best and brightest innovators are wrapping their minds around designing diagnostics and drug innovations, aimed at solving problems like drug resistance. PATH, too, has contributed to this discussion, my colleague Dipika Matthias, who leads PATH’s Global Health Innovation Hub practice, has spoken on the changes in innovations that have targeted maternal and child health problems throughout the years. This gives me hope to realize that through adversity, the seeds of creative thinking are flourishing in a highly unique way that is a part of the Indian reality.
Photo credit: PATH/Gabe Bienczycki.Read more