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Improving hygiene practices is considered to be the single most cost-effective means of reducing the global health burden of infectious diseases. Hygiene promotion and disease prevention interventions often portray and promote “hygiene” from a biomedical perspective, which may not be optimally effective for achieving their goal of changing people’s behaviors. This study aimed to educe the meaning of hygiene for the residents of a low-income community in Bangladesh and how that meaning shapes their personal hygiene practices. We conducted this study in the Tongi township in Dhaka, Bangladesh, from September 2014 to June 2016. The research team purposively selected 24 households. The team conducted day-long observations using the participant observation approach and in-depth interviews with specific members of the 24 households. The concept of “hygiene” had two separate meanings to the study participants: cleanliness and holiness. The participants reported that cleanliness was required to remove odors, grease, hot spices and dirt. The motivation for cleanliness was to feel fresh, avoid heavy feelings, feel light and feel comfortable. To maintain the holiness of the body, bathing and ablution needed to be performed following particular religious rules/rituals. The motivation of holiness was derived from their accountability to God. The participants also reported that the cleansing processes and methods for the body and the home for cleanliness reasons were also different from those for holiness reasons. The notion of “hygiene” was multidimensional for the residents of the low-income urban community in Bangladesh. Our study participants did not explicitly conceptualize a notion of hygiene that was based on the germ theory of diseases but rather a notion that was based on individual physical comfort and cultural belief systems. Future studies on the prevention of hygiene-related diseases should combine and link the biomedical aspect to religious and cultural rituals to promote improved hygiene practices.

Objective: To present a systematic review of methods for measuring domestic water use in settings where water meters cannot be used. Methods: We systematically searched EMBASE, PubMed, Water Intelligence Online, Water Engineering and Development Center, IEEExplore, Scielo, and Science Direct databases for articles that reported methodologies for measuring water use at the household level where water metering infrastructure was absent or incomplete. A narrative review explored similarities and differences between the included studies and provide recommendations for future research in water use. Results: A total of 21 studies were included in the review. Methods ranged from single-day to 14-consecutive-day visits, and water use recall ranged from 12 h to 7 days. Data were collected using questionnaires, observations or both. Many studies only collected information on water that was carried into the household, and some failed to mention whether water was used outside the home. Water use in the selected studies was found to range from two to 113 l per capita per day. Conclusion: No standardised methods for measuring unmetered water use were found, which brings into question the validity and comparability of studies that have measured unmetered water use. In future studies, it will be essential to define all components that make up water use and determine how they will be measured. A pre-study that involves observations and direct measurements during water collection periods (these will have to be determined through questioning) should be used to determine optimal methods for obtaining water use information in a survey. Day-to-day and seasonal variation should be included. A study that investigates water use recall is warranted to further develop standardised methods to measure water use; in the meantime, water use recall should be limited to 24 h or fewer.

Bats are important wildlife to their ecologic system, but they are also a zoonotic disease reservoir. Close bat-human interaction can lead to pathogen spillover. We conducted a qualitative study in two districts of Bangladesh and interviewed 30 bat hunters who hunt bats primarily for consumption, to understand the process and their reasons for hunting bats and their perceptions about bats and bat-borne disease. Most hunters catch bats during winter nights, using a net. Bat meat is used for household consumption, and the surplus is sold to cover household expenditures. They prepare the bat meat at home to sell it in their own and in neighboring communities. They also sell live bats to traditional healers. They report that the bat population has declined compared with 5 or 10 years ago, a decline they attribute to hunting and deforestation. Many have heard of a disease from bat-contaminated date palm sap but do not believe that bats can spread such disease to humans. Close bat-human interaction reported in this study pose a risk of pathogen spillover. Conservation initiatives have the potential to reduce such interaction and so both reduce disease risk and support the ecology.

Objective We aimed to estimate the proportion of symptomatic and asymptomatic laboratory-confirmed COVID-19 cases among Bangladesh's population. Design We conducted a cross-sectional survey in Dhaka City and other districts of Bangladesh between April 18 and October 12, 2020. We randomly selected 32 districts outside Dhaka, where one village and one mahalla from each district, and from Dhaka City, selected 25 mahallas. From each village or mahalla, we enrolled 120 households through systematic random sampling. Results A total of 44,865 individuals were interviewed from 10,907 households. The majority (70%, n-31488) of the individuals were 4 members in their households. We estimated, 12.6% (n=160) of the households had ≥1 COVID-19 infected individuals, among them, 0.9% (n=404) individuals had at least one COVID-19 like symptom at the national level. Prevalence of COVID-19 was 6.4% among the general population. Among the COVID-19 positive individuals, 87% were asymptomatic. Conclusions The substantial high number of asymptomatic cases all over Bangladesh suggests that community-level containment and mitigation measures to combat COVID-19. Future studies to understand the transmission capability could help to define mitigation and control measures.

To date, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has infected over 80 million people globally. We report a case series of five clinically and laboratory confirmed COVID-19 patients from Bangladesh who suffered a second episode of COVID-19 illness after 70 symptom-free days. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), is a leading public health research institution in South Asia. icddr, b staff were actively tested, treated and followed-up for COVID-19 by an experienced team of clinicians, epidemiologists, and virologists. From 21 March to 30 September 2020, 1370 icddr,b employees working at either the Dhaka (urban) or Matlab (rural) clinical sites were tested for COVID-19. In total, 522 (38%) were positive, 38% from urban Dhaka (483/1261) and 36% from the rural clinical site Matlab (39/109). Five patients (60% male with a mean age of 41 years) had real-time reverse transcription-polymerase chain reaction (rRT-PCR) diagnosed recurrence (reinfection) of SARS-CoV-2. All had mild symptoms except for one who was hospitalized. Though all cases reported fair risk perceptions towards COVID-19, all had potential exposure sources for reinfection. After a second course of treatment and home isolation, all patients fully recovered. Our findings suggest the need for COVID-19 vaccination and continuing other preventive measures to further mitigate the pandemic. An optimal post-recovery follow-up strategy to allow the safe return of COVID-19 patients to the workforce may be considered.

In Bangladesh, highly pathogenic avian influenza H5N1 is endemic in poultry. This study aimed to understand the biosecurity conditions and farmers' perception of avian influenza biosecurity in Bangladeshi small commercial chicken farms. During 2011-2012, we conducted observations, in-depth interviews and group discussions with poultry farmers in 16 farms and in-depth interviews with seven local feed vendors from two districts. None of the farms were completely segregated from people, backyard poultry, other animals, households, other poultry farms or large trees. Wild birds and rodents accessed the farms for poultry feed. Farmers usually did not allow the buyers to bring egg trays inside their sheds. Spraying disinfectant in the shed and removing feces were the only regular cleaning and disinfection activities observed. All farmers sold or used untreated feces as fish feed or fertilizer. Farmers were more concerned about Newcastle disease and infectious bursal disease than about avian influenza. Farmers' understanding about biosecurity and avian influenza was influenced by local vendors. While we seldom observed flock segregation, some farmers used measures that involved additional cost or effort to protect their flocks. These farmers could be motivated by interventions to protect their investment from diseases they consider harmful. Future interventions could explore the feasibility and effectiveness of low-cost alternative biosecurity measures.

Highly pathogenic avian influenza (HPAI) has been a public health threat in Bangladesh since the first reported outbreak in poultry in 2007. The country has undertaken numerous efforts to detect, track, and combat avian influenza viruses (AIVs). The predominant genotype of the H5N1 viruses is clade 2.3.2.1a. The persistent changing of clades of the circulating H5N1 strains suggests probable mutations that might have been occurring over time. Surveillance has provided evidence that the virus has persistently prevailed in all sectors and caused discontinuous infections. The presence of AIV in live bird markets has been detected persistently. Weak biosecurity in the poultry sector is linked with resource limitation, low risk perception, and short-term sporadic interventions. Controlling avian influenza necessitates a concerted multi-sector ‘One Health’ approach that includes the government and key stakeholders.

Background In March 2011, a multidisciplinary team investigated 2 human cases of highly pathogenic avian influenza A(H5N1) virus infection, detected through population-based active surveillance for influenza in Bangladesh, to assess transmission and contain further spread. Methods We collected clinical and exposure history of the case patients and monitored persons coming within 1 m of a case patient during their infectious period. Nasopharyngeal wash specimens from case patients and contacts were tested with real-time reverse-transcription polymerase chain reaction, and virus culture and isolates were characterized. Serum samples were tested with microneutralization and hemagglutination inhibition assays. We tested poultry, wild bird, and environmental samples from case patient households and surrounding areas for influenza viruses. Results Two previously healthy case patients, aged 13 and 31 months, had influenzalike illness and fully recovered. They had contact with poultry 7 and 10 days before illness onset, respectively. None of their 57 contacts were subsequently ill. Clade 2.2.2.1 highly pathogenic avian influenza H5N1 viruses were isolated from the case patients and from chicken fecal samples collected at the live bird markets near the patients' dwellings. Conclusion Identification of H5N1 cases through population-based surveillance suggests possible additional undetected cases throughout Bangladesh and highlights the importance of surveillance for mild respiratory illness among populations frequently exposed to infected poultry.

Background Family caregivers are integral to patient care in Bangladeshi public hospitals. This study explored family caregivers' activities and their perceptions and practices related to disease transmission and prevention in public hospitals. Methods Trained qualitative researchers conducted a total of 48 hours of observation in 3 public tertiary care hospitals and 12 in-depth interviews with family caregivers. Results Family caregivers provided care 24 hours a day, including bedside nursing, cleaning care, and psychologic support. During observations, family members provided 2,065 episodes of care giving, 75% (1,544) of which involved close contact with patients. We observed family caregivers washing their hands with soap on only 4 occasions. The majority of respondents said diseases are transmitted through physical contact with surfaces and objects that have been contaminated with patient secretions and excretions, and avoiding contact with these contaminated objects would help prevent disease. Conclusion Family caregivers are at risk for hospital-acquired infection from their repeated exposure to infectious agents combined with their inadequate hand hygiene and knowledge about disease transmission. Future research should explore potential strategies to improve family caregivers' knowledge about disease transmission and reduce family caregiver exposures, which may be accomplished by improving care provided by health care workers.

Slaughtering sick poultry is a risk factor for human infection with highly pathogenic avian influenza and is a common practice in Bangladesh. This paper describes human exposures to poultry during slaughtering process and the customs and rituals influencing these practices in two Bangladeshi rural communities. In 2009, we conducted 30 observations to observe slaughtering practices and 110 in-depth and short interviews and 36 group discussions to explore reasons behind those practices. The villagers reported slaughtering 103 poultry, including 20 sick poultry during 2 months. During different stages of slaughtering, humans, the environment, healthy poultry, and other animals were exposed to poultry blood and body parts. Women performed most of the slaughtering tasks, including evisceration. Defeathering required the most time and involved several persons. During festivals, ceremonies, and rituals, many people gathered and participated in the slaughtering of poultry. Exposure to poultry slaughtering created numerous opportunities for potential avian influenza transmission. Strategies that can be further tested to determine if they reduce the risk of transmission include skinning the carcasses of sick poultry, using hot water for defeathering and cleaning, using a bucket to contain slaughtering blood and carcass, burying the offal and encouraging handwashing.

Objective To explore child defecation and faeces management practices in rural Bangladesh with the aim to redesign and pilot a tool to facilitate removal and disposal of faeces. Methods We conducted six group discussions, six short interviews and three observations of practices and designed the new tool. We piloted the new tool and elicited feedback through two in-depth interviews and two observations. Results Until three years of age, a child commonly defecates in the courtyard and occasionally inside the house. A heavy digging hoe was commonly used to remove child faeces. Mothers preferred a redesigned ‘mini-hoe’ and found it easier to use for removal and disposal of liquid faeces. Conclusions Promoting modified local tools may contribute to improving environmental sanitation and health. Objectif Explorer les pratiques de defecation des enfants et les efforts pour l'enlevement et l’elimination des excrements, en zone rurale au Bangladesh, dans le but de developper et appliquer un outil pour faciliter ce processus. Methodes Nous avons mene 6 discussions de groupe, 6 courtes interviews, 3 observations de pratiques et avons concu le nouvel outil. Nous avons applique ce nouvel outil et suscite des commentaires a travers 2 interviews en profondeur et 2 observations. Resultats Jusqu’a trois ans, un enfant defeque souvent dans la cour et parfois a l'interieur de la maison. Une houe a creuser etait couramment utilisee pour enlever les selles de l'enfant. Les meres ont prefere une version remaniee «mini-houe» et l'ont trouvee plus facile a utiliser pour l'enlevement et l’elimination des selles liquides. Conclusions Promouvoir des outils locaux modifies peut contribuer a l'amelioration de l'assainissement de l'environnement et de la sante. Objetivo Explorar las practicas de defecacion de los ninos, asi como los esfuerzos para retirarlas y desecharlos en zonas rurales de Bangladesh, con el objetivo de desarrollar y adaptar una herramienta que facilitase el proceso. Metodos Hemos realizado 6 discusiones en grupo, 6 entrevistas cortas, 3 observaciones de practicas y el diseno de una nueva herramienta. Hemos probado la nueva herramienta y obtenido informacion de los usuarios mediante 2 entrevistas en profundidad y 2 observaciones. Resultados Hasta los tres anos de edad por lo general un nino defeca en el jardin, y ocasionalmente dentro de la casa. Comunmente se utilizaba una azada grande y pesada para remover las heces del nino. Las madres preferian utilizar una “pequena azada” redisenada, la cual encontraron que era mas facil de utilizar para remover y deshacerse de las heces liquidas. Conclusiones Promover herramientas locales modificadas puede contribuir a mejorar la sanidad ambiental y la salud.

Introduction Backyard poultry raising is common in rural communities and a valued resource that provides food and income for subsistence farmers. Close contact with infected backyard poultry has been associated with H5N1 human cases in different countries. The emergence of this virus within Bangladesh means that backyard poultry raisers are at risk of avian influenza infections. The aim of this study was to understand why people raise backyard poultry and to characterize people's regular interaction with their poultry. Methods In 2008, a qualitative study was conducted in two villages from two districts of Bangladesh. In a social mapping exercise the villagers drew all the households in their village: 115 households in the village in Netrokona and 85 households in the village in Rajshahi District. Selected were 40 households (20 households from each of the two villages) for data collection through in-depth interviews (n=40) and household mapping (n=40), and observation sessions (n=16). Results In both villages, 92% of households raised backyard poultry. The majority of the owners was female and used the money earned from poultry raising to purchase cooking ingredients, clothing, and agricultural seeds, and pay for children's education expenses. The households consumed poultry meat and eggs. In the village in Netrokona, 80% (85/106) of households kept poultry inside the bedroom. In the village in Rajshahi, 87% (68/78) of households had separate cage/night sheds. During feeding the poultry and cleaning the poultry raising areas, villagers came into contact with poultry and poultry feces. Poultry scavenged for food on the floor, bed, in the food pot and around the place where food was cooked. Poultry drank from and bathed in the same body of water that villagers used for bathing and washing utensils and clothes. Conclusion Although raising poultry provides essential support to the families' livelihoods, it exposes them to the risk of avian influenza through close contact with their poultry. Simple warnings to avoid poultry contact are unlikely to change practices that are essential to household survival. Interventions that help to protect poultry flocks and improve household profitability are more likely to be practiced.

Introduction: Highly pathogenic avian influenza (H5N1) virus (known as "bird flu") is an important public health concern due to its potential to infect humans and cause a human pandemic. Bangladesh is a high-risk country for an influenza pandemic because of its dense human population, widespread backyard poultry raising, and endemic H5N1 infection in poultry. Understanding poultry raisers' perceived risks and identifying their risk exposures can help to develop interventions to reduce the risk of avian influenza transmission. This paper explores the perception of Bangladeshi backyard poultry raisers regarding poultry sickness and zoonotic disease transmission and relevant practices. Methodology: We conducted a qualitative study using social mapping (n=2), in-depth interviews (n=40), household mapping (n=40) and observation (n=16), in two backyard poultry-raising communities. Results: The poultry raisers recognized various signs of poultry illness but they did not distinguish among diseases using biomedical classifications. They perceived disease transmission from poultry to poultry, but not from poultry to humans. They usually kept sick poultry under the bed. If the poultry did not recover, they were slaughtered and consumed or sold. The poultry raisers had close contact with sick birds while handling and slaughtering poultry. Conclusions: The poultry raisers are unlikely to follow instructions from health authorities to prevent "bird flu" transmission because many of the instructions ask low-income producers to change their existing practices and require time, money, and financial loss. Villagers are more likely to comply with interventions that help to protect their flocks and address their financial interest.

This paper reports on evaluation of an initiative to use paramedics as the first-level mental health counsellors of abused women in rural Bangladesh (2003–2004) from the perspective of the abused women who participated in one or more counselling sessions. Thirty in-depth interviews, followed by a survey (n=372), targeted to cover all participants, were conducted in 2006. Overall, the arrangement, management of ethical issues, and skills of paramedics were rated favourably. Most (89%) abused women (n=372) considered the session useful; one-fourth of these women considered it very useful; and only a few abused women considered the session useless. Usefulness of the session was expressed mostly in terms of relief attained after talking about the issue. Most (87%) women reported being encouraged to be self-confident. In a context characterized by low self-confidence of women, lack of opportunity to talk about violence, and absence of professional mental health counselling services, this initiative is sufficiently promising to warrant further testing.