Policy priorities for strengthening smokeless tobacco control in Bangladesh:A mixed-methods analysis

Introduction Smokeless tobacco (ST) remains poorly regulated in Bangladesh. This study describes the prevalence and trends of ST use in Bangladesh, presents ST-related disease burden, identifies relevant policy gaps, and highlights key implications for future policy and practice for effective ST control in Bangladesh. Methods We analyzed secondary data from the two rounds (2009 and 2017) of The Global Adult Tobacco Survey, estimated ST-related disease burden, and conducted a review to assess differences in combustible tobacco and ST policies. In addition, we gathered views in a workshop with key stakeholders in the country on gaps in existing tobacco control policies for ST control in Bangladesh and identified policy priorities using an online survey. Results Smokeless tobacco use, constituting more than half of all tobacco use in Bangladesh, declined from 27.2% (25.9 million) in 2009 to 20.6% (22 million) in 2017. However, in 2017, at least 16947 lives and 403460 Disability-Adjusted Life Years (DALYs) were lost across Bangladesh due to ST use compared to 12511 deaths and 324020 DALYs lost in 2010. Policy priorities identified for ST control have included: introducing specific taxes and increasing the present ad valorem tax level, increasing the health development surcharge, designing and implementing a tax tracking and tracing system, standardizing ST packaging, integrating ST cessation within existing health systems, comprehensive media campaigns, and licensing of ST manufactures. Conclusions Our analysis shows that compared to combustible tobacco, there remain gaps in implementing and compliance with ST control policies in Bangladesh. Thus, contrary to the decline in ST use and the usual time lag between tobacco exposure and the development of cancers, the ST-related disease burden is still on the rise in Bangladesh. Strengthening ST control at this stage can accelerate this decline and reduce ST related morbidity and mortality

Building the health-economic case for scaling up the WHO-HEARTS hypertension control package in low- and middle-income countries

Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in lowand middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average <US$ 5 per patient per year in the public sector. This health economic evidence will make a compelling case for government ownership and financial support for national scale hypertension control programs

Influenza Vaccination After Myocardial Infarction: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial.

BACKGROUND: Observational and small, randomized studies suggest that influenza vaccine may reduce future cardiovascular events in patients with cardiovascular disease. METHODS: We conducted an investigator-initiated, randomized, double-blind trial to compare inactivated influenza vaccine with saline placebo administered shortly after myocardial infarction (MI; 99.7% of patients) or high-risk stable coronary heart disease (0.3%). The primary end point was the composite of all-cause death, MI, or stent thrombosis at 12 months. A hierarchical testing strategy was used for the key secondary end points: all-cause death, cardiovascular death, MI, and stent thrombosis. RESULTS: Because of the COVID-19 pandemic, the data safety and monitoring board recommended to halt the trial before attaining the prespecified sample size. Between October 1, 2016, and March 1, 2020, 2571 participants were randomized at 30 centers across 8 countries. Participants assigned to influenza vaccine totaled 1290 and individuals assigned to placebo equaled 1281; of these, 2532 received the study treatment (1272 influenza vaccine and 1260 placebo) and were included in the modified intention to treat analysis. Over the 12-month follow-up, the primary outcome occurred in 67 participants (5.3%) assigned influenza vaccine and 91 participants (7.2%) assigned placebo (hazard ratio, 0.72 [95% CI, 0.52-0.99]; P=0.040). Rates of all-cause death were 2.9% and 4.9% (hazard ratio, 0.59 [95% CI, 0.39-0.89]; P=0.010), rates of cardiovascular death were 2.7% and 4.5%, (hazard ratio, 0.59 [95% CI, 0.39-0.90]; P=0.014), and rates of MI were 2.0% and 2.4% (hazard ratio, 0.86 [95% CI, 0.50-1.46]; P=0.57) in the influenza vaccine and placebo groups, respectively. CONCLUSIONS: Influenza vaccination early after an MI or in high-risk coronary heart disease resulted in a lower risk of a composite of all-cause death, MI, or stent thrombosis, and a lower risk of all-cause death and cardiovascular death, as well, at 12 months compared with placebo. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02831608

May Measurement Month 2018: a pragmatic global screening campaign to raise awareness of blood pressure by the International Society of Hypertension

Aims Raised blood pressure (BP) is the biggest contributor to mortality and disease burden worldwide and fewer than half of those with hypertension are aware of it. May Measurement Month (MMM) is a global campaign set up in 2017, to raise awareness of high BP and as a pragmatic solution to a lack of formal screening worldwide. The 2018 campaign was expanded, aiming to include more participants and countries. Methods and results Eighty-nine countries participated in MMM 2018. Volunteers (≥18 years) were recruited through opportunistic sampling at a variety of screening sites. Each participant had three BP measurements and completed a questionnaire on demographic, lifestyle, and environmental factors. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or taking antihypertensive medication. In total, 74.9% of screenees provided three BP readings. Multiple imputation using chained equations was used to impute missing readings. 1 504 963 individuals (mean age 45.3 years; 52.4% female) were screened. After multiple imputation, 502 079 (33.4%) individuals had hypertension, of whom 59.5% were aware of their diagnosis and 55.3% were taking antihypertensive medication. Of those on medication, 60.0% were controlled and of all hypertensives, 33.2% were controlled. We detected 224 285 individuals with untreated hypertension and 111 214 individuals with inadequately treated (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) hypertension. Conclusion May Measurement Month expanded significantly compared with 2017, including more participants in more countries. The campaign identified over 335 000 adults with untreated or inadequately treated hypertension. In the absence of systematic screening programmes, MMM was effective at raising awareness at least among these individuals at risk

Declining trend of tobacco use in a rural community of Bangladesh, 2006-2013

Background Tobacco use in Bangladesh especially in rural area has been high, but report on its trend is lacking. The aim of this study was to examine tobacco use trend in a rural area of Bangladesh concomitant to a simple but persistent intervention. Methods The study was done in Ekhlaspur village located in Chandpur district that has about 1000 households. Four cross-sectional surveys between 2006 and 2013 were done among adults (aged 25 to 64 years) to assess the trend of tobacco use in this village. One adult per household was selected targeting 400 to 1000 randomly selected households. Concomitantly an intervention package has been ongoing that included yard meetings, facility based counselling tagged with clinical services, observance of no tobacco days, special lectures in schools, and engagement of community organizations and opinion leaders. Prevalence of tobacco use and their 95% confidence intervals (CI) were obtained. Linier trend analysis was done using Excel to examine the trend of tobacco use. Results Participants' mean age varied between 41 and 44 years in all four surveys. About half of them completed a five years of primary education. Six in 10 people at the beginning were found to use tobacco in any form in the village. A consistent decline in tobacco use has been observed from 62% (95% CI 57% to 68%) to in 2006 to 32% (24% to 41%) in 2013. The prevalence of smoking (from 35% to 14%) and smokeless tobacco (from 40% to 20%) showed a similar declining trend. Sex-specific results also showed similar trends (Figure 1). Conclusions Community interventions in a sustainable manner can control tobacco use in rural communities of Bangladesh. Similar interventions can be replicated all over the country using lower tier of health system, public or private

Keep it simple: designing a user-centred digital information system to support chronic disease management in low/middle-income countries

Objective Implement a user-centred digital health information system to facilitate rapidly and substantially increasing the number of patients treated for hypertension in low/middle-income countries.Methods User-centred design of Simple, an offline-first app for mobile devices to record patient clinical visits and a web-based dashboard to monitor programme performance.Results The Simple mobile application scaled rapidly over the past 4 years to reach more than 11 400 primary care facilities in four countries with over 3 million patients enrolled. Simple achieved median duration for new patient registration of 76 s (IQR 2 s) and follow-up visit entry of 13 s (IQR 1 s).Conclusions A fast, easy-to-use digital information system for hypertension programmes that accommodates healthcare worker time constraints by minimising data entry and focusing on key performance indicators can successfully reach scale in low-resource settings

Community health workers for non-communicable diseases prevention and control in Bangladesh: A qualitative study

Background: The increasing burden of Non-Communicable Diseases (NCDs) in Bangladesh underscores the importance of strengthening primary health care systems. In this study, we examined the barriers and facilitators to engaging Community Health Workers (CHWs) for NCDs prevention and control in Bangladesh. Methods: We used multipronged approaches, including a. Situation analyses using a literature review, key personnel and stakeholders’ consultative meetings, and exploratory studies. A grounded theory approach was used for qualitative data collection from health facilities across three districts in Bangladesh. We conducted in-depth interviews with CHWs (Health Inspector; Community Health Care Provider; Health Assistant and Health Supervisor) (n = 4); key informant interviews with central level health policymakers/ managers (n = 15) and focus group discussions with CHWs (4 FGDs; total n = 29). Participants in a stakeholder consultative meeting included members from the government (n = 4), non-government organisations (n = 2), private sector (n = 1) and universities (n = 2). Coding of the qualitative data and identification of themes from the transcripts were carried out and thematic approach was used for data analyses. Results: The CHWs in Bangladesh deliver a wide range of public health programs. They also provide several NCDs specific services, including screening, provisional diagnosis, and health education and counselling for common NCDs, dispensing basic medications, and referral to relevant health facilities. These services are being delivered from the sub-district health facility, community clinics and urban health clinics. The participants identified key challenges and barriers, which include lack of NCD specific guidelines, inadequate training, excessive workload, inadequate systems-level support, and lack of logistics supplies and drugs. Yet, the facilitating factors to engaging CHWs included government commitment and program priority, development of NCD related policies and strategies, establishment of NCD corners, community support systems, social recognition of health care staff and their motivation. Conclusion: Engaging CHWs has been a key driver to NCDs services delivery in Bangladesh. However, there is a need for building capacity of CHWs, maximizing CHWs engagement to NCD services delivery, facilitating systems-level support and strengthening partnerships with non-state sectors would be effective in prevention and control efforts of NCDs in Bangladesh

Use of community health workers to manage and prevent noncommunicable diseases: Policy options based on the findings of the COACH study

Rawal, LB ORCiD: 0000-0003-1106-0108Noncommunicable diseases (NCDs) have been increasing rapidly and are now the major cause of disease burden and deaths in the Asia Pacific region. This rising disease burden has challenged health systems in countries of the region and could hamper achievements of the Millennium Development Goals. This has raised concerns among policy-makers about the need to identify innovative approaches to control NCDs and meet the health needs of the public. Strengthening primary health care (PHC) services and the workforce to deliver such services has been considered as an option to address the growing need of services for NCDs. Community health workers (CHWs) have increasingly been recognized as a frontline health-care workforce to support government actions to combat NCDs. However, the role of CHWs within the PHC system is not well defined. To provide policy-makers with a package of options to engage CHWs in NCD care, this policy brief summarizes CHW-led programmes, describes challenges to integrating CHW-led NCD programmes and make recommendations. The development of this policy brief was based on experiences in four countries of the region – Bangladesh, China, Nepal and Viet Nam. However, it is worth emphasizing from the outset that our study is not designed to be representative of the four countries but exploratory in nature

Ecological and Human Health Risk Assessment of Heavy Metals in Cultured Shrimp and Aquaculture Sludge

Shrimp is one of the major export products in South Asian countries and also an eminent source of nutrition for humans. Hence, any negative effect of this industry may affect not only the country&rsquo;s economy but also human health. Therefore, in this study, we aimed to assess heavy metal contamination and associated human health risks in cultured shrimp (Penaeus monodon) and aquaculture sludge collected from three shrimp farms of the Cox&rsquo;s Bazar district, Bangladesh. The results showed that among the eight metals studied, Pb (17.75 &plusmn; 1.5 mg/kg) and Cu (9.43 &plusmn; 2.8 mg/kg) levels in all shrimp samples were higher than the recommended limit, whereas the concentrations of Cd (0.09 &plusmn; 0.03 mg/kg), Mn (4.83 &plusmn; 2.2 mg/kg), As (0.04 &plusmn; 0.02 mg/kg), Hg (0.02 &plusmn; 0.006 mg/kg), Zn (18.89 &plusmn; 2.9 mg/kg) and Cr (0.69 &plusmn; 0.6 mg/kg) were within the permissible level. The concentrations of Mn (1043.37 &plusmn; 59.8 mg/kg), Cr (30.38 &plusmn; 2.1 mg/kg), Zn (74.72 &plusmn; 1.13 mg/kg) and Cu (31.14 &plusmn; 1.4 mg/kg) in the sludge of all farms were higher than the recommended limit, whereas the concentrations of Pb (20.23 &plusmn; 1.9 mg/kg), Cd (0.09 &plusmn; 0.2 mg/kg), As (0.44 &plusmn; 0.34 mg/kg) and Hg (0.08 &plusmn; 0.02 mg/kg) in all sludge samples were lower than the threshold limits. However, the estimated daily intake (EDI), targeted hazard quotient (THQ) and hazard index (HI) assessed for potential human health risk implications suggested that Pb and Cr may pose non-carcinogenic health effects, although carcinogenic risks (CR) values were acceptable for consumers. However, the pollution load index (PLI) of the studied area was below 1, which indicates low deterioration of the area. Geoaccumulation index (Igeo) and contamination factor (CF) analyses revealed that study area is unpolluted and sludge is enriched with metals in the following order: Mn &gt; Zn &gt; Cu &gt; Cr &gt; Cd &gt; Hg &gt; Pb &gt; As