key: cord- -vaikav m authors: ferdous, m. z.; islam, u. s. title: universal health coverage and covid- pandemic: a bangladesh perspective date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vaikav m background: like many other countries around the world, bangladesh adopts universal health coverage (uhc) as a national aspiration. the central theme of its providing quality and affordable health services which is a significant element of social protection. this paper was aimed to provide a narrative understanding of the perspectives of uhc in bangladesh towards covid- based on the existing literature. methods: we conducted a review combining articles and abstracts with full html and pdf format. we searched google scholar, sciencedirect and google using multiple terms related to uhc, covid- and bangladesh without any date boundary and without any basis of types of studies, that is, all types of studies were scrutinized. results: this short description highlights that the current pandemic covid- holds lessons that health systems and economies in several countries like bangladesh are not in enough preparation to tackle a massive public health crisis. it reports the shortage of health workers, scarcity of personal protective equipment, limited and ineffective diagnostic facilities, inadequate infrastructure of health care facilities, scarcity of drugs, and underfunded health services. further, covid- pandemic highlights the country's health system needs an ongoing rehab post-covid- with strong coordination in governance, in health economics, in health systems, in information systems, as well as in community participation in health to achieve uhc. conclusions: addressing the needs for uhc achievement, it is important to break down the access barriers and keeping up to date all the activities addressing public health crisis like covid- . rehabilitation when and where appropriate without financial hardship among the user (who, a) .approximately half of the people across the globe are deprived from health services they need including million are pushed below poverty line every year because of out of pocket payment on their health [ ] . in , the nations of the world set uhc as one of the target under goal when adopting sustainable development goals. by achieving uhc countries can achieve progress towards other health-related targets including other goals since sound health allows children to learn, adults to earn, helps to reduce poverty, and strengthen economic development [ ] .therefore, all countries has given their consent towards achieving uhc as part of the agenda except bangladesh. according to the commitment of the prime minister of bangladesh in the th world health assembly held in may , the country committed to gain uhc by [ ] . less than % of the total population has a health coverage scheme against health expenditure including . % is pushed into poverty line for paying health services each year. though bangladesh has achieved significant progress over the last decades, % health expenditure is still come from out of pocket. as a result it is experiencing the highest expenditure ( %) compared to neighboring country india ( % to %) and thailand ( %) [ ] . the recent covid- is an ongoing global public health crisis according to who declaration on th january, which was first emerged at wuhan city of china [ ] , [ ] . in bangladesh, institute of epidemiology, disease control and research (iedcr) declared the first confirmed cases on th march, [ ] . after that country has taken numerous control measures fighting against covid- though these available control measures are significantly influenced by the knowledge, attitudes, and practices (kap) towards covid- [ ] . however, adoption of control measures, the country is facing frequent problem like economic and social standstill and among them health sector is the most affected sector by the pandemic [ ] . as of th november, bangladesh confirmed , cases with . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint deaths and , recovery [ ]. this study aims to assess the impact of covid- in bangladesh and lesson learned towards achieving uhc by . we reviewed the literature (pubmed, google scholar, sciencedirect, google and online newspapers in bangladesh) to get recent information on uhc, uhc and covid- in bangladesh. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint public health emergency leads any country in a danger if it beyond under control. likewise, recently declared public health emergency covid- affected more than countries and territories with , , confirmed cases and , , deaths as of th november, around the world. it has shown the critical need for the preparedness during a disaster to the world. preparation is the fundamental tool for mitigating the impact of any catastrophe and covid- taught the world a great lesson by showing its severity. when many countries are struggling to provide uhc to its community, a new emerging public health problem such as covid- pose a global threat and continue to rise and spread its impact on people in many ways like physically, mentally, economically, and so on. extended health emergencies due to the pandemic of covid- the supply sides (like health systems) went under an enormous pressure. the aftermath has a significant impact on the vulnerable population by lacking social protection and access to health care services in their normal life [ ] . the lancet global health commission addressed poor quality care is now a bigger barrier to reducing mortality than insufficient access. it estimates approximately % of deaths from conditions amenable to health care are due to poor quality care, whereas the remaining deaths result from non-utilization of the health system [ ] . this situation more is dreadful for vulnerable groups including the poor, the less educated, adolescents, those with stigmatized conditions, and those at the edges of health systems, such as people in prison [ ] . compared to other south asian countries, bangladesh has one of the best government health infrastructure including upazila health complex, union sub centers, satellite clinics, secondary, and tertiary care hospitals. yet the country is facing lack of skilled health care professionals particularly in rural areas, scarcity of health care resources, financial constraints. most of the time patients have to pay all cost related to health service from their pocket which leads to poor people become poorer and even rich are also facing hardship with is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the costly treatment procedure [ ] . during covid- pandemic the country has a severe scarcity of testing kits in stocks and only some , have been distributed to other parts testing laboratories around the country [ ] , [ ] . however, china provide some testing kits, masks, infrared thermometers, and ppe to deal with the crisis but this amount only covers a small proportion needs [ ] . approximately, . million slum dwellers living in extremely close quarters are hardly conscious about the threat of covid- and most of them passed their life with great difficulty by losing jobs due to pandemic crisis. these families have less facilities of bathroom, toilet with scarcity of water. therefore, maintaining hygiene is a challenge to them. the same situation goes for rohingya refugees, who fled in bangladesh from neighboring country myanmar in , leading to vulnerable health condition among these population and increase more chance to illness [ ] [ ] [ ] . since there is scarcity of ppe (personal protective equipment), testing facilities most of the health workers which is not sufficient compared to large population refused to provide service with this crisis due to fear of infection [ ] . according to a study conducted in gazipur upazila, e-health care have dropped % due to absence of doctors, % being deprived of basic human needs, % pregnant women missed their regular anc check-ups, % female faced familial complications, and expanded program on immunization (epi) has also dropped during pandemic [ ] . as a result, shortage of health workers, scarcity of personal protective equipment, inadequate infrastructure of health care facilities, scarcity of drugs, and underfunded health services has revealed more clearly during this pandemic that shows a consistent impediment to achieve uhc in bangladesh. in addition relocating medical staff to emergency site from previous department increase scarcity of service delivery in those site like non-communicable diseases, hiv, tuberculosis, mental health, maternal and child health, increased unwanted pregnancy, malaria, and diphtheria [ ] . furthermore, in this is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint critical time, smart planning with sufficient preparation for mitigating the incidence and prevalence of disease including designing the future prospect is very important to achieve uhc [ ] . because evidence on the management approaches of current covid- pandemic is still limited though the numbers of affected countries are increasing as the days go by [ ] . however, to achieve uhc in bangladesh should include development of a long term national human resources policy and action plan considering the emerging and re-emerging health risks, establishment of a national insurance system, building of an interoperable electronic health information system and investment to strengthen the capacity of the ministry of health. health is a fundamental human right, and uhc is a key to achieve health for all. addressing the needs for uhc achievement, it is important to break down the access barriers by removing financial, geographical and cultural barriers in a sustained way that reduce the out of pocket expenditure among bangladeshi people. additionally, covid- pandemic focused the necessity of healthy economy by controlling the pandemic effectively with sustainable solution measures. as a lower middle income country, bangladesh has limited resources in health sectors which needed rapid reforms of resources for achieving uhc by . hence, by developing the need basis stronger and resilient health infrastructure the country will be able to provide timely response during any health crisis including better protection against future outbreak control with access to needed health care excluding financial burden. the authors declare no competing interests. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint universal health coverage universal health coverage (uhc) building awareness on universal health coverage: advancing the agenda in bangladesh universal health coverage in bangladesh: the challenges immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china coronavirus disease (covid- ) update," world health organization the impact of covid- pandemic on mental health & wellbeing among homequarantined bangladeshi students: a cross-sectional pilot study knowledge, attitude, and practice regarding covid- outbreak in bangladesh: an online-based cross-sectional study bangladesh: rapid assessment findings on covid- effects on urban health -bangladesh | reliefweb bangladesh coronavirus: , cases and , deaths -worldometer towards universal health . cc-by-nc-nd . international license coverage: lessons learnt from the covid- pandemic in africa the lancet global health commission on high quality health systems year on: progress on a global imperative crossing the quality chasm_ nigeria's long walk to universal health coverage -the center for policy impact in global health covid- : immediate expansion of testing labs to districts needed | dhaka tribune govt now scrambles for testing kits, ppe | the daily star china to give bangladesh testing kits, protective gears socio-economic and health status of slum dwellers of the kalyanpur slum in dhaka city water and sanitation in dhaka slums : access, quality, and informality in service provision coronavirus fear grips rohingya camps in bangladesh covid- and bangladesh: challenges and how to address them rapid needs assessment covid- impacts on urban health in bangladesh -care | evaluations it is made available under a perpetuity.is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprintthe copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a perpetuity.is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprintthe copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprintthe copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint key: cord- -qr xynn authors: uzzaman, md. nazim; jackson, tracy; uddin, aftab; rowa-dewar, neneh; chisti, mohammod jobayer; habib, g m monsur; pinnock, hilary title: continuing professional education for general practitioners on chronic obstructive pulmonary disease: feasibility of a blended learning approach in bangladesh date: - - journal: bmc fam pract doi: . /s - - - sha: doc_id: cord_uid: qr xynn background: continuing medical education (cme) is essential to developing and maintaining high quality primary care. traditionally, cme is delivered face-to-face, but due to geographical distances, and pressure of work in bangladesh, general practitioners (gps) are unable to relocate for several days to attend training. using chronic obstructive pulmonary disease (copd) as an exemplar, we aimed to assess the feasibility of blended learning (combination of face-to-face and online) for gps, and explore trainees’ and trainers’ perspectives towards the blended learning approach. methods: we used a mixed-methods design. we trained gps in two groups via blended (n = ) and traditional face-to-face approach (n = ) and assessed their post-course knowledge and skills. the copd physician practice assessment questionnaire (copd-ppaq) was administered before and one-month post-course. verbatim transcriptions of focus group discussions with course attendees and interviews with three course trainers were translated into english and analysed thematically. results: forty gps completed the course (blended: ; traditional: ). the knowledge and skills post course, and the improvement in self-reported adherence to copd guidelines was similar in both groups. most participants preferred blended learning as it was more convenient than taking time out of their busy work life, and for many the online learning optimised the benefits of the subsequent face-to-face sessions. suggested improvements included online interactivity with tutors, improved user friendliness of the e-learning platform, and timing face-to-face classes over weekends to avoid time-out of practice. conclusions: quality improvement requires a multifaceted approach, but adequate knowledge and skills are core components. blended learning is feasible and, with a few caveats, is an acceptable option to gps in bangladesh. this is timely, given that online learning with limited face-to-face contact is likely to become the norm in the on-going covid- pandemic. provision of postgraduate training in family medicine is increasing in asia pacific, but rarely uses innovative online learning [ ] that could enhance access to continuing medical education (cme) essential for building and maintaining a high-quality primary care workforce [ ] . traditionally in bangladesh, post-graduate training involves face-to-face study, but shortage of physicians in many rural and semi-urban areas [ ] , mean that physicians often cannot leave their practices to attend several days of training. blended learning is a combination of face-to-face and online learning [ ] , which has become possible in bangladesh with recent substantial improvements in internet coverage, and may be a useful way to achieve cme [ ] . chronic obstructive pulmonary disease (copd) is an exemplar of a condition in which there are concerns that limited awareness of guideline recommendations amongst general practitioners (gps) [ , ] leads to misdiagnosis and inappropriate management [ , ] . copd affects an estimated million people worldwide [ ] and globally, is predicted to be the third leading cause of death by [ ] . although copd burden varies between countries, almost % of copd deaths occur in low-and middleincome countries (lmics) [ ] . the national copd guideline [ ] is not widely used in bangladesh. some clinicians follow global guidelines [ ] , however, substantial gaps exist between guideline recommendations and gps' practice. closing this gap is a priority research need for the international primary care respiratory group (ipcrg) [ ] . blended learning was introduced initially in undergraduate teaching [ ] [ ] [ ] [ ] and is now extending to postgraduate learning [ ] , though the concept is relatively new in bangladesh [ ] . an online component allows practitioners increased time and flexibility for study, wider and easier access to learning resources, and a higher level of autonomy in learning than in exclusively face-to-face courses [ , ] . management of copd requires acquisition of practical skills (spirometry; inhaler technique) necessitating a face-to-face component. therefore, we aimed to assess the feasibility of a blended learning approach to a copd cme course for gps in bangladesh. our mixed-methods feasibility study was conducted in june to august . quantitative data measured pre-post self-assessment of adherence to copd guidelines and qualitative focus groups and interviews explored trainee and trainers' perspectives of the blended learning. gps providing public and private primary healthcare services in bangladesh were invited to participate. gps in bangladesh have an mbbs (bachelor of medicine and surgery) are registered by the bangladesh medical and dental council, have at least two years' experience of clinical service but with no specialist post-graduate training. we excluded gps who had previously participated in post-graduate copd training at any time. the copd course, which was provided free of charge, was advertised nationally through the training management portal of the international centre for diarrhoeal disease research, bangladesh (icddr,b), and social media was used to disseminate the course advertisement. potential participants applied through the icddr,b portal. we screened applicants for eligibility, randomly selected participants who were randomly allocated (using a computer generated randomisation list) to either blended learning or the traditional face-to-face course. this was a feasibility study, so no sample size calculation was required [ , ] . resource availability allowed us to run two courses, so we allocated participants to each group. this is our normal group size, and is a sufficient sample size for assessing feasibility [ ] . the total training hours was h in both blended and traditional learning approaches and the courses contained the same content: components aimed at enhancing copd knowledge ( h) and skills ( h). a private facebook group was created to provide online learning support for both groups monitored by a tutor and for peer discussion. the tutors were gps with expertise in respiratory care and had considerable experience of delivering training. the learning approaches are summarised in table with further details in additional file . to assess how the training impacted on participants' practice and adherence to copd guidelines, the copd physician practice assessment questionnaire (copd-ppaq) was administered to all participants prior to starting training and after course completion. due to fellowship time restrictions, the copd-ppaq was administered only month after the course completed. this validated questionnaire is designed for the selfassessment by physicians of their implementation of key items (two domains: diagnosis and assessment; treatment and follow-up) of copd guidelines. the answers are globally reproducible [ ] . in line with the usual assessment on completion of icddr,b courses, skills were assessed by an oral examination and knowledge was assessed using a written multiple-choice questionnaire examination. following completion of training, all participants were examined on their copd knowledge and skills. from previous experience we anticipated that knowledge of copd and spirometry skills of gps with no prior copd training would be very low; we therefore did not assess this pretraining. all participants who completed the blended learning training were invited to participate in one of three focus groups facilitated by mnu supported by a note-taker. discussion addressed participants' perceptions of blended learning, preferences compared to previous experiences of face-to-face or online learning, advantages/ disadvantages of the blended learning. the three course trainers were interviewed individually to explore their views and opinions about the practicalities of delivering training using this approach (see additional file ). all discussions were digitally recorded and transcribed verbatim in the spoken language (bengali). the emotional context such as pauses, laughter, emphasis and non-verbal communication were included as notes in the transcripts to aid analysis. transcripts were translated (by mnu who led the focus groups) from bengali to english for analysis. examination scores, and copd-ppaq scores are expressed as percentages. summary statistics were calculated as means, proportions as necessary. stata statistical software (statacorp lp, college station, texas, usa) was used for data analysis. we used thematic analysis for the qualitative data [ ] using a coding framework developed by mnu in discussion with the other authors. the focus group discussions with trainees and interviews with trainers were analysed separately. this involved coding the whole data set and the codes were then synthesised into emerging themes which were combined into overarching themes including synthesised data from participants and tutors. the first author is a gp, employed by icddr,b, to deliver cme to healthcare professionals. he was involved in developing the learning materials, and facilitating training sessions which might have influenced the interviews/ focus groups and his interpretation of the data. to mitigate against this, themes were discussed within the multi-disciplinary author group. we received a total of online applications which were screened for eligibility. the commonest reasons for ineligibility were less than the minimum two years of clinical service (n = ), and already having specialised post-graduate training (n = ). did not provide complete information (eg. no qualification dates or experience) leaving eligible applicants. we randomly selected participants and allocated to each group. of the allocated participants, ( %) completed blended learning and ( %) traditional learning. the commonest reason for withdrawal in both groups was inability to take time out of practice. other reasons were illness, domestic or family responsibilities. most of the gps ( %) were between to years and half had - years' experience of patient care. almost half the participants of both groups were used to consulting with or more patients daily (table ) . the quantitative results are presented with the caveat that this was a feasibility study which was not powered to show a difference. detailed outcomes are therefore placed in additional files and without any statistical comparisons to avoid over interpretation. the overall end-of-course examination scores was similar in both groups, both for overall knowledge, and for assessment of skills. gps self-reported adherence to copd guidelines using copd-ppaq showed similar improvement in both groups. the self-assessment of key recommendations suggested that participants in both groups scored substantially better in all aspects of their practice except in smoking cessation and referral to specialist. eighteen of the blended learning course attendees (trainees) who completed the training participated in one of the three focus groups. they were aged - years and from nine districts of bangladesh. the location of their workplaces varied from three to over km from the training venue. the number of participants from urban, semi-rural and rural areas were nine, five and four respectively ( table ) . all trainees had previous experience of attending traditional training, half had participated in entirely online training and six had previous experience of a blended learning approach. interviews were conducted with the three trainers who were between and years of age. no further details are provided to maintain confidentiality of trainers. three main themes emerged in the analysis of both focus group discussions with trainees and interviews with course trainers. the themes and sub-themes are listed in table and described below. this was echoed by the trainers who were positive about the online resources being available ' hoursanytime, anywhere'. in contrast, one trainee preferred the traditional approach because it enabled him to focus on the topic for the duration of the course, whereas online learning could too easily be postponed. he also considered that the traditional approach was better for practical demonstrations (e.g. cardio-pulmonary resuscitation). one of the course trainers preferred the traditional approach, although he recognised that it was difficult for busy gps to be away from their practice. almost all the trainees felt confident of their knowledge and skills in diagnosing and managing copd patients after completing the training. most wished to participate in future courses using a blended approach and said they would recommend it to others. one participant was sufficiently confident in his acquired knowledge and skills that he felt he would be able to disseminate what he had learnt to staff in his practice. in contrast, a few participants felt that they did not get enough time to perform spirometry manoeuvres during "during practical session i expected more to learn about spirometer (how to operate the machine). however, we didn't have the scope to learn spirometer, especially with real patient". (trainee, p ) theme ii: educational advantages and disadvantages advantages of blended learning reasons provided for preferring the blended learning approach were the convenience of not having to relocate and the option to do some of the training in their own time which fitted around their practice work. reducing their physical presence in class was considered very helpful as it caused minimal interruption to their patient care. this view was particularly apparent in accounts from doctors who worked in rural areas and remote places where learning opportunities are limited, and staff resource is at a critically low level. "those of us who live in remote areas; the blended approach is a blessing for us which would allow us to add to our knowledge deficit quite a lot. those who stay centrally, get many opportunities to attend scientific seminars, cme (continued medical education) etc which we couldn't manage". (trainee, p ) in the blended learning approach, participants learned online before they attended face-to-face classes when they could solve the queries that had arisen while using the online resources. "we got learning contents in advance and were able to go through online. we know in advance what we will learn tomorrow. we solved our queries that arose during online learning when we were in faceto-face classes." (trainee, p ) a few participants said that blended was more attractive and interactive compared to a traditional approach or only online training. two of the trainers mentioned that the blended approach offered two-way learning with scope for providing better student support compared to either traditional or entirely online training. most of the trainees did not mention any generic drawbacks of the blended-learning approach. instead they discussed the weakness of the particular e-learning module they had used, and highlighted a few areas of the face-to-face classes which needed improving. some trainees found reading online content uncomfortable, mentioning that they were more comfortable with familiar paper rather than online documents. specifically, excessive screen exposure caused eye pain and headache to one of the trainees. although most participants completed the online module, a few mentioned that they had neglected the online learning either deliberately thinking that they would learn it from the faceto-face classes or procrastinating and not quite getting round to doing it in their busy schedules. "because of having the face-to-face part, we often have neglected the online part thinking that we have face-to-face classes"! (trainee, p ) apart from sharing the concern about the discomfort of online reading, trainers had some additional concerns about blended learning. one trainer was concerned that the online component might be considered as an extra pressure by some trainees. another trainer thought that the three-week gap between the online and face-to-face learning might increase participant dropout from the course. in addition, one of the trainers noted that unreliable internet access in some locations might limit the usefulness of the blended approach in bangladesh. in addition, this trainer was concerned that many physicians were not accustomed to using computers and if they only completed the minimum face-to-face tasks it might affect skill development of the trainees. almost all participants (trainees and trainers) thought the elearning module needed further development, with suggestions about more videos, animation, and quizzes with analytical questions to make it more interactive and attractive. opinions were divided about whether the contents were 'somewhat disorganised'. some trainees suggested including the content of the subsequent face-to-face classes in the e-learning module so that learning was reinforced. "practical sessions like inhaler techniques may be given online which would help us to learn better as we may not learn the technique in one face-to-face class. in future, if we get confused, we can watch the video and make our technique correct". (trainee, p ) most of the trainees wanted prompt feedback via the online platform rather than having to use a separate facebook group for this purpose. facebook was associated with social communication during leisure time and not as an effective medium for solving professional queries. indeed, some people noted that it was a distraction which wasted a lot of time. moreover, participants had only met once during the orientation class, so some did not feel sufficiently familiar with each other to be able to engage proactively in online group discussions. from a practical perspective they had to open facebook separately alongside the e-learning module which they found burdensome and although delegates tried it at least once, only delegates engaged in discussion. "yes, we had a facebook group [for solving queries]. but to me, when i logged on it, a lot of time went away unknowingly." (trainee, p ) a few trainees said that provision of a tutor for a scheduled online discussion would be helpful to solve queries and this would allow more time for practical tasks during face-to-face classes. two of the trainers with previous experience of online discussions, agreed and considered that the online discussion could help trainees to engage and learn more. "the provision of online discussion would help participants to learn more. even participants could ask question online which they couldn't understand in face-to-face classes". (trainee, p ) in contrast, some trainees considered that a fixed time for an online discussion was unlikely to be convenient for everyone, and reduced the flexibility that was an advantage of the online learning. they suggested that face-to-face classes were a better option for solving their queries. "i don't think we can align our time with the online tutor". (trainee, p ) "since we had the opportunity of face-to-face classes, here we didn't have the need of online classes". (trainee, p ) other trainees suggested that the e-learning platform should have a discussion board where a mentor would give his/her feedback, and everyone could see answers and learn accordingly. "i'd say that the online platform itself should keep an option of asking question […] a coordinator will reply to our queries in a particular time of a day". (trainee, p ) the majority of the trainees encountered challenges reading the online contents; only two participants did not have any problems. there were difficulties reading documents in full screen, sometimes a chapter showed as 'incomplete' even though it had been completed. a few trainees with previous experience of online courses suggested that chapters should be completed in order to qualify for the chapter accomplishment quiz. one trainee wanted the option of a mobile-based application along with the provision of offline access to the contents that they completed earlier for rereading as necessary. "mobile based app could be introduced where we can even get access without having internet connection [smiling]". (trainee, p ) almost all trainees shared that the practical sessions should involve "patients", if only for a short period of time. the practical classes were mostly device oriented. since we will apply our knowledge on patients, i think the practical classes need to be real patient-based which will make the course much more effective". (trainee, p ) the majority of the trainees thought that face-to-face classes would be more convenient if they were delivered days apart, preferably during weekends, so they would not need to leave their practice during working days. we all are busy, or it is difficult to manage leave for two-three consecutive days for face-to-face training. classes could be taken seven days apart and during weekend". (trainee, p ) two of the participants wanted an honorarium for participating in the course while one participant strongly opposed this issue. "we have been provided with food during training. if you could provide us some honorarium, that would be very good. after a certain age, we have more financial liabilities." (trainee, p ) in contrast, one trainer was concerned about the nonattendance of some participants suggesting that a course fee should be paid by the participants to make them more responsible. "this time we found that few participants didn't complete the course although there were many applicants who were very interested to attend the course. […..] one of the reasons might be that the participants didn't have to pay the course fee of their own". (trainer, t ) of the trainees allocated to each group, completed blended learning and completed the traditional faceto-face learning. inability to take time-out of practice was the commonest reason for attrition in both groups. the gain in knowledge and skills by the participants in both groups was similar. in addition, self-reported adherence to copd guidelines before and after training revealed similar improvement in both groups. all participants, except one trainer and one trainee, preferred the blended learning approach as it was more convenient within their busy work schedules. although a few participants 'neglected' the online modules, for most the online learning optimised the benefits of the face-toface sessions. there were a number of practical problems with internet connections and finding it 'uncomfortable' to read on-screen documents and most participants suggested improving interactivity. online support from tutors was valued, but embedded in the learning platform rather than using facebook which was associated with social interaction. a strength of our mixed method design is that it allowed triangulation of results; for example, the participants' perception of increased confidence in managing copd was matched by measured gains in skills and knowledge. the quantitative data will inform potential outcomes for a future evaluation of blended learning on copd and the qualitative data gave insights into both positive and negative perspectives. moreover, the practical suggestions and operational challenges will be helpful in refining future training. the examiners were aware of the allocation of both groups which risked biasing the quantitative outcomes, but the same examiners assessed participants from both groups ensuring consistency of assessment. blinded assessment was not possible within the resources of the study. we were aware of the impact of reflexivity, as the researcher conducting the focus groups and interviews (mnu) was also involved with training coordination and development of learning materials. involvement of a multidisciplinary author group unconnected with icddr,b or the course helped ensure a balanced interpretation of the data. although we achieved data saturation with respect to the trainee opinions, the limited number of trainers meant we only heard three perspectives. our aim was to assess the feasibility of the blended learning intervention, and the single location (dhaka) of the course and the small numbers limit generalisable, though our findings may be applicable to others working in similar settings in bangladesh or beyond. studies show that blended learning allows greater flexibility and responsiveness in adult learning processes [ , , ] . the addition of online learning overcomes limitations of time and space, reaches more students and supports instructional methods that may be hard to achieve without increased resources [ ] . some studies have found a mismatch regarding preferred learning approaches where trainers assumed that technology-based learning suited the trainees' style; however, trainees felt differently [ ] . in our study, trainees and trainers almost all agreed that blended learning overcame two limitations compared to entirely online or traditional learning. first, the e-learning component reduced the need for prolonged time out of practice to attend a course, and second, the prior online work optimised the learning of skills in the face-to-face class. a previous study with gps also found e-learning a useful way to gain knowledge and the face-to-face component a suitable way of transferring practical knowledge [ ] . furthermore, some participants in our study suggested blended learning was cost-effective [ ] as a substantial number of doctors could be trained within a short period of time [ ] . in contrast, a few trainees found it difficult to adapt their learning styles to a blended approach [ ] . some felt that provision of paper versions of the e-learning module would be helpful as they were accustomed to reading paper books [ ] . flexibility is generally seen as a strength as e-learning allows participants to learn at a convenient time [ ] . in our study, it was also viewed as a challenge because some gps found it difficult to schedule study time. also, some neglected online study hoping to catch-up in the face-to-face sessions. trainers living at a distance found it less efficient to schedule face-to-face classes involving long travel time for shorter meetings. the lack of a blended learning approach to cme in lmics may be associated with limited technological resources [ ] . echoing other studies that have highlighted poor access to technology as a barrier to the implementation of technology-enhanced teaching [ ] , our participants described annoying technical problems such as losing information on progress, or the need to switch between pages. the use of social media (in particular facebook) was associated with social communication and considered an ineffective way of interacting with fellow participants and solving queries though other studies have successfully used this approach [ ] . like several other studies, some trainees and trainers considered that, for productive interaction, it is important that tutors actively moderate online discussions [ ] [ ] [ ] . more patient involvement in skills development was wanted, and contributing to online modules could be a convenient way to incorporate patients. the dropout of participants ( in in our study) was another challenge. an outbreak of dengue fever in bangladesh was one factor and cultural context is also important. in lmics like bangladesh, food and honorarium are two important issues that need to be considered when developing education. government employees typically expect to receive an honorarium when they participate in any training. provision of accessible cme is central to maintaining the quality of primary healthcare and the morale of the workforce [ ] . in the context of copd, where underdiagnosis and inadequate management is common [ ] [ ] [ ] , our blended-learning course was a feasible approach to enhancing knowledge and skills of gps about copd. the observation by some of the participants that they were sufficiently confident in their learning to be able to pass on the knowledge to others in their practices is encouraging but needs further evaluation. 'train the trainer' programmes have been used successfully by the international primary care respiratory group [ ] , and blended learning offers the potential for online modules to be used to pass on knowledge. the flexible and practical blending of online and face-to-face learning has the potential to be used for cme of other long-term conditions in bangladesh and beyond. with some caveats, blended learning was an acceptable educational model and preferred by most of the busy gps in bangladesh. quality improvement requires a multifaceted approach, but adequate knowledge and skills are a core component; blended learning is a feasible option which could contribute to improved implementation of guideline recommendations. online cme was a novel approach in our lmic setting, but learning with limited face-to-face contact is likely to become the norm in the current covid- pandemic making this a timely message. received: june accepted: september the status of family medicine training programs in the asia pacific family medicine vocational training and career satisfaction in hong kong the health workforce crisis in bangladesh: shortage, inappropriate skill-mix and inequitable distribution blended learning: the convergence of online and face-to-face education. promising practices in online learning. north american council for online learning perceptions toward a pilot project on blended learning in malaysian family medicine postgraduate training: a qualitative study copd patients need more information about self-management: a cross-sectional study in swedish primary care copd management in primary care: is an educational plan for gps useful? diagnosing copd in primary care: what has real life practice got to do with guidelines? under-and over-diagnosis of copd: a global perspective chronic obstructive pulmonary disease (copd): key facts projections of global mortality and burden of disease from to national guidelines: asthma, bronichiolitis, and copd global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease the international primary care respiratory group (ipcrg) research needs statement teaching differential diagnosis in primary care using an inverted classroom approach: student satisfaction and gain in skills and knowledge improving education in primary care: development of an online curriculum using the blended learning model a blended learning approach to teaching basic pharmacokinetics and the significance of face-to-face interaction student perceptions of a virtual learning environment for a problem-based learning undergraduate medical curriculum blended learning for postgraduates; an interactive experience improving physicians' capacity for chronic obstructive pulmonary disease care through blended e-learning: a pilot study in the past, present and future of blended learning: an in depth analysis of literature amee guide : e-learning in medical education part : learning, teaching and assessment nuts and bolts of conducting feasibility studies information for authors: pilot and feasibility studies an audit of sample sizes for pilot and feasibility trials being undertaken in the united kingdom registered in the united kingdom clinical research network database the physicians' practice assessment questionnaire on asthma and copd using thematic analysis in psychology blended learning: strengths, challenges, and lessons learned in an interprofessional training program learning from focus groups: an examination of blended learning introducing an online community into a clinical education setting: a pilot study of student and staff engagement and outcomes using blended learning blended learning in cme: the perception of gp trainers blended learning: efficient, timely and cost effective building effective blended learning programs a new vision for distance learning and continuing medical education the role of blended learning in the clinical education of healthcare students: a systematic review the uses of information and communication (ict) in teaching and learning in south african higher education practices in the western cape : research : information and communication technologies facebook as a learning tool: perception of stroke unit nurses in a tertiary care what are the perceived benefits of participating in a computer-mediated communication (cmc) environment for distance learning computer science students? online discussion in blended courses at saudi universities blended learning in teacher education: an investigation across media global initiative for chronic obstructive lung disease. global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. gold executive summary prevalence and underdiagnosis of copd by disease severity and the attributable fraction of smoking report from the obstructive lung disease in northern sweden studies management, morbidity and mortality of copd during an -year period: an observational retrospective epidemiological register study in sweden (pathos) improving care for people with asthma: building capacity across a european network of primary care organisations-the ipcrg's teach the teacher programme publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we gratefully acknowledge the contribution of mohammod rafiqul islam for online learning management system coordination. we are thankful to the trainers for their contribution in delivering the intervention. icddr,b acknowledges with gratitude the commitment of nihr global health research unit on respiratory health (respire) to its research efforts. icddr,b is also grateful to the governments of bangladesh, canada, sweden and the uk for providing core/unrestricted support. supplementary information accompanies this paper at https://doi.org/ . /s - - - .additional file . programme outline.additional file . topic guide for focus group discussion and interview. additional file . practice assessment of trained physicians using copd physician's practice assessment questionnaire (copd-ppaq). the qualitative data that support study findings may be available from the corresponding author on request.ethics approval and consent to participate ethics approval obtained from the international centre for diarrhoeal disease research, bangladesh (icddr,b) ethical review committee (pr- ) and sponsored by the academic and clinical central office for research and development (accord ac ). all participants provided written informed consent. not applicable.competing interests mnu, and au are involved with developing cme courses at icddr,b. the other authors declare no competing interests. key: cord- -jz d m e authors: hasan, md. mahbub; das, rasel; rasheduzzaman, md.; hussain, md hamed; muzahid, nazmul hasan; salauddin, asma; rumi, meheadi hasan; rashid, s m mahbubur; siddiki, amam zonaed; mannan, adnan title: global and local mutations in bangladeshi sars-cov- genomes date: - - journal: biorxiv doi: . / . . . sha: doc_id: cord_uid: jz d m e corona virus disease- (covid- ) warrants comprehensive investigations of publicly available severe acute respiratory syndrome-coronavirus- (sars-cov- ) genomes to gain new insight about their epidemiology, mutations and pathogenesis. nearly . million mutations were identified so far in ∼ , sars-cov- genomic sequences. in this study, we compared of sars-cov- genomes reported from different parts of bangladesh and their comparison with globally reported sequences to understand the origin of viruses, possible patterns of mutations, availability of unique mutations, and their apparent impact on pathogenicity of the virus in victims of bangladeshi population. phylogenetic analyses indicates that in bangladesh, sars-cov- viruses might arrived through infected travelers from european countries, and the gr clade was found as predominant in this region. we found mutations including missense mutations, synonymous mutations, insertions and deletions with other mutations types. in line with the global trend, d g mutation in spike glycoprotein was predominantly high ( . %) in bangladeshi isolates. interestingly, we found the average number of mutations in orf ab, s, orf a, m and n of genomes, having nucleotide shift at g (n= ), were significantly higher (p≤ . ) than those having mutation at d (n= ). previously reported frequent mutations such as p l, d g, r k, g r and i f were also prevalent in bangladeshi isolates. additionally, unique amino acid changes were revealed and were categorized as originating from different cities of bangladesh. the analyses would increase our understanding of variations in virus genomes circulating in bangladesh and elsewhere and help develop novel therapeutic targets against sars-cov- . severe acute respiratory syndrome-coronavirus- (sars-cov- ) has become an etiological agent of the disease called coronavirus disease- (covid- ) . as of august , globally there have been , , confirmed cases of covid- , including , deaths, reported to who. to explore the viral pathogenesis, modern genomics tools are highly crucial and has been employed by researchers around the world. hundreds of virus whole genomes are now submitted in publicly accessible databases from different parts of the globe everyday. it is hightime to analyze the variations among those sequences which will help future strategic efforts for its preventive measures such as vaccine design and therapeutics. sars-cov- consists of positive-sense single-stranded rna with a genome size ranging from ~ to kb. it contains a variable number ( ) ( ) ( ) ( ) ( ) ( ) of open-reading frames (orfs). the first orf is almost two-third of the whole genome and encodes four structural, non-structural and eight accessory proteins [ , ] . according to a recent study on , of sars cov- genome sequences, , mutation events have been observed globally in comparison to the reference genome of wuhan. among these sequences, india, congo, bangladesh and kazakhstan have significantly high numbers of mutations per sample compared to the global average [ ] . out of these mutations, d g mutation (causing aspartate to glycine in s protein position ) is reported to be the most prevalent mutations reported from europe, oceania, south america, africa [ ] . zhang et al. ( ) reported that the level of angiotensin-converting enzyme (ace ) expression was distinctly higher by the retroviruses pseudotyped with g compared to that of d [ , ] . the functional properties of the (d ) and (g ) were compared in this study and g was found to be more stable than d with more transmission efficiency, supporting the previous epidemiological data [ ] . another reported mutation of orf ab is p l linked with d g, that has been reported to have a strong relationship with higher fatality rates in countries and states of the united states [ , ] . three other mutations namely c t (orf b), c t ( ' utr), c t (orf a) is reported to be common and co-occurring in the same genome while g t has been found mostly in asian countries [ ] . hassan et al. ( ) investigated the accumulation of orf a mutations of sars-cov- from india where they revealed four types of mutations (q>h, d>y and s>l) near traf, ion channel and caveolin binding domain, respectively [ ] . notable that all these mutations might have implications in maintaining the virulence of the virus and nlrp inflammasome activation. in bangladesh, as of august, , nearly , people are infected and people have died due to covid- (https://iedcr.gov.bd/). among them, of sars-cov- genome sequences were deposited in gisaid database (https://www.gisaid.org). analysis of these sequences is sparsely reported in the literature. analyzed sequences and identified the presence of mutations in the coding regions of the viruses and mutations at nsp was the most prevalent [ ] . due to the small numbers of genome sequence analyzed, most of these findings were not conclusive and representative. further comprehensive analyses is therefore necessary to better understand the circulating virus in the country. in this study, we first compared genome sequences isolated from bangladesh with time-resolved phylogenetic analysis and investigated the origin of imported covid- cases to bangladesh. then, we studied the variants present in different isolates of bangladesh to investigate the pattern of mutations, identify ums, and discuss the pseudo-effect of these mutations on the structure and function of encoded proteins, with their role in pathogenicity. most interestingly, we found ums with a total count of in bangladeshi isolates which will increase our understanding of distribution of sars-cov- virus in different regions and associated pathogenicity. as of june, , a total of , whole genomic rna sequences of sars-cov- had been submitted to gisaid. from these downloaded sequences, a custom python script was used to retrieve unique sequences. the same script also removed any sequence containing "n" and other ambiguous iupac codes [ ] . this resulted in a total of complete genomic sequences. to select representative sequences from curated sequences and make a comparison against sequences from bangladesh, priorities were given to those countries that had a higher number of infections in each continent (source: https://www.worldometers.info/coronavirus/). we selected these sequences in such a way that each continent must contain at least one sequence from each gisaid clade. the number of sequences selected from a country was based on the total number of unique sequences retrieved. this resulted in a total of unique representative sequences from countries (see supporting file table s ). from bangladesh, whole-genome rna sequences of sars-cov- were uploaded to gisaid as of july, . only high coverage complete sequences (n= ) were kept for analysis. all these sequences were aligned with the previously selected representative sequences along with that of wuhan- (accession id mn ) as a reference sequence [ ] . to ensure comparability, the flanks of all the sequences were truncated to the consensus range from to , [ ] , with nucleotide position numbering according to the wuhan reference sequence, prior to alignment. multiple sequence alignment (msa) and phylogenetic tree construction were carried out using molecular evolutionary genetic analysis (mega x) software [ ] . all selected sequences were aligned using muscle software tool [ ] . later, an nj (neighbor-joining) phylogenetic tree [ ] was constructed using the tamura-nei method. tree topology was assessed using a fast bootstrapping function with replicates. tree visualization and annotations were performed in the interactive tree of life (itol) v [ ] . the genome detective coronavirus typing tool version . was used for variant analyses of sars-cov- genome which is specially designed for this virus analysis (https://www.genomedetective.com/app/typingtool/cov/) [ ] . for analysis of (um) among genomic sequences from bangladesh, we used a cov server hosted in gisaid server (https://www.gisaid.org/epiflu-applications/covsurver-app/). the server analyzed our dataset against all available genomic sequences of sars-cov- including the wuhan reference sequence deposited on gisaid until july , . descriptive and inferential statistics were used to analyze different mutations and their correlation with different categorical variables. for correlation, we used one-way analysis of variance using spss statistics (ibm, armonk, new york) licensed to king's college london. to understand the sars-cov- viral transmission in bangladesh, we performed phylogenetic analysis on the selected viral genomes reported from different districts of bangladesh along with selected globally submitted sequences as reported from countries and continents ( figure ). this apparently represents the overall clade distribution of all global sequences along with sequences from bangladeshi isolates. gr clade was found predominant in bangladesh as about % of the sequences were grouped to this clade followed by gh and g with ~ and ~ %, respectively. similar clade distribution has been found in isolates submitted from european countries. we also attempted to compare the sequence data among different districts of bangladesh from where patient samples were collected for sequencing, looking at the districtwise distribution of clade (figure ) , it was found that the sequences from three districts, namely dhaka, narayanganj and rangpur primarily belong to gr clade. conversely, only sequences from chattogram district were from s and gh clades. on another note, phylogenetic analyses of the clade distribution of isolates from countries like saudi arabia, where gh clade was predominant [ ] it is highly likely that the introduction of gh and s clades in bangladesh could be of middle-eastern origin. based on the datsets, we hypothesized that bangladeshi sars-cov- isolates belonging to different clades might have critical implications concerning viral transmission rate, virulence, severity and other aspects of disease pathogenesis. in addition, the presence of different clades of sars-cov- strains in different districts could also have implications in the accuracy of diagnostic tests that are underway. our analyses revealed a total of mutations observed among bangladeshi genomic sequences that constitutes a number of missense, synonymous, insertion/deletions and other mutations (table ) . we identified mutations like i f (nsp ), p l (nsp ), d g (s glycoprotein), r k and g r (n protein) are the most frequently occurring common mutations found in bangladesh with a frequency of , , , and , respectively ( figure ). notable that, no particular mutations occurred at any specific time period rather they have been observed over the whole period of disease incidence. firstly, a>t (i f), can be a destabilizing factor for nsp and thus modulating the strategy of host cell survival [ , ] . this mutation can lead to a reduction of conformational entropy due to the presence of the side chains that can result in charge neutralization of the phosphorylated serine residues [ ] . secondly, rna dependent rna polymerase (nsp ) is significant for replication and transcription of the viral rna genome. therefore, p > l at in nsp may have some effects on rna transcription. this mutation was also observed in most of the usa states ( out of ). the same mutation was prevalent in european countries like spain, france etc. this alteration could affect the pathogenesis triggered by antibody escape variants with the epitope loss [ , ] . thirdly, korber et al. ( ) stated that the g type might have originated either in europe or china [ ] . they also reported that the original wuhan d form was also predominant in asian samples. meanwhile, the g form had clearly established and started expanding in countries outside of china. we also noticed . % of genomes from bangladesh have d g mutation, which is also dominant in the world. however, the average number of mutations per orf is varied among d and g containing genomes that we have studied (n= ) as revealed by table . the average number of mutations in orf ab, s, orf a, m and n of genomes having mutated g (n= ) are significantly higher (p≤ . ) than those having wild d (n= ) in s glycoprotein (table ; figure ). interestingly, the average mutation number is declined in orf of genomes having g mutation (p< . ). this correlation indicates that the genomes containing d g mutation are more prone to bear other mutations which may facilitate the notion that the link of this mutation with the transmission and pathogenesis of sars-cov- [ , , ] . finally, r k and g r mutations in n protein were previously reported in indian, spanish, italian, and french samples [ , ] . these mutations are located in the site of the sr-rich region which has been reported to be intrinsically disordered [ ] . this region further incorporates a few phosphorylation sites [ ] , including the gsk phosphorylation at ser and a cdk phosphorylation site at ser which are located close to the position of this mutation. the 'srgts' ( - ) and 'spar' ( - ) sequence motifs are dependent on gsk and cdk phosphorylation motifs, respectively. other variations ( g>a and g>a) together convert polar to non-polar amino acid (r k) and g>c variation converts nonpolar to polar amino acid (g r). we observed unique shifts from the different proteins of sars-cov- genomes found in bangladesh (table s ). details of their pseudo-effects on viral replication, assembly, transmissivity and pathogenicity are corroborated in table s . surprisingly, most of these um were localized except a few exceptions. for example, the ums e d (e), s t (n), l j and is involved in the transcription and replication of cov rnas. we observed ums in nsp , but the location of these amino acids was not in the kh domain (k and h of nsp ), which binds with ribosome s subunit [ ] . however, nsp acts as a primary virulence factor in sars-cov- infection, and mutation in this protein could affect the structure and functional properties, thereby altering its virulence properties. nine ums were seen in nsp , but their effects on host cells were merely reported in the literature. since nsp interacts with the host proteins and disrupts the host cell survival signaling pathway [ ] , any mutation in nsp may play a crucial role in sars-cov infections. in a recent study, it has been found that, compared to bat sars-cov, sars-cov- has a stabilizing mutation at amino acid position , t q, which alters the viral pathogenicity and makes the virus more contagious [ ] . we did not observe this mutation in our study. the mutations of nsp are responsible for affecting the virus assembly and hence their replication. it is due to the disruption of replicase polyprotein processing into nsps. these nsps assemble with cellular membranes and facilitate virus replication. the ums found in nsp might have some probable effects. firstly, the ums (a v, r g, s f and v f) were found in the main domain of nsp that is important for processing endopeptidases from coronaviruses. secondly, many um (e.g. a v, a s, g c, i s, a s, d b, k r, l m, n s, n d, r g, t is, y c and y h etc) are found in topological (cytoplasmic) domain rather than transmembrane domain which could interfere less on cytoplasmic double-membrane vesicle formation, necessary for viral replication. thirdly, we observed three ums (l m, y c and y h) in adp-ribose- ′-phosphatase (adrp) or (macro) domain. it has been shown that mutations of the adrp domains does not diminish virus replication in mice, but reduces the production of the cytokine il- , which is an important pro-inflammatory molecule [ ] . however, we did not observe any mutation in the active sites and zinc finger motif, attributing normal catalytic activity of nsp . the general opinion is that sars-cov pl-pro domain is important for the development of antiviral drugs and of the actual role of this enzyme in the biogenesis of the covid- replicase complex is yet not explored. it is proposed that the proteins nsp , nsp and nsp , through their transmembrane domains, are involved in the replicative and transcription complex [ ] . in our study, we observed only ums in nsp and nsp , respectively. meanwhile, nsp encodes c-like proteinase which cleaves the c-terminus of replicase polyprotein at sites. the five ums that we found in nsp did not fall in its active sites ( and in orf ab) requiring further investigation with large number of sequence datasets. the present global outbreak of covid- , caused by 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production date: - - journal: food control and biosecurity doi: . /b - - - - . - sha: doc_id: cord_uid: gqekw si abstract the people of rural and periurban india depend on backyard farming system for poultry meat and eggs. it is used by weaker sections of society, such as marginal farmers as insurance against crop failure, for ready cash and to ensure basic economic returns and the empowerment of women and children. however, backyard farming does not appear to be a promising strategy to achieve the poverty reduction until the production level is increased. the major constraint in increasing the production in backyard birds is microbial infection due to lack of biosecurity knowledge among the farmers. the mitigation of the microbial infection depends on the detection of the infection route and its prevention. the source of microbial infection (salmonella, escherichia coli) and their dissemination through the eggs in backyard flocks kept in different agroclimatic zones of west bengal, a major egg producing state in india, was identified. the pattern of virulence gene specially associated with urinary tract infection and antibiotic resistance genes, such as extended spectrum β lactamase (esbl) genes of the isolates was studied. the chapter will elaborate the backyard farming including breeds reared, housing, feeding with special emphasis on suggested biosecurity strategies and consequence of the adapted strategy. the food and agricultural organization of the united nations (fao) classified poultry production system into four sectors based on the level of biosecurity and marketing of birds and their products (fao, ) . apart from commercial poultry maintained in integrated farming systems with moderate to high levels of biosecurity (sector - ), there is a "backyard" or "village level" poultry sector with minimal biosecurity (sector ). in this backyard sector, native birds or locally available breeds are maintained, and the birds or their products are mostly consumed locally. the concept of backyard farming is as old as civilization. many families in the villages of the rural world keep a small chicken flock of various ages. the majority of these birds are kept in free-range systems, in which the birds scavenge around the house or in the backyard during daytime. the term backyard farming is originated from it. a primitive type of poultry house is offered to the birds during night. the feed consists of household wastes or kitchen scraps like raw vegetables, cooked rice, insects, larvae, seeds, and so on (samanta et al., ) . the world organisation for animal health (oie) considered the backyard system as the most familiar system of poultry rearing throughout the world because the system is highly adaptable to local climate, and it requires less capital and other inputs to establish (fao, a) . in the economy of developing countries this kind of poultry plays a major role by means of income generation and household food security. it is an important component of small farmers' livelihoods and a tool for poverty alleviation (sambo et al., ) . it can provide meat and eggs throughout the year and ready cash in times of hardship or emergency, which may make the difference between life and death. the ready cash is also used for school expenditure, daily household need, buying of other domestic animals, etc. (fao, a) . the supply of eggs and meat can be maintained by backyard farming to meet the rising demand. sometimes the products are consumed by the owners or used as gifts to the friends and relatives during festival and as sacrificial offer to traditional deity (hamilton-west et al., ) . in bhutan, backyard products also act as a source of protein for the female members of the household during pregnancy and postparturition period (tashi and dorji, ) . backyard chicken eggs are popular among urban and educated consumers due to their higher nutritional quality. these eggs contain higher concentration of vitamins, omega- fatty acids, and β-carotene (long and alterman, ) . the backyard farming reduces environmental pollution by the conversion of kitchen scraps into proteins (meat and eggs), and the use of chicken manure as garden fertilizer. moreover, production of meats and eggs locally reduces the transport of the items from distant places and thus reduces carbon emission (fukumoto, ). besides rural backyard farming, in the urban area of developed countries, also, there is a growing trend for keeping chickens in backyards. this rearing system is known as "hobby/ peridomestic/fancy poultry" or "urban backyard farming." in urban backyard farming, the birds are primarily kept for a homemade source of food, for fun, or as a hobby or companion pet to improve psychological health of the owners. this last purpose is usually a family tradition, exposing children to the food production process and general affection for birds, and functioning as insect control (usda, ) . this kind of farming is not associated with economical benefit because their rearing costs are often higher than the production (pollock et al., ) . in urban united states, keeping backyard poultry flocks have been steadily increasing in popularity. the study in the united states detected that . % of urban and . % of suburban residents prefer to keep backyard poultry (elkhorabi et al., ) . even a number of cities in the united states, such as columbia, missouri, ann arbor, michigan, denver, colorado, and auburn, alabama have passed regulations allowing chickens to be kept at residences (bartling, ) . the trend of keeping urban backyard poultry is also detected in the greater london area in the united kingdom (karabozhilova et al., ) , canada (burns et al., ) , and new zealand (lockhart et al., ) . in british columbia (canada), an authorized person may keep up to egg-producing hens and may produce up to kg of chicken meat per year (british columbia farm review board, ). backyard poultry farming is considered as an integral part of livelihood for many rural families throughout the world. in ethiopia (africa), chicken constitutes the largest share among the farm animal species (mammo et al., ) and % of the chicken population is maintained under a scavenging system (yemane et al., ) . similarly, in asian countries, such as in vietnam, thailand, and bangladesh, % of rural households rear poultry in their backyard and it makes a contribution to the monthly income of rural families and to the national economy (chakma, ; chantong and kaneene, ; edmunds et al., ) . in india, the majority of families ( %- %) in west bengal, tripura, and assam practiced backyard poultry production (nsso, ) . in pakistan, after textiles, the poultry industry is the biggest commercial sector in the country and it contributes considerably to the national economy. pakistan also maintains a large backyard poultry sector and it is observed that every rural family and every fifth urban family breed poultry at home (sadiq, ) . in developing countries, this kind of farming system also offers women empowerment, because women directly control the farming and the income generated from the sale of chickens and chicken products. studies in ethiopia and other african countries showed that this is the only source of independent income for women due to scarcity of resources (wilson, ) . in rural bangladesh, poultry rearing is an occupation of % of women (sultana et al., a) . no literature is currently available regarding the economic importance of this means women empowerment through backyard farming. in developed country, such as in chile, %- % of the studied farms were maintained by men alone or jointly with women (hamilton-west et al., ) . in bangladesh, % of the total egg production is contributed by backyard sector with an annual egg production of . billion from this sector itself (dolberg, ) . in india, this rural poultry sector contributes % of the total national egg production (ngullie and sharma, ) and the income per bird per annum ranges between us$ . - . (indian rupees - per bird/month) (ahuja et al., ) . this contribution is considerably low for a rural livelihood, but it can be increased by expanding the egg production level. the major constraint in increasing the egg production in backyard birds is microbial infection due to lack of biosecurity practices followed by the farmers (conan et al., ) . similarly, in developed countries, such as chile, the farmers mostly sell their products to their neighbors during any occasion or to the tourists who occasionally visit the farms (hamilton-west et al., ) . thus, the income is not sustainable and considerably low. chicken (gallus sp.) is the most common species kept in backyard farming throughout the world. for example, the majority of the backyard farmers in chile, new zealand (north island) and egypt prefer to rear domestic chicken (abdelwhab and hafez, ; hamilton-west et al., ; zheng et al., ) . in ethiopia, however, cattle are the most common species reared by backyard farmers, which is followed by chickens (sambo et al., ) . other species of birds, such as turkeys (meleagris gallopavo), geese (aseranser), ducks (anas sp.), muscovy ducks (cairina sp.), quail (coturnix sp.), pigeons (columbidae sp.), and guinea fowl (numididae sp.) are also reared in some countries and sometimes housed together. ducks are the second predominant species after chicken kept by backyard farming in southeast asian countries (e.g., thailand). in thailand, ducks are raised on rice fields after the harvest to feed on leftover rice grains. the ducks are moved by truck or other vehicle from one rice field to another during the postharvest season ( - months out of the year) (gilbert et al., ) . the ducks are also reared on ponds or channels with or without fish/ pig farming on the same site. rearing pigs in an enclosure within the backyard farm was also observed in new zealand (zheng et al., ) . in some countries (e.g., india), fighting cocks are reared for income generation in places where cock fighting is a traditional recreation among villagers. cockerels (male chickens less than year of age) are reared for cultural and religious purposes in some places (fao, a) . a small number of people (e.g., % of studied population in chile and some people of thailand) prefer to keep wild birds, such as austral thrush (turdus falcklandii), shiny cowbird (molothrus bonariensis), austral blackbird (curaeus curaeus) and common diuca finch (diuca diuca), and ostrich (struthio camelus) as backyard pets (gilbert et al., ; hamilton-west et al., ) . selection of livestock or poultry breeds is an age-old practice that depends on the folk traditions, needs, agroclimatic zone of the country, and availability of the breeds (banerjee et al., ) . among the domestic chicken breeds, indigenous or native or nondescript breeds are preferred for backyard farming due to easy availability, higher adaptability to the local environment, resistance to some diseases, good egg and meat flavor, hard eggshell, high fertility and hatchability, and high dressing percentage (abdelqader et al., ) . in west bengal (india), common indigenous breeds that are maintained in backyard farming are native feathered chickens (desi), naked neck chickens (galakata murgi), frizzled fowls (sojaru murgi), muffed/bearded fowl (dariwala murgi), creeper chickens (bete murgi), crested fowls (khopa murgi), rumpless fowl (bocha murgi), and feathered shank fowl (aseel, haringhata black/black haringhata) (figs. . and . ) (banerjee, ; samanta et al., ) . similarly in bangladesh, indigenous or nondescript breeds of chickens are the preferable choice for rearing. sometimes, the farmers keep fayoumiand sonali (cross-breed of rhode island red and fayoumi) chickens in a semiscavenging system (biswas et al., ) . in bhutan, native breeds, such as seim (sm), phulom (pl), yuebjha narp (yn), and khuilay (kl) are ideal breeds for backyard farming (tashi and dorji, ) . the most common backyard chicken breeds in thailand are native and mixed breed chickens (e.g., three-bloodbreed). three types of duck breeds are reared in thailand-namely, egg-laying ducks (khaki campbell), crossbreed of khaki campbell and native laying ducks, and a small number of meat type ducks (pekin, white cherry valley) (gilbert et al., ) . in sudan and ethiopia (africa), large beladi (lb), bare neck (bn), betwil (bt) dwarf, naked neck, and gasgie and gugut breeds of chickens are kept in backyard farms (getu et al., ; wani et al., ) . some temperate/artificial breeds of poultry were introduced in tropical countries, such as in india and ethiopia for better production and up gradation of native breeds, which altered the traditional husbandry systems. in india and ethiopia, the rhode island red (rir) breed was introduced through government-sponsored developmental schemes, such as rastriyo krishi vikas yojana (rkvy), a self-help group developmental program in india and poultry extension package in ethiopia (dinka et al., ; samanta et al., ) . the better egg production ( eggs per bird/annum) of rir chicken than the native breeds ( - eggs/bird/annum) was observed in west bengal (india) when the birds were provided with supplemented feed along with scavenging . in ethiopia, rir breeds of chicken showed poor tolerance to the local climate. moreover, supply of rir hen's eggs, pullets, and cocks in the localities reduced the brooding capacity of the native breeds and their adaptation to the local feeding system (dinka et al., ) . moreover, a synthetic breed (kuroiler) developed by a private organization was introduced in india for backyard rearing. kuroiler is a dual type bird having higher production capacity than the indigenous (desi) chickens with some features of native birds, such as feather color and alertness ( fig. . ) (ahuja et al., ) . in urban backyard farming, chickens are the most preferred species in the united states. layer breeds of chickens producing colored eggs, such as rir, plymouth rock, ameraucana, orpington, and wyandotte are preferred (elkhorabi et al., ) , although in minnesota (usa), meat-type chickens are also reared (yendell et al., ) . other birds, such as turkeys, ducks, pigeons, doves, game birds, and guinea fowl are also reared (beam et al., ) . in some countries, raptors (hunting birds) are reared in the backyard (fao, b) . the management practices for keeping backyard birds vary between the countries throughout the world. in chile, the birds are kept in three types of systems-namely, permanent confinement, free-range, and a mixed confinement. in mixed confinement, the birds scavenge freely in the courtyard of the farmer's house during daytime, and at night they are kept in an indigenous pen. among these three systems, the mixed confinement is the most common one (hamilton-west et al., ) . the indigenous pens are mostly made of bamboo with or without an asbestos shade in asian countries (samanta et al., ) . in thailand and sudan, at night the birds are kept under a bamboo basket also (chantong and kaneene, ; wani et al., ) . on the north island of new zealand, most of the farms ( %) allow free movement of chickens and ducks in nearby pastures, including access to waterways, such as ponds, streams, rivers, and drains (zheng et al., ) . in bangladesh, most of the farmers ( %) keep the birds within their houses, and others keep them in a coop in the front yard. the coop is made of soil or wood and it has a tin shade (alam et al., ; sultana et al., a) . the majority of the farmers prefer to keep the birds on a wooden perch constructed inside their own houses in ethiopia (yemane et al., ) . resting of the birds on treetops at night was observed in south pacific island countries (ajuyah, ) . development of brick houses for the poultry is rarely observed ( %) in india (west bengal) (banerjee, ) . during crisis periods, such as flooding the farmers keep the chickens in a cage and hang the cage inside the room as observed in bangladesh (sultana et al., a) . the average flock size of the birds in rural backyard farming is variable. in ethiopia and sudan, the average flock size per household was . and . , respectively (wani et al., ; yemane et al., ) . in another study in ethiopia, a lower average flock size ( . ) was detected (sambo et al., ) . in other countries, such as in bangladesh and belgium, the mean flock size of small holdings of poultry was observed to be less than (alam et al., ; van steenwinkel et al., ) . in a study in some districts of west bengal (india), such as jalpaiguri, dinajpur, west medinipur, howrah, and south parganas, the average flock size was observed as - (samanta et al., b) . scavenging in yards, animal sheds, bushes, neighbouring houses and the nearest grain field is the major source of feed for the backyard birds. mostly small worms, insects, snails, rice, fallen cereal brans, kitchen wastes, household vegetables, and green grasses are taken by the birds during the scavenging period and are considered as scavenging feed resource base (sfrb). in asian countries, such as in india, bangladesh, and thailand, women also offer the supplementary feed and drinking water from local ponds to the birds once or twice in a day (chantong and kaneene, ; sultana et al., a; samanta et al., ) . in developed countries, such as in new zealand (north island), however, the birds were mostly provided with drinking water collected from bore ( %), rivers, and streams ( %). only a few people ( %) use ponds or dams as a source of drinking water for their birds (zheng et al., ) . the birds are mostly bred within the flock to increase the flock size. the breeding activity of the birds is conducted by the women of the family, as observed in ethiopia and chile (aklilu et al., ; hamilton-west et al., ) . in new zealand, chickens were usually homebred ( %) (zheng et al., ) . in bangladesh, the women of the family select a space within their bedroom or on the windowsill for the chickens to lay and brood eggs. however, ducks prefer to lay the eggs where they stay at night (sultana et al., a) . the farmers utilize other sources of birds to introduce new birds in the existing flocks. examples of other sources include neighbors, local markets, commercial farms, breeders, shows/auctions, and government supported developmental schemes. in chile, % of the studied population used the other sources to purchase new birds (hamilton-west et al., ) . in new zealand, % of the owners obtained the chickens privately, and a few people ( %) bought the chicken from local commercial dealers (zheng et al., ) . in ethiopia, an average of . chickens were added to a flock annually (yemane et al., ) . during the introduction of new birds, no quarantine or other preventive measures to reduce the transmission of infections are followed. urban backyard farming is a little different than the rural farming. most of the persons keeping the birds have high income, higher education, and in the united states only % people were associated with agriculture. the flock size is almost the same as it is in rural backyard farming. in the united states, most of the people rear - birds (elkhorabi et al., ) . in new zealand too, small flock size (median, ; range, - ) was detected (lockhart et al., ) . however, higher flock size ( - ) was detected in minnesota (usa) (yendell et al., ) . the age range of chickens in the flocks surveyed in the united states was - years with predominantly female chickens. among the studied flocks, % of flocks had no rooster, % had , and % more than rooster in a flock (elkhorabi et al., ) . most of the bird keepers in the united states prefer to keep the birds indoor in a shed/coop. some of them ( %) provided enclosed run space along with the coop, % of them provided free-range during daytime and a small proportion of keepers ( %) preferred both of them (elkhorabi et al., ; yendell et al., ) . very few bird keepers used portable housing or cages for rearing the birds. in a us-based study, perches ( %) and nest boxes ( %) were mostly used as roosting and egg-laying space, respectively (elkhorabi et al., ) . similarly, in new zealand, the majority of the bird keepers rear the birds by free-range within the boundaries of the property during daytime (lockhart et al., ) . the women even with high educational background mostly take care of the birds like rural backyard farming. in the united states, the birds ( %) mostly receive a mixed ration of feed (purchased and kitchen scraps). although a small fraction of keepers ( . %) did not offer any supplementary feed to the birds in expectation that the birds will collect their feeds from free range. similarly, majority of the keepers ( %) provide fresh water to the birds and only . % of the keepers allowed the birds to obtain the drinking water from natural sources. the bird keepers ( %) also used supplemental grit and calcium for their birds, especially for the laying hens (elkhorabi et al., ) . in new zealand, the majority of the keepers use purchased feeds (lockhart et al., ) . in the european union, countries feeding kitchen scraps (except raw vegetables from the garden) to the food-producing animals, including chickens kept as pets, is banned since to prevent the transmission of zoonotic infections. access of poultry to the compost mass containing kitchen waste is also restricted (whitehead and roberts, ) . in developing countries, the backyard poultry sector mostly suffers from two infectious diseases, such as avian influenza (ai) and newcastle disease (nd) due to lack of biosecurity and proper vaccination (alexander, ) . surveillance of infectious diseases (such as ai) in backyard and free-grazing poultry is challenging due to the reluctance of the farmers to report outbreaks (kanamori and jimba, ) . avian influenza virus (aiv) infection is reported from poultry and wild birds in asia, africa, and europe (oie, ). the transmission of zoonotic aiv has so far (january ) generated human cases with deaths (who, .). among different subtypes of aiv, h and h are considered as pathogenic and are frequently isolated from chicken, turkeys, quails, and pheasants (suarez et al., ) . ducks and shorebirds mostly carry h , h , h , h , h , and h sybtypes of aiv (suarez and schultz-cherry, ) . genetic reassortment between avian and swine influenza can occur and generate a new subtype. h n is an example of a reassorted subtype that was detected in backyard birds and swine in ohio (killian, among the african countries, egypt is considered as endemic for aiv in spite of several attempts to eradicate the virus. in , backyard flocks accounted for % of the ai outbreaks in poultry. the infection was further confirmed in human patients having exposure to the backyard flocks (kandeel et al., ) . moreover, higher infection rates of aiv (h and h ) were observed in backyard birds and birds from local bird markets in comparison to birds from commercial farms in egypt (osman et al., ) . furthermore, a higher prevalence of aiv was reported in backyard flocks that had mixed populations of chickens and waterfowls together (el-zoghby et al., ) . two clades of hpai-h n are circulating in egypt, known as classic . . and variant . . strains (hafez et al., ) . the classic strain originated from ducks (saad et al., ) and currently is maintained in backyard birds. the variant strain has been circulating in commercial poultry since late (hafez et al., ) . the phylogenetic analysis of hpai strains from egypt revealed close relationship with the h n viruses circulating in gaza and israel, suggesting a common virus progenitor (el bakrey et al., ) . similarly in libya, hpai-h n belonged to . . lineage having similarities with egyptian isolates. it was detected in backyard flocks (kammon et al., ) . (chaka et al., ) . furthermore, in central africa (cameroon, central african republic, congo-brazzaville, gabon), evidence of aiv was detected in chickens, ducks, songbirds, and kingfishers (fuller et al., ) . in mali (west africa), ai seroprevalence was significantly higher in backyard birds than the commercial farms (molia et al., ) . severe h n outbreaks were detected in all kinds of poultry in thailand (asia) during - , which was later controlled, and in , toie declared thailand as free of h n infection (oie, ) . the study with the scenario of the tree modeling approach in backyard flocks in thailand also revealed the high probability to be free from h n infection (goutarda et al., ) . however, the backyard flocks in other asian countries possess the aiv. evidence of h n aiv was observed in a village backyard flock in kandal province in cambodia (theary et al., ) . in pakistan, two highly pathogenic subtypes (h n and h n ) caused a sporadic ai outbreak in poultry in . vaccination was done in poultry against h , h , and h subtypes to control the infection. as a consequence of reassortment with vaccine strains a more virulent subtype (h n ) of the virus appeared, which crossed the species barrier and further infected human. this reassorted subtype (h n ) possessed a nonstructural gene segment of h n , which increased the capacity of the virus to adapt to new hosts (due to ifn-β inhibitory activity) and environments (munir et al., ) . currently the existence of h n subtype is also detected in apparently healthy backyard flocks in pakistan. so, the backyard flocks in pakistan act as asymptomatic carrier of h n with increased possibility of human transmission (munir et al., ) . the h n virus circulating in pakistan belonged to the g lineage of virus (qa/hk/g / ), which was also common in hong kong (iqbal et al., ) . h n originated in turkeys in (homme and easterday, ) . since then it has been considered as a low pathogenic strain (lpai) and is panzootic in multiple avian species in asia, middle east, africa, and europe (capua and alexander, ) . the property of cross species transmission to human was first detected in in hong kong and china, which also originated from poultry (peiris et al., ; butt et al., ) . in bangladesh (asia), h n subtype of lpai is frequently detected in commercial poultry and backyard flocks that are phylogenetically related to south asian and middle east isolates (parvin et al., ) . moreover, h n isolates of bangladesh also possessed the evidence of reassortment between h n and h n subtypes like their counterparts in pakistan (parvin et al., ) . a low proportion ( %) of backyard birds in bangladesh die every day due to hpai infection. clinical study showed that cyanotic comb and wattle are frequently observed in both commercially farmed and backyard poultry (p = . ), but edema of the head and face, drowsiness, and huddling were more common in backyard farms (p = . ; p = . ) (biswas et al., a,b) . furthermore, full genome analysis of hpai viruses (h n ) isolated from poultry including backyard flocks in bangladesh revealed the evidence of reassortment between two circulating clades of viruses ( . . . and . . . ) and also between hpai (h n ) and lpai (h n ) strains (gerloff et al., ) . the virus clade . . . was introduced in bangladesh after and the strain spread into different places and species (chickens, crows) in the country (islam et al., ) . the aiv belonged to similar lineage with bangladeshi isolates were also detected in nepal suggesting the transboundary transmission either through trade or wild birds (nagarajan et al., ) . similarly in india (neighbouring country of bangladesh) the existence of hpai-h n clade . . . was observed in poultry since (nagarajan et al., ) . until , the clade . dominated in indian poultry (chakrabarti et al., ; pattnaik et al., ) . in europe, ai virus belonging to clade . was most prevalent among poultry and wild birds (brown, ). however, in romania, hpai h n virus of clade . . was detected in backyard flocks (reid et al., ) . in italy, eight hpai outbreaks in backyard poultry flocks infected with h n virus were reported in - (alexander, ) , while chickens raised for recreational purposes in the urban localities in the netherlands acted as major risk factors for a hpai outbreak in (slingenbergh et al., ) . in maryland (united states), low seroprevalence ( . %) of aiv was detected in backyard birds. no evidence of subtypes h , h , and h was observed. the seroprevalence was positively correlated (not statistically significant) with exposure to waterfowl, pest control, and location (madsen et al., ) . in new zealand also, low seroprevalence ( . %) of hpai was detected in backyard chickens and no influenza a virus was detected by molecular technique (zheng et al., ) . newcastle disease virus (ndv) belonged to the genus avulavirus and family paramyxoviridae (niewiesk and oglesbee, ) . all the ndvs come under a single serotype but based on phylogenetic analysis it is divided into two classes: class i and class ii. class i strains are mostly apathogenic for chicken except one isolated from waterfowl and shore birds. all the pathogenic strains belonged to class ii, and this class is further divided into genotypes (i-xi). among them, i, ii, iii, iv, and ix genotypes are considered as "early/old" (appeared between and ) and the genotypes appeared after are considered as late/recent (v, vi, vii, viii, x, xi) (kim et al., ) . backyard flocks throughout the world, especially in asian and african countries suffer or carry the ndv infection (permin and pedersen, ) . pakistan (asia) is considered as endemic for ndv infection in poultry. both commercial and backyard flocks can carry the infection, and all the virus isolates from both of the sectors belonged to genotype vii. the backyard flocks, however, do not show any syndrome of nd, but the virus isolated from the backyard flocks possessed a typical motif in f-protein associated with virulence. frequent contact with commercial poultry might be responsible for the transmission of virulent ndv into the backyard flocks and the virus was later adapted in the backyard flocks (munir et al., ) . however, in nepal, nd was detected to be responsible for % mortality in backyard flocks during (alexander, ) . in iran (bushehr province), % seroprevalence of ndv antibody was detected in unvaccinated backyard chickens (saadat et al., ) . in africa, studies revealed an average nd serological prevalence of . [ % (ci) . - . ] in poultry, which is more prevalent in the area with low altitudes, high humidity, and high human and poultry population densities. these predisposing factors are also favorable for persistence of ndv in backyard flocks because high humidity enhances virus survival and further transmission through the oral route. comparison of the ndv transmission rate within the flocks revealed more rapid transmission in the commercial sector than in the backyard flocks (miguel et al., ) . in a study in ethiopia, overall seroprevalence of the ndv antibody in backyard flocks was detected as . %- % in different seasons, which is higher than the average ndv seroprevalence ( . %) in africa . the backyard farmers also identified nd as the most prevalent infection among the birds in ethiopia (sambo et al., ) . moreover, in mali, among unvaccinated backyard birds, nd seroprevalence was . %, and the seropositivity was more associated with adult, female chickens than the ducks (molia et al., ) . in the middle-east countries, ndv has been circulating in poultry populations since the last century. in oman, high seroprevalence ( %) of ndv was detected in backyard flocks with mild or no symptoms. the management practices, such as introduction of new birds into existing flocks, direct contact with neighboring poultry and feeding of uncooked poultry waste were correlated with this high seroprevalence (al . the seroprevalence data of ndv in backyard flocks in other countries is variable. in new zealand, . %- % of the studied backyard chickens were seropositive for ndv antibody. all the chickens reared with ducks were found seropostive (dunowska et al., ) . in the periurban area of madagascar, a study showed that ndv was responsible for % of annual mortality in local backyard chickens (maminiaina et al., ) . in brazil, higher seroprevalence of ndv was detected in backyard flocks in which the farmers introduced their own poultry to restock the flock. this replacement caused the continuous presence of virus in the flock. further, proximity to water bodies (estuary) provided direct contact with other infected birds and favored the transmission of ndv (marks et al., ) . the ectoparasites were the most commonly reported health problem in backyard flocks in developed countries, such as in united states and canada (garber et al., ; burns et al., ) . in a study in california (united states), % of the backyard premises were observed to be infested with ectoparasites. the permanent ectoparasites detected in the study were six species of chicken louse, such as menacanthus stramineus ( %), goniocotes gallinae ( %), lipeurus caponis ( %), menopon gallinae ( %), menacanthus cornutus ( %), and cuclotoasterheterographus ( %). among the chicken mites, three species were most prevalent [ornithonyssus sylviarum ( %), knemidocoptes mutans ( %), dermanyssus gallinae ( %)]. it is noteworthy to mention that these parasites were exclusively detected in backyard flocks, not in commercial layers in california (murillo and mullens, ) . backyard flocks kept in and around the mississippi river delta suffered from black fly (simulium spp.) infestations. the external signs, such as cutaneous hemorrhagic lesions and a huge numbers of black flies within the digestive tract of the birds (after post mortem) were found. black flies can also transmit some blood protozoa (leucocytozoon spp., haemoproteus spp.), which cause further infection in the affected poultry. moderate occurrence ( %) of leucocytozoon spp. was detected in black fly infested backyard flocks (jones et al., ) . in the united states, toxoplasma was detected in %- % of backyard chickens although clinical cases of toxoplasmosis are rarely reported in poultry (dubey and jones, ) . in tropical countries, humid climatic conditions favor the growth of helminths, which reduce the egg and meat production of backyard poultry. in a study in india (jammu and kashmir), % of the backyard flocks were determined infested with gastrointestinal helminths. in the studied state of india, ascaridia galli was the most prevalent helminth ( . %) among the flocks. other helminths, such as heterakis gallinarum, raillietina cesticillus, and raillietina echinobothrida were also detected. the backyard chickens of the studied area take various insects as feed present in the soil, which may act as intermediate hosts for helminths ( fig. . ) (katoch et al., ) . similarly, in other tropical countries, such as in ethiopia (africa), % of the backyard flocks were infected with several cestode and nematodes (hussen et al., ) . low occurrence ( %) of histomonas meleagridis, a blood protozoon, was detected in backyard flocks in vietnam (nguyen et al., ) . triatoma dimidiata, a vector of trypanosoma cruzi causing chagas disease in humans was identified in the chicken coops in mexico (koyoc-cardeña et al., ) . in australia, the study showed that % of the backyard flocks suffer from coccidiosis (eimeria). the weather of australia, such as ambient temperatures around °c and high humidity (> %), favors the growth of eimeria and three species, such as e. mitis, otu-y, and e. acervulina were most prevalent (godwin and morgan, ) . meat and poultry products are recognized as the major sources for transmission of salmonella spp.(a gram-negative zoonotic bacterium) to human with % of the clinical cases attributed to the consumption of egg and poultry products (sanchez et al., ) . nontyphoidal salmonella spp. is reported to cause . million sufferings, including , people admitted to hospitals and deaths in a year in the united states (scallan et al., ) . sometimes, poultry birds, although infected with salmonella spp. and appearing healthy, can shed the bacteria through the faeces (behravesh et al., ) . human outbreaks of salmonellosis, especially between the caretaker and children associated with backyard poultry, are a global concern nowadays (cdc, ). moreover, many serovars of salmonella spp. can produce serious diseases and deaths in chickens too, especially at a young age (samanta, ) . the seroprevalence rate of salmonella in backyard chicken was moderate ( %) in argentina (xavier et al., ) . however, a lower isolation rate was reported by (jafari et al., , namata et al., and leotta et al., who found . , , and . % as salmonella prevalence in backyard chicken flock in iran, belgium, and paraguay, respectively. in a study in backyard birds (rir breed) in india (west bengal), the isolation rate of salmonella was %. salmonella isolates were also obtained from feed ( %), drinking water ( %), and eggs ( %) of the studied backyard flocks. no salmonella was detected from utensil swabs, litter, swab from the wall of the poultry house, dried manure under the house, and soil collected from all the studied agroclimatic zones. salmonella isolation rate was significantly correlated (p < . ) with a higher-age group of the backyard birds ( - weeks) as compared to the middle-or lower-age group. further, none of the salmonella isolates possessed extended spectrum β lactamase (esbl) genes probably due to a lack of antibiotic exposure (samanta et al., a) . transmission of antimicrobial-resistance genes into the commensal flora may take place in the intestinal tract of animals, including birds (gustafson and bowen, ) . specifically, the esbl enzymes are increasingly expressed by many strains of bacteria with a potential for dissemination. these esbls diminish the activity of wide-spectrum antibiotics, creating major therapeutic difficulties in treatment of the patients (samanta et al., a) . e. coli are present as commensal microflora of the intestinal tract of mammals including poultry and their environment. among several pathotypes, avian pathogenic e. coli (apec) are able to cause colibacillosis due to possession of specific virulence factors (samanta, ) . in california, e. coli were the most commonly diagnosed infectious diseases among backyard birds (mete et al., ) . e. coli are also classified under several phylogenetic groups. the phylogenetic group b strains are commonly found in mammals and are often associated with extraintestinal infection in humans, pets, and avian species. the group b strains are more commonly associated with ectotherms, birds, and environment (blyton et al., ) . sometimes, e. coli present in avian (apec) and humans (uropathogenic e. coli, upec) share common virulence factors, such as iucc, tsh, papc (rodriguez-siek et al., ) . in india, e. coli isolated from backyard flocks (rir breed) did not possess the virulence genes (iucc, tsh, papc) associated with upec (samanta et al., b) . similarly, virulence gene (papc) was not detected in any of the e. coli isolates from free-range healthy layers in australia (obeng et al., ) . further, none of the e. coli isolates from backyard flocks in india (west bengal) was found to possess extended-spectrum β-lactamases (bla tem , bla shv , bla ctx-m ) or quinolone resistance gene (qnra) due to a lack of antibiotic exposure (samanta et al., b) . thus, the studied backyard birds in india can be considered as safe food in relation to virulent and antibiotic resistant commensal bacteria. similarly, no esbl-producing e. coli were detected in backyard flocks in finland (pohjola et al., ; miranda et al., ) , which also reported lower levels of antibiotic resistance in e. coli isolates from organic poultry meat. in contrast, tetracycline resistance was most common in e. coli isolates from backyard poultry ( %) than in-care birds ( %) and wild birds ( %) in australia due to the use of tetracycline for treatment of the birds (blyton et al., ) . fowlpox virus belongs to the genus avipoxvirus and family poxviridae. it can infect the poultry throughout the world. most of the infections in backyard birds are reported from asia. in a study in india (west bengal), fowlpox virus was detected in a backyard flock with pock lesions in comb, eyelid, beak, and wattle. sequence analysis revealed the presence of nearly full-length reticuloendotheliosis provirus within the genome of fowlpox virus (biswas et al., a,b) . a number of fowlpox outbreaks without reticuloendotheliosis virus have also been reported from backyard poultry at different regions of india and iran (dana et al., ; das et al., ; gholami-ahangaran et al., ; roy et al., ; saha, ) . further study detected immunodominant b-cell and t-cell antigens in the fowlpox virus isolates from backyard birds, which will be useful for vaccine production (roy et al., ) . . it seems that backyard poultry and free-ranging birds act as a center for ibv transmission currently (promkuntod, ) . in canterbury, new zealand, revealed the presence of campylobacter spp. in % of the studied backyard chicken flocks (anderson et al., ) . campylobacter jejuni alone, campylobacter coli alone and both c. jejuni and c. coli were detected in ( %), ( %), and ( %) of the flocks, respectively. pfge analysis and comparison of the genotypes with the pulsenetaotearoa campylobacter database showed the similarity of the isolates with the isolates from human and commercial chickens indicating the possibility of crosstransmission. in finland, backyard chickens were also detected as a reservoir of c. jejuni strains (pohjola et al., ) . clinical listeriosis is rare in birds. however, recently an outbreak of listeria monocytogenes was observed in backyard flocks in seattle (united states). depression, lack of appetite, labored breathing, and increased mortality were noted in several affected birds. the pathologic changes in the internal organs of infected birds included severe myocarditis, pericarditis, pneumonia, hepatitis, and splenitis. no lesions were noted in the brain (crespo et al., ) . in finland too, backyard chickens were observed to possess l. monocytogenes, although their role as a primary reservoir is questionable (pohjola et al., ) . in europe, seroprevalence studies in backyard and fancy-breed poultry flocks revealed the presence of mycoplasma gallisepticum, ornithobacterium rhinotracheale, and avian metapneumovirus antibodies (haesendonck et al., ) . in another study in oman, backyard flocks were positive for avian metapneumovirus subtype b (al- . pasteurella multocida causing fowl cholera was detected in . % backyard birds in egypt. most of the p. multocida isolates belonged to a: serotype (mohamed et al., ) . among noninfectious conditions, fatty liver hemorrhagic syndrome (flhs) and reproductive tract adenocarcinoma were the leading causes of mortality in backyard flocks in california (mete et al., ) . necropsy findings in flhs include abundant coelomic fat and an enlarged, tan to yellow, friable liver with hemorrhages. another study revealed absence of hepatocellular lipidosis in % of the flhs cases and mild hepatocellular lipidosis in % of the flhs cases in the backyard birds (trott et al., ) . lead toxicosis was detected in backyard flocks in california and the flaking paint from a wooden structure in the chicken coop was identified as the source of toxicosis. no clinical signs in the birds were detected. however, the birds were excreting the lead through the eggs. the edible portion of the eggs contained lead levels as high as . µg/g (bautista et al., ) . in urban backyard flocks in the united states, ectoparasites, diarrhea, injuries, prolapsed vent, sour crop, and vices (feather pecking, cannibalism, piling, aggression) are most common menaces. mortality due to diseases or vices is uncommon. the predation is the major cause of mortality in urban backyard flocks both in the united states and the united kingdom (elkhorabi et al., ; karabozhilova et al., ) . in minnesota, lameness was the most commonly observed symptom followed by nasal or eye discharge, coughing, sneezing, and swollen sinuses in urban backyard flocks (yendell et al., ) . vaccinations are an important tool for disease prevention in all poultry flocks throughout the world. the vaccines against ndv infection are available for decades, but in most of the countries they are sold in large vials of more than doses, which are expensive for small-scale backyard farmers. the reconstituted vaccine should be used within a short period of time to avoid the loss of potency (merck animal health, ) . further, in remote villages, accessibility of the vaccines, proper diluents, cold chain, and, moreover, qualified paraveterinarians are limited. in some countries, such as in ethiopia, the vaccines are produced locally, which also creates challenges, such as irregular supply of specific pathogen-free (spf) eggs, required for sustainable vaccine production (sambo et al., ) . consequently, production and supply of vaccine is often hampered. because of all these factors, conventional vaccination is not usually performed in most of the backyard flocks each year to prevent the outbreaks. in the literature, very few examples are present regarding successful vaccination in backyard flocks. in java (indonesia), a large-scale mass vaccination was carried out to control outbreaks of hpai in backyard flocks, and positive titer to h was detected in %- % of poultry sampled in the mass vaccination area. in the hpai-nd combined vaccination group, %- % of the population had positive nd titers, compared to %- % in the areas without nd vaccination . in another study in indonesia, the results suggested that the hpai-nd combined vaccination significantly reduced the incidence of hpai in backyard poultry (bett et al., ) . several types of inactivated h n and h n vaccines were also used in egypt to control hpai outbreaks (abdelwhab and hafez, ) . however, use of live vaccine against hpai is a controversial issue, and it is presumed that such vaccination against hpai in china helped in the evolution of more virulent virus strain (smith et al., ) . in pakistan, too, it is speculated that import of live poultry and extensive use of live vaccines can pose a huge risk for the emergence of new ndv strain (munir et al., ) . in most of the endemic countries, such as in india, vaccination is not practiced to control the hpai infection in poultry. culling or stamping out birds in a - km declared infected area is the official policy to control the outbreak in india (dadf, ). the metapopulation dynamic study of a poultry population in the united states demonstrated the effectiveness of culling in reducing the number of outbreaks in large poultry populations (hosseini et al., ) . besides conventional vaccines, a novel approach in the form of fast-dissolving tablets (fdt) against nd virus was also produced. the virus (lasota strain) was freeze-dried into tablets containing a small number of doses, which is economically feasible for backyard farmers. the vaccine tablet can be diluted in water and administered either in drinking water of birds or by intraocular and/or intranasal route. the compact packaging of the fdts will also provide cost savings in storing and distributing the vaccine in the cold chain (lal et al., ) . treatment of diseases in backyard flocks is also limited. the backyard poultry farmers in india (west bengal) are reluctant to call for the assistance of local veterinarians or paraveterinarians due to lack of awareness, time, and motivation. in addition, doorstep services are also unavailable, especially in the remote villages (debnath et al., ) . the landless or marginal farmers also could not afford the treatment or vaccine costs (indian rupees or us$ . per bird/year) (sapplpp, ) . this is the probable reason the backyard birds reared in this part of india are not exposed to the antimicrobials and thus the commensal (e. coli, salmonella spp.) present in the birds do not possess major antibiotic resistance genes (samanta et al., b) . in bangladesh, sometimes the farmers prefer to collect the medicines and suggestions from the local medicine shops. the farmers also avoid the government animal health centers due to lack of proper diagnosis and availability of poultry medicines (sultana et al., b) . the reluctance of owners to seek veterinary attention was also noted even in developed countries, such as the united states ( . % farmers use veterinary service), the united kingdom, and chile (garber et al., ; hamilton-west et al., ; karabozhilova et al., ) . the urban backyard farmers in the united states mostly use dewormers (coccidiostats) and antibiotics in larger flocks (< ) of birds (elkhorabi et al., ) . in chile, the backyard birds were sometimes treated with the drugs approved for human use, which could be responsible for presence of drug residues in the poultry products (greenlees, ) . the animals and animal products (examination for residues and maximum residue limits) regulations, , control residues of medicines in food animals, including poultry, in european union countries. these regulations divide medicinal substances into three categories: allowed, prohibited, and unlisted. use of prohibited/unlisted medicines in poultry (commercial and backyard) is illegal (table . ) (whitehead and roberts, ) . occasionally, elderly farmers offered ethnoveterinary medicines, such as sour fruits, chili, and warm water to their backyard flocks (sultana et al., a) . similarly, in ethiopia, tobacco leaf, "melia" plant, pepper, garlic, lemon juice, and table oil is administrated with drinking water to the sick birds (sambo et al., ; yemane et al., ) . in brazil, ash is applied on the body of backyard birds to prevent parasite infestation. in nigeria, the ashes after burning of nicotiana rustica, n. tabacum, or carica papaya leaves are used. this is rubbed into the plumage to protect against parasitic infestation. shea butter is used as a curative method against bird scabies. palm oil is used especially against fleas and mites. tobacco leaves (nicotiana tabacum) provide protection for approximately month against sarcoptes, psoroptes, and demodex (salifou et al., ) . in bangladesh, indonesia and china, the sick birds are slaughtered and consumed when the treatment fails (padmawatia and nichterb, ; sultana et al., b; zhang and pan, ) . addition of an indigenous homemade probiotic (axone/akhuni) in diet (at % w/w) significantly improved the growth rate, egg production, and egg weight of backyard poultry in india (vanraja variety). microbiological analysis of the probiotic (axone) revealed the presence of bacillus coagulans, a well-known beneficial bacterium (singh and singh, ) . the zoonotic pathogens, such as hpai are transmitted to humans from the backyard birds through direct or indirect contact. the direct contact takes place while walking through the flocks and handling sick poultry and while slaughtering poultry personally without appropriate protection (burns et al., ; liao et al., ). at the time of slaughter, the most commonly identified risk factors were direct contact with infected blood or other body fluids (van kerkhove et al., ) . associated risk factors related to environmental exposure include cleaning poultry areas, removal of feces, using poultry waste as fertilizer, inhalation, ingestion, and intranasal inoculation of contaminated water (van kerkhove et al., ) . indirect contact is more frequent and takes place when backyard farmers are exposed to apparently healthy poultry without any precautions (rabinowitz et al., ) and when the farmers meet with each other (burns et al., ) . backyard poultry acted as greater source of hpai transmission than the commercial birds due to the absence of biosecurity measures. it is also estimated that average daily contact rate of humans was higher with the backyard flocks than with commercial poultry ( . or contacts per year) (patyka et al., ) . rural people are at higher risk of hpai transmission than their urban counterparts due to greater amount rearing of these backyard birds. besides from being an essential component of rural livelihood, poultry rearing is also an important sector of the agricultural ecosystems. the droppings of chickens are used to feed aquatic animals and as soil fertilizers, which facilitates pathogen transmission (liao et al., ) . moreover, asian rural people prefer to take freshly slaughtered poultry than the packaged and processed meat. in a study in southeast asia, it was observed that almost all vietnamese and more than half of the thai people slaughtered the birds by themselves at home. this kind of practice also increases the possibility of disease transmission (liao et al., ) . cock fighting (a traditional recreation in rural asia) with backyard birds may also play a role in disease transmission. the owners transport their birds long distances to participate in bouts and sometimes they lick the wounds on their fighting cocks (edmunds et al., ) . more hazardous practices, such as keeping birds inside the bedroom, scavenging of birds around the places where food is cooked, using the same water source where villagers bath or wash their utensils for the birds' drinking were observed in bangladesh (sultana et al., b) . the hpai virus belonged to clade . . and was prevalent in backyard and commercial poultry in india and bangladesh before (who, ) . during that period ( ), an hpai outbreak in humans was detected, which was also followed by two subsequent human cases. in all these cases, the etiological virus belonged to clade . . with other similar genetic characteristics indicating the cross-transmission from the poultry (brooks et al., ) . in vietnam, most of the human exposure ( %) to hpai occurred from the backyard poultry (fielding et al., ) . in thailand, during - , confirmed h n cases in humans were detected of which persons died (who, ) . the history of direct contact to the backyard chickens and free-grazing ducks appeared to be related to h n infections in humans in thailand (chantong and kaneene, ) . in china, a total of h n infections were identified in the zhejiang province in humans during . all the live poultry markets were closed and backyard poultry were slaughtered to control the outbreak in the locality (gong et al., ) . in beijing (china), farmers who reared ducks in their backyards possessed antibody against avian influenza, but they never vaccinated, indicating the means for possible transmission . using logistic regression, it was shown that backyard poultry could act as a source of campylobacter jejuni infection to children (el-tras et al., ) . lpai is also transmitted from poultry to humans causing influenza-like syndrome (cdc, ) . antibodies against h and h avian influenza virus were detected in a small locality in lebanon among the backyard farmers (kayali et al., ) . there is serologic evidence that waterfowl hunters, wildlife professionals, and veterinarians are at higher risk of infection with lpai (gill et al., ; myers et al., ) . urban backyard flocks also pose a major risk for transmission of zoonotic pathogens, such as salmonella spp. in young and elderly persons handling the birds (pollock et al., ) . centres for disease control and prevention (cdc) had warned about handling of poultry by people below years of age (cdc, ) . other than transmission of zoonotic pathogens, eggs of the backyard birds are also detected to be contaminated with dioxins (lin et al., ) . during scavenging, the birds get access to the source of dioxins, such as soil, feeds, plants, insects, building materials containing fly ashes, debris, etc. (solorzano-ochoa et al., ) . dioxins enter the body through ingestion and mostly accumulate in the liver, ovarian follicles, and the adipose tissue (piskorska-pliszczynska et al., ) . the vicious cycle of hpai virus transmission from the reservoir ducks into the backyard flocks was detected. in south asia, domestic ducks were the major risk factor for hpai persistence and transmission into the backyard poultry (gilbert and pfeiffer, ) . in madagascar, the high density of ducks (palmipeds) and prevalent rice paddies were associated with ai infection in backyard birds (andriamanivo et al., ) . the water bodies and their banks or rice paddies are contaminated with the virus excreted by the reservoir ducks. the virus survives in the lower temperature of the water. the backyard flocks are exposed to the contaminated water and the virus is transmitted through oral route. so the presence of water bodies adjacent to the backyard farm is considered a major risk factor for the transmission of pathogens. other than ducks, wild birds found around the water bodies, such as teals (anas chlorotis), swans (cygnus atratus), shags (phalocrocorax carbo), seagull (larus novaehollandiae scopulinus), pheasant (phasianus colchicus), turkeys (meleagris gallopavo), and hawks (circus approximans) also play an important role in transmission of hpai in backyard flocks (zheng et al., ) . sparrows (passer domesticus) and starlings (sturnus vulgaris) most commonly visit the place where the backyard flocks are kept. both sparrows and starlings are susceptible to experimental hpai infection (boon et al. ) and thus may act as a source of infection for the backyard birds. moreover, in a metapopulation dynamics study, it was observed that movement of ai virus between commercial and backyard poultry may contribute to the maintenance of outbreaks in an area, but direction of the viral transmission cannot be predicted (farnsworth et al., ) . in bangladesh, the poultry purchased from the market are slaughtered at home and the remnants are offered to their backyard flocks. this malpractice is considered as the strongest risk factor for transmission of hpai in backyard flocks in bangladesh (biswas et al., ) . in egypt, significant correlation exists between disposal of poultry carcass and feces in the environment and hpai infection in poultry (f = . , p < . ) (sheta et al., ) . in ethiopia, scavenging behavior of backyard chickens and chicken dealers were considered a major risk factor for infecting the backyard flocks. a number of farmers identified dogs bringing infected carcasses home to be an additional risk factor for transmission of infection (sambo et al., ) . female backyard birds were found to be more susceptible to ndv infection than male chickens due to extensive roaming throughout the village with a greater possibility of exposure to infected birds (molia et al., ) . biosecurityis in practical terms a mindset or philosophythat must be developed by the producers to prevent the entry of disease into the flock. it is an approach with a focus on maintaining or improving the health status of the birds and preventing the introduction of new pathogens by assessing all the possible risks (permin and detmer, ) . in rural backyard farming specially in developing countries, biosecurity measures are not practiced due to a lack of awareness and high cost of the measures (samanta et al., c) . for example, the cost of a hen house in cambodia (southeast asia) is us$ , whereas, the average monthly income of a cambodian family is us$ (conan et al., ) . a study conducted in a broiler farm in finland detected . euro cents (us$ . ) per bird as an average biosecurity cost (siekkinen et al., ) . in bangladesh, although government circulated -point biosecurity measures to prevent aiv transmission, the backyard farmers ignored these recommendations because they were unable to identify the infection and measure the transmission risk. most of the farmers considered the disease as fate or god's will or due to exposure to evil gas and air (sultana et al., b) . after confirmation of human h n infections in anhui province (china), the provincial government decreed that all backyard poultry must be kept in cages but the authority failed to implement the law (kaufman, ) . similarly, poultry farmers of indonesia (java) and china (haining) ignored the biosecurity practices due to lack of knowledge regarding zoonotic potentiality of avian influenza (padmawatia and nichterb, ; zhang and pan, ) . in literatures, there are very few examples of the biosecurity practices being followed in the rural backyard farms in the developing countries. in ethiopia, removal of manure and bedding from the chicken coops was occasionally performed to sell the objects directly as fertilizer. the materials used to build the chicken sheds, such as mud and cow dung made it difficult for sufficient cleaning with chemical disinfectants (sambo et al., ) . in ghana, general biosecurity practices, such as hand washing after handling poultry, was low in the farmers (odoom et al., ) . in bangladesh, the farmers who kept the birds in the sheds, cleaned the sheds every - days. the dried poultry feces and other debris were collected in a basket and directly used as fertilizer. the sick birds were mostly slaughtered for consumption. hand washing with soap after slaughter, cleaning up the slaughter place in the yard with detergent was rarely practiced. the offals and visceras after slaughter were thrown into the nearest water bodies and bushes (sultana et al., b) . similarly in india (west bengal), a low level of biosecurity awareness was observed among the backyard farmers, such as preparation of feed with boiled water (only % of the cohort), cleaning of feeding utensils and the drinking trough once in a month ( %), frequency of change of drinking water in the trough in days interval ( %), frequency of change of litter in days ( %), and storage of eggs at room temperature ( %). majority of the farmers ( %) did not wash their hands before providing feed to the birds and before entry or exit of the poultry houses (table . ) (samanta et al., c) . in developed countries, a moderate level of biosecurity awareness among the backyard farmers was observed probably due to higher education and socioeconomic conditions. in chile, dead or sick backyard birds were neither consumed nor sold (hamilton-west et al., ) . in european union countries, consumption of birds kept for the purpose samanta, i., joardar, s.n., ganguli, d., das, p.k., sarkar, u., b . evaluation of egg production after adoption of biosecurity strategies by backyard poultry farmers in west bengal. vet. world , [ ] [ ] [ ] [ ] [ ] [ ] of showing or as pets is prohibited (whitehead and roberts, ) . in new zealand, poultry waste was composted prior to use as fertilizer on pastures or gardens to reduce the possibility of disease transmission (zheng et al., ) . in canada (british columbia), the biosecurity measures, such as limiting human visitors to the flock, isolation of new and sick birds, use of footbaths during entry or exit of the shed, changing clothes when returning home, designing pens to decrease risk of wild bird contact, and not sharing equipments were observed (burns et al., ; yendell et al., ) . in the united states, the keepers of the backyard flocks followed similar kind of biosecurity measures, especially hand washing after handling the birds (beam et al., ) . however, majority of them did not use separate clothes to enter the coops and allowed visitors in the coop area. feed and water of their birds were accessible to wild birds and rodents. the keepers were mostly unaware about the disease transmission possibility associated with the presence of wild birds or rodents (elkhorabi et al., ) . lack of knowledge regarding the sources of infection and transmission pathways is still deficient among bird keepers, even in developed countries (beam et al., ; burns et al., ; garber et al., ; karabozhilova et al., ; lockhart et al., ) . cdc played a major role by publishing educational documents on the risk of zoonotic pathogens from contact with live poultry, especially for inexperienced flock owners (cdc, ) . the guideline is also framed for urban backyard poultry owners to reduce the risk of pathogen transmission. the guideline stressed limited flock size, composting of manure before using as fertilizer, prohibition of slaughter, required veterinary care to sick birds, and appropriate disposal of dead birds (tobin et al., ) . the fao had issued several guidelines for the farmers on how to increase biosecurity in backyard flocks, but a significant proportion of villagers continue their at-risk practices as observed in several countries (fao, (fao, , . this discrepancy was explained by the fact that measures were often costly and may not be correlated with the economic benefits of the farmers (aini, ) . in bangladesh, the biosecurity recommendation issued by the government to decrease the transmission of ai was not followed by the farmers because change in practices caused financial losses (sultana et al., b) . in india (west bengal), a cost-effective, agroclimatic zone-specific biosecurity strategy was developed for backyard farmers. the strategy stressed daily cleaning of the utensils with ash, offering potable drinking water to the birds, preparation of feed with boiled water, daily change of drinking water in the trough, sprinkling of detergent water left after washing of clothes in the scavenging area, disposal of carcasses by garden burial, washing of the eggs, storage of the eggs in cold temperature maintained by indigenous structures, and so forth. the strategy was moderately well adopted among the farmers due to its cost-effective nature and the ease of administration. adoption of such strategies caused change in practices (table . ) and as a consequence, the egg production level in the studied village increased (samanta et al., c) . the chapter elaborated the backyard farming including breeds reared, housing, feeding, with special emphasis on suggested biosecurity strategies and consequence of the adapted strategy. other than chicken as the primary species, turkeys, geese, ducks, muscovy ducks, quail, pigeons, and guinea fowl are reared by backyard farming throughout the world. the birds are kept by permanent confinement, free-range, and mixed confinement. in developing countries, the backyard poultry sector mostly suffers from two infectious diseases, such as ai and nd due to lack of 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of this study was to investigate the prevalence of depression and anxiety among bangladeshi university students during the covid- pandemic. it also aimed at identifying the determinants of depression and anxiety. a total of university students living in bangladesh participated in this cross-sectional web-based survey. a standardized e-questionnaire was generated using the google form, and the link was shared through social media—facebook. the information was analyzed in three consecutive levels, such as univariate, bivariate, and multivariate analysis. students were experiencing heightened depression and anxiety. around % of the students reportedly had moderately severe depression, whereas . % were severely suffering from anxiety. the binary logistic regression suggests that older students have greater depression (or = . , % ci = . – . ). it is also evident that students who provided private tuition in the pre-pandemic period had depression (or = . , % ci = . – . ). it is expected that both the government and universities could work together to fix the academic delays and financial problems to reduce depression and anxiety among university students. the outbreak of coronavirus diseases (covid - ) has been substantially influencing the life and living of people across the world, especially after the declaration of a global pandemic by the world health organization in the second week of march [ ] . as of june , , around . million people were infected with the covid- , with a confirmed fatality of another . million worldwide [ ] . hence, many countries implemented a range of anti-epidemic measures, such as restricting travel for foreign nationals [ ] , closing down public spaces, and shutting down the entire transit system [ , ] , to contain the transmission of the highly contagious infections from human-to-human. following the detection of first covid- case on march , [ ] , bangladesh like many other countries put the lockdown strategy into effect on march , , to ensure 'social distance' through 'home quarantine' to curb the 'spread' among its population [ ] [ ] [ ] , since a precise treatment or vaccine for the infected and people at risk are yet to achieved by the global health community [ , ] . however, all education institutions were closed initially from march to march , across the country and later extended to the mid of june in phases [ , ] . this unprecedented experience of 'home quarantine' under lockdown with the uncertainty of academic and professional career has multifaceted impacts on the mental health of students. for example, a canadian study focusing on the effects of quarantine after the severe acute respiratory syndrome (sars) epidemic found an association between longer duration of quarantine with a high prevalence of anxiety and depression among people [ ] . the ongoing covid- pandemic is creating a psycho-emotional chaotic situation as countries have been reporting a sharp rise of mental health problems, including anxiety, depression, stress, sleep disorder as well as fear, among its citizens [ ] [ ] [ ] [ ] [ ] , that eventually increased the substance use [ ] and sometimes suicidal behavior [ ] [ ] [ ] . researchers in china observed that the greater exposure to 'misinformation' through social media are more likely contributing to the development of anxiety, depression, and other mental health problems among its population of different socioeconomic background [ ] [ ] [ ] [ ] . studies before the covid- pandemic also suggested an inverse relationship between media exposure and mental health [ , ] . on the contrary, a study in south korea during the middle east respiratory syndrome (mers) reported a positive relationship between risk perception and media exposure [ ] . given the unexpected circumstances, it is crucial to explore the psycho-social experience of university students in bangladesh, especially during the covid- pandemic. such a study is expected to measure the psychological impacts of an unforeseen emergency on students, as well as to formulate and execute effective interventions and strategies to mitigate the mental health of people at large. this study was designed to address the psychological problems experienced by university students in bangladesh. the survey was conducted in the second week of may, from may to may , . students enrolled in different universities across bangladesh were the target population. an easy to understand questionnaire was used to collect 'basic information,' 'depression,' and 'anxiety' related information. an online-based platform was used to distribute the e-questionnaire, developed by using the google form, to the students. university students from all the divisions in bangladesh were contacted through different social networks and interviewed (see fig ) . the snowball sampling technique was used for collecting information from students. an informed consent form was attached to the e-questionnaire, and each participant consented to participate in the survey after reading the consent form. the participants were asked to share the e-questionnaire with their friends using their personal and institutional facebook and messenger. this study was formally approved by the ethical clearance committee of khulna university, bangladesh. the participants responded anonymously to the online survey by filling up an informed consent letter in the first section of the e-questionnaire. in the consent form, all the participants were provided with information concerning the research purpose, confidentiality of information, and right to revoke the participation without prior justification. basic information. 'basic information' contained the personal information of the respondents. current 'age' of students (' - ', ' - ', '> '), whether the student is 'lagging behind study' ('yes' and 'no'), doing any sorts of 'exercise during lockdown' ('yes' and 'no'), students who did 'tuition' before lockdown ('yes' and 'no'), the gender of the student ('male' and 'female'), 'place of residence' of students ('rural' and 'urban'), is he/she 'living with family' during lockdown ('yes' and 'no'). depression. depression was determined by using the patient health questionnaire (phq- ). phq- is an easy way to use in a questionnaire for screening depression of the responses that are used to predict depression of an individual and what state he/she is in during the survey. the scores in phq- range from ' = not at all' to ' = nearly every day' [ ] . the reason for choosing phq- was that it proved to be a useful tool for detecting depression [ ] . the levels of depression for the study were categorized as 'mild = - ', 'moderate = - ,' 'moderately severe = - ,' 'severe = � .' anxiety. anxiety was evaluated by using the generalized anxiety disorder (gad- ). in the questionnaire, the questions were used for screening anxiety state of an individual on a scale ranging from ' = not at all sure' to ' = nearly every day' [ ] . gad- has been found successful in identifying anxiety among different populations and thus used for its reliability [ ] . the levels of anxiety for the study were categorized as 'none-minimal = < ,' 'mild = - ,' 'moderate = - and 'severe = � .'. frequency tabulation was used to summarize basic information of respondents, as well as their response to depression and anxiety. binary logistic regression [ ] was used to identify variables influencing depression and anxiety among students by categorizing the outcome variable into two categories, i.e., depressed = 'yes' and 'no' and anxious = 'yes' and 'no,' which would provide a clearer idea about how intensely different factors are influencing the outcomes. logistic regression generates the coefficients (and its standard errors and significance levels) of a formula to predict a logit transformation of the probability of the presence of the characteristic of interest: where p is the probability of the presence of the characteristic of interest. the logit transformation was defined as the logged odds: and, rather than choosing parameters that minimize the sum of squared errors (like in ordinary regression), estimation in logistic regression accepts parameters that maximize the likelihood of observing the sample values. table shows the descriptive information of different selected variables of the university student in bangladesh. results show that ( . %) students were found to have mild to severe depressive symptoms, and ( . %) students were found to have mild to severe anxiety symptoms. more than % of the students were male ( . %), and the rest were female. one in three students lived in rural areas ( . %). less than a quarter percent of students ( . %) believed that they were not academically lagging, and just over % reportedly have exercise regularly during the lockdown at home. table shows the prevalence of depression and anxiety among bangladeshi university students. out of the total valid participants, ( . %) were found to have mild to severe depressive symptoms. male ( . %) had higher depressive symptoms than the female ( . %) counterparts, whereas students in the early twenties ( . %) showed higher depressive symptoms than other age groups. depression was also prevalent among students with no physical exercise ( . %) and those who consider themselves lagging behind others in terms of academic activities ( . %). besides, students living with families ( . %) and in urban areas ( . %) showed higher depressive symptoms. in the case of anxiety, ( . %) students exhibited mild to severe anxiety symptoms. out of the total students suffering from an anxiety disorder, females ( . %) had lower anxiety symptoms than males ( . %), whereas students in the early twenties ( . %) showed higher anxiety. like depression, anxiety was also prevalent mostly among students with no physical exercise ( . %), troubled with the thought of lagging behind others academically ( . %). moreover, students living in urban areas ( . %) with families ( . %) also showed symptoms of anxiety. table reveals that students who thought that s/he was lagging behind others in academic activities were . times ( % ci: . , . ) more likely to be depressed than the student with no such worries. students living with families were . times ( % ci: . , . ), more likely to be depressed than the students living apart from families. on the other hand, students providing supplementary classes before lockdown were . times ( % ci: . , . ), more likely to show mild to severe anxiety symptoms than their counterparts with no such involvement. students who were worried about their academic activities were . times ( % ci: . , . ) more likely to exhibit mild to severe anxiety symptoms than students with no such worries. students living with families were . times ( % ci: . , . ), more likely to have mild to severe anxiety symptoms than students staying away from families during the lockdown. covid- pandemic came out as the most devastating and challenging crisis for public health in the contemporary world. apart from the soaring mortality rate, nations across the globe have also been suffering from a spike of the excruciating psychological outcomes, i.e., anxiety and depression among people of all ages. university students are no exception, as all the educational institutions are unprecedentedly closed for more than usual, and for bangladesh, it is more than two months in a row. such closure, in general, triggers a sense of uncertainty about academic and professional career among the educands and intensifies persistent mental health challenges among university students [ , , ] . given such circumstances, the main goal of this study was to investigate the prevalence of depression and anxiety among the bangladeshi university students during the covid- pandemic and to explore the factors influencing the presence of depression and anxiety disorder. the findings of the web-based cross-sectional survey indicate that more than two-thirds of the students were experiencing mild to severe depression ( . %) and anxiety ( . %). earlier studies in bangladesh observed the presence of both depression and anxiety among students in higher academia. for example, a survey of medical students in suggested that more than % of students in medical colleges are suffering from depression ( . %) and anxiety ( . %) [ ] . another study, on university students excluding the freshmen, complemented the previous work and found that the prevalence rate of depression and anxiety was . % and . %, respectively [ ] . compared to the earlier studies, our study suggests that university students in bangladesh are experiencing an unparalleled growth of depression and anxiety under the current global pandemic situation. the results also suggest that the university students' involvement in private tuition is a critical factor in understanding the increased prevalence of depression and anxiety among them. in bangladesh, a significant number of students are involved in part-time jobs, such as private tuition, to finance their educational expenses, and sometimes to support their families, and their reliance on private tutoring as a part-time job is increasing gradually [ ] . however, being unable to provide tuition under the lockdown situation means disruption of regular income and joblessness. the prolonged unemployment, together with financial insecurity, is the most significant stressors contributing to the increased rates of depression and anxiety among university students in bangladesh. a study suggests that unemployment is significantly associated with mental and somatic disorders, which could limit the individuals' chances for feelings of achievement, accomplishment, and satisfaction, and eventually lead to the impairment of psychological functioning [ ] . self-esteem could also be affected by the loss of work as studies found that lack of family support during unemployment adversely affects the mental well-being of individuals [ , ] . apparently, the sudden joblessness and financial insecurity are putting the university students in an unpleasant situation, affecting their socioeconomic and mental well-being [ ] . it has been well accepted that living with families strongly generate reassurance among the individuals, therefore, reduce depression and anxiety. because positive family environments often benefit the mental health of the vulnerable youth experiencing depression or anxiety [ ] . however, this pandemic has brought extreme financial pressure on families. most of the families have been suffering from unmanageable debts and a decline in income, thus, leaving the family members in a traumatized situation [ , ] . university students, who used to earn and contribute to their families before lockdown, can hardly assist their parents in this crisis moment. the results of this study suggest that despite living with family, anxiety and depressive symptoms have been increasing among university students in bangladesh mainly due to financial insecurity. universities in developed countries put strict health protocols into action, such as washing hand, using face-mask, advising 'stay-home' strategy when sick, to facilitate continuation of education in higher academia and later switched to campus-wide online learning [ , ] . in bangladesh, the protective interventions, such as wearing mask or using the personal protective equipment, are yet to be enforced largely due to limited supplies [ , ] , hence, the government opted to implement the country-wide lockdown. approximately two-thirds of the students are getting depressed thinking they might be falling academically behind their contemporaries in other parts of the world during the prolonged closure of universities. they, however, reiterated that the online classes could not fulfill their requirements [ ] and a significant percentage of the students are still out of the reach of the online class. in addition, their research projects and internships had to be ceased since they were instructed to leave the halls (dormitories for students) of their respective universities [ ] . not only that, the covid- crisis also created a severe challenge of the global reversion for the graduates to accomplish their future academic and working goals [ ] . although university closures were intended to keep students safe, for many, these notions came out with different sets of mental health issues. meanwhile, a study reported that graduate students generally experience significant amounts of stress and anxiety, which also affects their usual behavior [ ] . the results in this study stressed on the fact that the nation-wide lockdown in bangladesh is going to cause a significant disruption in the academic programs and create a gap in both teaching and learning. the academic delays could have long-term impacts on the psychology of students as they are more likely to be graduated later than they have expected. in this regard, faculties, as well as university authorities, should stay connected with the students using social media platforms and motivate them to move forward together during this difficult time. apart from the issues mentioned above, this study found no significant differences between male and female students with relation to depression or anxiety, thus complement previous studies [ , , ] . however, egyptian research remarked that female university students are more likely to suffer anxiety and less prone to depression than male students [ ] . the current study did not find any statistically significant association between the socio-demographic variables (including place of residence and exercise) with depression and anxiety. a few studies, on the contrary, reported a significant association between socio-demographic variables [ ] and exercise [ ] with depression and anxiety. a malaysian study reported substantial differences concerning age and permanent residence with depression or anxiety, however, observed no significant association between some socio-demographic variables (including gender, ethnicity, study major, monthly family income) and the psychological problems [ ] . the strengths and limitations of the current study are determined by several issues. the equestionnaire allows to assess the prevalence of anxiety and depression among university students while maintaining the who recommended "social distance" during the covid- pandemic, which otherwise would be impossible. moreover, the data for the e-survey were collected by globally validated standardized tools for quantitative analysis. on the contrary, given the limited resources available and the time-sensitivity of the covid- outbreak, the snowball sampling strategy was chosen instead of random samples. in this cross-sectional study, the identified factors are regarded as associated factors, which could be either be the causes or the results of depression or anxiety. furthermore, due to ethical requirements on anonymity and confidentiality, the contact details of the respondents was not collected. however, the use of validated screening e-questionnaire was considered as a cost-effective approach to explore the situation in general, therefore, used in this study. since the research methodology could not reach people with medically examined depression and anxiety symptoms, the provision of the results may not fully reflect the severity of depressive and anxiety symptoms among students. another limitation of this study is not using the tools designed specifically for the covid- pandemic, such as the coronavirus anxiety scale (cas). meanwhile, it would be ideal for conducting a prospective study on the same group of participants with tools developed especially for the covid- pandemic after a period to provide a concrete finding and to facilitate the demand for a focused public health initiative. despite some limitations, this study gives the first empirical evidence that a large percentage of bangladeshi university students have been suffering from depression and anxiety symptoms during the ongoing pandemic. in addition to academic and professional uncertainty, financial insecurity is contributing to the rise of depression and anxiety among university students. to minimize the growing mental health problems, the government, along with the universities, should work together to deliver promptly and accurately economy-oriented psychological support to the university students. to ensure the continuous involvement of students in educational processes, the universities should initiate all-inclusive online-based educational programs to reach out the students living 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tribune covid- : use of face mask. the financial express online learning: a panacea in the time of covid- crisis closure of universities due to coronavirus disease (covid- ): impact on education and mental health of students and academic staff mental health and suicidal behavior among graduate students prevalence and socio-demographic correlates of mental health problems among iranian health sciences students. academic psychiatry inadequate sleep and exercise associated with burnout and depression among medical students depression, anxiety and stress among first year medical students in an egyptian public university we are grateful to the participants, as well as thankful to the editors and anonymous reviewers. key: cord- -idh io v authors: hassan, md. zakiul; sturm-ramirez, katharine; rahman, mohammad ziaur; hossain, kamal; aleem, mohammad abdul; bhuiyan, mejbah uddin; islam, md. muzahidul; rahman, mahmudur; gurley, emily s. title: contamination of hospital surfaces with respiratory pathogens in bangladesh date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: idh io v with limited infection control practices in overcrowded bangladeshi hospitals, surfaces may play an important role in the transmission of respiratory pathogens in hospital wards and pose a serious risk of infection for patients, health care workers, caregivers and visitors. in this study, we aimed to identify if surfaces near hospitalized patients with respiratory infections were contaminated with respiratory pathogens and to identify which surfaces were most commonly contaminated. between september-november , we collected respiratory (nasopharyngeal and oropharyngeal) swabs from patients hospitalized with respiratory illness in adult medicine and paediatric medicine wards at two public tertiary care hospitals in bangladesh. we collected surface swabs from up to five surfaces near each case-patient including: the wall, bed rail, bed sheet, clinical file, and multipurpose towel used for care giving purposes. we tested swabs using real-time multiplex pcr for viral and bacterial pathogens. case-patients with at least one pathogen detected had corresponding surface swabs tested for those same pathogens. of patients tested, had a laboratory-confirmed respiratory pathogen. of the swabs collected from surfaces near these patients, ( %) had evidence of contamination with at least one pathogen. the most commonly contaminated surfaces were the bed sheet and the towel. sixty-two percent of patients with a laboratory-confirmed respiratory pathgen ( / ) had detectable viral or bacterial nucleic acid on at least one surface. klebsiella pneumoniae was the most frequently detected pathogen on both respiratory swabs ( %, / ) and on surfaces near patients positive for this organism ( %, / ). surfaces near patients hospitalized with respiratory infections were frequently contaminated by pathogens, with klebsiella pneumoniae being most common, highlighting the potential for transmission of respiratory pathogens via surfaces. efforts to introduce routine cleaning in wards may be a feasible strategy to improve infection control, given that severe space constraints prohibit cohorting patients with respiratory illness. with limited infection control practices in overcrowded bangladeshi hospitals, surfaces may play an important role in the transmission of respiratory pathogens in hospital wards and pose a serious risk of infection for patients, health care workers, caregivers and visitors. in this study, we aimed to identify if surfaces near hospitalized patients with respiratory infections were contaminated with respiratory pathogens and to identify which surfaces were most commonly contaminated. between september-november , we collected respiratory (nasopharyngeal and oropharyngeal) swabs from patients hospitalized with respiratory illness in adult medicine and paediatric medicine wards at two public tertiary care hospitals in bangladesh. we collected surface swabs from up to five surfaces near each case-patient including: the wall, bed rail, bed sheet, clinical file, and multipurpose towel used for care giving purposes. we tested swabs using real-time multiplex pcr for viral and bacterial pathogens. case-patients with at least one pathogen detected had corresponding surface swabs tested for those same pathogens. of patients tested, had a laboratory-confirmed respiratory pathogen. of the swabs collected from surfaces near these patients, ( %) had evidence of contamination with at least one pathogen. the most commonly contaminated surfaces were the bed sheet and the towel. sixty-two percent of patients with a laboratory-confirmed respiratory pathgen ( / ) had detectable viral or bacterial nucleic acid on at least one surface. klebsiella pneumoniae was the most frequently detected pathogen on both respiratory swabs ( %, / ) and on surfaces near patients positive for this organism ( %, / ). surfaces near patients hospitalized with respiratory infections were frequently contaminated by pathogens, with klebsiella pneumoniae being most common, highlighting the potential for transmission of respiratory pathogens via surfaces. efforts to introduce routine cleaning in wards may be a feasible strategy to improve infection control, given that severe space constraints prohibit cohorting patients with respiratory illness. pathogens present in ill patients' respiratory secretions can contaminate nearby hospital surfaces, such as floors, walls, bedrails and mattresses, through coughing, sneezing and touching [ ] [ ] [ ] [ ] . respiratory viral and bacterial pathogens, including staphylococcus aureus, streptococcus pyogenes, influenza viruses, respiratory syncytial virus, adenovirus, rhinoviruses and novel coronavirus strains, can survive on hospital surfaces for days, weeks or even months. furthermore, touching contaminated surfaces may lead to nosocomial transmission of pathogens between patients, family caregivers, visitors, and healthcare workers [ , , ] . patient care areas in bangladeshi hospitals are open wards with multiple beds in a room and are frequently overcrowded with patients, family caregivers, and visitors [ , ] . a previous study by rimi et al. found a median of four people per sq. feet of floor space in hospital wards in bangladesh and observed a median of five uncovered coughs or sneezes per sq feet per hour [ ] . due to shortage of health care workers, family caregivers (family members who provides hour hands on care to sick patient, including bedside nursing and cleaning) are integral part of inpatient care in bangladeshi public hospitals, contributing crowding of hospital wards [ , ] . the world bank estimated that in only $ of public funds per capita were spent annually on health infrastructure in bangladesh. thus, resources for infection control are severely limited in bangladeshi hospitals [ , ] , making it difficult to implement international infection control guidelines [ ] . the lack of routine infection control practices, including no regular surface cleaning, may increase the transmission of respiratory pathogens via hospital surfaces [ , , , ] . family caregivers, visitors, and hospital staff may acquire respiratory infections either through direct contact with infected patients or via droplets, aerosols or contaminated surfaces. contaminated hospital surfaces can pose a serious risk of infection for patients, health care workers, caregivers and visitors. within this context of scarce resources, describing the magnitude of surface contamination in bangladeshi hospitals, particularly identifying priority areas for decontamination, could influence infection control policy and practice. our objective was to assess the frequency with which patients hospitalized for respiratory illnesses in bangladeshi public hospitals contaminate nearby surfaces, to identify commonly contaminated surfaces, and to determine which pathogens are detected most frequently. we conducted the study in two public tertiary care teaching hospitals in rajshahi and jessore, bangladesh between september and november . rajshahi medical college hospital contains approximately , beds with eight adult medicine wards and four pediatric wards. jessore medical college hospital is a -bed hospital with two adult medicine wards and one pediatric ward. paediatric wards typically admit patients < years of age and older patients are admitted to adult medicine wards. the mean bed occupancy proportion in these hospital wards are consistently > % with patients being treated on the floor and in hallways when beds unavailable [ , ] . study physicians in adult medicine and pediatric wards identified patients aged � years who met the severe acute respiratory illness (sari) case definition of subjective or measured fever (� c˚) within the past seven days with cough or sore throat [ ] . in pediatric wards, physicians identified children < years of age who met the severe pneumonia (sp) case definition: cough or difficulty breathing and at least one danger sign (i.e. chest indrawing, stridor while calm, history of convulsions, inability to drink, lethargy or unconsciousness and/or intractable vomiting) with onset of symptoms within the last seven days [ ] . since case-patients were identified immediately after admission, their illnesses were mostly community acquired. study physicians collected respiratory swabs (nasopharyngeal and oropharyngeal) from identified cases using the world health organization's laboratory safety manual protocol [ ] and pooled them into a single cryovial containing viral transport media (vtm). trained research assistants in each hospital collected one swab sample from five different surfaces near each enrolled case patient: the wall next to the patient's bed, bed rail, bed sheet, clinical record files, and a multipurpose towel. the multipurpose towel is a cloth brought from home by family caregivers and used to clean patient respiratory secretions, wiping the patient's face or head, and to dry caregivers' hands and face [ ] . we selected these surfaces because patients, caregivers, and healthcare workers (hcws) frequently come into contact with them in the hospital wards [ , , ] . the research assistants collected surface swabs between - hours after the case-patients' admission to the hospital. this allowed for adequate time for hospital surfaces to be exposed to possible contamination by respiratory pathogens, while also making sure that surfaces were swabbed before the enrolled patients were discharged or died, as patient turnover in wards was high with a median hospital stay of three days [ ] . the risk for infection from these potentially contaminated surfaces between patients within a room, between patients and healthcare workers, or between patients and family caregivers would vary based on the particular surface and how these different risk groups interacted with the surface. with one sterile rayon swab stick per surface, the research assistant swabbed the area of the wall in contact with the bed cm high from the level of the bed sheet, all surfaces of the bed rail located in the area near the patients' head, half of the bed sheet where the patient's head was including underneath the patient, front and back cover of the patient file and both sides of the multi-purpose towel. not all patients had a wall or bedrail nearby as some patients were cared for on the floor, due to overcrowding. swab samples from each surface area were put into individual cryovials containing vtm and kept in a cool box for up to minutes with a temperature between ˚- ˚c. both the respiratory swabs and surface swab samples were labelled, packaged, stored in a nitrogen dry shipper (- ˚c) and sent to the icddr,b virology laboratory by batch twice a month. the swab samples were thawed and the cryovials containing the sample were vortexed. about μl of the swab supernatant was used for nucleic acid extraction using invimag pathogen kit/kf (stratec molecular, berlin, germany) and the final eluted volume of nucleic acid solution was μl, as per the manufacturer's instruction [ ] . the real-time multiplex pcr assay was performed as per the manufacturer's instructions using an agpath-id ™ one-step rt-pcr kit (ambion) with the fast track diagnostic (ftd) respiratory pathogens kit (fast track diagnostics, luxembourg) for different viruses and bacterial pathogens [ ] . casepatients with at least one pathogen detected in their respiratory swab had corresponding surface swabs tested for those same pathogens. detection of nucleic acid of at least one similar pathogen on respiratory swab and a nearby surface was defined as contamination of that surface. to investigate wider hospital contamination, we also tested the surface swabs collected near casepatients with no pathogens detected in their respiratory swabs for the most commonly detected pathogens identified on surfaces near patients with detected respiratory pathogens. we summarized the data using descriptive statistics. we assessed the difference in proportion of pathogen detection in respiratory swabs and surface swabs between adult and paediatric ward patients using chi-square test considering fisher exact test where appropriate. any association with a p value < . was considered statistically significant. study participants (aged � years) or their legal guardians (if aged < years) provided informed written consent. the institutional review board of icddr,b reviewed and approved the study protocol. the institutional review board at the centers for disease control and prevention (atlanta, ga, usa) deferred to icddr,b's approval. we collected and tested respiratory swabs from patients hospitalized with respiratory illness: sari cases from adult medicine wards and severe pneumonia cases from paediatric medicine wards. the median age of patients in the adult wards was years (iqr - ) and in paediatric wards three months (iqr - ). the male-to-female ratio was . : (table ) . of the patients, ( %) had detectable viral and/or bacterial nucleic acid in their respiratory swabs. paediatric patients more frequently had one or more detectable pathogen in their respiratory swabs than adult patients ( % versus %, p = . ). bacterial pathogens were identified in % of adult respiratory swabs. klebsiella pneumoniae, streptococcus pneumoniae and human cytomegalovirus ( ) ( ) human parainfluenza viruses ( ) ( . ) other viruses b ( ) ( ) ( staphylococcus aureus were most commonly detected during the study period. in contrast, viral pathogens were commonly detected among paediatric patients, including human cytomegalovirus, respiratory syncytial viruses, and human rhinoviruses (table ) . clinical features, mean duration of symptom onset to sample collection ( . days vs days) did not vary between patients with a detectable viral and a detectable bacterial nucleic acid in respiratory swabs. two patients, one with klebsiella pneumoniae and one with streptococcus pneumoniae detected in their respiratory swabs, had been hospitalized at other facilities within two weeks prior to admission to the study hospital, suggesting that these organisms could have been hospital-acquired. both these patients had abnormal chest x-rays and were diagnosed with severe pneumonia in the study hospital. we tested the surrounding hospital surface swabs for each of the patients with evidence of respiratory pathogens for the same viral/bacterial nucleic acid detected in their respiratory swabs. we collected and tested surface swabs near the patients as not all these patients had a wall or bedrail near them. nearly half of the hospital surface swabs ( % [ / ]) had evidence of contamination by at least one pathogen included in the testing panel. the most commonly contaminated surfaces were the bed sheet, the multipurpose towel, and the bed rail. we infrequently detected bacterial or viral nucleic acid on wall surfaces or on patients' clinical record files (fig ) . sixty-two percent of patients ( / ) had detectable viral and/or bacterial nucleic acid on at least one (range: - ) nearby surface, including % of adults ( / ) and % ( / ) of pediatric patients. the most common bacterial pathogen detected on surface swabs was klebsiella pneumoniae and % ( / ) of patients positive for klebsiella pneumoniae had at least one surface with detectable dna. the most frequently detected viral pathogen on surfaces was human cytomegalovirus and % ( / ) of patients positive for human cytomegalovirus had detectable dna on nearby surfaces ( table ) . we tested nearby surfaces for patients ( patients from adult wards and from pediatric wards) without detectable viral/bacterial nucleic acid in their respiratory swabs. we tested these surfaces for six frequently identified pathogens in respiratory swabs of case-patients: klebsiella pneumoniae, streptococcus pneumoniae, staphylococcus aureus, human cytomegalovirus, respiratory syncytial viruses and human rhinoviruses. klebsiella pneumoniae was detected on at least one nearby surface in % ( / ) of these patients, staphylococcus aureus in % ( / ), and streptococcus pneumoniae in % ( / ) patients. viruses, including, human cytomegalovirus ( / ), respiratory syncytial viruses a and b ( / ) and human rhinoviruses ( / ), were rarely detected nearby these patients. nearly two-thirds of the patients hospitalized with laboratory-confirmed acute respiratory infection had at least one nearby contaminated surface. klebsiella pneumoniae was the most commonly detected pathogen in patients' respiratory swabs, and was detected in nearly every environmental swab testing, suggesting widespread hospital contamination from current and previously hospitalized patients. with the ability to spread rapidly in the hospital environment, klebsiella pneumoniae has been linked to several nosocomial outbreaks [ , ] . the most frequently contaminated surfaces were the bed sheet, towel, and bed rail, further highlighting the perils of no routine surface cleaning practices in these hospitals. studies in tertiary care hospitals of bangladesh have shown that one in patients with a hospital stay greater than three days developed a hospital-acquired respiratory infection, and that only % of those infections had a viral aetiology, suggesting a large proportion of these infections might be bacterial [ , ] . since, future work should further investigate the role of klebsiella pneumoniae may be an important nosocomial pathogen in these hospitals. several other studies have identified multidrug resistant klebsiella pneumoniae in hospital environments and its association with severe infections, prolonged hospital stays and increased mortality rates, particularly in debilitated and immunocompromised patients [ , ] . a study in an urban tertiary care hospital in dhaka, bangladesh, reported that % of the clinical specimens (sputum, pus, urine, throat, and vaginal swabs) collected from hospitalized patients were drug resistant [ ] . moreover, our study findings were consistent between the two hospitals despite being located in different geographical areas and may suggest surface contamination with klebsiella pneumoniae as a wider public health problem. the predominant bacterial pathogens we identified, klebsiella pneumoniae, streptococcus pneumoniae, and staphylococcus aureus, can survive on surfaces from a few days to a few months [ , , ] . bacteria, in the presence of low humidity, forms biofilms protecting microorganisms from harsh environmental influences and are difficult to eradicate [ , ] . in bangladesh, hospital surfaces are not adequately cleaned and hospitals report insufficient supplies of cleaning agents [ , , ] . to remove and prevent biofilm formation, hospital decontamination protocols should include strategies such as daily cleaning of surfaces with disinfectant (e.g. . % sodium hypochlorite or % chlorhexidine solutions). among the most commonly detected viral pathogens, rsv was prevalent in respiratory swab of paediatric patients and nearby surfaces. rsv has been a major nosocomial hazard on pediatric wards and has been linked with hospital outbreaks [ , ] . with reported higher case fatality among patient with nosocomial rsv infections (or . , % ci . - ), widespread surface contamination with rsv is concerning for low income hospitals ( , ) . we identified, that towel, was frequently contaminated with respiratory secretions. [ ] . islam et al. reported that family caregivers frequently used a multipurpose towel for patient secretions and for their own use, without cleaning it in between these uses [ ] .this suggests that the towel may act as a potential vehicle for transmission of respiratory viral and bacterial pathogens from patient to caregiver [ ] . infection control could target care giving practices associated with the use of the towel and should test feasible low-cost interventions such as the supply of low cost disinfectant by hospitals that encourage caregivers to clean the towels more frequently and to improve hand washing practices, including the use of hand sanitizer. an important limitation of our study is that we only identified the presence of viral or bacterial nucleic acid on different hospital surfaces, and cannot be sure that the pathogens we detected were viable. a second limitation is that we conducted the study in only two public hospitals, so the findings may not be representative of all public hospitals. however, our findings were consistent between the two typical tertiary care hospitals we studied, located in completely different parts of the country. a third limitation is that we only sampled surfaces once, which limits our ability to comment on duration of contamination, and did not have the ability to observe contamination from seasonal infections. influenza, for example, has a known seasonal pattern in bangladesh, circulating usually between may and september, potentially explaining the low detection rate in our study [ , ] . lastly, we did not investigate drug resistance patterns of the bacteria we detected due to resource constraints. based on evidence from other studies, however, it is likely that many of the pathogens we detected on surfaces were drug resistant and future studies should consider including investigations about drug resistance [ ] . this study identified that hospital surfaces in these bangladeshi hospitals, were frequently contaminated with respiratory pathogens and pose a potential threat for fomite-borne transmission of respiratory infections to patients, healthcare workers and family caregivers. to prevent the spread of klebsiella and other infections between patients, healthcare personnel must follow specific infection control precautions including strict adherence to hand hygiene and the use of gloves. in addition, our data clearly indicate that efforts to regularly disinfect environmental surfaces and ensure clean towels for patient caregiving could reduce risk of exposure to patients, healthcare staff and visitors. the government of bangladesh has taken a number of initiatives to improve infection control in hospitals [ ] . despite this, a nationally representative survey of healthcare facilities showed that healthcare workers performed recommended hand hygiene in only % of opportunities, suggesting low adherence to international standards [ ] . barriers include awareness, training, accountability and appropriate infrastructure (among health facilities, % handwashing locations had no water, % had no soap and - % had no alcohol based sanitizer) to support these behaviours [ , , ] this study highlighted the gaps in practice, as well as the substantial barriers to improvement that will require widespread investments to address. in , the directorate of hospital infection control, directorate general of health services (dghs) at the ministry of health and family welfare in bangladesh has communicated the intention to form infection control committees in each district and tertiary care hospital across the country to improve the safe care [ ] . further investigation to identify the true contribution of fomites in the transmission of respiratory pathogens within hospital settings could be useful to help these committees prioritize efforts to improve hand and surface cleaning. supporting information s file. dataset. 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international nosocomial infection control consortium report, data summary of countries for - : device-associated module incidence of and risk factors for hospital-acquired diarrhea in three tertiary care public hospitals in bangladesh. the american journal of tropical medicine and hygiene who interim global epidemiological surveillance standards for influenza manual for the laboratory diagnosis and virological surveillance of influenza a quantitative approach to defining "high-touch" surfaces in hospitals economic burden of influenza-associated hospitalizations and outpatient visits in bangladesh during . influenza and other respiratory viruses maternal vitamin d supplementation during pregnancy and lactation to prevent acute respiratory infections in infancy in dhaka, bangladesh (mdari trial): protocol for a prospective cohort study nested within a randomized controlled trial ftd respiratory pathogens luxemburg: fast track diagnostics an outbreak of hospital-acquired klebsiella pneumoniae bacteraemia, including strains producing extended-spectrum β-lactamase outbreak of klebsiella pneumoniae producing a new carbapenem-hydrolyzing class a β-lactamase, kpc- , in a new york medical center incidence and viral aetiology of hospital-acquired respiratory infections at three tertiary care hospitals in bangladesh rates of hospital-acquired respiratory illness in bangladeshi tertiary care hospitals: results from a low-cost pilot surveillance strategy detection and treatment options for klebsiella pneumoniae carbapenemases (kpcs): an emerging cause of multidrug-resistant infection predictors of hospital surface contamination with extended-spectrum β-lactamase-producing escherichia coli and klebsiella pneumoniae: patient and organism factors. antimicrobial resistance and infection control prevalence of extended-spectrum βlactamase-producing escherichia coli and klebsiella pneumoniae in an urban hospital in dhaka, bangladesh survival of enterococci and staphylococci on hospital fabrics and plastic survival of enterococci and staphylococci on hospital fabrics and plastic survival strategies of infectious biofilms efficacy of disinfecting solutions in removing biofilms from polyvinyl chloride tracheostomy tubes. the laryngoscope healthcare worker and family caregiver hand hygiene in bangladeshi healthcare facilities: results from the bangladesh national hygiene baseline survey risk of nosocomial respiratory syncytial virus infection and effectiveness of control measures to prevent transmission events: a systematic review. influenza and other respiratory viruses the clinical and phylogenetic investigation for a nosocomial outbreak of respiratory syncytial virus infection in an adult hemato-oncology unit nipah virus contamination of hospital surfaces during outbreaks influenza in outpatient ili case-patients in national hospital-based surveillance estimates of seasonal influenzaassociated mortality in bangladesh bangladesh: dghs, ministry of health & family welfare behaviour change intervention to reduce caregivers' exposure to patients' oral and nasal secretions in bangladesh health worker and family caregiver hand hygiene in bangladesh healthcare facilities: results from a nationally representative survey bangladesh: health economics unit, health sevices division we would like to thank authorities of participating hospitals, all the study participants, the study physicians, field staff and laboratory staff for their contribution. we acknowledge gladys leterme for reviewing and editing this manuscript.icddr,b acknowledges with gratitude the commitment of cdc to its research effort. icddr,b is also grateful to the governments of bangladesh, canada, sweden and the uk for providing core/unrestricted support. key: cord- -v ly m authors: zaman, shamrita; sammonds, peter; ahmed, bayes; rahman, taifur title: disaster risk reduction in conflict contexts: lessons learned from the lived experiences of rohingya refugees in cox's bazar, bangladesh date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: v ly m bangladesh is currently hosting more than one million stateless rohingya refugees, who fled from the rakhine state to avoid serious crimes against humanity persecuted by the myanmar army. the newly arrived rohingyas were accommodated in overcrowded refugee camps in cox's bazar district (cbd). the camps are highly vulnerable to landslides, tropical cyclones, flash-flooding, and communicable disease outbreak. although a number of improvement measures are ongoing, however, no study to date has addressed rohingyas' self-adopted strategies to mitigate disaster risks. consequently, this paper aims to explore how refugees cope with risks associated with environmental hazards in the kutupalong rohingya camp in cbd. a mixed-methods research strategy incorporating both quantitative household questionnaire survey and qualitative focus group discussions (fgds) techniques were applied. in total rohingya refugees were selected for the questionnaire survey using a stratified random sampling method from camps and , and two fgds (male and female-only) were carried out in camp involving rohingya participants. results derived from the study show that responding to early warning systems, storing dried food and medicine, utilising available resources, relocating to safer shelters, and keeping hopes high were some of the coping strategies practised by the respondents. literacy level imposed a significant impact over respondents' perception to accept various measures. for instance, the probability of storing dried food in preparation for disasters was times higher among literate rohingya compared to their illiterate counterparts. similarly, for literate respondents, the probability was times higher to store medicine than for illiterate. guaranteed distribution of shelter strengthening kits among all refugee households, inclusion of disaster risk awareness and preparedness trainings, ensuring safe and dignified return in myanmar, and global and regional cooperation to address the refugee crisis are some of the propositions recommended in this study for improving rohingyas' future adaptation strategies in a humanitarian context. disasters triggered by natural hazards cause loss of life, property damage, forced displacement, hunger, and disease outbreaks. the world's poorer or less-resilient nations, and especially marginalised groups such as minorities, displaced people and refugees are also highly impacted by natural hazards [ ] . considerable emphasis has been given by the scientific community to identifying traditional coping strategies practised by the urban or rural poor in a disaster context [ ] [ ] [ ] [ ] [ ] . however, there is a gap in conducting research solely on refugees in such a meticulous way. the present study attempts to focus on exactly this point by considering the rohingya refugees crisis in cox's bazar district (cbd), bangladesh as an example. by definition, refugees are persons "someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion" [ ] . from this definition, the arrival of refugees is considered as a temporary phenomenon for the host country. the durable solution regarding refugees is that they will be able to return to their homeland voluntarily as soon as the situation, which forced them to flee from their territory, ends [ ] . but the real situation is quite different. a study by the united nations (un) high commissioner for refugees (unhcr) reported that around . million individuals, including . million refugees (registered only), were forcibly displaced worldwide at the end of . currently, % of the global total refugees are being hosted by the least developed countries where they live very distressing lives. bangladesh is ranked th , accommodating nearly million rohingya refugees from myanmar [ ] . fragile camp settings with limited access to basic provision of infrastructures and aid, difficult camp locations (e.g., too arid or too hilly), overpopulation and rickety shelters are some of the common phenomena with which the refugees are forced to deal with recurrently. such fragile physical settings act as driver to increased vulnerability to natural hazards [ ] . for instance, communications between the leitchuor refugee camp in ethiopia and the surrounding community were interrupted for a month because of the disruption of the camp's main access road due to flooding in july . again, shelters on steep hillslopes in refugee camps in rwanda were destroyed due to a landslide in . a survey conducted by unhcr in countries suggested that out of . million refugees, , were affected and , were displaced by disasters associated with natural hazards during and owing to living in vulnerable camp settings [ ] . consequently, the question is how the refugee communities can build coping strategies to respond to potential disaster risks. vulnerability of the poor in their own territory and vulnerability of refugees in a host country are not similar phenomena. the vulnerable in their own country may enjoy freedom of movement, better access to relief aid, alternative livelihoods, access to evacuation shelters, internet, telecommunications, vaccines and so on, to mitigate disaster risks, which typically are denied for refugees. rohingyas are the second largest ethnic group of the rakhine state in myanmar [ ] . they have distinguished culture, heritage, language and religion [ ] . their citizenship was denied by the myanmar government in [ ] [ ] . being targeted by the state-sponsored persecution, rohingyas fled from myanmar and started arriving in bangladesh chronologically, first in , then in - , , , and lastly in late august . nevertheless, it was august when bangladesh experienced by far the largest and fastest refugee influx [ ] . the international court of justice (icj) has instructed myanmar to take actions to stop genocide of the rohingyas on january , and the final verdict on the punishment of the crime of genocide is still pending [ ] . nearly , rohingya refugees (officially known as forcibly displaced myanmar nationals) including more than , children ( . % boys and . % girls) and , adult women have fled into cbd since august , and they are now settled in two main camps -kutupalong and nayapara [ ] . cbd is currently hosting , rohingyas ( fig. ) who are officially registered by the unhcr [ ] . [ ] . in addition, the crisis has adversely impacted more than , host community members. the joint response plan (jrp) is seeking us$ million to respond to the critical humanitarian needs in cbd [ ] . the rohingya refugees are not only unique in terms of their great numbers, but also in the sense of their exposure to adverse weather condition in the refugee camps [ ] . every year, the rohingyas are facing catastrophic impacts of natural hazards in cbd. for instance, heavy downpour for five consecutive days with landslides on july affected more than , rohingya families and took away lives of two people [ ] . again, a total of , rohingyas were affected by the rainfall-triggered landslides, flash floods and waterlogging during may-december in . moreover, the devastation caused by the cyclone fani in may recognised the need for better preparedness against extreme storm events in the rohingya camps [ ] . in this context, the paper aims is to assess refugees' adopted strategies to cope with the shifting risks (i.e., the type of risks associated with natural hazards that has changed over time with the change of location) and also, the level of organisational involvement in implementing disaster resilience interventions in the camps. the central argument of the paper is that a new dimension can be added to the studies of coping strategies for the physical and built environment field by exploring disaster risk reduction (drr) strategies developed and practised by a refugee community. accordingly, the research question is 'despite facing many challenges, how do rohingya refugees sustain their existence against the growing vulnerability raised by extreme weather events'? the alternative hypothesis of this study states that rohingyas have developed their own coping mechanisms, in an attempt, to protect themselves against shifting risks posed by natural hazards. the null hypothesis is that no such coping mechanisms have been developed by the rohingyas. the study area, kutupalong balukhali expansion site or here in short kutupalong rohingya camp (located in between ° ' '' and ° ' north latitudes and in between ° ' and ° ' '' east longitudes), is bounded by bandarban district on the northeast, teknaf upazila (sub-district) on the south, the rakhine state (formerly known as arakan) of myanmar on the east, and the bay of bengal on the southwest. the kutupalong camp is the largest refugee settlement in the world which is sheltering over , rohingya per square kilometre (e.g. population density of london, tokyo, and new york cities are respectively , , and per km ). the study area is mostly composed of small hillocks and valleys. the surface geology is primarily composed of sandstone, clay and siltstone. the average temperature of cbd is . °c and average annual rainfall is , mm. the total area of the main kutupalong camp is approx. . km , and around % and % areas are highly susceptible to flooding and landslides, respectively. camps , , and were selected for this study (fig. ) because of their high exposure to different natural hazards [ ] [ ] [ ] . for example, from april to november , over , landslide incidents impacted , households, wind/storm incidents impacted , households, and flooding incidents impacted , households across all camps. overall, the incidents were responsible for individual refugee injuries and fatalities, and , households were displaced [ ] . some basic information about the selected camps are described in table . families with persons of special needs (%) source: unhcr, [ ] . the study deployed a mixed-methods research strategy combining both quantitative household-based questionnaire survey and qualitative focus group discussions (fgds) techniques. fgds were conducted followed by the household questionnaire survey to verify the results obtained from the fieldwork. it is well-accepted that integration of quantitative and qualitative data analysis is necessary to capture the overall vulnerability scenario of a community. while questionnaire surveying enables to extract information regarding socio-economic and demographic issues of a community, fgds enable the participants to share their perception, knowledge and future plans [ ] . first, household questionnaire surveying was conducted with the newly arrived adult rohingyas (over years old) who entered into bangladesh following the august violence. the survey was administered face-to-face individually with rohingyas in camps and in order to acquire reliable primary data. a 'stratified random sampling' method (also known as a random walk process) was adopted in this research, because it offers greater precision than a simple random or systematic sample. only participants living on extremely vulnerable hill slopes or floodplains were selected by ensuring gender balance. the questionnaire consisted of both open and close-ended questions yielding quantitative data, highlighting rohingyas' exposure to hazards, adopted ways to cope with shifting risks, organisational response to hazards, and the scopes and challenges of implementing good practice. a draft questionnaire was piloted and tested in april . the first draft of the questionnaire had some issues related to redundancy, length, selecting appropriate options for different questions, adjusting cultural understanding and contextualisation. the overall testing performance was satisfactory. a revised questionnaire (see appendix-i) was prepared for the final round of fieldwork which was carried out in may . all the field surveyors were given necessary training and background instructions prior to conducting the survey, covering issues such as the selection of survey participants, gender balance, due diligence, taking field notes, transcription and translations, risk assessment, research ethics, principles of reliability and validity, permissions, security and safety, unconscious bias, data protection, and professional code of conduct. participants were informed about anonymity and project objectives, and their consent was sough beforehand. fieldwork permissions were officially granted by the office of the refugee relief and repatriation commission (rrrc) in cox's bazar. five field surveyors (three males and two females) conducted the whole survey who were selected based on their fluency in rohingya and bengali languages, and successful completion of the training. second, two fgds were conducted in camp on february to address the limitations in quantitative methods and validate the results obtained from the questionnaire survey. the fgd participants were divided into men-only (aged between and ) and women-only (aged between and ) groups comprising ten and eleven members respectively. the reason behind forming gender-specific group was to understand their gendered experiences. particular time schedule and suitable location were fixed beforehand. the fgds were conducted in the heath management bd (hmbd) foundation's premise inside camp by maintaining all relevant fieldwork ethics and regulations. two trained field enumerators (one male and one female) conducted the fgds with the presence of hmbd doctors and nurses. as the study involved human participation, institutional ethical approval (ucl project id: / , and data protection id: z / / / ) and risk assessment were in place before the commencement of the face-to-face questionnaire surveying and fgds in the camps. responses from complete questionnaires were compiled preparing a database in spss software [ ] and used for the statistical analyses. test of two proportions, chi-square test of homogeneity ( x c) and binomial logistic regression are three powerful statistical tests that were used in this study. the test of two proportions and chi-square test of homogeneity ( x c) were used to determine whether the difference between the binomial proportions of independent variables on a dichotomous dependent variable is statistically significant or not. the basics of these two tests are mostly similar except the nature of dealing with the number of independent categories. test of two proportions is applicable where the experiment demands to explore statistical significance between two independent categories [ ] [ ] , whereas the chi-square test of homogeneity ( x c) is applicable if independent variable contains three or more categories [ ] [ ] . binomial logistic regression is another test that was used to predict the probability that an observation falls into one of two categories of a dichotomous dependent variable based on one or more independent variables [ ] [ ] [ ] . binomial logistic regression proved to be the best fit for examining the type of interaction that was sought between the dependent and independent variables in this study. during the fgds, detailed notes were taken in bengali language, and later it was translated into english for further analysis. of the rohingyas surveyed, % were male and % were female. respondents' age ranged from to above years old. nearly % of the respondents were aged between and , while about % were aged between and , and the rest of % were above years old. approximately % of the respondents were from maungdaw township of rakhine state; others were from akyab, buthidaung and rathedaung townships. only % were literate which means that the literacy rate is very low in this community. rohingyas' primary source of income in myanmar was agriculture and fishing. other occupations were business, teaching, tailoring, day labouring, and so on (fig. a) . male participants showed diversification in their livelihoods; while only a minority of women had varied livelihoods (e.g., farming, business) other than being a housewife. the average monthly income for those who did business or fishing was above , kyat (kyat is the currency of myanmar; usd = kyat during this research). other professionals, like physician, tailor, teacher and farmer had a monthly income of above , kyat on an average. in contrast, above % of men and % of women were found unemployed in the selected refugee camps (fig. b) in cbd. less than % of men were involved with 'cash for work' programmes run by the un agencies or non-governmental organisations (ngos). both men and women described working as volunteers or running small-scale informal businesses. 'block head' (majhi in bengali) is a type of unpaid service with which male refugees were reported to be involved. the unemployed refugees are entirely dependent on aid, more specifically on food rations. the refugees, who have entered bangladesh since august , have not yet received any legal approval to work [ ] . such barrier to income generation has amplified their vulnerability to environmental disasters including communicable disease outbreak. results suggest that more than % of the respondents came from maungdaw township in rakhine state. around % of the respondents reported their exposure to cyclone, % to flooding (riverine and coastal) and only % stated their exposure to landslide hazards in rakhine. during the fgds, rohingyas also recognised their low exposure to landslides in rakhine as most of them lived in low-lying flat land. in contrast, rohingyas are now highly exposed to rainfall-triggered landslide in the camps in cbd. the rohingyas who participated in the survey confirmed three natural hazards to which they were vulnerable (fig. ) , namely extensive rainfall, windstorm and landslides. during the fgds, rohingyas living on steep slopes have expressed no fear to flash flooding, but showed concern about the rainfall-triggered landslides. they gave credit to the spiritual power/almighty (allah) for not having encountered any catastrophic cyclone in the last three years. rohingyas revealed through the survey that receiving an early warning message and acting accordingly, maintaining storage spaces above the ground to protect non-food items, storing of medicines and dry foods were very common type of measures in preparation for a disaster. the study investigated whether the demographic features such as age or education made an impact on adapting coping strategies or not. receiving and understanding early warnings among different age groups of rohingya population produced mixed results. respondents aged under years old were more able to receive and understand early warning messages compared to other age groups (fig. ) . a sensitivity analysis was conducted to split the respondents within several age clusters. pattern of receiving and understanding early warning messages among various age groups in rohingya population in cbd. using chi-square test of homogeneity ( x c), the recorded proportional difference of receiving and understanding early warning messages within different age groups was found not to be statistically significant at the . level (p = . ). it indicates that irrespective of age groups, respondents had the similar ability in receiving and interpreting early warning messages. this hypothesis was supported by the fact that while in rakhine, most rohingya faced at least one type of natural hazard-induced disaster that taught them how to react after receiving early warnings in the event of a disaster [ ] . while in rakhine, about % of respondents of different age groups practised deliberate relocation to the nearest cyclone shelter or other ad hoc shelter (e.g., monastery, school) based on early warnings received. apart from the relocation, they used to practise some other tactics in rakhine based on the early warnings received, which they discussed in the fgds. for instance, some of them used to take shelter on the higher ground before flooding and would come back to the plains after draining out of water. again, some of them used to move all their furniture, kitchen utensils and necessary documents to the upper storey of twostoried building before flooding. the study also aimed at determining the impact of rohingya literacy on the implementation of coping strategies before disasters. a binomial logistic regression model was used to predict the probability to store dried food before a disaster strikes based on rohingya literacy status. it was important to know the overall model evaluation, statistical significance of the individual predictors and validation of predicted probabilities to assess the soundness of the model [ ] which are given in table . rohingya literacy status was a significant predictor for storing dried foods as a coping mechanism before disaster (p < . ). the logistic regression model was statistically significant (χ = ). the model explained . % (nagelkerke r ) of the variance in the storage of dried food and correctly classified . % of cases. sensitivity (the proportion of correctly classified events) was . %, specificity (the proportion of correctly classified non-events) was %. the positive predicted value (the percentage of correctly predicted cases with the observed characteristic [ ] , i.e., participants responded as 'yes' in case of storing dried food compared to the total number of cases predicted as 'yes' in case of storing dried food in advance of the disaster) was . % and the negative predicted value (the percentage of correctly predicted cases without the observed characteristic [ ] , i.e., participants responded as 'no' in case of storing dried food compared to the total number of cases predicted as 'no' in case of storing dried food in advance of the disaster) was . %. another important component is the odds ratio which deals with the change in the odds with the increase of one unit of the independent variable [ ] . here, for the rohingya literacy status, an increase in one unit (i.e., being literate) increases the odds by . it means that the odds of storing dried food before disasters ('yes' category) is times higher for literate as against illiterate rohingya (table ) . similarly, another regression model was run to predict the probability of storing medicines in advance of disasters based on rohingya literacy status. results showed that the variable 'rohingya literacy status' was statistically significant (p< . ). the logistic regression model was statistically significant (χ = ). the model explained % (nagelkerke r ) of the variance in the storage of medicines before disasters and correctly classified % of cases. the sensitivity was %, specificity was %, positive predicted value was %, and negative predicted value was %. literates have . times higher odds to exhibit storing medicines before disasters than illiterates. the study also analysed how respondents perceived relocation to a safer shelter during the disaster period in the selected rohingya camps. the majority of respondents were reluctant to evacuate to safer shelter; roughly % of them were willing to move in the case of any event. further analysis indicated that literate rohingya had the tendency to avoid relocation to safer shelters compared with their illiterate counterparts. around % of literate rohingya reported unwillingness to move to safer shelters/places while the figure was around % for the illiterate rohingya. using the test of two proportions, existing proportional difference between illiterate and literate rohingyas in case of avoiding relocation was found to be not statistically significant at the . level (p = . ). this supported the hypothesis that irrespective of the literacy status, all the respondents were uncomfortable to leave their current shelter and relocate to a safer place during any disaster. surveys revealed the reasons behind rohingyas' tendency to avoid relocation to safer shelter which include possible unsuitability of the relocation site, fear of losing the individual's own shelter, surrounding kinship bond, and weak relationship with the camp-in-charge and target population. the rohingya respondents were asked about their perception of present shelter locations. about % of the respondents reported that they either live on unstable hilltops/slopes or at the edge of hills. only % marked their shelter were located in safer zones. among them, approximately % and % respondents pointed out that their shelters are exposed to landslides and windstorms, respectively (fig. ). . . perception of rohingya on shelters exposed to natural hazards. construction of permanent structures is strictly prohibited in the camps as instructed the government of bangladesh (gob) and rrrc. refugees' shelter condition was found unsatisfactory both in terms of living standards and structural integrity to withstand natural hazards. a number of humanitarian actors have initiated several steps for shelter improvements to protect the refugees. the distribution of emergency shelter kits (esks) and upgraded shelter kits (usks) by humanitarian actors were ongoing in the camps. each usk consists of bamboo 'borak', bamboo 'mulli' ('borak' and 'mulli' are local categories of large and small-sized bamboos respectively, which are currently being used in the rohingya camp for bamboo housing construction purpose), tarpaulin and ropes [ ] . in this study, nearly % respondents stated that they received usks. in addition, shelter tie down kits (tdks) were distributed on an emergency basis to provide additional strength to the shelters to withstand against the strong winds and cyclones. each tdk consists of m of mm rope, steel pegs, sandbags, printed infographic materials on how to use tdks to secure shelters, and pieces waterproof plastic bags [ ] . around % respondents of this study received shelter tdks. during the fgds, it was also found that while most of the refugees used tdks, some of the recipients sold them to get some cash. those who got tdks used it in various ways to strengthen their shelters. for instance, respondents used the tie down ropes to resist uplifting forces (fig. a ) from strong wind, placed biodegradable sandbags at the edge of the cluster of shacks to prevent them from blown away (fig. b) , and used extra bamboos and plastic bags to reinforce the shelters to tackle monsoon rains and winds (fig. c) . a binomial logistic regression model was run to predict the probability of respondents to use tdks based on their capacity to receiving and interpreting early warning messages about upcoming disasters. results showed that the variable 'receiving and interpreting early warning messages in the camp' was statistically significant (p< . ). the logistic regression model was statistically significant (χ = ). the model explained % (nagelkerke r ) of the variance in the storage of medicines before the disasters and correctly classified % of cases. the model explained . % (nagelkerke r ) of the variance in the use of tdks and correctly classified % of cases. sensitivity was . %, specificity was %, positive predicted value was . %, and negative predicted value was . %. rohingyas who were able to interpret early warning messages exhibited times higher probability of using shelter tdks than those who were unable to interpret the alerts. the stability of shelters in the hilly area is related with the stability of the hills itself. respondents were asked about organisational strategies to stabilise the hills against rainfall-triggered landslides. they conferred some strategies that have been implemented in the camp such as placement of bamboos (fig. a) and sandbags (fig. b ) on steep hillslopes, construction of drainage system (fig. c) , retaining walls, large-scale mechanised work to level the steep hilltops, and plantation of vetiver grass across the hill slopes to avert soil erosion and the risk of landslides. around % of the participants stated that government officials take substantial measures to clear debris from roads or drainage system during the post-landslide period. also, % respondents did not get any drr training. the participants in the fgds reported that before the cyclone season, ngos provided some training in the form of briefings. however, they wanted drill exercises in their blocks. overall, participants expressed scepticism about the success of ongoing small-scale drr trainings in the camp. space constraint in the refugee camp remains one of the greatest push factors increasing disaster vulnerability. congested settlements, scarcity of open spaces, poor access to roads and other basic provisions, and restriction of movement are increasing disaster vulnerability. the availability of land has been expanded to a total of , acres in the ukhiya and teknaf upazilas [ ] . still, the gob is struggling to resolve the overcrowded situation in the camp in order to meet basic international humanitarian standards for refugees. relocation to safer places can only be a possible solution in such scenarios. bhasan char island (see appendix-ii) has been identified as a potential site to relocate around , refugees by the gob. it is a -hectare silted-up island floating in the bay of bengal and located in hatiya upazila of noakhali district ( ° ' . ''n and ° ' . ''e, elevation - m) in bangladesh [ ] . nearly % of the respondents had heard about relocation option to bhasan char island. approximately % of them were willing to move from their present location, and % were not sure about their decision. those who wanted to relocate themselves to the island identified factors that influenced their decision: access to safe drinking water, diversified income opportunities, permanent housing and more secured life in bhasan char than in myanmar (fig. ). they believe that even though the island's situation is unfavourable, life on the island is much better than tolerating violence in rakhine, myanmar. about % of respondents did not want to relocate in the island. they figured out major factors (multiple answers were captured) in favour of their decisions: instability of the island, inappropriate for human settlement, adverse weather condition, and fear to lose surrounding neighbourhoods (fig. ) . fig. . perception of the rohingya in the context of avoiding relocation to bhasan char island. a broader percentage (around %) of the respondents were inclined to repatriate to myanmar with proper citizenship. other top responses were access to proper housing, freedom of movement outside the camp, and access to diversified income opportunities (fig. ) . differences of opinion regarding repatriation to myanmar between male and female groups emerged from the fgds. men emphasized on right to property, citizenship, justice, and freedom of movement. the women participants were very concerned regarding their safety and security in rakhine. similar findings were reported by the department of peace and conflict studies at the university of dhaka in their recent publication on the rohingya exodus [ ] . attempts to adapt to changing risks posed by natural hazards has become an integral part of rohingyas' life since moving from the plain land in rakhine to the mountainous regions in cbd. the findings clearly demonstrate a positive correlation between disaster coping strategies and literacy level of rohingya refugees. regression analysis shows that the educated community is far ahead compared to the illiterate community in dealing with disasters by adopting various strategies. similar results were found by ronan et al. ( ) who reported that youth involved in hazards education programme had an increased level of disaster risk perception [ ] . mishra and suar ( ) established that people having prior disaster education and experience were more prepared to tackle flooding and heatwave events in orissa, india [ ] . education is essential to make the rohingya community resilient to disasters. however, above % of children (aged - years) and % of adolescents and youths (aged - years) still do not have access to any educational or skills development activities [ ] . no formal education is permitted in the camps and the learning centres neither follow the bangladesh nor the myanmar curriculums. in january , the gob has approved the un partners to provide informal education through a newly designed programme known as the learning competency framework and approach (lcfa). the lcfa covers english and burmese language, mathematics, life skills and science across levels to . but more than % rohingya children do not have learning competencies at lcfa grades or above [ ] . some of the obstacles are socio-cultural norms of restricting girls' mobility after puberty (purdah), allocation of learning centres in highly disaster-prone zones, difficulties in achieving education facilities, and absence of educated rohingya learning facilitators [ ] . the humanitarian actors are addressing these issues by emphasizing on sustainable learning approaches, including the establishment of new learning centres, mainstreaming weather and disaster management related issues in learning materials, and alternative learning modalities (i.e., home-based learning, mobile learning, radio-based teaching) [ ] . marlowe and bogen ( ) found that young people from refugee backgrounds in new zealand can be leaders in drr within their communities [ ] , which necessitates proving wider drr education and trainings among the rohingya children and adolescents. the culture of using shelter strengthening kits and the involvement of humanitarian actors in distributing those kits suggest that institutional cooperation enables rohingya to involve in drr initiatives. being able to understand the early warning message means to get a clear idea about the severity of the imminent disaster. rohingya who got access and capacity to interpret early warning messages were most likely to use tdks to increase the robustness of their shelter to withstand against natural hazard-induced disasters. receiving early warning messages about impending disasters in time requires improved access to information systems, which is being addressed by the communication with communities working group [ ] . it should be noted that the inter sector coordination group (iscg), in close association with the gob, manages all the active project partners and currently ongoing projects in the rohingya refugee camps in cbd. the natural hazard risk analysis taskforce (nathaz tf) operating under the iscg produces and validates hazard maps, and provides guidelines on drr strategies. the study reveals that about % respondents did not receive any drr trainings in the selected camps. there exists a growing necessity to integrate drr and emergency preparedness through a community-based approach. the jrp reports that only % shelters meet desired performance standard, % households are benefitting from treated bamboo, and % households have updated multi-hazard operational plan [ ] . the 'preparation and contingency plan' proposed by the jrp is based on a scenario where most camps and displaced rohingyas are likely to be threatened by the landfall of a category- cyclone in cbd. conceptually it is a continuing process where community learns how to respond to early warning, where to seek assistance and how to keep themselves protected during disaster period. the simulation exercise plan also highlights prevailing limitations regarding evacuations. one limitation is that construction of permanent or semi-permanent structures for the purpose of evacuation, like cyclone shelters is strictly prohibited at any part of the camp [ ] . refugees are obliged to use transitional shelters or other types of houses for the evacuation purpose which are not robust as like a permanent cyclone shelter. considering all the constraints stated above, the gob decided to transfer about , rohingyas to the island of bhasan char although there are many arguments for and against this proposition. the project with a construction cost of us$ . million has been implemented on bhasan char which includes facilities like concrete built houses, flood prevention systems, cyclone shelters, potable water and solar power systems, livelihood opportunities (fishing, agriculture, and raising livestock), hospital, police and fire station, and office premises for the partners [ ] . however, about % of the respondents in this survey did not want to be relocated to bhasan char. the island is distinctively vulnerable in terms of its formation with silt, uneven ground with mangroves and flat land, frequent change of shoreline over the past years, and extreme threats of cyclones, flooding and storm surges [ ] . some of these issues were raised by the respondents as a major cause to avoid relocation to bhasan char. the respondents were also asked about how they aspire in the long-term for better future. the answer to this question expresses their ultimate desire for repatriation to myanmar. as per the signatory of the memorandum of understanding (mou) between unhcr and bangladesh on april , no rohingya are allowed to return until conditions in myanmar are conducive for them. rohingya return to myanmar has to be voluntary, safe, dignified and sustainable in line with international standards. failure of the recent repatriation plan on august suggests that still rohingya are in fear of facing torture and violence in myanmar [ ] . the overall disaster context in the rohingya camps in cbd is dynamic and scenarios change quite frequently. the gob and humanitarian agencies have undertaken a number of emergency preparedness initiatives (as updated on march ) in each camp -such as formation of a disaster management committee, identifying temporal communal shelters (existing learning centres) and emergency back-up distribution sites, reinforcing critical infrastructure, prepositioning adequate emergency shelter stock (tarpaulins, ropes and flood mats), providing emergency rapid food assistance, mapping infrastructure and services in high risk zones, protection messaging and awareness-raising, ensuring minimal disruption to critical services like health, water, sanitation, and hygiene (wash), and protection, and continued training for temporary learning centre facilitators, teachers and students [ ] . the novel coronavirus (covid- ) pandemic is another major concern for the rohingya refugees in cbd, as they do not have freedom of movement, are living in exceedingly overcrowded camps, and the existing health centres are not equipped with necessary testing and treatment facilities (e.g. intensive care unit, oxygen supply and ventilators, and personal protective equipment for health workers). the covid- outbreak, in addition to natural disasters, would result in a severe humanitarian crisis. as instructed by the un covid- global humanitarian response plan [ ] , the gob, iscg and partners are advancing with the construction of an isolation and treatment centres, reducing activities to essential services and assistances only, promoting hygiene activities, training healthcare workers, and ensuring social distancing inside the camps [ ] . as of april , the entire cbd including the camps are now locked down, and no rohingya is even allowed to move between two camps until further notice. unprecedented deforestation and indiscriminate hill cutting activities took place in cbd to build makeshift shelters and supply cooking materials (wood) for the rohingya refugees. because of it, nearly , hectares of forest land cover disappeared [ ] that has also increased landslide disaster risk significantly. to address this matter, the partners are now providing liquid petroleum gas (lpg) cylinders and refilling them monthly. almost % rohingya households are now covered under this scheme for the purpose of cooking and household-level lighting [ ] . the gob is also considering to initiate the myanmar national curriculum framework in to ensure more formal education for the rohingya children and adolescents and facilitate their sustainable repatriation in myanmar [ ] . regarding the rohingya relocation to bhasan char, the gob is not insisting to implement the plan as it will be voluntary. the un desires to assess the overall situation in bhasan char in terms of its safety and sustainability, exposure to natural hazards, freshwater availability and the standard of protection facilities. as of today, there is no further progress on the un assessment and the decision of relocating the rohingyas is halted [ ] . in the meantime, on march , the gob has instructed low-income bangladeshi citizens, who are unable to maintain their livelihood in urban or rural areas, to take refuge or use the facilities in bhasan char amid the growing threats of coronavirus (covid- ) outbreak. to withstand during the cyclone and monsoon season (may to october), immediate steps should include strengthening and reinforcing refugees' makeshift shelters and critical infrastructures. in the short-term, wider level and continuing education should be in place to promote good practices, skill development trainings and education on drr. this is a protection crisis, and the rohingya refugees specially women and girls face extreme gender-based violence, many of them are subject to human trafficking, and the rohingyas' top priorities are shelter materials, food, clean drinking water, fuel and electricity [ ] . therefore, in the long-run, it is necessary to safeguard them, continue life-saving assistance, promote peaceful co-existence with host communities, and achieve sustainable solutions in myanmar to create an environment for their voluntary, dignified, and safe repatriation. fig. illustrates rohingyas' physical, social, economic, environment, cultural and institutional dimensions of vulnerability to environmental hazards. the outcomes validates that disasters are not exclusively natural [ ] . it is the (flawed) decision making process and blending of complex socio-economic and socio-cultural aspects [ ] that are accountable for converting hazards into catastrophic disasters. the decision makers, camp in charge (cic) and emergency managers should have indepth knowledge on the root-causes of disaster vulnerability for achieving a sustainable solution them. the study aims to find out how rohingya are coping with extreme weather events, such as floods, heavy rains, landslides, and windstorms in the kutupalong camp in cox's bazar district. the results show some preventive and impact minimising strategies developed and adopted by the rohingyas to withstand disasters. these include practices in individual household (e.g., receiving multi-hazard early warning messages and acting accordingly, maintaining storage spaces above the ground to protect non-food items, storing medicine and dry foods before any impending disaster) to collective efforts (e.g., strengthening shelters by means of shelter improvement kits distributed by the humanitarian actors). furthermore, slope stabilisation works such as placement of bamboos or sandbags on the hillslopes, construction of retaining walls and drainage, implementation of mechanised work to level steep hilltops, and plantation of vetiver grass are some examples undertaken to make the camps resilient to natural hazards. it is understood that rohingyas have adopted several risk mitigation strategies to sustain their existence with the paradigm of shifting risks posed by natural hazards. consequently, the study gets enough evidence to accept the alternative hypothesis of this study. the study has three major contributions in the field of drr. first, it provides a solid baseline on how a refugee community in a humanitarian context might differ compared to other grassroot communities in terms of coping with disasters. second, it contributes in achieving some of the priorities outlined by the sendai framework for disaster risk reduction (understanding disaster risk) [ ] , and the un sustainable developments goals (ensuring education for all, leaving no one behind, promoting peaceful and inclusive societies, and making cities and human settlements resilient) [ ] . lastly, the findings and recommendations would support the government of bangladesh, united nations and humanitarian stakeholders to identify some of the gaps in mitigating disaster risks from extreme natural hazards in the rohingya camps in bangladesh. the authors have no competing interests to declare. more peaceful and secure than our habitats in rakhine ii. i receive aids from humanitarian agencies iii. i receive food without doing any work iv. we are treated here with dignity; not as an illegal immigrant or danger v. all of the above vi. others, please specify . if no, why? what were the benefits in rakhine? i. property ii. access to formal schooling iii. access to health facilities iv. employment v. it was our own land vi. all of the above vii. others, please specify . what else could be provided to make things better for you? repatriation with proper citizenship of myanmar ii. freedom of movement in bangladesh iii. if proper housing is provided, i will stay in bangladesh iv. access to schooling in bangladesh v. diversified livelihood opportunity vi. more upgraded drr training vii. all of the above viii. others, please specify climate change and disaster management response to dynamic flood hazard factors in peninsular malaysia flooding, vulnerability and coping strategies: local responses to a global threat local disaster risk reduction in latin american 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united nations office for the coordination of humanitarian affairs (ocha) global humanitarian response plan covid- . the united nations office for the coordination of humanitarian affairs (ocha) covid- : preparedness and response for the rohingya refugee camps and host communities in cox's bazar district. inter sector coordination group (iscg) -bangladesh. united nations office for the coordination of humanitarian affairs (ocha) application of geospatial technologies in developing a dynamic landslide early warning system in a humanitarian context: the rohingya refugee crisis in cox's bazar disaster by choice: how our actions turn natural hazards into catastrophes framing vulnerability, risk and societal responses: the move framework sendai framework for disaster risk reduction - . the united nations office for disaster risk reduction (unisdr) sustainable development goals. the united nations (un) questionnaire for household survey in the rohingya camps in cox's bazar, bangladesh survey date: survey time: survey location female iii. other, please specify . specify your: education (class) or illiterate? where you live in burma? (village, district/state) previous occupation (in rakhine) your avg. monthly income in rakhine when did you arrive in bangladesh? section b -rohingya refugees' perception on natural hazards and disaster risk reduction (drr) if yes, what were the natural disasters to which you were exposed in the rakhine state of burma? chronological development of settlements ( - ) in the bhasan char island in bangladesh we are grateful to the ministry of disaster management and relief (modmr), ministry of foreign affairs (mofa), office of the refugee relief and repatriation commission (rrrc), university of dhaka (du), and the cox's bazar development authority (coxda) for allowing us to enter the rohingya camps in cox's bazar and supporting us to conduct necessary fieldwork/surveys. we are also indebted to the respective rohingya refugees and members of the host communities for assisting us on numerous occasions. this research is funded by the british academy as part of the project, "rohingya journeys of violence and resilience in bangladesh and its neighbours: historical and contemporary perspectives" (award reference: sdp \ ), supported under the uk government's global challenges research fund (gcrf). the first author was a commonwealth scholar funded by the uk government. key: cord- -q hqra authors: paul, kishor kumar; salje, henrik; rahman, muhammad w.; rahman, mahmudur; gurley, emily s. title: comparing insights from clinic-based versus community-based outbreak investigations: a case study of chikungunya in bangladesh date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: q hqra abstract background outbreak investigations typically focus their efforts on identifying cases that present at healthcare facilities. however, these cases rarely represent all cases in the wider community. in this context, community-based investigations may provide additional insight into key risk factors for infection, however, the benefits of these more laborious data collection strategies remains unclear. methods we used different subsets of the data from a comprehensive outbreak investigation to compare the inferences we make in alternative investigation strategies. results the outbreak investigation team interviewed , individuals from homes. ( %) of individuals had symptoms consistent with chikungunya. a theoretical clinic-based study would have identified % of the cases. adding in community-based cases provided an overall estimate of the attack rate in the community. comparison with controls from the same household revealed that those with at least secondary education had a reduced risk. finally, enrolling residents from households across the community allowed us to characterize spatial heterogeneity of risk and identify the type of clothing usually worn and travel history as risk factors. this also revealed that household-level use of mosquito control was not associated with infection. conclusions these findings highlight that while clinic-based studies may be easier to conduct, they only provide limited insight into the burden and risk factors for disease. enrolling people who escaped from infection, both in the household and in the community allows a step change in our understanding of the spread of a pathogen and maximizes opportunities for control. infectious disease outbreaks have the potential to place a significant burden on public health resources. understanding who is at risk of becoming infected is critical for the focused targeting of interventions. due to relative ease of access and limited cost requirements, outbreak investigations typically focus on cases that present at formal healthcare centers such as hospitals or community clinics. for example, data collection performed as part of epidemiological investigations during the recent epidemics of ebola, zika and mers focused on quantifying the number of cases and their characteristics. (al-abdallat et al., , lu et al., , teixeira et al., these case-counting exercises provided key insights into fundamental epidemiological parameters such as the basic reproductive number and case fatality rates, and allowed the projection of the future course of the epidemic. (aylward et al., , lessler et al., , lewnard et al., , yamin et al., however, without information on the underlying population, and especially characteristics of individuals who avoid infection, these approaches limit our ability to make mechanistic insights, quantify burden of disease, and identify risk factors for infection, hampering efforts to develop targeted control strategies. cases that present at healthcare centers may only represent a small minority of all cases. in addition, some individuals are more likely to visit formal healthcare providers than others, including those with more severe illness, and differences in healthcare seeking can vary by age, gender and socioeconomic status. (chowdhury et al., , nikolay et al., , pandey et al., household-based outbreak investigations, where investigation teams visit affected j o u r n a l p r e -p r o o f communities, permit a more comprehensive understanding of pathogen spread that limits the impact of healthcare seeking patterns. (france et al., ) however, these investigations are usually still focused on identifying individuals that got sick. (boore et al., , france et al., without also understanding who is avoiding infection in a community, it is difficult to identify the key risk factors for infection, limiting potential inferences. the possible insights from alternative investigation strategies have not previously been systematically compared. here, we use the results of a detailed chikungunya outbreak investigation from bangladesh as an example to consider the inferences made under different investigation scenarios. chikungunya virus is a mosquito-borne alphavirus transmitted to humans by aedes mosquitoes causing acute fever, joint pain, and skin rash. (aubry et al., ) chikungunya fever was first recognized in in tanzania. (lumsden, ) since then, outbreaks of chikungunya have been regularly identified across the tropics and sub-tropics. the first chikungunya outbreak in bangladesh was identified in in two northwestern districts bordering india.(icddr) since then regular outbreaks have been detected. (khatun et al., , salje et al., b here we use the results from a detailed investigation of an outbreak of chikungunya virus in a village in tangail, bangladesh where the outbreak team visited every household in the community and interviewed all members in each household. the comprehensive household investigation captured both those who did get infected and those that escaped from infection. the objective of this study was to compare our approach, in terms of the inferences about the outbreak, to more limited investigation strategies. in late november , a local health official of gopalpur sub-district in tangail households in the village consented to being enrolled in the study. questionnaires were administered in all households to identify suspected cases, identify demographic characteristics, and travel histories of individuals within households. suspect cases were defined as residents with acute onset of fever with rash or joint pain within months prior to beginning the investigation. study staff administered questionnaires to household heads about household members' demographic data and history of illness, water source, construction materials, and mosquito control measures in the household. potential mosquito breeding containers in and around the participating households with stored water were inspected for presence of larvae. suspected cases were asked about their symptoms with onset date and specifics about their treatment seeking behavior. the gps location of all homes was also recorded. determining the etiology of the outbreak all household members, irrespective of their suspected case status, were asked to provide a single ml blood specimen for laboratory testing. blood specimens were spun in the field to separate serum, which were then stored on ice and transported to the virology laboratory of iedcr. the serum samples were tested for igm antibodies against chikungunya by enzyme linked immunosorbant assay (elisa) (standard diagnostics, inc., south korea). suspected casepatients who had igm antibodies against chikungunya in their serum were termed laboratory confirmed cases. we created four different datasets that allowed us to consider different outbreak investigation strategies: this dataset consisted of all suspect cases that reported that they visited a formal healthcare setting (defined as government or non-government primary healthcare center/clinic/hospital) following the onset of symptoms. this dataset consisted of all suspect cases, irrespective of their healthcare seeking behaviors. this dataset consisted of all suspect cases plus controls consisting of household members of these cases. this dataset consisted of all members of all households in the community, regardless of symptoms. the epidemic curve was constructed using symptom onset date of chikungunya cases. gps locations of households with and without chikungunya cases were used to prepare spatial distribution maps. for the case-only datasets (datasets a and b), we compared the age and sex distribution of the cases with that for the district from the census (bangladesh bureau of statistics, ) . for the datasets with information on individuals who escaped from infection (datasets c and d), we initially used simple logistic regression to compare the demographics, typical apparel worn, travel history within the last six months, and household characteristics of cases with non-cases. we then built multivariable logistic regression models to identify adjusted risk factors for chikungunya fever. we initially placed all variables with a p-value of < . in the unadjusted analysis into a multivariable model. we then used backward stepwise selection using the akaike information criterion (aic) (sauerbrei et al., ) to identify the best model. not all individuals who get infected will present with symptoms. we attempted to capture these individuals by asking for blood samples from all community members. to assess the impact of j o u r n a l p r e -p r o o f misclassifying asymptomatically infected individuals as controls in datasets c and d, we conducted sensitivity analyses where these individuals were reclassified as cases. all participants provided written informed consent prior to interviews and blood specimen collection and the ministry of health and family welfare, government of bangladesh reviewed and approved the outbreak investigation plan. the ninety-five suspect cases reported visiting a formal healthcare facility for symptoms consistent with chikungunya between july and november, with the peak number of cases occurring in j o u r n a l p r e -p r o o f october (figure : panel a). cases sought care in three different centers: sought care in a government run community clinic, in a government run sub-district health complex and in a private clinic. the median age was years (interquartile range (iqr) = - years) and the majority ( %) were female (table ). if we used the age and sex distribution of the district from the national census, we find that there is an increased risk of disease in those between the ages of - compared to those aged below years (or . , % . - . ) and that females were at increased risk of infection compared to males (or of . , % ci: . - . ) ( table ) . an additional suspect cases were identified in the community who did not seek care in formal healthcare facilities. of these, individuals visited a local pharmacy and individuals visited the informal sector (unlicensed medical practitioner, traditional healer, and homeopath). the distribution of dates of symptom onset for all cases was nearly identical to the distribution for those that visited clinics (spearman correlation of . ) ( figure a ). the proportion of suspect cases visiting a clinic varied between % in - years age group and % in ≤ years age group ( figure b) . the conclusions about age, sex, educational levels, use of mosquito controls and clinical presentation of suspect cases were similar when using datasets of all cases or only those that sought care in clinics (table ) , however, those who presented to clinics were more likely to travel outside the district ( % vs %, p-value . ). cases who attended formal healthcare settings also appeared to come from similar parts of the community as cases who did not (figure a-b) . similar to the analysis using clinical cases only, using data from the national census identified increasing risk among females for being a case (table ) . inference from community cases plus controls from same household j o u r n a l p r e -p r o o f incorporating controls from the households where cases reside allowed us to assess additional potential risk factors for being a case. consistent with inferences using census data, logistic regression models that used household controls also identified increased risk among females (aor . , % ci . - . ) ( table ). in addition, this analysis showed that cases were significantly less likely to have secondary (aor . , % ci . - . ) or more formal (higher secondary) education (aor . , % ci . - . ) compared to the household controls. incorporating data from the entire community showed that the chikungunya outbreak was largely constrained to the center of the village, with few households affected on the east and west borders but virtually all households affected in the center ( figure c ). this is despite the entire community only being a few hundred meters wide. the expanded dataset also allowed us to understand the risk factors for infection in the wider community. as with the previous analyses, females had an increased risk of being a case (or: . , % ci . - . ) ( table ), although the difference by sex was concentrated in adults with no difference among children ( figure c ). further individuals who reported usually wearing clothing that exposed both limbs had . the odds of being a case compared to individuals wearing clothing that exposed upper limbs only ( % ci . - . ). those who had travelled outside tangail district within the last six months also had increased odds of being a case (aor . , % ci . - . ). individuals who had higher secondary or more formal education (aor . , % ci . - . ) were less likely to be a case than individuals without formal education. we did not identify any household characteristics that were associated with being a case, including presence of mosquito larvae (aor . , % ci: . - . ), daily use of anti-mosquito coil (aor . , % ci: . - . ), number of j o u r n a l p r e -p r o o f household members (aor . , % ci: . - . ), and number of rooms in the household (aor . , % ci: . - . ). fifty-two individuals without symptoms tested positive for chikv. we found no significant demographic differences between symptomatic suspected cases and igm-confirmed asymptomatic cases in those who gave blood (table s ). in sensitivity analysis, we removed these individuals from the 'control' population and included them in the 'case' populations. risk factors for being a case identified in the previous analysis remained similar in both scenarios where we considered household contacts as controls and individuals from all community households as controls (supplementary information, table s ). however, we found important differences in the probability of providing blood. those with symptoms were . times more likely to provide blood than those without symptoms. further, among asymptomatic individuals, only % of children - years provided a sample compared to % among those - (table s ). there were also significant differences by sex ( % of asymptomatic males gave blood compared to % of females, p-value < . ) and educational level with more educated people less likely to provide samples (table s ). outbreak investigations are central to informed responses to public health emergencies caused by the emergence of an infectious pathogen. however, outbreak investigations currently largely revolve around case-counting exercises that limit our ability to identify who is at risk for j o u r n a l p r e -p r o o f infection and who is not. here, by using the results of a comprehensive outbreak investigation, we have been able to explicitly explore the impact of different investigation strategies in the same outbreak. we found that a clinic-based study that used data from all the formal healthcare settings would have identified a quarter of all cases and, using census data, have correctly identified female sex as an important risk factor for disease. however, it is only through the recruitment of people who did not get sick that we could identify the importance of travel history, educational level and apparel usage in determining who gets sick. controls from the wider community were also required to demonstrate which household-level characteristics were important for risk, showing that the use of mosquito coils was not protective, and to map spatial heterogeneity in risk, key to intervention development and deployment. this study highlights the significant heterogeneity in healthcare seeking. even in a small community such as this, cases visited nine different sources of healthcare, three of which could be considered formal healthcare settings. infectious disease surveillance activities are unlikely to be able to collate datasets from this diverse range of healthcare sources, even among only those within formal sector, suggesting that outbreak investigations that rely on cases that seek healthcare likely substantially underestimate the magnitude of outbreaks. using the results of our study, we provide our assessment of the ability of different investigation strategies to capture key characteristics of an outbreak (table ). in practice, the decision to expand outbreak investigations beyond information available from healthcare systems will depend on the resources available. where outbreak teams are already performing communitybased case-investigations, the additional time and effort to also collect data on those without symptomsboth from case-households as well as neighboring householdsmay be marginal. this comprehensive outbreak investigation employed ten field-based investigators and took seven days to complete. an investigation strategy only focused on cases in the community would have taken only marginally less person-time as finding cases in the community anyway typically requires comprehensive door-to-door surveys. our findings highlight how this additional data collection effort can help reveal the drivers of transmission, allowing mechanistic insight into pathogen spread and maximizing opportunities to control, many of which would not be possible from case-based investigations (table )..where it is collected, an additional major benefit of the comprehensive dataset is that it can inform mathematical models that reconstruct entire outbreaks, allowing us to estimate the mean transmission distance (previously estimated here at meters) (salje et al., b) . travelling outside tangail district within the six months before the outbreak was associated with increased chikungunya fever risk. human movement can introduce chikv into new areas, causing epidemics (chretien and linthicum, ) . no other areas of bangladesh were reporting outbreaks of chikv at this time, though outbreaks may have been missed due to poor surveillance. although individuals of all ages were affected by chikungunya in this outbreak, incidence increased with age among females, potentially linked to increased time women spend at home compared to males, increasing their risk of being bitten by the largely home-dwelling aedes mosquito (salje et al., b) . in this outbreak, household use of mosquito coils was not protective against chikungunya, which is consistent with the findings from a recent meta-analysis on household level risk factors for dengue, which is also spread through aedes mosquitoes (bowman et al., ) . serum samples have the potential to provide important information about the level of asymptomatic infection during an outbreak, as has previously been shown during previous chikv outbreaks (salje et al., a , sissoko et al., . in addition, this outbreak investigation was carried out six months after the outbreak began and community members may have been unable to reliably recall their symptoms or the date their symptoms started, particularly for milder illnesses, which may have led to an underestimation of suspected cases. serological confirmation could help detect any missing infections. however, our study highlights how some caution needs to be taken when interpreting serological data. firstly, while we sought to obtain blood samples from all participants, only one in five individuals agreed. we found that the probability of agreeing to provide blood depended strongly on having had chikungunya symptoms (individuals who had symptoms were more likely to provide samples). children, women and those with a high educational level were less likely to give blood. secondly, the sensitivity of the commercial assay we used has been estimated to be < % in individuals where igm is still circulating (johnson et al., ) and is likely to be even lower here, as the blood draw occurred after igm antibodies would have waned to undetectable levels for many infected individuals (kam et al., ) . future studies should consider underlying biases in who is providing blood as well as considering the use of complementary igg assays to help improve the interpretability of serological findings. this investigation suggests that chikungunya virus has become an emerging public health problem in bangladesh, and outbreak investigations of emerging infections often have the objective of estimating attack rates of diseases and identifying the risk factors that lead to infection. our analysis suggests that the optimal strategy for attaining these objectives during an outbreak is to conduct case finding, testing, and data collection in communities. many recent j o u r n a l p r e -p r o o f outbreaks of emerging infections have suffered due to a lack of detailed information about attack rates and risk for infection, due to their limited investigation strategies (ahmed et al., , ballera et al., , khatun et al., . future investigations of emerging infection outbreaks should consider using these more intensive strategies, at least in a subset of investigations, to improve our understanding of these infections and our public health response. according to institutional data policy of the international centre for diarrhoeal disease research, bangladesh (icddr,b), summary of data can be publicly displayed or can be made publicly accessible. to protect intellectual property rights of primary data, icddr,b cannot make primary data publicly available. however, upon request, institutional data access committee of icddr,b can provide access to primary data to any individual, upon reviewing the nature and potential use of the data. requests for data can be forwarded to: this work was supported by centers for disease control and prevention (cdc), atlanta, usa [cooperative agreement no: u ci ]. in addition, the government of bangladesh, canada, sweden and the uk provided core/unrestricted funding support for this work. the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. chikungunya virus outbreak hospital-associated outbreak of middle east respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description chikungunya outbreak ebola virus disease in west africa--the first months of the epidemic and forward projections investigation of chikungunya fever outbreak in laguna bangladesh population and housing census added value of a household-level study during an outbreak investigation of salmonella serotype saintpaul infections is dengue vector control deficient in effectiveness or evidence?: systematic review and meta-analysis delivery complications and healthcare-seeking behaviour: the bangladesh demographic 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title: a novel rna virus, macrobrachium rosenbergii golda virus (mrgv), linked to mass mortalities of the larval giant freshwater prawn in bangladesh date: - - journal: viruses doi: . /v sha: doc_id: cord_uid: l v x mass mortalities of the larval stage of the giant freshwater prawn, macrobrachium rosenbergii, have been occurring in bangladesh since . mortalities can reach % and have resulted in an % decline in the number of hatcheries actively producing m. rosenbergii. to investigate a causative agent for the mortalities, a disease challenge was carried out using infected material from a hatchery experiencing mortalities. moribund larvae from the challenge were prepared for metatranscriptomic sequencing. de novo virus assembly revealed a kb single-stranded positive-sense rna virus with similarities in key protein motif sequences to yellow head virus (yhv), an rna virus that causes mass mortalities in marine shrimp aquaculture, and other viruses in the nidovirales order. primers were designed against the novel virus and used to screen cdna from larvae sampled from hatcheries in the south of bangladesh from two consecutive years. larvae from all hatcheries screened from both years were positive by pcr for the novel virus, including larvae from a hatchery that at the point of sampling appeared healthy, but later experienced mortalities. these screens suggest that the virus is widespread in m. rosenbergii hatchery culture in southern bangladesh, and that early detection of the virus can be achieved by pcr. the hypothesised protein motifs of macrobrachium rosenbergii golda virus (mrgv) suggest that it is likely to be a new species within the nidovirales order. biosecurity measures should be taken in order to mitigate global spread through the movement of post-larvae within and between countries, which has previously been linked to other virus outbreaks in crustacean aquaculture. the giant river prawn (macrobrachium rosenbergii) is a species of global aquaculture importance, with culture rapidly expanding from < t in to > , t worldwide in [ ] . production, particularly in developing parts of asia, provides direct and indirect employment, a food source to alleviate poverty, and export income in a high value international market [ ] . despite the exponential growth of the prawn industry, disease has been a significant problem, and when mortalities occur they are usually high, causing widespread impacts to the socioeconomic balance in these countries [ ] . bangladesh is considered to be a favourable environment for farming m. rosenbergii, named 'golda' by bangladeshi farmers, due to its vast inland freshwater river systems with adjacent brackish areas and a suitable climate for culturing tropical and sub-tropical aquaculture species [ ] . in , bangladesh was the world's second largest producer of m. rosenbergii, producing , t [ ]. despite this promising production figure, m. rosenbergii hatcheries have been experiencing mass mortalities of larvae, resulting in the number of hatcheries actively producing larvae declining by almost % over the past decade as they are unable to complete the production cycle and it becomes uneconomical to continue. between and , over hatcheries were operating in bangladesh, producing up to two hundred million post-larvae (pl) per year; however, in production had decreased to . million pl/year from only hatcheries [ , ] . hatcheries experiencing mortalities reported that larvae had abnormal shapes, reduced appetite, issues with moulting and a gradual whitening of the body, finally resulting in either disappearance from the culture system, or mortality [ ] . to compensate for the loss of hatchery-produced post-larvae, wild post-larvae are being caught from the vast river systems in the south of bangladesh, violating a government ban on the capture of wild pl [ ] . ahmed and troell [ ] reviewed the potential for negative environmental impact associated with fishing for wild pl and identified two main issues; high levels of invertebrate and fish bycatch associated with fishing for larvae (and a subsequent decline in biodiversity) and a reduction in numbers of larvae returning to the freshwater environment as adults to spawn (reducing natural m. rosenbergii abundance). as fishing for wild post-larvae increases due to the hatcheries being unable to complete production cycles, it is likely that the negative environmental impact caused by fishing will become more pronounced. a number of surveys have been carried out by several organisations to determine possible causes for the mortalities observed in hatcheries in bangladesh. the surveys identified many shortcomings, including deficiencies in water quality, water filtration systems, temperature fluctuations due to weather conditions, feeding practices, probiotic use and poor-quality inputs that had been exposed to formalin and bleaching [ ] . however, despite these constraints, hatcheries were successfully completing production cycles until , suggesting that a new factor has arisen, which could be disease-related. biosecurity has been highlighted as a major issue, in relation to the spread of mortalities throughout the hatcheries of bangladesh. as the culture of m. rosenbergii has increased globally, the incidence of diseases and emergence of novel pathogens has increased in parallel [ ] . diseases known to affect different life stages of the giant freshwater prawn include numerous pathogenic bacteria, viruses and fungi. opportunistic bacteria such as aeromonas spp., pseudomonas spp. and vibrio spp. can cause infections in all life stages of m. rosenbergii culture (reviewed in pillai and bonami [ ] ). spiroplasma eriocheiris [ ] has been shown to cause mortalities in later life stages of m. rosenbergii. macrobrachium rosenbergii nodavirus (mrnv) [ ] , in association with extra small virus (xsv) [ ] , causes white tail disease (wtd), a disease listed by the world organisation for animal health (oie). the viruses have caused devastation in the prawn hatchery industries of thailand [ ] , china [ ] , india [ ] , taiwan [ ] and indonesia [ ] . other viruses causing mortalities include macrobrachium rosenbergii taihu virus (mrtv), a novel dicistrovirus associated with larval mortalities in china [ ] , infectious hypodermal and haematopoietic necrosis virus (ihhnv) [ ] , and decapod iridescent virus (div ) [ ] . other pathogens have been identified to infect m. rosenbergii without large mortalities including: macrobrachium parvo-like virus (mpv) [ ] and white spot syndrome virus (wssv) [ , ] . with the lack of immortal shrimp cell lines, disease challenges can be used to identify pathogenic agents infecting m. rosenbergii. this technique was recently used to determine that mrnv alone can cause mortalities in m. rosenbergii in the absence of xsv [ ] . alam et al. ( ) attempted to determine the causative agent(s) associated with the larval mortalities in bangladesh hatcheries using a screen for vibrio spp., which are known to cause disease in larval stages of prawn culture [ ] . however, this study was unable to find a strong correlation between the vibrio species present and the levels of mortalities seen in larvae. larvae were also screened for the presence of mrnv and xsv, but neither of these were detected. therefore, no significant pathogens have yet been associated with the large-scale larval mortalities in bangladesh. the clinical signs of disease observed in these larvae associated with the current large-scale mortalities do not precisely fit those described for infection with any of the known larval prawn pathogens; therefore, an approach to detect novel pathogens was needed to determine if there was a pathogenic cause for the mortalities. in this study we ( ) carried out an experimental challenge trial using larvae sourced from a hatchery displaying disease, ( ) generated and analysed metatranscriptomic libraries obtained from pools of larvae from experimental trials to identify any potential pathogens present in moribund animals, and ( ) screened for pathogens identified as a risk in other hatcheries that had been experiencing mortalities to determine whether these agents were present. larvae were collected from six hatcheries in southern bangladesh over the production seasons of and . batches of approximately - whole larvae were fixed in rnalater. in the same years, adult m. rosenbergii were collected from seven rivers, also in southern bangladesh (figure ). to produce materials for disease challenge, moribund larvae were collected from a hatchery that was experiencing mortalities at the time of the study. larvae were ground using a sterile pestle and mortar, suspended in phosphate buffered saline (pbs) and filtered through a . µm syringe filter. larvae from a healthy hatchery that had not experienced mortalities in past production cycles were also collected and prepared in the same manner as a control treatment. experimental larvae were obtained from bangladesh fisheries research institute's (brfi) domesticated f broodstock. after hatching, larvae were reared up to stage three, before splitting into three groups for different experimental tank exposures. experimental larvae were directly immersed into filtered challenge medium from moribund larvae for min prior to being transferred to a fibreglass tank. experimental larvae were fed artemia that had been immersed in challenge medium from moribund larvae for min. experimental larvae were immersed into filtered challenge medium from healthy larvae for min prior to being transferred to a fibreglass tank. for all experiments, ± larvae were used, and experiments were carried out in l fibreglass tanks heated to a constant temperature of • c with a submerged thermostat heater. larvae were fed three times per day ( g/ l) with red jungle brand ® artemia (ocean star international, snowville, ut, usa). twenty to thirty larvae were collected every day for the first five days of the experiment and on days seven and ten. rna was extracted using ribozol™ (vwr, radnor, pa, usa). for larvae, approximately larvae were added to ml ribozol, and for adults, approximately mg of each tissue type (pleopod, hepatopancreas, gill, gut) was pooled and added to ml of ribozol. rna extraction was carried out following the manufacturer's protocol, with a final resuspension in µl molecular grade water (fisher scientific, waltham ma, usa). to remove any dna co-extracted with rna, a dnase step was carried out using dnase (sigma aldrich, st. louis, mo, usa), following the manufacturer's protocol. first strand synthesis was performed in µl reaction volumes using µl of mmlv-rt × buffer (promega, madison, wi, usa), . µl of dntps ( mm) (promega), . µl of recombinant rnasin (promega), µl of random hexamer primers (promega) and µg of rna in . µl. prior to the addition of µl of mmlv-rt enzyme (promega), the reaction was incubated at • c in order to denature double stranded rna. following the addition of the mmlv-rt, the reaction was incubated at • c for h. second strand synthesis was performed immediately after first strand synthesis. single-stranded cdna was incubated at • c for min, followed by • c for min. following incubation, µl sequenase buffer (thermo fisher, waltham, ma, usa), . µl sequenase (thermo fisher) and . µl molecular grade water (thermo fisher) were added. following this, reactions were incubated at • c for min, • c for min and • c for min. during incubation at • c, . µl : (sequenase:sequenase dilution buffer (thermo fisher)) diluted sequenase was added to reactions and incubated at • c for min and • c for min prior to transfer to ice. three pools of cdna were constructed from in vivo tank experiments: ( ) challenge days - larvae from immersion and feeding challenges using filtered medium from moribund larvae ( ) challenge days - larvae from immersion and feeding challenges using filtered medium from moribund larvae and ( ) larvae from a hatchery that had been experiencing mass mortalities. these pools were prepared for metatranscriptomic sequencing using the illumina compatible nextera xt library preparation kit (illumina, san diego, ca, usa) and sequenced on an illumina miseq using v chemistry (illumina). the generated raw illumina paired-end sequence reads were trimmed to remove adaptor and low quality sequences using trim galore! v . . [ ] . trimmed sequences were quality-checked using fastqc v . . [ ] before reads from individual pools were assembled using both rnaspades v . . [ ] and the iterative virus assembler (iva) v . . [ ] . assembled contigs were subsequently annotated using the blastp algorithm of diamond v . . [ ] and the full ncbi non-redundant (nr) protein database (downloaded november ), and the results were visualised using megan community edition v . . [ ] . paired reads from all samples were then mapped to the assembled contig representing the viral genome sequence using bwa-mem v . . and samtools v . with default parameters [ , ] . the output from bwa-mem was visualised with integrative genomics viewer (igv) v . . [ ] . assembly quality and accuracy were assessed with qualimap v . . [ ] . predicted open reading frames (orfs) were identified using four different tools: prokka v . [ ] fgenesv (softberry.com), genemarks v . [ ] and vgas [ ] . orfs that were supported by two or more programs were analysed further. supported orfs were annotated using ncbi blastp and the full ncbi protein sequence database (downloaded december ) and protein motifs were identified by hhpred [ ] (default parameters) and interproscan [ ] . predicted protein motifs were aligned against known nidovirus protein motifs using mafft [ ] and multiple sequence alignments (msas) were visualised in esprict v . [ ] (default parameters). transmembrane regions were identified using tmhmm v . [ ] (default parameters). ribosomal frameshift identifiers were found using fsfinder using the virus genome settings [ ] . secondary structure of the untranslated region (utr) was predicted using mfold [ ] (default parameters). phylogenetic analyses was performed using the rna-dependent rna polymerase (rdrp) protein domain as in saberi et al. [ ] , conserved in known and proposed nidovirales, on nidovirales with representatives from arteriviradae, roniviridae, mesoniviridae, mononiviridae, euroniviridae, coronavirinae and torovirinae families and subfamilies. two representatives from the astroviradae order of viruses were also aligned as an outgroup. msas were performed using default parameters in mafft [ ] . maximum likelihood phylogenetic analyses were carried out using raxml blackbox v. [ ] (generalised time-reversible (gtr) evolutionary model; all parameters estimated from the data). a bayesian consensus tree was constructed using mrbayes v. . . [ ] . two separate multi-core markov-chain monte carlo (mc ) runs with randomly generated starting trees were carried out for million generations each with one cold and three heated chains using a gtr model. all parameters were estimated from the data. the trees were sampled every generations and the first , generations discarded as burn-in. all phylogenetic analyses were carried out on the cipres server [ ] . primers specific to the predicted enveloping protein orf of mrgv were designed using primer v . . [ ] using default settings and an amplicon length of - bp: mrgv_f : -tttgcccaggttaattgccc- and mrgv_f : -acaagtgccagtgagacgta- , producing an amplicon of bp. pcr amplification was performed in µl reactions using µl × green gotaq flexi buffer (promega), . µl mgcl ( mm) (promega), . µl of each primer ( µm), . µl dntps ( mm) (promega), . µl gotaq polymerase (promega), . µl molecular grade water and . µl of template cdna. initial denaturation was carried out at • c for min, followed by cycles of • c for s, • c for s and • c for s. this was followed by a final extension at • c for min. amplicons were purified with wizard ® sv gel and pcr clean-up system (promega) and sequenced via the eurofins tubeseq service. primers were tested on larval cdna from five hatcheries and cdna from wild adult m. rosenbergii sampled from the river networks surrounding the hatcheries. cdna from penaeus monodon tissues infected with yellow head virus (yhv) were tested as a negative control. pcr screens for specific pathogens were carried out with the following primers: mrnv using mrnv af and mrnv ar primers [ ] ; xsv using xsv-external forward and reverse primers [ ] ; mrtv using mrtv f and mrtv r primers [ ] ; wssv using f , r , f and r primers [ ] ; penaeus monodon nudivirus (pmnv) using f and r primers [ ] ; spiroplasma eriocheiris using f and r primers [ ] ; and yhv using yc-f a, yc-f b, yc-r a, yc-r b, yc-f a, yc-f b, yc-r a and yc-r b primers [ ] . all pcr reactions were performed as above using the cycling conditions specified in the original publications. at the end of the -day disease challenge, mortalities exceeding % had occurred in all three experimental groups, including larvae exposed to an extract produced from a hatchery that at the time had not experienced mortalities ( figure ). however, it was later discovered that the healthy hatchery experienced mass mortalities to a similar level of other hatcheries in the south of bangladesh shortly after they were sampled for the experimental material. as the challenge progressed, reduction in swimming ability, feeding and growth were observed in all treatments. moribund larvae appeared white in colour compared to healthy larvae. a total of , , , , , and , , illumina read-pairs were generated for libraries , and , respectively, and after quality-trimming and filtering, , , , , , and , , read-pairs remained. contigs assembled using rnaspades, both separately and by combining all three libraries, were annotated using diamond in blastx mode. rnaspades assembly of combined libraries produced , contigs; contigs, of average length bp, had similarity in protein sequence to yhv or gill-associated virus (gav), but when the trimmed reads were aligned against the yhv genome (accession number gca_ . ), no alignment was seen. de novo virus assembly using iva from library three produced contigs, and two non-overlapping contigs, of lengths , and , had blastx similarity to yhv. iva assembly using a pool of all three libraries produced a full genome consensus sequence of . kb, with an average coverage of ×. the two contigs produced by iva assembly of library three mapped to the . kb consensus sequence. the full genome sequence is deposited under accession number mt on genbank. henceforth, we refer to this novel virus as macrobrachium rosenbergii golda virus (mrgv). mapping trimmed and quality-filtered reads from each individual library back to the consensus genome gave coverage of . × for library one (pooled challenged larvae from days - ), . × for library two (pooled challenged larvae from days - ) and . × coverage for library three (pooled larvae from a hatchery experiencing mortalities). to compare the efficiency of the rnaspades assembly, assembled contigs from individual and pooled libraries were mapped back to the consensus genome. eleven contigs from library one mapped to mrgv with . × coverage, contigs from library two mapped with . × coverage, contigs from library three mapped with . × coverage and contigs from the pooled libraries mapped with . × coverage. rnaspades contigs from libraries two and three gave good coverage over the whole genome but failed to assemble the and ends. a comprehensive table of assembly statistics is in supplementary table s . fgenesv predicted five protein-coding orfs in the positive sense direction, four of which were supported by genemarks, prokka and vgas (figure ), which were investigated in more detail. the two longest orfs, orf a and orf b, showed homology to the replicase polyproteins of yellow head virus (evalues of × − and ), whereas orf showed homology to glycoproteins associated with species in the negarnaviricota phylum (realm riboviria), including a number of species in the genus orthobunyavirus (e value of × − ). orf had no significant similarity to any known proteins. hhpred produced confident predictions (≥ %) for a picornain-like protease and endopeptidase enzyme in orf a, a coronavirus-like rna-dependent rna polymerase (rprp), a metal-binding helicase and a - exoribonuclease (exon) in orf b. hhpred did not detect any zinc-binding domains (zbds); however, when orf b was run against the interpro database using interproscan , a coronavirus-specific zbd was identified. in orf , hhpred identified an enveloping glycoprotein associated primarily with viruses of the order bunyavirales. both hhpred and interproscan were unable to identify any other protein domains; therefore, predicted mrgv orfs were aligned against the nidovirus domains identified in saberi et al. [ ] . msa identified a further three protein motifs: a nidovirus rdrp-associated nucleotidyltransferase (niran) and s-adenosylmethionine (sam)-dependent n -and -o-methyltransferases (n-mt and o-mt, respectively). as nidovirales typically translate orf a and orf b consecutively to produce pp ab by − ribosomal frame shift [ ] , fsfinder [ ] was used to identify − frameshift sites in the overlap between orf a and orf b. both major elements of − frameshifting were identified in the overlap: a slippery site at position , nt with the sequence "gggtttt", proceeded by a stem-loop stimulatory structure located a few nucleotides downstream between positions , and , nt. analysis of the utr secondary structure following the final stop codon of the final orf revealed a thermodynamically stable rna hairpin secondary structure (figure ) . the predicted hairpin structure of mrgv is stabilised by three helices with a nt hairpin loop (∆g = − . ), in comparison to the gav -utr structure, which forms a nt hairpin loop stabilised by four helices (∆g = − . ), previously identified in wijegoonawardane et al. [ ] . a bayesian consensus tree was produced based on the rdrp protein domain universally conserved in nidoviruses, including the rdrp sequence generated in this study for mrgv, and the only nidovirus protein domain able to align to the rdrp of astrovirales (outgroup). all families within nidovirales were monophyletic in our analyses. mrgv branched as sister to gav and yhv within the roniviridae clade ( figure ). other invertebrate-infecting nidovirales shown in figure include charynivirus- infecting the crab charybdis, and paguronivirus- infecting hermit crabs [ ] , all branching within the euronivirdivae clade. all invertebrate-infecting nidoviruses branched together with maximal bayesian posterior probability. as mrgv branches within roniviridae, which have a distinct genome organisation to other nidoviruses [ ] , mrgv orf and orf were aligned against the corresponding orfs of gav. this alignment ( figure ) showed similarities in protein sequences of the three transmembrane helices of orf of gav to the predicted transmembrane helices of mrgv. sequence similarities were also seen in orf of gav to orf of mrgv ( . % residue similarity), as well as gp ( . % residue similarity) and gp ( . % residue similarity) protein coding regions of orf in comparison to the aligned regions in mrgv orf . the virus was not detected by specific pcr in cdna from any adult tissues from wild river populations across the two-year sampling period ( animals) and s. eriocheiris was the only pathogen detected in adult m. rosenbergii ( / ). however, mrgv was detected in larval cdna from all three hatcheries sampled in production cycles and all five hatcheries sampled in production cycles with no other pathogens detected by pcr in hatchery larvae. mrgv was also detected in brfi 'control' hatchery larvae prior to challenge, potentially explaining the low survival of treatment larvae. no histopathological signs of infection were seen in the larvae. we report and analyse the complete genome of a novel single-stranded positive-sense rna virus infecting cultured m. rosenbergii from hatcheries in southern bangladesh. the novel virus, macrobrachium rosenbergii golda virus, has a similar genome arrangement to viruses of the order nidovirales, and appears to be most closely phylogenetically related to yellow head virus and gill-associated virus, both infecting penaeid shrimp. mrgv was detected by specific pcr in larvae from three hatcheries in , two of which were experiencing mass mortality events when sampled, and one which was sampled just prior to a mass mortality event. in , two of the hatcheries that had experienced mass mortalities the previous year were re-sampled during mass mortality events and were again positive for mrgv; both of these hatcheries underwent two production cycles, both suffering mass mortality events and both were pcr positive for mrgv. in addition to the two hatcheries that were re-sampled in , a further three hatcheries, none of which had been sampled in , were sampled in during mass mortality events. these further three hatcheries were also pcr positive for mrgv. given the number of hatcheries affected by mass mortalities linked to mrgv, its temporal prevalence and spatial spread, with one of the hatcheries over km in distance to the nearest hatchery that was pcr positive for mrgv, we suggest that this novel virus represents a very significant threat to m. rosenbergii aquaculture within bangladesh, and may be a significant factor in the collapse of larval production in the industry of bangladesh since . all pcr screens of larvae collected from hatcheries experiencing mass mortalities for pathogens known to infect the larval stage of m. rosenbergii were negative: mrnv and xsv, the causative agents of white tail disease [ , ] ; mrtv, a virus associated with mass larval mortalities in china [ ] , spiroplasma eriocheiris [ ] , and wssv-shown to be able to infect m. rosenbergii experimentally [ ] . larvae were also screened for yhv and pmnv, viruses known to infect all life stages of marine shrimp species [ , ] ; these screens were all negative. furthermore, no sequences were assignable to any other known pathogens of m. rosenbergii in our metatranscriptomic data. the absence of these pathogens and no obvious bacterial cause observed by alam et al. [ ] strongly suggests that the survival problems in bangladesh hatcheries are not due to a currently known pathogen and that mass mortalities were linked either to hatchery practice factors or/and the emergence of a novel pathogenic agent. despite numerous problems identified in hatchery practices, hatcheries were successfully producing until , and since then, hatchery practices have not changed, suggesting that this is not the main source of mortality events. pcr screens of adult m. rosenbergii cdna from rivers used to collect berried females as the supply of broodstock for the hatcheries were also all negative for mrgv, suggesting that broodstock may not be the entry route of mrgv into the hatcheries. adults were also negative for all other pathogens as above, except for s. eriocheiris. all larvae sampled from hatcheries experiencing mortalities were negative for s. eriocheiris and no reads for any spiroplasma species were detected in metatranscriptomic analysis of the moribund larvae, suggesting that s. eriocheiris is also not causing the mortalities in hatcheries. nidoviruses (order nidovirales) are enveloped positive-sense rna viruses infecting a range of hosts including both vertebrates and invertebrates [ ] . the invertebrate nidoviruses are composed of families: mesoniviridae, roniviridae, mononiviridae and euroniviridae, with the latter two families discovered within the last four years [ , , ] . roniviridae comprises one genus, okavirus, composed of two closely related crustacean-infecting viruses: gav and yhv [ ] . both gav and yhv are associated with disease in marine shrimp farming, with the former initially associated with mid-crop mortality syndrome (mcms) in penaeus monodon in australia [ ] and the latter first associated with yellow head disease (yhd) in p. monodon in thailand [ ] . prior to this study, no nidoviruses had been discovered in macrobrachium rosenbergii. when amino acid sequences of mrgv were screened against the ncbi non-redundant protein database, there was weak similarity to yhv and even weaker similarity to other nidoviruses. however, the only significant matches in pp a and pp ab were to this order; therefore, we searched for protein motifs shared among other nidoviruses. through database searches we identified five protein motifs present in all known nidoviruses: a protease, an rna-dependent rna polymerase, a zinc-binding domain, a helicase and a methyltransferase-exoribonuclease complex. a further three domains were found by sequence alignment of mrgv to the protein motifs of niran and (sam)-dependent n -and -o-methyltransferases (n-mt and o-mt, respectively). we also identified nucleotide sequences within the overlap of orf a and orf b suggestive of a − ribosomal frameshift. the slippery sequence "gggtttt" proceeded downstream by a putative stem-loop stimulatory rna structure suggests that pp a and pp ab are translated continuously by programmed ribosomal frameshift, a characteristic of nidoviruses [ ] . the genome of okavirus, the genus to which gav and yhv belong, have a unique genome architecture to that of vertebrate nidoviruses-orf , encoding a nucleocapsid protein, is located upstream of the glycoprotein gene (orf ) [ ] . this structure is also seen in mrgv, as well as sequence similarity of orf and orf to the corresponding orfs in gav. a characteristic of positive-sense rna viruses is the presence of a secondary rna structure at the utr; this is present in other members of the nidoviruses including coronavirdae and arteriviradae [ ] . these utr structures and/or specific sequences have been shown to be critical to polymerase recognition and minus-strand genomic rna synthesis [ ] . a utr secondary structure has been identified in gav and yhv, and appears to be well conserved, with complementary base-changes implemented in yhv genotypes to retain a conserved stem-loop structure stabilised by four helices [ ] . in this study we used mfold to predict the secondary rna structure of mrgv in the utr of the genome following the final stop codon of the orfs. mfold predicted a stem loop structure of a similar size to that of gav and yhv, with three helices stabilising a nt hairpin loop. it is hypothesised that the utr rna structure in gav and yhv may act as a polymerase recognition site for minus-strand rna synthesis [ ] , and given the similarities in the utr rna structure in mrgv to gav and yhv, this structure in mrgv may have a similar function. based on multiple sequence alignment of the rdrp protein motifs of a representation of families within nidovirales, mrgv groups phylogenetically with family roniviridae, which, thus far, exclusively comprises gav and yhv. we hypothesise that mrgv also belongs to roniviridae; however, further sampling is needed to obtain additional material for electron microscopy to visualise the virus in situ in order to confirm that virion morphology conforms with the rod-shaped characteristics of the family [ ] . our study has also highlighted that choice of assembly tool is important in assembling viruses. rnaspades was not able to assemble the complete mrgv genome, even when libraries were pooled to give higher coverage than single libraries alone, whereas iva was able to assemble the full genome from the same pool of libraries. it is likely that iva was able to assemble the full genome as it is capable of assembling rna sequences at highly variable depths [ ] , a useful tool in the case of the nidoviruses, which are prone to variability in sequencing depth due to the production of sub-genomic mrnas (sgmrnas). the presence of sgmrnas were not assessed in this study but given that rnaspades could not assemble the full genome, it is likely that these sgmrnas do exist. future work includes identifying the presence or absence of sgmrnas and potential transcription regulation sites (trss). samples for histology or electron microscopy matching those used for molecular analyses were not available from the disease challenge studies carried out here. therefore, there is currently no information about histopathological signs of disease caused by mrgv. histological samples were taken from the larvae sampled from hatcheries in , however these animals were likely not to be moribund and were probably in the early stages of infection by mrgv and thus, though infected, no pathology was seen. furthermore, rna viruses can only be visualised indirectly in histology sections (normally associated with damaged host cells and nuclei). further sampling is ongoing in order to visualise the virus infecting larval tissue(s) using transmission electron microscopy. the challenge experiment data from this study were unable to determine the route of entry of mrgv into the hatchery system, as it was later determined that control animals were sourced from a hatchery assumed to be free of mrgv, but which after sampling larvae for the challenge experienced mass mortalities to a similar level as seen in other hatcheries in southern bangladesh. larvae were sampled from the apparently unaffected hatchery and fixed before challenging; these animals were screened by pcr for all pathogens as above and were only positive for mrgv, thus suggesting that animals were infected with mrgv prior to the challenge, explaining the high levels of mortality in 'control' animals. this confounding situation nonetheless further suggests the role and ubiquity of mrgv in mass mortality events across multiple hatcheries in bangladesh. future work to identify how the virus is entering the hatcheries is ongoing to suggest preventative methods that could be implemented to ensure biosecurity. the use of metagenomic techniques to identify both novel rna and dna viruses is becoming more common in aquaculture, with new viruses identified in economically-important species including fish, crustaceans and molluscs (reviewed in munang'andu et al. [ ] ). metatranscriptomics has recently been used to identify another novel rna virus in m. rosenbergii, crustacea hepe-like virus (chev ), associated with animals exhibiting growth retardation in china [ ] . the identification of mrgv is the first study, to our knowledge, to use a metatransciptomic approach to investigate the mass mortalities experienced in hatchery-reared prawn larvae in bangladesh. previous studies have investigated possible agents involved in mortality events using pcr screens and microbial culture, but required the agent to have gene sequences sufficiently similar to known pathogens to amplify with pcr primers or culturable on media, respectively, thus limiting the detection of more genetically divergent pathogens, possibly including many viruses. the metatranscriptomic approach used in this study to discover the agent involved in the bangladesh mortalities was able to identify and characterise a novel pathogen that would likely have not been identified by most 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on virus discovery and diagnostic role of viral metagenomics in aquatic organisms a novel hepe-like virus from farmed giant freshwater prawn macrobrachium rosenbergii this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -qg s authors: singh, bikash chandra; alom, zulfikar; rahman, mohammad muntasir; baowaly, mrinal kanti; azim, mohammad abdul title: covid- pandemic outbreak in the subcontinent: a data-driven analysis date: - - journal: nan doi: nan sha: doc_id: cord_uid: qg s human civilization is experiencing a critical situation that presents itself for a new coronavirus disease (covid- ). this virus emerged in late december in wuhan city, hubei, china. the grim fact of covid- is, it is highly contagious in nature, therefore, spreads rapidly all over the world and causes severe acute respiratory syndrome coronavirus (sars-cov- ). responding to the severity of covid- research community directs the attention to the analysis of covid- , to diminish its antagonistic impact towards society. numerous studies claim that the subcontinent, i.e., bangladesh, india, and pakistan, could remain in the worst affected region by the covid- . in order to prevent the spread of covid- , it is important to predict the trend of covid- beforehand the planning of effective control strategies. fundamentally, the idea is to dependably estimate the reproduction number to judge the spread rate of covid- in a particular region. consequently, this paper uses publicly available epidemiological data of bangladesh, india, and pakistan to estimate the reproduction numbers. more specifically, we use various models (for example, susceptible infection recovery (sir), exponential growth (eg), sequential bayesian (sb), maximum likelihood (ml) and time dependent (td)) to estimate the reproduction numbers and observe the model fitness in the corresponding data set. experimental results show that the reproduction numbers produced by these models are greater than . (approximately) indicates that covid- is gradually spreading in the subcontinent. the coronavirus disease (covid- ) pandemic has spread so rapidly around the globe that the modern world could not have imagined its severity at the beginning of the outbreak that started in wuhan, china in late december . on january , the world health organization (who) first released information on the disease outbreak that a cluster of cases of pneumonia caused by an unknown reason was detected in wuhan city [ ] . after that, the chinese authorities identified the disease caused by a novel coronavirus [ ] on january . who temporarily termed it as -ncov [ ] on january ; was later officially named as "severe acute respiratory syndrome coronavirus (sars-cov- )" by the international committee on taxonomy of viruses (ictv) based on genetic analysis [ , ] . initially, who declared the outbreak as a public health emergency of international concern (pheic) [ ] on january . eventually by evaluating the severity and alarming levels of the transmission of its high contagiousness, who characterized the covid- as a pandemic [ ] on march . with this declaration covid- becomes the fifth recorded pandemic after the spanish flu pandemic [ ] . as of june , covid- is still in a pandemic with , , confirmed cases and , deaths worldwide [ ] , and continues to climb globally. unlike all other pan-demics recorded in history, large amounts of data and news about covid- are rapidly spreading and widely reported, and scholars in various fields have been mobilized to concentrate on analyzing these data and proposing solutions. since the governments of different countries have responded to the covid- pandemic seriously, it is important that the researchers estimate: (i) the pandemic regionally based on the basic reproduction number, (ii) the arrival of the peak time, and forecast the time course of the epidemic by analyzing the data on the total number of infected cases, (iii) the total number of confirmed cases, (iv) the total number of deaths, and (v) the total number of cases recovered, etc. many researchers around the globe have estimated the prediction of the covid- spreading and the end of the epidemic in different countries [ , , , , , , , , ] . some of these methods are based on statistical models [ , , , ] and some other methods use deterministic epidemic models known as susceptible infectious recovery (sir) with different forms [ , , , , , ] . recently, some countries in south asia, especially in bangladesh, india and pakistan, cases of covid- are increasing rapidly. in particular, the covid- cases became a new hot spot after countries began to relax locking restrictions. in this study, we use sir, eg, sb, ml and td models to analyze data to determine the reproduction number and pre-dict the epidemic trend of covid- in bangladesh, india and pakistan. more particularly, this article investigates the basic reproduction number r and effective reproduction number r(t) using these models. previous studies show that r is applicable when an exponentially increasing epidemic starts in the case of a completely susceptible population [ ] . contributions: the contribution of this article is twofold: (i) estimating of r for bangladesh, india and pakistan, (ii) estimating r(t) which quantifies the transmission potential over time. as the epidemic progresses, this parameter will track the average number of secondary cases per case over time periods. after calculating the r and r(t)s, we compare the spread of covid- in the region of concern. experimental results show that the r and r(t)s in all these countries are higher than about . . the rest of the paper is organized as follows. section discusses related work, while section outlines the concept of reproduction numbers. section describes several models that can be used to generate reproduction numbers, whereas section explains information about the data source. section explains the experimental results. finally, section summarizes the paper. a number of models have been proposed and applied to the area of infectious covid- . the majority of the mathematical models fall into the categories: (i) standard statistical models applied to the covid- dataset, (ii) deterministic epidemic models such as sir, seir etc. (iii) modified variants of the well-known models attempting to incorporate specific criteria such as incorporating social distancing into seir, and (iv) effectiveness of the contact tracing and isolation. in [ ] , authors choose auto regressive integrated moving average (arima) to predict the spread of covid- based on johns hopkins university dataset [ ] . authors intend to avoid potential biases of the evaluating model and select a simple and economical model therefore chosen arima. the arima model consists of an autoregressive (ar) model, moving average (ma) model, and seasonal autoregressive integrated moving average (sarima) model [ ] . results demonstrate the autocorrelation function (acf), and the partial autocorrelation function (pacf) prevalence and incidence of covid- are not influenced by the seasonality. however the claim is arguable as the covid- may have seasonality influences; it is just too early to claim. calafiore et al. [ ] presents a modified susceptible-infectedrecovered (sir) model for the contagion analysis of covid- in italy. besides the regular sir parameters the authors incorporate the initial number of susceptible individuals. most interestingly authors consider a proportionality factor i.e., the ratio of the detected number of covid positives to the actual number of infected individuals. two distinct algorithms (i) tuning of the model parameters and (ii) predicting the number of infected, recovered and deaths are presented in this article. kucharski et al. [ ] reported how transmission in wuhan varied over a time period (january -february ). the ar-ticle also attempts to put foresight on how human-to-human transmissions may occur outside wuhan by travellers. the article reported the median day-to-day reproduction number over the time in wuhan. the susceptible exposed infected and removed (seir) model is used for the evaluations. besides, the study attempts to incorporate the uncertainty of the detection and observation utilizing poisson process and binomial observation process on infection prevalence on flights. peng et al. [ ] attempted to modify the generalized seir model by incorporating quarantine into account and studied the covid- pandemic in provinces in mainland and counties in hubei province in china. the authors estimate the latent time, the quarantine time, the reproduction number, the possible ending time and the final total infected cases. wangping et al. [ ] proposed an extended susceptible infected removed (esir) model essentially an extension to the sir model attempting to address the effects of different intervention measures in dissimilar periods. the esir is applied to model the pandemic covid- analysis in italy. the markov chain monte carlo (mcmc) algorithm is utilized to obtain the posterior estimation of the unknown parameters in the sir model. chatterjee et al. [ ] modeled a variant of seir for covid- epidemic in india. in this stochastic modeling approach monte carlo simulation is used to model the concept with a run. the article shed into the hospitalization and intensive care unit (icu) requirements along with deaths. article also presents the impact of the lockdown and social distancing. liang el al. [ ] presents infection kinetic analysis of sars, mars and covid- . author attempts to acquire a propagation growth model by utilizing the growth rate, and inhibition constant of the aforementioned diseases. the inhibition constant depends on the prevention and control measures adopted for the population. the article assumes during the inception of the disease cycle no effective measure is in place. it figures out the growth rate, the multiplication cycle and infection inhibition constant. ndairou et al. [ ] provides a mathematical model i.e., essentially an extension to the sir model of covid- taking eight epidemiological classes into consideration. they are (i) susceptible, (ii) exposed, (iii) symptomatic and infectious, (iv) super spreaders, (v) infectious but asymptomatic, (vi) hospitalized, (vii) recovery, and fatality class. wuhan number of cases and deaths are compared with the model. roda et al. [ ] argued that these model predictions have shown a wide range of variations. and the variation of the performances of the models is due to the non-identify ability in model calibrations. the qualities of the statistical models are studied utilizing the akaike information criterion (aic). authors' finding the performance of sir over seir is explained as the failure of the even more sophisticated model is due to the more challenging realization of a comparatively more complex model. contrary to the other school of analytical models where the models used to predict the number of cases and deaths. hellewell et al. [ ] attempts to quantify the effectiveness of the contact tracing and isolation to control the covid- . the study considers a number of scenarios containing (i) initial cases, (ii) r , (iii) delay in-between symptom and isolation, (iv) probability of traced contacts, (v) proportion of transmission before symptom, and (vi) proportion of sub-clinical infections. contrarily this study attempts to find the transmission potential in the subcontinent. instead of relying on just one specific model this exploration employs sir, eg, sb, ml and td that realize definitive regional r and r(t) that get a conclusive outcome of the containment measure in place. infectious diseases can be analyzed with a so-called reproductive number (r) that quantify the invasion or extinction of diseases in a population [ ] . more precisely, the r is mainly used to determine the infectivity of a contagious disease. alternatively, we can say that r represents the speed with which a disease spreads in a population. so, the primary task is to impose policies to control the r in order to control the contagious disease. this can be achieved by zonal shut down, social distancing and other factors that lead to control the outbreak of the disease in a particular geographic region. fundamentally there are two types of rs: (i) basic reproduction number r and (ii) effective reproduction number r(t). the r refers to a measurement of the average number of cases that an infected person can spread over the person's infection period in a population [ ] . let, the r of covid- in a region x is y. then, each infection may lead to y number of new secondary cases in the region x i.e., each infected person may infect y new individuals in the x zone. however, r refers to a value that can indicate that the rate of the infected population has fallen or increased or remains constant. mathematically, r < indicates that the epidemic is in decline and it can be considered as under control. contrarily, r > implies that the epidemic is on the rise and therefore cannot be considered as under control. and finally r = demonstrates that the infection rate remains constant. contrarily, the r(t) is used to measure the infected cases when there is a certain immunity or certain interventions are taken place. in other words, r(t) is the number of infected cases calculated in a certain population over the period of time t, taking into account that infected people are immune to infectious diseases at any given time. therefore, we use the actual reproduction number r(t) in order to measure the number of newly infected individuals, on average, infected by a single person at time t in a population. in effect, r(t) represents the time variant r of the susceptible population where the change may be in decline or on the rise or remains constant. these three aforementioned conditions can be expressed as r(t) ≥ . likewise r , r(t) < , suggests the epidemic is on the decline and can be considered under control at time t. at r(t) > the epidemic is on the rise and not in control at t. finally, r(t) = implies the infection rate remains constant. interestingly, r(t) and r can be related to utilizing a simple relationship as r(t) can be measured with r * s where s represents the number of infected people in a particular population. in case the immunity to the disease of a particular population is high then s becomes low. consequently, r(t) becomes below . the implication is that as herd immunity is achieved, the number of new cases in the population will decrease to zero over time [ ] . in this paper, we are going to estimate r, i.e., r and r(t) through a variety of methods using the dataset of the selected countries such as bangladesh, india and pakistan. in the next section, we have explained the five most popular methods for estimating of r and r(t). there are numerous models that have been proposed and applied to the area of infectious covid- . in order to find the transmission potential in the subcontinent, we used five models, namely, sir model, exponential growth, sequential bayesian method, maximum likelihood estimation, and time-dependent estimation, briefly described in what follows. the sir model is a basic mathematical model for describing the dynamics of infectious diseases. it is also called the compartmental model because the model divides the population into different compartments. more particularly, the population of size n is divided into three compartments [ ] : susceptible, infectious, and recovered, which will be detailed in what follows. susceptible: is the number of people who are vulnerable to exposure with infectious people around at time t, denoted by s (t). infectious: is a group of people who are infected with the disease. moreover, they can spread the disease to susceptible people and can be recovered from it, in a specific time t, denoted by i(t). recovered: is a number of people who get immunity in a time t, denoted by r (t). therefore, they are not susceptible to the same disease anymore. however, we can write the sir model as a differential equation of each compartment [ ] : where t defines the time, s(t) = s (t) n , i(t) = i(t) n , r(t) = r (t) n , and n = (s (t) + i(t) + r (t)). likewise, β is a controlling parameter that defines the number of people infected by exposure in a specific time t, and γ defines the ratio of the infected individuals who can recover in a time t. using these two parameters (i.e., β, γ) we can estimate the (r ), mathematically, r = β γ , which defines the average number of people infected from single disease exposure. hence, if the r value is higher, the probability of the pandemic is also higher. the exponential growth (eg) rate is an important measure to see the speed of the spread of an infectious disease. as introduced in section . , the exponential growth rate can be written as r = β − γ, where, β defines the number of people infected by exposure in a specific time t, and γ defines the ratio of the infected individuals who may recover in time t. however, r is a disease threshold value when r is at zero (i.e., r = ). if r is positive (i.e., r > ), the disease can invade a population, whereas it cannot invade a population, if r is negative (i.e., r < ) [ ] . the relationship between r and growth rate r is not simple. for a specific distribution over generation time (e.g. gamma distribution), it can sometimes be simplified. assuming that the generation time is completely constant, such as t , the r can be written as [ ] , r = e (r * t ) . the sequential bayesian approach can be used to estimate the initial reproduction number (r ). technically, the bayesian method works in the context of probabilistic modeling. therefore, the probability model of r can be written as follows [ ] . where, t (t) is the total number of cases up to time t, and the occurrence of new infected cases over the period τ, and ∇t (t + τ) = t (t + τ) − t (t). the probability distribution p[∇t (t + τ) ← ∇t (t)] and p[∇t (t + τ) ← ∇t (t)|r ] are independent and dependent on r , respectively. hence, the sequential bayesian estimation of r can be made using the posterior distribution for r , at time t as the prior in the next estimation step at time t + τ. the maximum likelihood-based estimation relies on two considerations : (i) the number of secondary cases produced by an infected individual follows a poisson distribution, and (ii) the expected value r . suppose the data is a periodic incidence e.g., {n , n ,... n t }, where, t is a time unit, and n t defines the number of new cases at time t. therefore, the maximum likelihood can be estimated as follows [ ] : where, µ t = r min(k,t) j= n t− j * w j , where k is the constraint and w j is the time distribution. here, k < t . note that the maximum likelihood-based method is used for the estimation of the basic reproductive number (r ). typically, the time-dependent r estimation is not straightforward, because we can only see the epidemic curve. there is no information about who infected whom. however, using likelihood-based estimates of r, the time dependant r can be written as [ ] : r t = n t t j =t r j , where n t specifies the number of new cases at time t, and r j is the r(t) for case j, that is the sum over all cases i, mathematically, r j = i p i j , where p i j defines the relative likelihood. more precisely, the relative likelihood that case i has been infected by case j, normalized by the likelihood that case i has been infected by any other case k, which can be written as follows [ ] : where, w(t i − t j ) defines the time interval of the infectious diseases. we use a publicly available covid- dataset extracted from the coronavirus repository of the johns hopkins university center for systems science and engineering (jhu ccse). this dataset contains daily observations on covid- confirmed, recovered and death cases for most countries over the world. more precisely, the incidence data are provided on a daily basis. for this analysis, we consider data from south asian countries such as bangladesh, india, pakistan, nepal, bhutan, maldives and sri lanka. nonetheless, the top three populated countries (bangladesh, india, and pakistan) finally have been selected for this particular article. data dated upto june , is utilized. the entire dataset of covid- cases of these selected countries is observed for each day, as shown in figure . in addition, the table sequentially displays the date of the first confirmed case, the total number of confirmed incidences, the total number of deaths, the total number of recovery cases, population and covid- tested per million people in each country. the surprising fact is that these countries have conducted very few covid- tests in susceptible populations. therefore, it is very likely that this data set may not cover the real scenario of the covid- situation. however, we can use this data set to mainly calculate the reproduction numbers, so as to observe the spread of covid- . we conduct several experiments to analyze the trend of covid- in the concerned countries. the first experiment focuses on covid- cases as confirmed, deceased and recovered to compare the covid- situation in these countries. the motivation is to understand the deteriorated conditions for the covid- pandemic in this region. next, we conduct experiments through sir, eg, sb, ml and td models to estimate rs for these countries and predict the covid- pandemic. the result is analyzed to observe the model performances on the covid- dataset. for this, we use the r package provided by r programming language to impletement the code for the above methods [ ] . more particularly, we employ estimate.r function of r package to apply the above methods to a given epidemic curve. the result is analyzed to observe the model performances on the covid- dataset. this subsection analyzes the covid- data in order to observe confirmed, death and recovered cases in bangladesh, india and pakistan. figure shows the number of confirmed (figure a) , recovered ( figure b) , and death ( figure c however the aforementioned argument is inconclusive and rather unlikely as bangladesh conducted the least amount of tests per person compared to the other two. figure shows that sars-cov- tests per million people performed in bangladesh, pakistan and india are , and respectively. clearly, more tests reveal more infected people. with unexpectedly poor and nonuniform samples we rather not conclude as above and investigate further and focus on how covid- is spreading in the subcontinent. intuitively, the subcontinent case may reflect covid- spreading in the developing countries, especially spreading in south asia. therefore, the further analysis focuses on the transmission speed of covid- using different methods. in this experiment, we use the sir model to predict covid- cases in bangladesh, india and pakistan. bangladesh. figure a depicts the sir model fitting to the number of observed confirmed cases where figure b presents the same observation in the logarithmic scale in bangladesh. we observe that the number of cases (black dotted line as shown in figure a and in figure b ) follows the number of confirmed cases expected (black line as shown in figure a and figure b ) by sir model. note that, the observed data and predicted values overlapping with each other indicates covid- clearly is in an exponential phase in bangladesh. figure b shows that the curve is flattening in between mid march (around) to st april. this impliedly indicates that the spreading of covid- is comparatively in control in bangladesh. furthermore, the slope of the curve dropping down in between mid-march and april st conforms to the aforesaid observation (spreading of covid- is in control in bangladesh during this period). but then, the slope is going up at the steepest of all times until the end of may, i.e. in this time covid- is spreading rapidly. and then, the slope remains constant with a comparatively lower value. furthermore, we carry out the experiment to adapt the sir model to confirmed, death and recovered cases, as shown in figure c . with this experiment, we derive the estimated values of various parameters as shown in table . according to table , we can see that the r is around . indicating that covid- is spreading in bangladesh day by day. based on the r, we calculate the herd immunity threshold using the equation − r [ ] , i.e., . %. with this trend, the epidemic will be at its peak in - - . the sir model estimates that the maximum infected population in bangladesh will be , . of these, the serious cases will be , (assuming % of the infected population). it also shows that around , (assuming % of the infected population) people need intensive care and up to , deaths (assuming . % mortality rate). india. figure a and figure b represents the cumulative covid- infected cases in number and in logarithmic forms respectively in india. it clearly depicts that the spread of covid- is in an exponential phase in this particular period. in addition, figure b shows that the slope of the curve (black dotted line) was not steep in between february and mid-march, indicating that the spread of covid- in india was under control during this period. but then, it rose almost exponentially, which means that this time covid- is spreading rapidly. furthermore, figure c depicts the experimental results of the sir model for confirmed, death and recovered cases. we put all the estimated values of all the different parameters calculated using the sir model in the table . the r (derived from the sir model is about . ) indicates that covid- accelerates over time, where the computed herd immunity is . %. with this r the epidemic will peak in - - . moreover, according to the sir model, the maximum infected population is , , , among them, the serious cases will be , , (assuming % of the infected population). furthermore, around , , (assuming % of the infected population) people need intensive care and up to , deaths (assuming a mortality rate of . %) (see table ). pakistan. like bangladesh and india, we have conducted experiments on pakistan's covid- data through the sir model. figure a and figure b depicts the observed cumulative infected incidence in cases and in cases in logarithmic scale respectively. the figures indicate that the covid- is spreading exponentially. in addition, figure b shows that the slope of the curve (black dotted line) was not accentuated till mid-march, indicating that the spread of covid- in pakistan. but then it almost shot up, i.e., the covid- is spreading rapidly during this time period. in order to observe deeper insights, we have conducted sir model experiments on confirmed, death, and recovered cases, as shown in c. the estimated values of all the various parameters of the sir model are shown in table . it is worth noting that the estimated r of the sir model is about . , indicating that covid- accelerates over time. we find pakistan's herd immunity as . %. the epidemic will be at its peak in - - with r remaining at this particular rate. according to the sir model the maximum number of infection cases is , , . among them, the serious cases are , (assuming % of the infected population), the intensive care requirement is , approximately (assuming % of the infected population) and estimated maximum deaths is , (assuming a mortality rate of . %). comparison. table shows all the predicted values of various parameters of bangladesh, india and pakistan estimated by the sir model. it is worthy to mention that the r of bangladesh and pakistan are very close, i.e., . and . , respectively, while r of india is about . . it concludes that bangladesh and pakistan are experiencing an increasing number of infected people compared to india. in other words, india has so far somewhat stronger control over the spread of covid- compared to bangladesh and pakistan. next, we will use the rest of the methods (i.e., eg, sb, ml and td) to estimate the r in order to verify what the sir model foresees is consistent with other models. in this experiment, we consider various methods to compute the value of the r and r(t). this experiment investigates how the r has changed with the various methods of the estimation process, the role of excessive dispersion in the distribution of secondary cases and the aggregation of the epidemic curve at ever larger time intervals. in this experiment, we assume that the sequence interval of covid- for bangladesh, india and pakistan is equal to the sequence interval of covid- in wuhan, china with a mean of . days and a standard deviation of . days [ ] . figure depicts an estimation of r and r(t) for bangladesh (see figure a ) in the period from march to june (for days), for india (see figure b ) in the period from january to june (for days), and for pakistan (see figure c ) in the period from february to june (for days), respectively. moreover, table reports the computed r and r(t) for bangladesh, india and pakistan which we have estimated with various methods. according to the table , the r for bangladesh generated with the methods of exponential growth (eg), maximum like- table also shows the estimated values of r(t) for bangladesh, india and pakistan using the methods of sequential bayesian and timedependent. the results show that r(t) value for pakistan is higher than india and bangladesh. according to the obtained results depicted in table , we have observed that for different methods the r does not follow the same trend of values. therefore, we proceed to observe the curve fitting using these rs on the covid- data. figure shows that the r generated by maximum likelihood (ml) and time-dependent methods fit well to the data compared to the other methods for all countries. moreover, figure shows that sb method fits very poorly to the data for bangladesh, india and pakistan. the results show that bangladesh and pakistan have comparatively worse control over the spread of covid- , meaning r(t) is getting higher than that of india. however, it is worth noting that the r and r(t) in each country are greater than , i.e., covid- is still spreading in all of these countries. in this article, we provide an assessment of covid- outbreak and measure the spread rate among bangladesh, india and pakistan. we utilize the sir model to predict important parameters such as infection rate, recovery rate, herd immunity threshold, peak of the pandemic, maximum infected, severe cases, patients needing intensive care, deaths of covid- pandemics. we utilize eg, sb, ml and td models to val-idate the effectiveness of the estimated parameters of the sir model. for doing so, we find the basic reproduction number r and effective reproduction number r(t). experiments show that in all the considering countries, the estimated effective reproduction number r(t) is much larger than the basic reproduction number r , which means that the containment measures implemented by bangladesh, india and pakistan are ineffective and inefficient. besides that, according to different models the reproduction numbers of bangladesh, india and pakistan are all higher than about . , indicating that the outbreak of covid- is spreading rapidly. result directed recommendations are (i) to adopt stricter prevention and control measures, (ii) to improve the country's quarantine measures, define outcomes slowing down the spread of covid- . failure in doing so the pandemic situation of the region may decline rapidly. a new coronavirus associated with human respiratory disease in china of the international committee on taxonomy of viruses, the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- - )-and-the-virus-thatcauses-it, [online; accessed detail/ - - -statement-on-the-second-meeting-ofthe-international-health-regulations-( )-emergencycommittee-regarding-the-outbreak-of-novel-coronavirus-( -ncov), [online; accessed who, who director-general's opening remarks at the media briefing on covid covid- : the first documented coronavirus pandemic in history on dynamical analysis of the data-driven sir model (covid- outbreak in indonesia) estimating the unreported number of novel coronavirus ( -ncov) cases in china in the first half of january : a data-driven modelling analysis of the early outbreak why is it difficult to accurately predict the covid- epidemic? a conceptual model for the outbreak of coronavirus disease (covid- ) in wuhan, china with individual reaction and governmental action estimation of the transmission risk of the -ncov and its implication for public health interventions modified seir and ai prediction of the epidemics trend of covid- in china under public health interventions analysis and forecast of covid- spreading in china, italy and france time series analysis and forecast of the covid- pandemic in india using genetic programming coronavirus pandemic: a 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epidemic analysis of covid- in china by dynamical modeling extended sir prediction of the epidemics trend of covid- in italy and compared with hunan, china healthcare impact of covid- epidemic in india: a stochastic mathematical model mathematical model of infection kinetics and its analysis for covid- , sars and mers, infection mathematical modeling of covid- transmission dynamics with a case study of wuhan feasibility of controlling covid- outbreaks by isolation of cases and contacts reproduction numbers of infectious disease models pandemic potential of a strain of influenza a (h n ): early findings viral evolution and transmission effectiveness estimating epidemic exponential growth rate and basic reproduction number model-consistent estimation of the basic reproduction number from the incidence of an emerging infection real time bayesian estimation of the epidemic potential of emerging infectious diseases a likelihood-based method for real-time estimation of the serial interval and reproductive number of an epidemic the r package: a toolbox to estimate reproduction numbers for epidemic outbreaks different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures herd immunity: a rough guide estimating the generation interval for covid- based on symptom onset data key: cord- -gilnlwms authors: nahar, nazmun; asaduzzaman, mohammad; sultana, rebeca; garcia, fernando; paul, repon c.; abedin, jaynal; sazzad, hossain m. s.; rahman, mahmudur; gurley, emily s.; luby, stephen p. title: a large-scale behavior change intervention to prevent nipah transmission in bangladesh: components and costs date: - - journal: bmc res notes doi: . /s - - - sha: doc_id: cord_uid: gilnlwms background: nipah virus infection (niv) is a bat-borne zoonosis transmitted to humans through consumption of niv-contaminated raw date palm sap in bangladesh. the objective of this analysis was to measure the cost of an niv prevention intervention and estimate the cost of scaling it up to districts where spillover had been identified. methods: we implemented a behavior change communication intervention in two districts, testing different approaches to reduce the risk of niv transmission using community mobilization, interpersonal communication, posters and tv public service announcements on local television during the – sap harvesting seasons. in one district, we implemented a “no raw sap” approach recommending to stop drinking raw date palm sap. in another district, we implemented an “only safe sap” approach, recommending to stop drinking raw date palm sap but offering the option of drinking safe sap. this is sap covered with a barrier, locally called bana, to interrupt bats’ access during collection. we conducted surveys among randomly selected respondents two months after the intervention to measure the proportion of people reached. we used an activity-based costing method to calculate the cost of the intervention. results: the implementation cost of the “no raw sap” intervention was $ , and the “only safe sap” intervention was $ , . the highest cost was conducting meetings and interpersonal communication efforts. the lowest cost was broadcasting the public service announcements on local tv channels. to scale up a similar intervention in districts where niv spillover has occurred, would cost between $ . and $ . million for one season. placing the posters would cost $ , and only broadcasting the public service announcement through local channels in districts would cost $ , . conclusions: broadcasting a tv public service announcement is a potential low cost option to advance niv prevention. it could be supplemented with posters and targeted interpersonal communication, in districts with a high risk of niv spillover. electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. transmission may reduce the risk of a potentially large outbreak. based on previous pilot studies on interrupting bats access to sap [ ] [ ] [ ] , and on the government of bangladesh's recommendation to abstain from drinking raw sap, we developed and implemented a behavior change communication intervention using two different approaches to reduce the risk of niv transmission. after the intervention, local residents' knowledge of niv increased, and people reported changing their behavior to reduce the risk of niv transmission through date palm sap [ ] . thus, understanding the intervention development, process and logistics will help plan scaling it up. calculating the approximate cost of the intervention, and the proportion of people to be reached, is useful to make investment decisions [ ] [ ] [ ] between potential interventions to prevent not just niv, but other emerging zoonoses. the objective of our paper is to describe and calculate the cost of an already implemented behavior change communication intervention, and estimate the cost of scaling it up to districts where niv spillover was identified in bangladesh, using risk-based scenarios. we developed a behavior change communication intervention using two separate approaches, targeting rural areas from two niv endemic districts: rajbari and faridpur, where date palm trees are harvested and residents drink raw date palm sap (fig. ) . we selected these districts because both have been repeatedly affected by niv outbreaks, both are from the same geographical region, neighboring each other, and have similar raw sap collection and consumption practices. within those districts, we selected two sub-districts that do not border each other to avoid interference between the interventions. the population of rajbari and faridpur study sites was approximately , and , respectively. following the government of bangladesh's recommendation of abstaining from drinking raw sap, we developed an intervention discouraging people from drinking raw date palm sap in rajbari district, herein referred to as the "no raw sap" intervention. some people continued to drink raw sap though they were aware of the risk [ ] , thus we developed an "only safe sap" intervention in faridpur district, discouraging drinking raw sap but offering the option of drinking sap protected by a skirtlike barrier locally called bana (fig. ) . during collection, banas can stop bats from accessing and contaminating the sap with niv [ ] . we worked with a bangladeshi communication organization to develop posters, calendars, yearly planners, stickers, sweatshirts and tv public service announcements. our qualitative research data collection team pretested the materials conducting focus group discussions with audiences similar to our target audience. based on these results, we revised and fine-tuned the messages and illustrations. we also developed training guides for the staff implementing the intervention. the communication organization designed and printed the final training guides. we developed the "no raw sap" intervention, including production of the communication materials, from june to october, and the "only safe sap" intervention from august to september, (fig. ) . we visited local ngos from both districts to assess their experience and capability to implement the interventions in the selected sub-districts. using a competitive bidding process, we selected one local ngo from each district. we assessed their experience with similar interventions, knowledge of the areas to be covered and qualifications of their key personnel. we also compared the size of the organizations, as an indicator of their capacity to implement the intervention, and the budget required to carry it out. the selected ngos visited villages and talked to villagers to get an estimate on the number of households, and identify opinion leaders and local sap harvesters (gachhis). we provided training to the ngos' staff on interpersonal communication, on organizing and conducting meetings with opinion leaders and community residents, and on key intervention messages. in both intervention areas, the ngos conducted one opinion leaders and one community meeting per households approximately. prior to conducting the meetings, the ngos affixed niv prevention posters in public places such as health centers, bazaars, and areas with heavy traffic of people. we provided calendars or yearly planners, with niv prevention messages, to the opinion leaders, and broadcast-quality public service announcements, in the form of dvds, to the local tv channels. in the "only safe sap" area, the ngo trained gachhis on making banas, and encouraged using them on trees used for raw sap consumption. we also provided sweatshirts as an incentive to those gachhis who made and used banas. date palm sap is harvested during cold months from november to march [ ] . we implemented a full "no raw sap" intervention from december , to march , in villages in rajbari district (fig. ) . during the next sap harvesting season, from november , to january , , we only broadcast the tv public service announcement. we implemented a full "only safe sap" intervention from october , to january , in villages in faridpur district, including a gachhi training component. we started the "only safe sap" intervention slightly before the sap season because we needed to train gachhis on making and using banas before they started collecting sap. during the intervention implementation period, we received ngo weekly reports with photographs of the meetings. our monitoring team visited randomly selected villages to confirm placement of at least one poster, watched the tv public service announcements at least in one tea stall, and observed one meeting per village incognito. tea stalls with a television set exist in almost every village, and serve as gathering places where men drink tea, watch television and chat with others. since most of the villagers do not have television at home, this communication channel was used to target men. we also recruited tea stalls with television access in each study area to monitor the number of times the tv public service announcement was broadcast daily. we collected written weekly reports from those tea stalls, indicating dates and times when the announcements were broadcast. after the intervention, during april-may , our quantitative data collection team interviewed adult male and female respondents from randomly selected villages from each "no raw sap" and "only safe sap" district. we described the sampling procedure for this study elsewhere [ ] . our data collection team asked about niv knowledge, sap consumption behavior, use of banas and exposure to the interventions. in this manuscript, we only present data about the respondents' direct exposure to the intervention. we used an activity-based costing approach to compare health interventions [ ] [ ] [ ] [ ] [ ] . we identified, costed out, and quantified all development and implementation activities. we reviewed timelines and deliverables to confirm activities performed, transport requisition emails, and budgets submitted to the donor. we calculated the cost per activity performed using person time, with the exception of ngo activities that were calculated using per activity cost instead of person time cost. we separated the start-up cost from the intervention implementation cost ( table ). the start-up cost covered the development of materials before the implementation, from the period of time between the decision to implement, to the start of its delivery to the beneficiaries [ ] . because we developed some of the materials for both interventions, we were not able to completely separate the cost of developing all the materials for each intervention. thus, we could not add the start-up cost to the implementation cost to determine the total cost per intervention. the implementation cost included ngo cost, mass media dissemination expenditures (local tv channel, dvds copies and printing posters) and intervention monitoring cost. the cost of training ngo staff included training manuals, personnel, snack allowance, venue, electricity, photocopies, and transportation. in the "only safe sap" area, we also included the cost of bana-making materials and the allowance and transportation cost of a banamaking expert as part of the ngo staff training cost. the cost of training the ngo staff and printing the materials would be incurred before any future implementation, thus we included them in the implementation cost. we calculated the amount of money the ngos spent as cost of the meetings and gachhi training. since ngo staff affixed posters while visiting the villages for meeting purposes, the ngos did not include the cost for placing posters separately in their reporting. to estimate this cost, we assumed that one person could visit four villages per day, to affix posters per village, and estimated the cost of affixing one poster based on the daily salary, meal allowance and transportation costs. we deducted these costs from the meetings cost to calculate the cost per meeting. we calculated costs in us dollars, using a rate of . bangladeshi takas per us$ , the conversion rate used on the original budget. we did not include the cost of the research study in this analysis. we calculated the start-up cost first, followed by the implementation cost of the interventions. we calculated cost per meeting by dividing the total cost to conduct all meetings, provided by the ngos, by the total number of meetings conducted; and the cost per gachhi training by dividing the total training cost provided by the ngos by total number of gachhis trained. from our survey data, we calculated the percentage of people directly reached or exposed to each communication channel used during the intervention [ ] . we found that a lower percentage of respondents from the "no raw sap" area reported that they were directly exposed to the intervention than the respondents from the "only safe sap" area ( % vs. %). also a lower percentage of respondents reported exposure to each intervention component: tv public service announcement ( % vs. %), saw a poster ( % vs. %) and attend a meeting ( % vs. %) in the "no raw sap" area than the "only safe sap" area [ ] . we calculated the cost per person reached per channel by dividing the implementation cost by the total population ( , in the "no raw sap" area and " , in the "only safe sap" area) times the percentage of people reached per channel. we estimated the future start-up cost and intervention implementation cost in all districts where at least one niv spillover has been identified in the past. we added person-day cost for activities, including the cost of revising the intervention and materials, identifying cable operators, cost for transportation and phone communication. using different risk-based scenarios in all affected districts where niv spillovers were identified from • six districts with six or more spillovers ( % of all spillovers) • thirteen districts with two to five spillovers ( % of all spillovers) • eleven district with one spillover, ( % of all spillovers). we estimated the implementation cost at the district level, based on implementation expenditures during the - interventions. to estimate the cost of the meetings for a future intervention, we estimated the number of rural households in all sub-districts using census data [ ] . we projected conducting one opinion leaders meeting and one community meeting per every rural households, using the cost-per-meeting from the "only safe sap" area. we projected the approximate number of gachhis using ngo data from the "only safe sap" area ( gachhis per village or within households). to estimate the cost of training the gachhis we used the per-gachhi training cost from the "only safe sap" intervention. we assumed two cable operators per sub district to estimate the cost of broadcasting the tv public service announcement. we incurred most of the start-up costs developing the intervention, including expenditures on national and international experts and local staff, materials' pretesting, revisions and production, districts and ngo selection, and training of trainers ( table ). the second highest cost was the production of the tv public service announcements, followed by the cost of creating and producing the other communication materials. the ngos conducted opinion leaders and community meetings in the "no raw sap" area, and opinion leaders and community meetings in the "only safe sap" area. they affixed posters in the "no raw sap" area and posters in the "only safe sap" area. local channels broadcast the tv public service announcements times daily. in addition, in the "only safe sap" area, the local ngo conducted gachhi training sessions on how to make and use banas. our implementation cost was lower in the "no raw sap" intervention than in the "only safe sap" intervention ($ , vs. $ , ) ( table ). the cost of the intervention components, broadcasting the tv public service announcement ($ vs. $ ), promoting posters ($ vs. $ ) and conducting community meeting costs ($ , vs. $ , ) was lower in the "no raw sap" intervention than in the "only safe sap" intervention ( table ) . the cost per person directly reached by at least one intervention component was also lower in the "no raw sap" area than in the "only safe sap" area ( cents vs. cents). the cost to reach one person per communication channel was lower in the "no raw sap" area than in the "only safe sap" area: tv public service announcement was . cents versus . cents, poster was . cents versus . cents, and community meetings was cents versus cents. the cost of the gachhi training program in the "only safe sap" area, including the incentive of providing a sweatshirt to those observed using banas during follow up visits, was $ , . the per gachhi cost with incentive was $ . with no incentive was $ . ( table ) . to scale up the intervention, we estimated the start-up cost at $ , (table ; additional file ). our future estimated implementation cost of meetings, posters and the public service announcement was the same for both the "no raw sap" and the "only safe sap" intervention (table ). however, the gachhi training component increased the cost of the "only safe sap" intervention. thus, the implementation cost of a future intervention covering districts would be $ . million using an "only safe sap" approach, and $ . million using a "no raw sap" approach ( table ). the cost of printing and affixing the posters in districts would be $ , . broadcasting the tv public service announcement in districts would cost $ , . to implement an "only safe sap" intervention with community meetings, gachhi training, poster and the tv public service announcement in the six districts with % of all spillover would cost $ , . to implement it in the second most affected area, thirteen districts with % of all spillover, would cost $ . million and in eleven districts with % of all spillover, would cost $ . million. to implement a full "no raw sap" intervention with community meetings, posters and the tv public service announcement in the six most affected districts would cost $ , . in the second most affected thirteen districts it would cost $ million and another $ , to implement it in the other districts. we spent $ , implementing the "no raw sap" intervention and $ , on the "only safe sap" intervention. to scale these interventions up to districts in bangladesh where human infections with niv have been identified, we estimated a cost of $ . million us$ for the "no raw sap" and $ . million us$ for the "only safe sap" intervention. niv usually affects impoverished rural communities in bangladesh, thus, affected families often experience a severe social and financial crisis [ , ] . niv kills people and leaves survivors with permanent neurological sequelae, similar to those experienced by some survivors of japanese encephalitis [ , ] . sixty-one percent of niv cases affected males with a mean age of [ ] who could be the main wage earners of the family. most died [ ] , and those that survived could not continue to work due to the neurological effects of niv. in addition, niv is a disease that requires special care. hospitalization and illness episodes can last a week [ ] . the financial burden associated with hospitalization translates into reduced monthly food and children education expenditures, having to borrow money, taking loans with high interests, and selling assets [ ] [ ] [ ] . prevention could reduce the risk of disease transmission as well as save poor families from social degradation. despite the severity of nipah illness, since an average of fewer than niv cases are identified annually in bangladesh [ ] , the cost of niv prevention is unlikely to meet the traditional criteria for cost-effective interventions to prevent cases [ ] . however, in addition to causing sickness and death, outbreaks have social consequences including fear, social unrest, violence and economic loss [ ] [ ] [ ] [ ] . for diseases with moderate to high perceived severity, such as pandemic influenza, sars or ebola, investing and intervening earlier in the outbreak can be cost effective [ ] . niv is a deadly disease that can transmit from person to person and represents a global pandemic threat [ , ] . estimating niv prevention costs is of interest to local and global health communities, helping to make informed decisions on funding interventions to prevent this disease. if we prevent a large high-mortality niv pandemic, an effective intervention would be remarkably cost-efficient. disaster preparedness reduces the impact of disasters and associated costs, compared to a scenario without preparedness [ ] . initiatives to mitigate low probability, high catastrophic risks are not uncommon. nasa spends millions of dollars each year to track asteroids, though chances of dying from an asteroid impact are very low for the average person in the united states [ ] . investing in active surveillance activities for zoonotic infections, implementing effective ecological health interventions, improving modeling capabilities, increasing evaluations of health systems and public health needs and policies, and implementing better risk communication can improve the preparedness to respond to emerging infectious diseases [ ] . for example, taiwan established a nationwide emergency department, based on a syndromic surveillance system, that collaborated with hospitals for better public heath response to improve their pandemic flu preparedness and disease control capabilities [ ] . similarly, investing in preventing niv could provide an important benefit. health intervention studies from bangladesh, focusing on cost, find some similarities with our study [ ] [ ] [ ] . a study on neonatal and child health reported a lower cost per person reached through local tv channels than other intervention components [ ] . in our intervention, the cost of interpersonal communication was around times higher than broadcasting the televised public service announcement in the "only safe sap" area. the estimated cost of posters was also low and could be integrated in future interventions. findings from our trial suggested more behavior change resulted from a one season "only safe sap" intervention than a two-season "no raw sap" intervention [ , ] . this could be because the "only safe sap" intervention offered the option of drinking safe sap by promoting the use of banas among gachhis, an already existing behavior [ ] that still allowed people to enjoy drinking sap. the gachhi training component might also have contributed to increased exposure to the intervention. although its estimated scale up cost was higher than the "no raw sap" intervention, for upcoming seasons, the "only safe sap" intervention should be considered. spending us$ . million annually on an "only safe sap" intervention would be prohibitively costly for a low-middle income country like bangladesh that currently spends only $ . per capita per year for healthcare [ ] and . % of gross domestic product in total health expenditures [ ] . the high cost of the meetings used in this intervention makes it impossible to scale up and sustain this intervention without external funding. reducing meetings and interpersonal communication would reduce costs and so increase the feasibility of scaling it up. we could achieve a lower cost intervention by including community health workers [ ] and health workers from the expanded program of immunization (epi), as well as health workers from ngos such as brac [ , ] . they could conduct meetings in the areas immediately surrounding their offices, affix posters, provide leaflets, and disseminate messages to people receiving their services during the sap harvesting season, adding a minimal cost. in addition, eliminating the gachhi incentive for using banas would reduce the cost of the gachhi intervention by more than one-third. our intervention findings provide a framework to calculate costs of a future intervention to prevent niv. however, the following limitations of our findings require consideration. we did not include the intervention impact data in the results of this cost manuscript, therefore, we cannot calculate cost-effectiveness. the complexity of the impact data required a separate manuscript to be properly presented. nevertheless, this cost analysis, conducted from a provider's perspective, enables future providers to weight the costs of taking on this intervention against those of other interventions [ ] . better understanding of the cost, from intervention providers and recipients, would provide an understanding of costrelated potential barriers and obstacles to implementing the intervention. although we calculated the separate cost of each intervention component, we cannot interpret the separate impact of each component. since communication campaigns often rely on a synergistic effect, all of its components may need to run in parallel for maximum impact [ ] [ ] [ ] . therefore, although deploying only a single component markedly reduces cost, this body of work does not provide direct evidence that the standalone components will alter behavior. to reduce costs, we proposed engaging government and other health workers to conduct meetings within their locality. since, they already have other tasks to accomplish, small-scale pilot efforts could help identify practical strategies to integrate niv prevention messages into health worker activities. the government already broadcast the "no raw sap" public service announcement during the - season. continuing to measure the prevalence of raw sap consumption as these messages are disseminated more widely can provide useful guidance on adjusting interventions and messages going forward. exploring low cost strategies to communicate prevention messages in frequently affected districts, such as broadcasting the public service announcement on local channels, combined with health workers visiting communities to spread messages and affix posters in districts with high risk of niv spillover, may be an effective way to reduce the risk of niv. continuous monitoring efforts may help to further develop and refine the intervention components for more effective communication. person-to-person transmission of nipah virus in a bangladeshi community nipah virus outbreak with person-to-person transmission in a district of bangladesh recurrent zoonotic transmission of nipah virus into humanbangladesh nipah virus infection outbreak with nosocomial and corpse-tohuman transmission date palm sap linked to nipah virus outbreak in bangladesh foodborne transmission of nipah virus date palm sap collection: exploring opportunities to prevent nipah transmission a randomized controlled trial of interventions to impede date palm sap contamination by bats to 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covering nipah-affected districts with at least one nipah spillover, bangladesh, supporting document for table . the authors declare that they have no competing interests. all relevant data have been presented in the main paper and an additional supporting file has been uploaded. the ethical review committee of international centre for diarrhoeal disease research, bangladesh and family health international ′s institutional review board reviewed and approved the study protocol. the data collection team obtained written informed consent from the respondents before conducting interviews. support for this study was provided by fhi with funds from usaid cooperative agreement ghn-a- - - - . springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- - xtxmpg authors: dhillon, jasmine; banerjee, arinjay title: controlling nipah virus encephalitis in bangladesh: policy options date: - - journal: j public health policy doi: . /jphp. . sha: doc_id: cord_uid: xtxmpg nipah virus (niv) encephalitis is endemic in bangladesh, with yearly seasonal outbreaks occurring since . niv has a notable case fatality rate, – per cent depending on the strain. in bangladesh, primary transmission to humans is believed to be because of consumption of bat-contaminated date palm sap (dps). both the disease and the virus have been investigated extensively, however efforts to implement preventive strategies have met social and cultural challenges. here we present a variety of community approaches to control the spread of nipah encephalitis, along with advantages and disadvantages of each. this information may be useful to health workers and policymakers in potential niv outbreak areas in southeast asia. nipah virus (niv) is an emerging infectious disease (eid) and belongs to the genus henipavirus (family paramyxoviridae). first identified and isolated in the village of sungai nipah, malaysia in during a severe disease outbreak in humans and pigs, niv was initially diagnosed as a hendra-like virus and named 'nipah'. during this outbreak the virus was isolated from multiple species, including humans, horses, dogs, cats, cattle, and rats. , clinical symptoms in humans occurred in those with direct contact with pigs. further investigation found that malaysian outbreaks had begun in september and lasted until april , resulting in human deaths and culling of . million pigs. in western bangladesh, niv was first identified in april/may in an encephalitic outbreak with high case fatality ( out of ). a second outbreak in bangladesh occurred in january , during which people died (out of ). traceback information suggested two risk factors: climbing date palm trees and close association with patients. in , deaths (out of cases) were reported in a third outbreak in two separate communities. it was found to be a result of direct or indirect contact with fruit bats, including date palm sap (dps) consumption. during a subsequent outbreak in , researchers established a significant relationship between the consumption of raw date farm syrup contaminated by fruit bat saliva and niv infection ( out of cases died). between and , cases of nipah or nipah-like virus encephalitis were identified, with deaths (case fatality rate of per cent). niv appears to be increasingly virulent in bangladesh, with greater case fatality rates each year, peaking at per cent in and . recently, bats have been vectors in many eids, including speculation that the current ebola virus disease outbreak in west africa could be because of a spillover from bats. blum et al ( ), homaira et al ( ) and more recently gurley and colleagues ( ) , analyzed the social conditions associated with the spread of niv. they studied key stakeholders, operating beliefs, and scientific message responses. [ ] [ ] [ ] for knowledge translation and transference to occur, all these authors suggest that appropriate communication and community engagement is needed. in their absence, potential interventions are unlikely to be considered acceptable and adhered to by at risk community members. for bangladesh, luby ( ) described the main routes of niv transmission, all involving contact with materials containing the virus: (i) ingesting niv contaminated raw dps, (ii) person-to-person transmission (short chain transmission either from live or dead hosts), and (iii) contact with sick animals (less frequent). person-to-person transmission is not as commonly observed as for ebola, but it has been observed in hospital settings. person-to-person transmission was also observed during the faridpur outbreak in during which one physician died. this highlights the importance of appropriate training for health-care workers and frontline caregivers when dealing with any eid outbreak. a separate study of nosocomial transmission of nipah encephalitis found no risk to health-care workers. since the first bangladeshi outbreak in , more than people have been infected with niv, in more than different outbreaks. outbreaks occur between november and may (most commonly december-april), and infections appear to be limited to the northwestern and central parts of the country, probably due to a greater number of people who eat dps in this region. case mortality averages per cent, with some strains reaching per cent. fortunately the period of dps consumption (november-april) has not coincided with peak infection and transmission within bat colonies (june-july). similarly, although the potential for a 'super spreader' event is apparent (with a more infectious virus developing or increased shedding by specific individuals), this has not yet occurred. the bangladeshi epidemics differ from the outbreaks in malaysia where per cent of infected individuals had contact with pigs. in bangladesh most cases can be traced to bat excretion contamination, with few linked to livestock (depending on outbreak year). person-to-person transmission has been common in the bangladeshi outbreaks, compared with malaysia. evidence suggests a relationship between niv infection and consumption of fresh, raw dps (phoenix sylvestris), although consumption of contaminated fruits cannot be excluded. in addition, the niv strains observed in the malaysian and bangladeshi outbreaks show genotypic differences. these are also observed between outbreak years in bangladesh. though strains appear to be fairly stable within specific localities, they do differ geographically. this divergence could, in the future, impact infectivity in different areas. niv antibodies have also been isolated from pteropid bats through most of southeast asia -india, west bengal, thailand, and cambodia, among others. full strain lineages are still being investigated. , unfortunately, no vaccine exists at this time, although trials in african green monkeys using the vaccine for hendra virus, are currently showing promise. currently, the government of bangladesh strongly recommends against consuming raw dps during outbreak seasons unless the sap was protected by using bamboo skirts during collection or by boiling it for ten minutes. bamboo skirting effectively reduces sap contamination by fruit bats. sap harvesters consider it cost-effective and acceptable. , boiling the sap is less attractive to harvesters, as they believe it changes the taste and consistency of the drink, although it disables the virus. a report by the new york times mentioned a government ban on the sale of raw dps during the outbreak, suggesting a movement toward stricter prevention protocols, although they are difficult to enforce. in addition, a surveillance system has been implemented in five hospitals in the niv belt to detect outbreaks early. as there are no treatment options other than supportive care, nor a vaccine for people or animals, the government currently focuses on prevention by increasing public awareness. they use newspaper advertisements, talk shows, and discussions on local tv and radio. educational programming airs before and during each nipah virus season (november-may). the international centre for diarrheal disease research, bangladesh in collaboration with stanford university, is conducting trials in the districts of rajbari and natore. they want to compare the effectiveness of advising people not to drink raw dps versus drinking sap only from trees protected by skirts to prevent dps from contamination by bats. the results from the first phase of the study are due december . in february , a diverse group of graduate students (of which we were part) chose the niv problem as a case study for the integrated training program in infectious disease, food safety and public policy (itrap) at the university of saskatchewan, canada. they framed and suggested policy options using laswell's problem orientation. , please note that for optimal prevention of niv infection, the policies suggested here would be used in combination. specifically, the most effective intervention would include an integrated education and multi-species surveillance program that maximized public outreach and training (especially in high-risk areas), as well as early identification of disease and early outbreak response. preliminary studies show the local population, including health professionals, in bangladesh are generally misinformed about the transmission and spread of the nipah virus; they remain unaware of the signs of infection and methods of protecting themselves and family members. lack of communication, combined with reduced trust in the medical system and hospital care, has created a stream of misinformation, contributing to continued spread of the disease. an education strategy would inform the local population, providing key facts about the disease and how it is spread, both from bat-to-human and from human-to-human. one facet of the education program could pertain to what the local population, specifically the date palm harvesters, could do to limit their contact with bats. it could also illustrate the signs and symptoms of the disease and offer advice on how to care for loved ones in the event of an outbreak. at the same time, educating hospital staff and traditional healers about nipah virus, and how to provide information to patients and their families, would allow these well-respected groups to disseminate their knowledge to the local population in a culturally acceptable manner. adding education on niv into school curricula could provide information about risk factors to the younger generation. knowledge of an increased likelihood of niv (and eid) transmission in ecological environments with degraded and fragmented geographical landscapes, where wildlife share food resources with people and livestock, can empower individuals to make proactive choices about prevention strategies. education is a relatively inexpensive way to spread awareness about nipah and its mode of spread. involving the local population in the planning and decision process would help generate public acceptance of the education policy. educating people about nipah could help limit transmission, as people can be made aware of both bat-to-human and human-to-human transmission chains. educating the present generation will go a long way in disseminating the information to future generations, limiting future outbreaks. the engagement of a community and changing age-old beliefs and traditions takes time and can be challenging. yet it has worked for kuru in africa, and is also beginning to work in west africa, where people are beginning to change traditional burial practices to help curb the spread of ebola. education alone may not stop the spread of niv, as communities live in close proximity to bats, resulting in some unavoidable interspecies contact. preventing bats and other wildlife from coming into contact with dps can prevent disease spillover. changing beliefs and traditions through community engagement will need some time and resources to spread awareness. bangladesh, but potentially other species elsewhere). human serosurveillance using elisa of igg antibodies (stratified or cluster sampling) from exposed population will help outline yearly hotspots at the end of every seasonal outbreak of nipah. surveillance of hospital staff biweekly or monthly during the outbreak season (november-may) will help monitor the potential nosocomial spread of the disease and will also assess the human-to-human transmission potential of the evolving nipah virus. although nosocomial spread was found to be minimal by , this cannot be ruled out as a possible route of transmission. molecular epidemiology of the viruses isolated from patients will provide further information. routine elisa sero-surveillance of livestock in the nipah-belt will help monitor the viral strain circulating in livestock. this is important, as bats have been found to shed niv year round, and may be capable of transmitting niv to livestock via various means other than date palms, increasing the potential for transmission to communities through contact with their livestock. bat surveillance using serum antibody and virus isolation from feces, urine, and post mortem or trapping samples would again help track changes in the virus. ecological and gis surveillance of bat habitats will help define potential outbreak regions. surveillance of bats will help focus education and awareness programs on communities where niv infected bats cluster. routine surveillance will allow for early disease detection, avoiding economic and social disruption. early detection will also help reduce cases and case fatalities. the social and psychological benefits are immediate because of reduced apprehension and greater understanding. furthermore, reporting data from disease surveillance on a global level helps attract funding from international donors and the who. these can be used to strengthen the surveillance infrastructure. disease surveillance systems take a long time to reach laboratory-based conclusions. our ability to detect novel, emerging, or reemerging infections in a low-technology environment is poor. therefore the surveillance infrastructure needs upgrading. surveillance may be biased, accounting only for reported cases. for infectious diseases, vaccination may achieve herd immunity levels where the disease cannot persist. two recent advances against niv-like diseases (henipavirus) are worthy of note: . hendra-sg subunit vaccine and a human monoclonal neutralizing antibody, m . . the hendra-sg vaccine was developed in australia for equine use (known as equivac hev) and is the first bsl- (biosafety level ) agent vaccine for public use. . hendra-sg vaccines for humans and pigs. development of human and pig hendra-sg vaccines are underway, but meeting ethical standards for clinical trials is challenging. the m . has been used in people on a 'compassionate use' basis in australia and remains in pre-clinical development. although highly effective, the costs of vaccine per animal and for the human population (sap drinkers) remain high due to low demand in the absence of repeated outbreaks. a vaccine would save lives in the nipah belt, and potentially in other at risk southeast asian countries. a preventative vaccine would help alleviate the economic burden placed on the health-care system because of the long-term supportive care required of infected patients. a single dose vaccine, if developed, would also overcome the issue of compliance for boosters. the vaccine might also protect international travelers, thus reducing the disease's impact on tourism in the future. the absence of repeated outbreaks increases the cost of vaccine development, thus raising the cost per dose. adequate external funding might address this issue, as with the two ebola vaccines undergoing trials in liberia currently. it takes a long time to develop a vaccine, but it might be a long-term objective, as niv still has the potential to become a pandemic. a vaccination strategy (mass vaccination or ring vaccination) would need to be evaluated and decided upon by all stakeholders. is there a sufficient incentive for the pharmaceutical industry to produce a vaccine that does not yet have a global demand? surely repeated introduction of the same virus is a precursor to widespread disease, as with other viral eids such as sars, avian influenza, and hiv. changing the interface between humans and bats could have a dramatic impact on lowering infection rates. one option to inhibit virus spillover is to improve dps biosecurity by preventing bats from coming into contact with sap. this can be done with physical barriers. three types of physical barriers have been shown to prevent bats from coming into contact with dps: bamboo, 'dhoincha', and polythene skirts (for photographs of each of these barrier types, see khan su et al ( ) . it is an inexpensive and economically feasible alternative, and would effectively keep bats off dps pots. using physical barriers (skirts) does not impact the quality or quantity of sap collected. it is also socially acceptable for the sap harvesters. using skirts can reduce cases almost immediately in outbreak affected areas. this option has the added benefit of demonstrating cultural respect for the value placed on the custom and history of drinking dps. this option may not completely eliminate the disease as it targets only one form of virus transmission (bats-to-humans), but may help prevent the index cases in future sporadic outbreaks. there must also be community engagement and 'buy in' for this option to be successful. infection control interrupts disease transmission chains, especially person-to-person spread. five or more rural hospitals (including rangpur, rajshahi, bogura, faridpur, and rajbari) with the highest numbers of clinically reported cases, based on data analysis from to , have been identified. they now require an infectious disease control infrastructure to be itemized, documented, and procured. appropriate protocols, procedures, and equipment reduce the risk of health care-associated transmission and limit person-to-person transmission, once the virus is no longer spread within or from the hospital. good quarantine practices reduce the risk of developing pandemic strains of other diseases such as influenza as well, thus providing multiple benefits for increasing the biosafety and biosecurity of these institutions. nosocomial transmission of all infectious diseases will be prevented, because case management will be improved. with early recognition, patients will have better chances of survival. the initial development of protocols and procurement of paraphernalia is expensive in the short run, but economically justified on the basis of long-term control and prevention of future cases of nipah encephalitis, plus other infectious diseases. this option requires extensive training campaigns that may be possible with the help of the government and external funding agencies. although vaccination of wildlife reservoirs would immediately reduce the levels of niv (elimination of disease in bats), this is not a currently available option, as there is no vaccine for wildlife. vaccinating bats may be difficult because of their large geographic spread and their ability to fly. a bait system similar to the raccoon rabies vaccine used in quebec, canada would be needed. little is understood about bat immunology, thus developing a vaccine is a challenge. bats seem to be persistently infected with viruses that they harbor without developing disease. antibodies against some viruses have been isolated, but bats fail to completely eliminate the viruses they carry. understanding the physiology behind this would help develop a wildlife vaccine for bats. to curb sporadic outbreaks, we believe current goals should be focused on reducing exposure to bat contaminated sap. there are a myriad of options; a combination will surely work best. during the canadian students' itrap session, individuals from different training and philosophical backgrounds scored the feasibility, practicality, social acceptability, and ethical considerations of the options to identify the best possible strategy to control niv. the single option most likely to succeed, if only one were put in place, was 'education'. once the results from the clinical trial being conducted by the international centre for diarrheal disease research become available, an evidence-based policy should be possible. however, as previously noted, a combination of all of the alternatives is most likely to prevent a future pandemic, as human behavior drives spillover risk. in the mean time, the surveillance infrastructure should be improved to allow better reporting of cases. controlling nipah is a complex challenge. controlling the consumption of contaminated dps by targeting the communities where consumption is high appears to be the simplest way to control niv outbreaks. however challenging centuries old traditional beliefs and behaviors may pose problems. any solution must therefore consider the values of all stakeholders. prevention of human cases would inhibit the virus from adapting further to the human host. the adaptation is a step whereby it could gain full potential against human-to-human transmission. thus acting early on this virus is important. with no vaccines or antivirals available yet, education is crucial to spread awareness among community members, making it possible to control disease spread in every season. it will require communities to promote consumption of skirt-protected sap rather than the unprotected sap. although behavioral change is challenging, with consistent community engagement and support, it can be done. it could be a painfully long process to convince communities to modifying their ageold practices, but it has worked in africa for kuru and is beginning to work in west africa for ebola. gaining the trust of the affected community goes a long way in winning the battle against an infectious disease. canada. she is an epidemiologist specializing in zoonotic disease prevention. her research currently focuses on dog bite prevention and dog population management in first nations communities. arinjay banerjee (bsc, msc) is a phd student at the western college of veterinary medicine, university of saskatchewan, canada. he is a virologist and his research currently focuses on exploring the role of the innate antiviral response in bats, which could play a role in allowing bats to survive coronavirus infections, that are often lethal in other species (for example, sars-cov, mers-cov). nipah virus outbreaks in bangladesh: a deadly infectious disease a review of nipah and hendra viruses with an historical aside the natural history of hendra and nipah viruses nipah virus: an emergent deadly paramyxovirus infection in bangladesh nipah virus infection outbreak with nosocomial and corpse-tohuman transmission foodborne transmission of nipah virus nipah virus outbreaks in the who south-east asia region ) vulnerability, hysteria and fear -conquering ebola virus in-depth assessment of an outbreak of nipah encephalitis with person-to-person transmission in bangladesh: implications for prevention and control strategies nipah virus outbreak with person-to-person transmission in a district of bangladesh ecological determinants of nipah virus risk in bangladesh: the convergence of people, bats, trees and a tasty drink. paper presented in the rd international one health conference person-to-person transmission of nipah virus in a bangladeshi community transmission of human infection with nipah virus risk of nosocomial transmission of nipah virus in a bangladesh hospital nipah virus infection in bats (order chiroptera) in peninsular malaysia the ecology of nipah virus in its natural reservoir, pteropus giganteus, in bangladesh. paper presented in the rd international one health conference characterization of nipah virus from outbreaks in bangladesh nipah virus in lyle's flying foxes a hendra virus g glycoprotein subunit vaccine protects african green monkeys from nipah virus challenge a randomized controlled trial of interventions to impede date palm sap contamination by bats to prevent nipah virus transmission in bangladesh piloting the use of indigenous methods to prevent nipah virus infection by interrupting bats' access to date palm sap in bangladesh bangladesh bans sale of palm sap after an unusually lethal outbreak nipah still a major health concern community intervention to prevent nipah spillover the science of public policy. the evolution of the policy sciences species and ecosystem conservation: an interdisciplinary approach a treatment for and vaccine against the deadly hendra and nipah viruses twenty years of active bat rabies surveillance in germany: a detailed analysis and future perspectives host immunity to repeated rabies virus infection in big brown bats vikram misra, kesiena akpoigbe, teresia maina, roshan madalagama, ellen rafferty, kurt kreuger, ibrahim elsohaby, and geetika verma, contributed to our discussions. this study, part of the integrated training program in infectious disease, food safety and public policy held at the university of saskatchewan, was supported by a grant from the natural sciences and engineering research council of canada (nserc). key: cord- -qm kalyt authors: chowdhury, fazle rabbi; ibrahim, quazi shihab uddin; bari, md. shafiqul; alam, m. m. jahangir; dunachie, susanna j.; rodriguez-morales, alfonso j.; patwary, md. ismail title: the association between temperature, rainfall and humidity with common climate-sensitive infectious diseases in bangladesh date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: qm kalyt bangladesh is one of the world’s most vulnerable countries for climate change. this observational study examined the association of temperature, humidity and rainfall with six common climate-sensitive infectious diseases in adults (malaria, diarrheal disease, enteric fever, encephalitis, pneumonia and bacterial meningitis) in northeastern bangladesh. subjects admitted to the adult medicine ward of a tertiary referral hospital in sylhet, bangladesh from to with a diagnosis of one of the six chosen climate-sensitive infectious diseases were enrolled in the study. climate-related data were collected from the bangladesh meteorological institute. disease incidence was then analyzed against mean temperature, humidity and average rainfall for the sylhet region. statistical significance was determined using mann-whitney test, chi-square test and anova testing. patients were enrolled ( % male, % female, ratio . : ). all six diseases showed highly significant (p = . ) rises in incidence between the study years ( cases) and ( cases), compared with no significant rise in overall all-cause hospital admissions in the same period (p = . ). the highest number of malaria ( ), diarrhea ( ) and pneumonia ( ) cases occurred during the rainy season. on the other hand, the maximum number of enteric fever ( ), encephalitis ( ) and meningitis ( ) cases occurred during autumn, which follows the rainy season. a positive (p = . ) correlation was observed between increased temperature and the incidence of malaria, enteric fever and diarrhea, and a negative correlation with encephalitis, meningitis and pneumonia. higher humidity correlated (p = . ) with a higher number of cases of malaria and diarrhea, but inversely correlated with meningitis and encephalitis. higher incidences of encephalitis and meningitis occurred while there was low rainfall. incidences of diarrhea, malaria and enteric fever, increased with rainfall, and then gradually decreased. the findings support a relationship between weather patterns and disease incidence, and provide essential baseline data for future large prospective studies. a a a a a global warming is not a myth, rather a reality [ , ] , and the impact of climate change is multidimensional on health. the world health organization (who) recently reported an estimated . million deaths each year due to unhealthy environments, particularly climate change and pollution [ ] . the report also identifies diarrheal diseases, respiratory infections and malaria in the top ten causes of environment related deaths [ ] . climate change influences the emergence and re-emergence of many infectious diseases [ , , , ] . dengue fever, tickborne diseases, diarrheal disease, enteric fever, viral encephalitis, respiratory tract infections, and meningitis are much increased in recent times [ ] [ ] [ ] [ ] ] . in addition, emerging and reemerging diseases such as chikungunya and zika, have also been linked to climate change influences, and have been proposed as partially responsible for autochnous transmission in places not traditionally endemic for such diseases [ , ] . analysis of global temperature data led the intergovernmental panel for climate change (ipcc) to the conclusion that the average global temperature over land and ocean surfaces has risen by . ˚c in the period from to [ ] . they predicted that global surface temperature will increase by . ˚c compared to the year by the end of the st century ( - ) [ ] . climate change is predicted to directly influence zoonotic infectious disease transmission by changing the geographic range of a vector [ ] . altered climatic conditions may increase vector biting rate and the reproduction rate of the vector and shorten the pathogen incubation period [ ] [ ] [ ] [ ] . climate-related increases in sea surface temperature and sea levels can lead to higher incidence of waterborne infectious diseases [ , , ] . as a low-income country, bangladesh itself plays very little role in the process of global warming, but becomes one of the most seriously affected victims of climate change. bangladesh is the biggest delta and contains the second largest river basin in the world [ ] . the majority of the land is low and flat, and only % lies over one meter above the mean sea surface [ ] . because of monsoon weather and the presence of the bay of bengal in the south, extreme weather events like flood and cyclone are common [ , ] . this unique geographic and topographic location makes it reportedly the most vulnerable country to climate change effects [ ] . lack of resilience and adaptive capacity, dense population and poverty make the situation worse [ ] . unfortunately, very few studies on the relationship between various environmental variables and trends of infectious disease incidence have been performed so far in bangladesh, although there are reports of some infections increasing sporadically in different regions of the country [ ] [ ] [ ] . climate change and health related studies are so far mainly reported from developed countries, but studies from vulnerable countries are still meagre [ , ] . furthermore, published studies typically only focus on a single disease. this study examined six infectious diseases based on clinical syndromes and laboratory support (malaria, enteric fever, encephalitis, diarrheal disease, pneumonia and meningitis) to offer a broader scope on the trend of these infectious diseases and their possible relation to climate change in bangladesh. we chose these six diseases based on the reports of ipcc ( ) and who ( ) where they were listed as climate-sensitive infectious diseases important for asia [ ] [ ] [ ] . the main objective of the study was to see the burden of the six climate sensitive diseases over five years and to analyze the possible relationship of them with common climatic variables. the findings will be of interest to public health experts and policy makers to stimulate effective measures to combat infectious diseases and related epidemics in bangladesh and in other vulnerable countries. sylhet divison in northeast bangladesh, an area of approximately , km with a population of around million. all case files of the adult medicine ward from to were enrolled from the hospital archive. the diagnosis of the six studied diseases were confirmed based on the combination of clinical and relevant laboratory diagnosis. incomplete files, patients discharged on risk bonds, patients who died within hours (due to insufficient time to reach a diagnosis) and absconded patients were excluded from the study. square p< . ) whereas encephalitis occurred more frequently in females in females ( % vs. %, chi square p< . ) ( table ). the highest percentage ( %; ) of disease over the five years studied occurred in the th year ( ). there was a trend towards increasing number of cases of the six infectious diseases studied over the five years ( fig a) and there is a significant difference (p = . ) between the total number of cases in ( ) and ( ). all six infectious diseases individually increased in number over the five years, especially pneumonia which rose from cases in to cases in . this increase does not appear to be due to increased numbers of patients using the hospital overall. in comparison, the number of admissions for all causes to the hospital and to the medicine department over three of the years of study from to (data unavailable for and ) did not change (mann-whitney u test p = . , fig b) . the highest number of cases occurred in autumn ( ; %) followed by rainy season ( ; %), winter ( ; %) and summer ( ; %). pneumonia ( ; %) was the most common disease of the six, and malaria ( ; %) was the least prevalent disease. individually, the highest number of malaria ( ), diarrhea ( ) and pneumonia ( ) cases occurred in rainy season. on the other hand, the maximum number of enteric fever ( ), encephalitis ( ) and meningitis ( ) cases occurred during autumn (fig ) . the mean temperature in our study region during - was . ˚c, and there was no significant difference in the number of cases occurring below or above that level (table ). in , the average temperature was more than ˚c in eight out of twelve months (fig ) . there was a significant positive correlation between increasing temperature and the incidence of malaria (p = . ), and a trend for positive correlation between increasing temperature and the incidence of diarrhea (p = . ). there was a significant negative correlation between increasing temperature and incidence of encephalitis (p = . ), meningitis (p = . ) and pneumonia (p = . ). table shows the association of the six diseases with the average humidity of the studied period of to . we analysed the incidence of each disease in each of three groups of humidity recordings by month: less than . %, . - . % and more than . % based on the mean humidity of the study site. less than . percent humidity was associated with the highest percentage ( ; %; p = < . ) of all the six studied diseases (table ) . average humidity of . - . % and > . % was associated with % ( ) and % ( ) disease respectively. however, in , the average humidity was ! . % in nine out of twelve months (fig ) . higher humidity was correlated with a higher number of cases of malaria (p = . ), enteric fever (p = . ) and diarrhea (p = . ), but inversely correlated with meningitis (p = . ), encephalitis (p = . ) and pneumonia (p = . ). the average rainfall by month was divided into three groups, less than mm, - mm and more than mm in table . the highest percentage ( ; . %) of all the six diseases studied were related with less than mm of average rainfall. % ( ) malaria, % ( ) enteric fever, % ( ) diarrhea, % ( ) encephalitis, % ( ) pneumonia and % ( ) meningitis fell under this category (chi-square p = . ). average rainfall of - mm and > mm was associated with % ( ) and % ( ) of the total disease burden respectively. analyzing the data of , in six out of twelve months, there were mm average rainfall (fig ) . higher incidences of encephalitis (p = . ) and meningitis (p = . ) happened while there was low rainfall. incidences of diarrhea (p = . ), malaria (p = . ), pneumonia (p = . ) and enteric fever (p = . ) increased with rainfall, and then gradually decreased. ( - ) . the highest number of malaria, diarrhea and pneumonia cases occurred in rainy season, whilst the maximum number of enteric fever, encephalitis and meningitis recorded during autumn. student t test was applied to obtain the level of significance. https://doi.org/ . /journal.pone. .g table . association of disease with the temperature of five years ( - ). temperature previous studies in bangladesh have either focused on a single disease or relied on people's perception of climate change and infectious disease. to our knowledge, this study is the first observational study which specifically focuses on individual infectious diseases and explores the relationship between each disease and three common weather variables. the male to female ratio in this study was . : . although there are no published data, it is generally believed that more males come into hospital in bangladesh because traditionally females wait at home with their disease until complications develop [ , ] . it is likely that women get less opportunity to come into hospital and have less access to medical care. there was no significant difference by gender in the frequency of each individual disease except pneumonia and encephalitis, which significantly affected a greater proportion of the male and female population respectively. the increase in pneumonia cases seen in males may be because men have more occupational exposure to conditions that increase the chance of receiving a diagnosis of pneumonia such as dust, fumes, smoking etc. all six diseases showed a significant (p = . ) rise in incidence between the study years and . the number of cases more than doubled for all diseases except enteric fever, which also showed significant increases. in contrast, during this same period the total number of admissions to the medical ward and to in the hospital showed no significant rise. we propose that the rise in frequency of the studied diseases could be explained by the influence of weather changes. it is important to note that during this period no epidemics of the studied diseases happened in the sylhet region. the total impression is consistent with previous reports. in a review of the literature, the incidence of pyogenic meningitis, encephalitis and dengue was predicted to be greatly influenced and increased by global warming in the coming years [ ] . w.h.o reported dengue, viral encephalitis, diarrheal disease, enteric fever, pneumonia and meningitis as most sensitive to climate factors, and predicted a huge rise of cases in tropical countries [ ] . climate change cell, bangladesh reported that, from to there were , cases of malaria in bangladesh, but from to it increased to , ( % increased incidence) [ ] . although after the introduction of artemisinin treatment and government and other partner organization lead massive drive for malaria elimination, the cases decreased to . / population in bangladesh [ ] . the same report revealed an increasing trend for diarrheal diseases, kala-azar and skin diseases in three districts (drought-prone rajshahi, flood-prone manikganj and salinity-dense satkhira) of bangladesh between to [ ] . the report also described a positive correlation between rainfall and diarrheal and skin disease in rajshahi and satkhira, and a negative correlation of diarrheal disease with temperature [ ] . another focus group discussion (fgd) based study reported an increased number of diarrheal diseases, typhoid and skin problems after the cyclone sidr and aila in southern part (barguna and khulna) of the country [ ] . we found the highest number of malaria ( ), diarrhea ( ) and pneumonia ( ) cases occurred during the rainy season. the findings are consistent with other national and international studies. highest cases of falciparum malaria were found in north-eastern india during higher humidity was correlated with a higher number of cases of malaria, enteric fever and diarrhea, but inversely correlated with meningitis, encephalitis and pneumonia. two-way anova test was applied to obtain the level of significance. https://doi.org/ . /journal.pone. .g temperature, rainfall, humidity and climate-sensitive infectious diseases in bangladesh the rainy season [ ] . in the chittagong hill tract districts of bangladesh, where malaria is most endemic, the frequency of cases was highest in rainy season [ ] . an increased incidence of malaria in north-west of india has been suggested through computational modelling [ ] . studies in africa revealed mixed results, with the highest number of malaria cases during the rainy season in mali, but most cases during autumn in northern ghana [ , ] . according to the ipcc report, respiratory infections also follow a seasonal pattern [ ] . in tropical settings, where most deaths due to pneumonia occur, the incidence of lower respiratory tract illness in children is generally increased during rainy season and it supports our findings [ ] . a thai study of viral pneumonia reported the highest number of cases in rainy season [ ] , in line with our findings. this pattern of increased pneumonia cases during rainy season in tropical countries contrasts with the well described increase in pneumonia seen during colder months in temperate climates [ , ] . for diarrheal disease, our findings are supported by previous reports of increased incidence during the rainy season in taiwan ( ) and bangladesh ( ) . we found a large number of enteric fever cases ( ; %) occurred in rainy season and autumn. this agrees with earlier studies in both dhaka, bangladesh ( ) where the highest number ( %) of enteric fever occurred during monsoon period [ ] ,and a cambodian study [ ] but no relationship between incidence of enteric fever and season was seen in kenya [ ] . in our study, most meningitis ( ; %) and encephalitis ( ; %) occurred during autumn and winter. this finding is partly consistent with other studies done in africa. meningitis epidemics in west africa occurred during the coolest season [ ] . a recent time series analysis over countries found that bacterial meningitis season peaks during the winter months, [ ] , similar to our findings. a major causative organism of meningitis (neisseria meningitides) was found to be high and active during dry periods in the presence of dust and were then washed away with rainfall, so as the case frequency fell down [ , ] . however, in our study, we found an almost equal number of meningitis cases in rainy season compared to other seasons. regional findings of seasonality in terms of encephalitis are also supportive of our findings. highest number of encephalitis cases in rainy period (august-september) were seen in nepal [ ] . in india, the incidence of japanese encephalitis was also highest during august to november (rainy and early winter) with a peak in october [ ] . another study from china also reported similar findings [ ] . the current rate of increase of the annual minimum temperature (by . ˚c) is higher than that of the annual maximum temperature (by . ˚c) in bangladesh [ ] . the annual average rainfall is increasing by . mm per decade outside the usual rainy period, while rainfall during the season is decreasing by . mm per decade [ , ] . in our study, we found a positive correlation between the incidences of malaria, enteric fever and diarrhea with increasing temperature. these results are similar to other national and international findings. a previous study in chittagong, bangladesh showed increased malaria cases with increasing temperature table . association of disease with the rainfall of study years ( - ). temperature, rainfall, humidity and climate-sensitive infectious diseases in bangladesh [ ] . studies have shown a positive relationship between increased malaria and increasing temperature [ , ] . studies in south asia and south america (venezuela and columbia) have documented the association between malaria outbreaks and the el nino southern oscillation (enso) cycle [ ] . a significant increase in malaria cases with increasing temperature was seen in rwanda and uganda [ , ] , but this was not seen in studies done in the african highland region [ , ] . increased temperature allows faster replication of mosquito incidences of diarrhea, malaria, pneumonia and enteric fever increased with rainfall. two-way anova test was applied to obtain the level of significance. https://doi.org/ . /journal.pone. .g temperature, rainfall, humidity and climate-sensitive infectious diseases in bangladesh populations [ , ] . higher temperatures also change human behavior, for example more outdoor activities may be undertaken which further increases the risk of exposure [ ] . diarrheal cases including dysentery have been found to be higher in high temperature in bangladesh, taiwan and china [ ] [ ] [ ] . a study in dhaka, bangladesh showed an increase number of enteric fever cases with an increase temperature which supports our findings [ ] , as does a similar study from southern australia [ ] . furthermore, a strong linear association has been noted between temperature and notification of salmonellosis globally [ ] . temperature affects the transmission of food-borne disease in various ways. the temperature directly affects the rate of replication of bacterial and protozoan pathogens and the survival of enteroviruses in the environment [ , ] . in addition, these variations may also have a significant impact on the environmental reservoirs of infection as well as human behavior [ ] . moreover, both salmonella and cholera bacteria, for example, proliferate more rapidly at higher temperatures; salmonella in animal gut and food, cholera in water [ , ] . our study shows an inverse relationship between encephalitis, meningitis and pneumonia with temperature. the pneumonia findings are consistent with a study done in china, but not with another study conducted in spain [ , ] . for encephalitis and meningitis our findings differ to other studies done in india, china and niger where they found increased evidence of cases and vector during hot environment [ , , ] .viral encephalitis cases in sweden have reportedly increased in response to a succession of warmer winters over the past two decades [ ] . this inverse relationship with temperature in our study merits further exploration. in recent decades, more heatwaves have been reported in south asia, which also bring a change in humidity [ ] . eighteen heatwaves were reported in india between and [ ] . our study found a higher trend of malaria, enteric fever and diarrhea cases with higher humidity. the findings are further supported by studies done in chittagong, bangladesh and china with similar trend [ , ] . relative humidity influences biological and feeding behavior of mosquitoes [ ] . at higher humidity, mosquitoes generally survive for longer and disperse further [ , ] . higher humidity also affects the rate of replication of bacterial and protozoan pathogens and their survival in the environment [ ] . we did not find any influence of humidity on enteric fever and pneumonia, in line with other studies [ , ] . the incidence of pneumonia, encephalitis and meningitis is inversely related to humidity in this study. in india an inverse association was seen between the number of culex mosquitoes (the vector for japanese encephalitis) and humidity [ ] , although in china, higher cases of encephalitis was seen with higher humidity [ ] . these mixed findings may reflect differences in etiology of encephalitis and bacterial meningitis, as well as differences in case definitions between study sites. these could also explained by diagnostic limitations, and in some cases the meningoencephalitis syndrome may be caused by bacteria favoring dry and dusty weather. heavy rainfall can have a diverse range of effects on disease. for example, in tropical and subtropical regions with crowding and poverty, heavy rainfall and flooding may trigger behavioral changes such as increased contact between people and distribution of pathogens in floodwater, leading to outbreaks of diarrhea [ ] . we found that the incidence of diarrhea, malaria, enteric fever and pneumonia increased with rainfall. for diarrhea, our findings are consistent with other national and international studies [ ] [ ] [ ] . a positive relationship between increased rainfall and the incidence of enteric fever was also found in dhaka, bangladesh and southern australia [ , ] . one possible explanation is, heavy rainfall may affect the frequency and level of contamination of drinking water and hence the spread waterborne infections [ , ] . area with existing high burdens of infectious disease and poor sanitary infrastructure often experience increased rates of diarrheal diseases after heavy rainfall [ ] . our findings in terms of malaria are also similar to other national and regional studies [ , ] . rainfall plays an important role in the transmission of malaria, as mosquitoes need water to support the larval and pupal stages of development [ , ] . a study also found higher deaths from acute lower respiratory tract illness during rainy season in a pediatric population [ ] . in - , the highest incidences of encephalitis and meningitis occurred while there was very low rainfall. our findings are supported by other reports in the case of meningitis [ , ] . nevertheless, researchers found the opposite for japanese encephalitis, where the vector replicates and transmits more disease with high rainfall [ , ] . we acknowledge a limitation of this study is the relatively short timeframe. extending our study duration to ten years would have allowed greater power to detect differences, but we did not have the resources to do this. another limitation is that due to the retrospective design of the study with recruitment from the hospital archive, we relied on the diagnosis in the patient notes, which in some instances may be wrong. we tried to overcome this limitation by setting case definitions for enrollment in the study and included only the cases who survived for more than hours, where there was more clinical information to make an informed diagnosis. the death rate in the first hours due to these infections (bacterial meningitis- . %; encephalitis . % and all-cause mortality . %) during that period was low and unlikely to influence our results [ ] . due to limitations of funding and time, we conducted this study in only one hospital of northeastern region of bangladesh. further studies in other regions of bangladesh are highly desirable to represent the situation across the country. this study reported the influence of temperature, humidity and rainfall on six climate sensitive infectious diseases in the northeastern region of bangladesh. weather and climate extremes affect all sectors of the health, economy and development. the findings can be used as a baseline to launch a large cohort study throughout the country in future. this study is pivotal in giving direction to 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analysis environmental risk and meningitis epidemics in africa dust clouds and spread of infection japanese encephalitis in hill and mountain districts a long-term study on vector abundance & seasonal prevalence in relation to the occurrence of japanese encephalitis in gorakhpur district weather variables and japanese encephalitis in the metropolitan area of jinan city temperature and precipitation projections over bangladesh and the upstream ganges, brahmaputra and meghna systems knowledge and perception about climate change and human health: findings from a baseline survey among vulnerable communities in bangladesh trends in extreme rainfall events of bangladesh theoretical and applied climatology how malaria models relate temperature to malaria transmission optimal temperature for malaria transmission is dramatically lower than previously predicted climate change and human health: present and future risks highland malaria in uganda: prospective analysis of an epidemic associated 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vectors in kurnool district of andhra pradesh, india severe heat waves over the indian subcontinent in , in perspective of global climate current science potential impact of macroclimatic variability on the epidemiology of giardiasis in three provinces of cuba ministry of health and family welfare (mohfw): sylhet m. a.g.osmani medical college hospital we thank the staff of the hospital archive and administration departments of somch for their cooperation. we are also grateful to the nurses and doctors of all the units of medicine department for their support. key: cord- -wkmnfph authors: hossain, mohammad anwar; jahid, md. iqbal kabir; hossain, k. m amran; walton, lori maria; uddin, zakir; haque, md. obaidul; kabir, md. feroz; arafat, s. m. yasir; sakel, mohamed; faruqui, rafey; hossain, zahid title: knowledge, attitudes, and fear of covid- during the rapid rise period in bangladesh date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: wkmnfph the study aims to determine the level of knowledge, attitude, and practice (kap) related to covid- preventive health habits and perception of fear towards covid- in subjects living in bangladesh. design: prospective, cross-sectional survey of (n = ) male and female subjects, – years of age, living in bangladesh. methods: ethical approval and trial registration were obtained before the commencement of the study. subjects who volunteered to participate and signed the informed consent were enrolled in the study and completed the structured questionnaire on kap and fear of covid- scale (fcv- s). results: twenty-eight percent ( . %) of subjects reported one or more covid- symptoms, and . % of subjects reported one or more co-morbidities. knowledge scores were slightly higher in males ( . ± . ) than females ( . ± . ). knowledge was significantly correlated with age (p < . ), an education level (p < . ), attitude (p < . ), and urban location (p < . ). knowledge scores showed an inverse correlation with fear scores (p < . ). eighty-three percent ( . %) of subjects with covid- symptoms reported wearing a mask in public, and . % of subjects reported staying away from crowded places. subjects with one or more symptoms reported higher fear compared to subjects without ( . ± . ; . ± . ). conclusion: bangladeshis reported a high prevalence of self-isolation, positive preventive health behaviors related to covid- , and moderate to high fear levels. higher knowledge and practice were found in males, higher education levels, older age, and urban location. fear of covid- was more prevalent in female and elderly subjects. a positive attitude was reported for the majority of subjects, reflecting the belief that covid- was controllable and containable. a a a a a bangladesh is among the top countries in terms of confirmed cases of covid- , with a positive case rate of . % - . % as of june , [ ] . however, questions remain regarding the actual number of cases and the scarcity of testing facilities [ ] . there are also concerns about bangladesh's ability to mount an effective response to the covid- pandemic [ ] . one newspaper also states [ ] that bangladesh is a developing economy and is mainly dependent on remittances, ready-made garments, and small trades. the country is mid-phase in a few financial megaprojects. natural calamities and covid- pose challenges for the bangladeshi government and its residents at home and abroad [ ] . due to economic concerns, bangladesh did not impose a countrywide lockdown. instead, the authorities sub-sectioned the country into red, yellow, and green zones based on the level of community contamination [ ] . additionally, the government website for coronavirus briefing measures is being used to improve the situation, raising individual awareness by improving individual knowledge, attitudes, and practices, which has helped alleviate unnecessary fears and social stigmas [ ] . battling the covid- pandemic is a lengthy process and requires the combined efforts of individuals and the government; adequate testing, isolation, and supportive treatment provision are the best ways to overcome the pandemic [ ] . there is ongoing research to develop a vaccine. nevertheless, measures to raise the general population's knowledge and implementation of recommended health practices are some of the best approaches to combating covid- [ ] . the world health organization (who) [ ] stated that only % of cases were projected to have severe symptoms, and one-third of the severe cases required critical care; the main priority of the who is to mobilize resources to improve community healthcare practices. there is an emphasis on developing a community's receptiveness to staying at home. moreover, the who raised concerns regarding mental health needs [ ] . mental health needs related to covid- are emerging regardless of age, occupation, and education and are related to isolation, financial uncertainty, quarantine effects, excessive time spent online, gaming, physical inactivity, insomnia, anxiety, depression, and fear of covid- [ ] . the study also suggests that extreme fear and anxiety led individuals in china to have more physical and psychological signs, even with mild to no symptoms reported. bangladesh reported a few cases of suicide due to extreme fear of covid- , with some cases showing negative outcomes after the administration of the real-time polymerase chain reaction (rt-pcr) test postmortem [ ] . bangladesh responded relatively early in march , with no cases for nearly a week. the subsequent arrival of travelers from italy who defied quarantine regulations could have been the source of the virus [ ] . besides, religious gatherings and the lack of travel restrictions are considered the primary reasons for the sharp upward projections in covid- cases [ ] . a population-based study was required to determine general knowledge about the disease and what practices were being taken by bangladeshi individuals to combat covid- . fear is thought to be one of the main contributors to mass anxiety and depression. fear has been shown to predict inadequate health overall, insomnia, and the suppression of immunity. other influencing factors of anxiety and depression include occupation, knowledge, attitudes, and practice of health-related habits, as well as other environmental indicators [ ] . determining knowledge, attitudes, practices (kap), and fear will provide a glimpse of how bangladesh is responding to the pandemic in this state of rising cases. this will further help to evaluate their overall preparedness. the covid- crisis is assumed to be a long-term process, and the only way to battle the pandemic is to know the right information and practice the recommended health advisories. it is also necessary to examine the relationship among demographic variables with kap and fear to explore the in-depth understanding of factors contributing to the preparedness for and response towards covid- . the study objectives were to determine the level of knowledge, attitudes, and practices related to covid- preventive health habits and the underlying fear of covid- in the bangladeshi population and how they are affected by socio-demographic factors. this study was a prospective cross-sectional survey conducted online through a structured questionnaire from april to may , . both male and female bangladeshi subjects, and aged to years, were able to respond to the questionnaire and were eligible for the study. subjects with an intellectual disability or an inability to communicate were excluded from the survey. a structured questionnaire has been designed by the authors to fulfill the objectives of the study. the questionnaire included socio-demographic variables (table ) , questions on kap, and fear. questions related to kap adapted from the survey questions used in a study conducted during a period of rapid case increases in china [ ] . the kap section of the questionnaire related to a total of score knowledge questions on covid- , categorical answers to attitudes towards the control of the pandemic, and practices of wearing masks and avoiding public gatherings. the co-morbidities and symptoms of covid- were obtained from who resources and asked to the respondents' whether present or not [ ] . the fear of covid- scale (fcv s) was used and reported to be valid and reliable in measuring fear attributed to coronavirus disease [ ] . the questionnaire complied with the forward and back-translation into bangla by a bilingual british researcher and sent to two renounced bilingual epidemiologists in bangladesh to examine the difference and suitability of the questionnaire. also, a pilot study was conducted before the commencement of the research. ethical permission was obtained from the institutional review board (bpa iprr/irb/ / / / ) of the institute of physiotherapy, rehabilitation, and research (iprr). participation was voluntary, consent was obtained, and confidentiality of the information was assured. the trial registration was obtained prospectively from a primary trial registry of the who (ctri/ / / ). from april to may , the questionnaire was disseminated online, and through email and social media, targeting students, professionals, and public groups on facebook. recipients of the questionnaire were encouraged to complete it themselves and to send it to family members and neighbors for completion. a video tutorial was also provided to ensure an appropriate response. for illiterate family members, another member assisted them in responding to the questionnaire. the survey was requested to be sent back after completion. a total of questionnaires were sent, and questionnaires were returned. the data auditor found responses that could be included in the study and analyzed. the respondents were from all areas of bangladesh and may represent the whole population. descriptive statistics were employed for correct answers to knowledge, and diverse attitudes and practices were presented. knowledge, fear scores, attitudes, and practice variables of respondents were presented and compared with independent sample t-tests or chi-square tests to determine associations (tables and ) between continuous data (knowledge and fear score) and categorical or nominal data (demographic variables) [ ] . binary logistic regression analysis using dichotomous demographic variables as dependent variables and knowledge and fear scores as covariates ( table ) was performed to measure the relationship between categorical dependent variables and continuous variables. the chi-square test was employed to determine the relationship between attitude and practice with demographic variables, and knowledge and fear score (table ). data analysis was completed using the ibm statistical package for the social sciences (spss) version . . the alpha level of significance was set at p < . . among respondents, ( . %) were male and ( . %) were female. the mean population age was . ± . years. the participants' ages ranged from years to years, and the majority of the respondents were aged - years ( . %). respondents were categorized as adolescents ( - years), youth ( - years), adults ( - years), and elderly (above years). there was a larger response among those with higher secondary education ( . %) and graduates ( . %). a total of . % of respondents were either undergoing primary education or reported low levels of literacy. respondents were from all divisions of bangladesh; the highest response was from dhaka ( %), and the lowest was from sylhet ( . %). the majority of the respondents were non-public servants ( %), % were healthcare professionals, . % worked or did business in a crowded place, . % were students, and . % of the respondents reported that a relative, colleagues or a neighbor had been diagnosed with covid- . other sociodemographic profiles are described in table . multiple response analyses found that . % of the respondents (n = ) reported one or more symptoms related to covid- in the last days, but none reported completing a covid- test during the response. the most prevalent symptoms were dry cough . % (n = ), cough with sputum ( . %), sore throat ( %), fever of more than ˚f ( . %), anosmia or taste loss ( . %), and shortness of breath ( . %); patients were diagnosed with pneumonia, and patients were hospitalized for pneumonia. multiple response analyses also found respondents ( . %) who reported one or more co-morbidities, including diabetes ( . %), chronic obstructive pulmonary disease (copd) ( . %), and heart disease or hypertension ( . %). nine subjects reported a chronic neurological disability, including stroke; subjects reported chronic kidney disease (ckd), and . % reported chronic smoking habits. in the population knowledge score, the mean was . out of , and the standard deviation was . . knowledge regarding covid was similar in both males ( . ± . ) and females ( . ± . ). there was a significant relationship found between knowledge scores and age (p < . ), an education level (p < . ), and geographical distribution (p < . ). no significant differences in knowledge scores were found in the following comparisons: between public servants ( . ± . ) and others ( . ± . ); between healthcare professionals ( . ± . ) and others ( . ± . ); working in a crowd ( . ± . ) or working alone ( . ± . ); or in people who reported covid- -positive relatives, friends or colleagues ( . ± . ) vs. those with associates without covid- ( . ± . ). significant differences were found between subjects with symptoms of covid- ( . ± . ) and subjects without covid- symptoms ( . ± . ) (p < . ). additionally, a significant difference (p < . ) was found in knowledge scores between subjects with co-morbidities ( . ± . ) and subjects without comorbidities ( . ± . ). the detailed associations are available in table . binary logistic regression analysis showed a significant correlation between knowledge scores and gender (p < . ). logistic regression associations were found between knowledge and education levels, with the lowest knowledge scores found in primary education compared to all other education groups (p < . ). dhaka "urban dwellers" reported significantly higher knowledge of covid- symptoms and precautions than did subjects from rural areas of bangladesh (p < . ). knowledge and education levels were directly associated, with bachelor of science (bsc) degree holders reporting higher knowledge of covid- symptoms and precautions than any other education group (p < . ). public servants reported higher knowledge than did other non-public servant groups (p < . ), and students reported higher knowledge of covid- symptoms and precautions than did other non-student groups (p < . ). subjects without symptoms showed a significant inverse relationship with knowledge than did those with symptoms (p < . ) ( table ). attitudes were measured concerning "beliefs" regarding whether bangladesh can overcome the challenge of covid- or "positive synergy" towards disease control. females reported a higher belief that covid- could be controlled (p < . ). similarly, graduates or more qualified respondents were confident that covid- can be controlled (p < . ) and agreed that bangladesh was capable of overcoming the challenge (p < . ). the majority of subjects who identified as public servants in bangladesh also reported belief that the disease was controllable (p < . ); however, they did not believe covid- would be overcome easily (p < . ). the subjects with a higher knowledge score of covid- and a higher score on the covid- fear scale also showed higher scores in "belief" that the virus was controllable (p < . ) and that eradication of the virus nationwide would be achieved (p < . ). subjects with covid- symptoms and co-morbidities reported a higher prevalence of the "belief" that the virus was both controllable and containable (p < . ). details are presented in table . additionally, table shows that the subjects with a higher knowledge score of covid- and a higher score on the covid- fear scale also showed higher scores on the "belief" that the virus was controllable (p < . ) and that eradication of the virus nationwide would be achieved (p < . ). practices were measured by the report of the subject's attendance in crowded areas and reports of wearing a mask. the majority of female subjects in the study followed the practice of staying home ( . %) and wearing a mask ( . %) to prevent the spread of covid- (p < . ). similarly, . % of qualified personnel who were graduates and above reported staying home and avoiding crowded spaces (p < . ). the majority of the population from dhaka followed the health advisory by staying home ( . %) (p < . ) and reported wearing a mask ( . %) (p < . ). no significant relationship was found between knowledge score and practice, but a highly significant association was found between fear scores and adhering to the health advisory and between fear scores and reporting mask-wearing (p < . ). the majority of subjects with covid- symptoms reported wearing a mask (p < . ) but also reported going to a crowded place. the majority of subjects with co-morbidities also reported staying at home but did not report wearing a mask (p < . ) ( table ) . table explores a significant association (p < . ) between knowledge scores and wearing masks. the population means the fear score was . out of , with a standard deviation of . . fear scores were strongly associated with gender, education and geography (p < . ), with females reporting a higher score ( . ± . ) and respondents aged - years, - years and - years reporting a higher score of fear of contracting covid- ( . ± . ; . ± . ; . ± . ). dhaka urban dwellers also reported a higher fear status than did rural dwellers ( . ± . ) (p < . ). the demographic relationship of fear scores is listed in table . binary logistic regression found gender differences in fear scores (p < . ). other regressions are described in table . an indirect, strong, but significant relationship (p < . ) was found between the fear scores and practices of recommended health advisory habits of subjects (table ). there were significant differences (p < . ) in fear scores between subjects with symptoms and those without symptoms ( . ± . ; . ± . ) ( table ) . inverse relationships were found among persons with positive covid- symptoms and fear scores (p < . ). table shows a significant association (p < . ) between fear scores and wearing masks. the study intended to explore the knowledge, attitudes, and practices of recommended health advice for the prevention of covid- and to explore the impact of fear towards contracting covid- on people living in bangladesh. there is little to no research published on this important topic for bangladesh to date. the study covered every geographical area of bangladesh according to administrative distribution and provided a glimpse of the time frame. questions of knowledge, attitudes, and practices have been used following a chinese study [ ] , which was relevant in terms of geographical distribution, as both bangladesh and china are on the asian continent. additionally, the time was relevant, the questionnaire was prepared for a rapid rise in cases, and bangladesh was the process of experiencing a rapid rise in cases from april to may as per who case definition [ ] . the questionnaire development and translation completed in a structured and standard process. the fear scale was a valid questionnaire [ ] and until the start of data collection, the bangla language validation had not been published. therefore, all the questionnaires have been translated with the who guidelines for translating questionnaires [ ] . among the respondents, there were more males ( . %) than females ( . %). that dhaka had the majority of sars-cov- cases, and it is considered to have the most challenges regarding the level of practice of healthcare advisory precautions [ ] . the baseline characteristics of subjects in comparative studies varied across the world. studies in india, china, and egypt had more responses from females, and the usa had more responses from males [ , [ ] [ ] [ ] [ ] indian, chinese, and egyptian studies had similar responses by age group and education, while the usa study reported a mean age higher than that in our study. our study found a satisfactory level of knowledge by gender, geography, occupation, and education (table ) and relatively higher fear scores than those observed in similar studies across the world. one study in china showed similar scores of fear by age concerning knowledge and occupation, while another study completed in india reported that % of people in need of mental health care for covid- experienced fear, anxiety, and depression [ , ] . twenty-nine percent ( . %) of the respondents (n = ) reported one or more symptoms related to covid- in the last days, including cough . % (n = ), cough with sputum ( . %), sore throat, ( %), fever ( . %), anosmia or taste loss ( . %), and shortness of breath ( . %). the symptoms were related to covid- , as per the cdc [ ] . the who south-east asia region reported the test positivity in bangladesh to be %, with positive tests being reported only for a person with one or more covid- -related symptoms [ ] . eleven percent ( %) of subjects reported co-morbidities, including subjective disabilities. besides, . % of the respondents were over years of age. the who south-east asia region country profile and the iedcr covid- update states that the number of deaths is higher among elderly persons, males, and those with pre-existing co-morbidities in bangladesh [ , ] . overall, we found a low number of elderly patients with symptoms, low reported levels of comorbidities, and a slightly higher rate of infection among males than among females. the reason behind the higher rate of infection among males is their greater exposure outside. at that time, bangladesh was in a state of "movement restriction", and no nationwide "lockdown" had been imposed [ , ] , so more male cases were expected. the symptoms were matched with the who statements [ ] of symptoms until then, and many cases were found to be relevant, but they were not tested. many reports have been published on unwillingness, droughts, and fear regarding covid- testing in bangladesh [ , ] . knowledge regarding covid- by the subject was satisfactory and similar across age, gender, and occupation. there were a few variations in perspectives by occupation. young, graduates and urban dwellers had more knowledge than did older adults, those with lower education, and those living in rural areas. several similar articles in the preprint found that more than half of the respondents reported "good knowledge" of covid- , with age and education showing a significant linear association with knowledge [ ] [ ] [ ] . this study is similar to one study in china that found a significant relationship between knowledge and age and knowledge and educational level, with males reporting higher levels of knowledge than females regarding covid- symptoms, precautions, and health advisory practices [ ] . however, in our study, subjects living in bangladesh reported similar knowledge for both males and females regarding covid- symptoms, precautions, and health advisory practices. this finding may be attributed to a similar degree of access to information through print and electronic media and internet access in bangladeshi populations, as the country's digital gateway is currently being prioritized. overall, a high prevalence of "positive attitudes" among the subjects regarding disease control was reported. female subjects and subjects with higher levels of education were more likely to believe that covid- can be controlled, but they doubted the ability of bangladesh to contain it. subjects with "good knowledge" or "high scores for fear" were more likely to believe that covid- can be controlled and that a collective effort can contain the spread of the disease. similar studies in bangladesh, india, and china all found similar results regarding the relationship between knowledge and fear of covid- regarding "practices", [ , , ] , and our study reported similarities to previous studies across the world [ , ] . our study found that . % of women reported "staying home", and . % reported wearing masks in public places. the majority of the population outside of dhaka, i.e., those living in the more rural regions, reported staying home ( . %) and wearing a mask ( . %). however, no statistical relationship was found between knowledge scores and practices. this is similar to results reported in studies in both india and china. however, our study did find subjects with high fear scores and who were also more likely to follow good preventive practices, as recommended by the health advisory. the fear score was significantly associated with female gender, higher education, and urban dwelling. senior citizens aged - years, - years, and - years reported the highest fear scores among individuals in all categories. one study suggests that fear comes from a longer duration of isolation, greater movement restriction, and greater reactivity to news and rumors from social media [ ] . women, senior citizens, and young adults had limited movement, were isolated from quarantining, and were attached to media. a study reports that fear and stress can lead to insomnia and psychological illness [ ] . fear is an important component in both positive and negative ways, as illustrated in the positivity explained earlier; hence, there have been cases of suicide due to the fear of covid- in bangladesh [ ] . however, although important as an indicator, this was not evaluated in this study and may be considered a limitation of the study. our study faced challenges regarding structured questionnaires, reporting, and resources. limitations included the response rate ( . %) and the completion of the questionnaire by none covid- -positive individuals. we recommend that future studies include information on the long-term observation of corvid- -positive cases or cases with symptoms with respect to movement, function, physical signs, mental health, and quality-of-life issues. in a resource-challenged country such as bangladesh, individual knowledge, positive attitudes, and practices of suggested precautionary and preventive health advisories are crucial to controlling the vicious community transmission of covid- . the study found that knowledge levels were adequate in the majority of the population and were directly and significantly related to higher education levels, younger age, and female gender. there were positive attitudes among respondents regarding the control of the disease and the overcoming of challenges related to covid- in bangladesh. the majority of the population had high fear scores, with significantly higher scores found in women and elderly adults. surprisingly, those with higher fear scores had good practices of staying at home and wearing masks. future studies on explanatory issues related to activity, function, social issues, and quality of life might add more insight into the bio-psychological impact of covid- in the most densely populated country in the world. covid- : bangladesh records highest deaths in a day, cases cross , mark official covid- numbers disguise undercounting bangladesh cannot afford to close its garment factories [internet]. the economist. 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outbreak: a quick online cross-sectional survey the fear of covid- scale: development and initial validation the chi-square test of independence who | process of translation and adaptation of instruments covid- : bangladesh records highest deaths, , cases in a day knowledge, perceptions, and attitude of egyptians towards the novel coronavirus disease (covid- ) knowledge and behaviors toward covid- among us residents during the early days of the pandemic: cross-sectional online questionnaire. jmir public health and surveillance study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid- pandemic centers for disease control and prevention attitude, and practice regarding covid- outbreak in bangladeshi people: an online-based cross-sectional study attitude and practices (kap) towards covid- and assessment of risks of infection by sars-cov- among the bangladeshi population: an online cross sectional survey knowledge and attitude towards covid- in bangladesh: population-level estimation and a comparison of data obtained by phone and online survey methods the covid- outbreak: crucial role the psychiatrists can play authors acknowledge rubayet shafin and ahnaf al mukit, research assistants for their contribution in data collection and input, also students of bangladesh health professions institute helped in collecting data. the authors are also grateful to professor dr. md. forhad hossain for his support in statistical analysis. key: cord- -twn poq authors: nikolay, birgit; salje, henrik; sturm-ramirez, katharine; azziz-baumgartner, eduardo; homaira, nusrat; ahmed, makhdum; iuliano, a. danielle; paul, repon c.; rahman, mahmudur; hossain, m. jahangir; luby, stephen p.; cauchemez, simon; gurley, emily s. title: evaluating hospital-based surveillance for outbreak detection in bangladesh: analysis of healthcare utilization data date: - - journal: plos med doi: . /journal.pmed. sha: doc_id: cord_uid: twn poq background: the international health regulations outline core requirements to ensure the detection of public health threats of international concern. assessing the capacity of surveillance systems to detect these threats is crucial for evaluating a country’s ability to meet these requirements. methods and findings: we propose a framework to evaluate the sensitivity and representativeness of hospital-based surveillance and apply it to severe neurological infectious diseases and fatal respiratory infectious diseases in bangladesh. we identified cases in selected communities within surveillance hospital catchment areas using key informant and house-to-house surveys and ascertained where cases had sought care. we estimated the probability of surveillance detecting different sized outbreaks by distance from the surveillance hospital and compared characteristics of cases identified in the community and cases attending surveillance hospitals. we estimated that surveillance detected % ( % ci %– %) of severe neurological disease cases and % ( % ci %– %) of fatal respiratory disease cases residing at km distance from a surveillance hospital. detection probabilities decreased markedly with distance. the probability of detecting small outbreaks (three cases) dropped below % at distances greater than km for severe neurological disease and at distances greater than km for fatal respiratory disease. characteristics of cases attending surveillance hospitals were largely representative of all cases; however, neurological disease cases aged < y or from the lowest socioeconomic group and fatal respiratory disease cases aged ≥ y were underrepresented. our estimates of outbreak detection rely on suspected cases that attend a surveillance hospital receiving laboratory confirmation of disease and being reported to the surveillance system. the extent to which this occurs will depend on disease characteristics (e.g., severity and symptom specificity) and surveillance resources. conclusion: we present a new approach to evaluating the sensitivity and representativeness of hospital-based surveillance, making it possible to predict its ability to detect emerging threats. we propose a framework to evaluate the sensitivity and representativeness of hospital-based surveillance and apply it to severe neurological infectious diseases and fatal respiratory infectious diseases in bangladesh. we identified cases in selected communities within surveillance hospital catchment areas using key informant and house-to-house surveys and ascertained where cases had sought care. we estimated the probability of surveillance detecting different sized outbreaks by distance from the surveillance hospital and compared characteristics of cases identified in the community and cases attending surveillance hospitals. we estimated that surveillance detected % ( % ci %- %) of severe neurological disease cases and % ( % ci %- %) of fatal respiratory disease cases residing at km distance from a surveillance hospital. detection probabilities decreased markedly with a a a a a distance. the probability of detecting small outbreaks (three cases) dropped below % at distances greater than km for severe neurological disease and at distances greater than km for fatal respiratory disease. characteristics of cases attending surveillance hospitals were largely representative of all cases; however, neurological disease cases aged < y or from the lowest socioeconomic group and fatal respiratory disease cases aged ! y were underrepresented. our estimates of outbreak detection rely on suspected cases that attend a surveillance hospital receiving laboratory confirmation of disease and being reported to the surveillance system. the extent to which this occurs will depend on disease characteristics (e.g., severity and symptom specificity) and surveillance resources. we present a new approach to evaluating the sensitivity and representativeness of hospitalbased surveillance, making it possible to predict its ability to detect emerging threats. • many countries rely on hospital-based surveillance for the detection of infectious diseases of national and global public health relevance. • it is often difficult to access suitable external reference data to assess the capacity of a surveillance system to detect cases and outbreaks or to characterize cases. • we demonstrate a novel approach using healthcare utilization data to evaluate the sensitivity and representativeness of severe infectious disease surveillance in bangladesh. • the capacity to detect cases and outbreaks decreased with distance from surveillance hospitals. • cases captured by surveillance differed from cases in communities by age and socioeconomic status. • geographic coverage of surveillance could be improved by including other hospitals in the surveillance system. • the presented approach is applicable for a wide range of infectious diseases in different settings, taking some practical considerations into account. • hospital-based surveillance may have low sensitivity in rural areas at greater distances from surveillance hospitals, suggesting a risk of unrecognized transmission of emerging infectious diseases. a well-functioning disease surveillance system is crucial for the identification and control of outbreaks, and hence the prevention of national and global health emergencies [ ] . the world health organization (who) highlighted the value of national surveillance systems in the international health regulations ( ) , an agreement among all member states to develop and maintain sufficient capacity for the detection, reporting, and control of public health threats of international concern [ ] . infectious disease surveillance should enable (i) the timely detection of outbreaks, (ii) the quantification of health problems, (iii) the identification of subpopulations at risk, and (iv) the assessment of temporal trends including the impact of control strategies [ , ] . national surveillance systems typically collect data from patients seeking care at sentinel hospitals or other healthcare facilities and can provide useful information for public health purposes. however, hospital-based surveillance generally underestimates disease burden since only a proportion of cases visit a hospital for care [ ] . low case detection may also undermine the value of hospital-based surveillance for outbreak detection. moreover, if patients captured by the surveillance system are not representative of all cases in the community, surveillance statistics could lead to erroneous interpretations of disease patterns and misallocation of prevention resources. in particular, sex, socioeconomic status, or distance can affect healthcare seeking at hospitals, especially where access to care is limited [ ] [ ] [ ] [ ] . surveillance evaluation guidelines, such as those established by the us centers of disease control and prevention, list sensitivity and representativeness among the attributes that a public health surveillance system should possess and that require assessment [ , ] . in order to follow these guidelines, we need external reference data that are often unavailable in resource-poor settings [ ] . here, we present a new approach to evaluating the capacity of a surveillance system to detect and characterize disease cases, with emphasis on outbreaks of emerging infections that often occur as small case clusters in remote areas. we apply our methodology to assess hospital-based surveillance of severe neurological infectious disease and fatal respiratory infectious disease in bangladesh. the field teams obtained written informed consent from participants or their guardians (if < y of age) during community surveys. healthcare utilization survey protocols were reviewed and approved by the ethical review committee of the international centre for diarrhoeal disease research, bangladesh. how epidemiological studies can be used to identify cases with severe symptoms in communities and capture their personal and healthcare utilization characteristics (data collection stage) (fig ) . in addition to detailing how we collected the data in this study, we provide information about how the approach could be varied in other settings. we subsequently demonstrate how such data can be used to evaluate the sensitivity and representativeness of surveillance systems (evaluation stage). we then apply our approach to the detection of severe neurological infectious diseases and fatal respiratory infectious diseases in bangladesh as a case study. selecting study locations. the first step was to randomly select communities at differing distances from the surveillance hospitals. we specified catchment areas of selected hospitals based on hospital records and subsequently randomly selected small administrative units from which all communities were surveyed. selection of communities could also be done through census data or using detailed population maps of the area. identifying people with diseases in the selected community. study teams visited the selected communities and identified cases that had had the disease of interest. the retrospective identification of severe disease cases in the community was based on syndromic criteria, used as a proxy for clinical case definitions that would be applied in healthcare facilities. the in the bangladesh example, the catchment areas of surveillance hospitals were first defined based on hospital records (e.g., areas where > % or > % of cases reside) [ , ] . subsequently, small administrative units were chosen at random from within the catchment area, and all communities in the selected areas were surveyed. cases in the community were identified based on lists of deaths in addition to community networking strategies (rural settings) or house-to-house surveys (urban settings). information on symptoms (to establish case definitions), healthcare seeking behavior, and characteristics of cases was collected. in other settings, the exact survey procedures may vary according to the context. identification of such cases in the community is often the most problematic step, and the optimum strategy will depend on the local context, the severity of the disease, and the specificity of disease symptoms. collecting information on healthcare seeking and personal case characteristics. to estimate case detection probabilities, identify biases in case statistics, and characterize the healthcare utilization behavior in the population, we needed information about the healthcare seeking and personal characteristics of cases. in particular, we needed to identify whether the cases attended a surveillance hospital. such information was obtained during household visits of identified cases. to understand the impact of distance from the hospital, we approximated the locations of households by the central positions of the small administrative units. alternatively, household locations could be recorded precisely using gps devices. quantifying the probability of detecting a case. we estimated the case detection probability as the proportion of cases who reportedly attended a surveillance hospital among all cases identified in the community. we further assessed how this probability changed with distance from the surveillance hospital. quantifying the probability of detecting outbreaks. we subsequently used the estimated case detection probabilities to quantify the capacity of the surveillance system to identify disease outbreaks. we estimated outbreak detection probabilities for varying outbreak sizes and for outbreaks occurring at different distances from surveillance hospitals. assessing the representativeness of detected cases. we evaluated the representativeness of detected cases by estimating the difference between case statistics (proportions of specific case characteristics) based on all cases in the community and based on identified cases who attended the surveillance hospital. the investigated characteristics included sex, age, and socioeconomic status. assessing alternative surveillance strategies. to investigate how sensitivity and representativeness of the surveillance system could be improved by integrating other healthcare providers, we applied the evaluation procedures as described above to other healthcare provider types. we demonstrate the application of the proposed evaluation strategy by using it to assess the capacity of hospital-based surveillance for severe infectious diseases in bangladesh, which is based on tertiary care hospitals located throughout the country. we used data from two surveys carried out in catchment areas of some of these hospitals that investigated the healthcare utilization behavior of individuals with severe neurological infectious disease or fatal respiratory infectious disease (fig a) [ , ] . these disease types are of great public health relevance in bangladesh (e.g., japanese encephalitis and influenza) but also represent symptoms typical of other emerging infectious diseases (e.g., nipah and severe acute respiratory syndrome). a first survey collected data between june and march about cases with symptoms of severe neurological infection that occurred within the previous mo in small administrative units (mean population size of , people) in the catchment areas of three surveillance hospitals [ ] . a second survey collected data between april and february about acute respiratory infection (ari)-related deaths that occurred within the previous mo in administrative units in the catchment areas of surveillance hospitals [ ] . we considered ari-related deaths as a proxy for respiratory disease of sufficient severity to require medical attention. the surveillance hospital in dhaka city was excluded from the original studies because of the difficulty of defining the catchment area (a step necessary for the original study purpose), as people nationwide seek medical care in dhaka. the surveys followed procedures as previously described and summarized below [ , ] . characteristics of the study population are described in fig. a in s text. [ ] . sixty-eight percent of the population in bangladesh lives > km from a surveillance hospital (including the dhaka surveillance hospital), a distance at which case and outbreak detection probabilities are low. (c) probability of surveillance case detection by distance. the observed probability was calculated as a moving average over a km distance window. case detection probabilities were estimated using logbinomial regression models including distance as an explanatory variable. evaluating hospital-based surveillance the catchment areas of selected hospitals were first specified based on hospital records (s text). small administrative units (mean population of , people) were subsequently selected randomly within the catchment areas, and all communities in the selected areas surveyed. the identification of cases in selected communities was based on social structures, i.e., cases were identified by visiting public meeting points, such as mosques, markets, or tea-stalls, where health problems in the community are often publicly discussed. cases were subsequently confirmed by household visits. in urban areas, house-to-house surveys were conducted to compensate for less pronounced community structures. additional fatal respiratory infectious disease cases were identified through lists of deaths provided by administrative officers. for both disease types, the identification of cases was based on syndromic criteria. we defined severe neurological infectious disease as fever with altered mental status for > h or with unconsciousness for ! h, or fever with altered mental status, unconsciousness, or a new onset seizure that resulted in death. fatal respiratory infectious disease (ari-related death) was defined as having any two of the following symptoms in the d prior to death: sudden onset of fever, cough, breathing difficulty, feeding difficulty, or runny nose. deaths in children aged < y were also classified as ari-related deaths if there was a sudden onset of breathing difficulty in the d prior to death. during surveys, information was collected on healthcare utilization behavior and personal characteristics of identified severe neurological and fatal respiratory disease cases. cases or their household members were asked whether the case visited the surveillance hospital or any other healthcare provider, including other nonlocal hospitals, during his/her illness. further, information on sex, age, socioeconomic status, and geographic location of households of cases was collected. we defined "community cases" as all severe neurological or fatal respiratory disease cases identified during community surveys (whether they attended a surveillance hospital or not) and "surveillance cases" as the subset of community cases who reportedly attended a surveillance hospital. for each case identified in community surveys, we identified whether they attended their nearest surveillance hospital. we then estimated the distance to that surveillance hospital as the distance between the residence administrative unit centroid and that specific surveillance hospital using qgis [ ] . age was categorized as < , - , - , and ! y. a socioeconomic status index was generated by principal component analysis based on household assets (electricity, working television, bicycle, motorcycle, sewing machine, mobile phone) and categorized into tertiles (lowest, middle, and highest) [ ] . in sensitivity analyses, we explored the use of continuous age and socioeconomic status classified into quintiles (s text). socioeconomic status was missing for of , fatal respiratory disease cases, who were excluded from the analysis where this information was required. three fatal respiratory disease cases were excluded from all analyses due to missing healthcare seeking information. we estimated the disease-specific case detection probability as the proportion of cases who reportedly sought care at a surveillance hospital among all cases identified during community surveys (number of surveillance cases/number of community cases) and computed % confidence intervals ( % cis) based on the clopper-pearson exact method [ ] . we quantified case detection probabilities by distance from a surveillance hospital using log-binomial regression analysis separately for severe neurological and fatal respiratory disease cases. we further investigated more complex functional forms of distance in log-binomial regression models. we fitted models with polynomial terms up to the fifth degree and models with basic splines with knots at various positions (between and km distance). model fit was compared based on the akaike information criterion (aic), and the models with lowest aic were selected. the fit of selected models was compared to the observed proportion of cases who attended surveillance hospitals at different distances (moving average over a distance window of km). we estimated the proportion of the population living > km and > km from a surveillance hospital using gridded population density estimates of × m resolution [ ] . to quantify the capacity of the surveillance system to detect outbreaks of varying sizes, we calculated the probability that at least one case was detected: pr outbreak is the outbreak detection probability based on a one-case threshold, pr is the case detection probability, and s is the outbreak size. this calculation assumes that the probability of detecting a sentinel case is independent of other cases. we used distance-specific case detection probabilities estimated by log-binomial regression and obtained confidence intervals of outbreak detection probabilities based on the % ci limits of case detection probabilities. we further estimated the size of the smallest outbreak that would be detected with ! % probability by distance from the surveillance hospital. for emerging infectious diseases of global health importance, such as nipah, severe acute respiratory syndrome, or avian influenza, a single detected case may be considered an outbreak. for other disease systems (e.g., endemic diseases or diseases for which differential diagnosis is difficult), an outbreak may be declared only after more than a single case is detected over a specified period of time and within specified geographic boundaries [ ] . we can extend the framework to estimate the probability of identifying an outbreak with different outbreak thresholds applied, and we provide examples for outbreaks defined as detection of at least two cases or at least five cases. we calculated the probability of detecting at least two cases (pr outbreak ) as one minus the probability of detecting no cases (pr ) and exactly one case (pr ): likewise, we estimated the probability of detecting at least five cases (pr outbreak ) as one minus the probability of detecting no cases (pr ) and exactly one (pr ), two (pr ), three (pr ), and four cases (pr ): we investigated the representativeness of surveillance cases (sex, age, and socioeconomic group) by comparing the proportion of cases with a specific characteristic (and exact binomial confidence intervals) among community cases to the proportion of cases with that characteristic among surveillance cases. we quantified the absolute difference in proportions (proportion of cases with characteristic among surveillance cases minus proportion among community cases) with % cis and p-values using bootstrapping ( , bootstrap iterations) [ ] . based on the collected healthcare utilization data, we evaluated how the sensitivity and representativeness of a surveillance system may be improved by integrating other healthcare providers. we classified healthcare providers as (i) surveillance hospitals, (ii) other hospitals (government and private clinics), (iii) qualified private practitioners, and (iv) the informal sector (unqualified practitioners such as traditional healers, village doctors, homeopaths, and pharmacies). we estimated the proportion of cases attending each healthcare provider class, with exact binomial confidence intervals, and estimated outbreak detection probabilities based on proportions attending the surveillance hospital plus (i) other hospitals, (ii) qualified private practitioners, or (iii) informal healthcare providers. furthermore, we compared the proportion of cases with each characteristic (sex, age, and socioeconomic group) among community cases to the proportion among those attending each healthcare provider class and quantified absolute differences in proportions with % cis and p-values using bootstrapping ( , bootstrap iterations). all statistical analyses and graphics were implemented in the r computing environment; maps were created using qgis software [ , ] . the studied communities were located within km (severe neurological infectious disease) and km (fatal respiratory infectious disease) of a surveillance hospital. in these communities, of severe neurological disease cases ( %, % ci %- %) and of , fatal respiratory disease cases ( %, % ci %- %) attended a surveillance hospital. adjusting for distance, the case detection probability was nearly twice as high among severe neurological disease cases than among fatal respiratory disease cases (risk ratio . , % ci . - . ; p < . ). at km distance, an estimated % ( % ci %- %) of severe neurological disease cases and % ( % ci %- %) of fatal respiratory disease cases were detected by the hospital-based surveillance. the detection probability decreased with distance from the surveillance hospital, and the decline was faster for fatal respiratory disease than for severe neurological disease. a km distance increase resulted in a % ( % ci %- %; p = . ) relative reduction in case detection probability for severe neurological disease but a % ( % ci %- %; p < . ) relative reduction for fatal respiratory disease (fig c) . including more complex functional forms of distance in the log-binomial regression models did not improve model fit based on aic (table a and figs . b and c in s text). the probability of detecting an outbreak of exactly three cases (if a single detected case was considered an outbreak) dropped below % at distances greater than km for severe neurological disease and at distances greater than km for fatal respiratory disease (fig a) . fig b and c show the minimum number of cases required for surveillance to detect outbreaks with a probability of ! % if different outbreak thresholds are applied. for outbreaks defined as detection of at least one case, we found that an outbreak of fatal respiratory disease required cases ( % ci - ) to be detected with % probability at km from a surveillance hospital, but cases ( % ci - ) to be detected at km. in contrast, the impact of distance on the outbreak size requirement was much more limited for severe neurological disease: eight cases ( % ci - ) at km and cases ( % ci - ) at km. for outbreaks defined as detection of at least two cases, severe neurological disease cases ( % ci - ) and fatal respiratory disease cases ( % ci - ) would be necessary for an outbreak to be detected at km distance, and severe neurological disease cases ( % ci - ) and fatal respiratory disease cases ( % ci - ) at km. the necessary outbreak sizes increased further when a five-case threshold was applied, so that severe neurological disease cases ( % ci [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and fatal respiratory disease cases ( % ci - ) would need to occur for an outbreak to be detected at km distance, and ( % ci - ) and ( % ci - ), respectively, cases at km. surveillance hospital attendance among community cases varied by case characteristics, leading sometimes to biased disease statistics among surveillance cases (table b in s text). for severe neurological disease, individuals aged < y represented % of community cases but only % of surveillance cases (p < . ). additionally, the proportion of cases in the lowest socioeconomic group was lower among surveillance cases than among community cases ( % versus %; p = . ), while the proportion of individuals aged - y was higher ( % versus %; p = . ) (fig a) . for fatal respiratory disease, the proportion of individuals aged ! y ( % versus %; p < . ) was lower among surveillance cases than among community cases, while the proportion of individuals aged < y ( % versus %; p = . ), individuals aged - y ( % versus %; p < . ), and cases in the highest socioeconomic group ( % versus %; p = . ) was higher (fig b) . we observed a slight difference in the proportion of females for fatal respiratory disease ( % among surveillance cases versus % among community cases; p = . ), but not for severe neurological disease ( % versus %; p = . ). results were consistent in sensitivity analyses with age as a continuous variable and socioeconomic status classified into quintiles (figs. d and e in s text). a substantial proportion of cases (severe neurological disease % [ % ci %- %]; fatal respiratory disease % [ % ci %- %]) visited multiple healthcare providers during their illness. forty-eight percent ( % ci %- %) of severe neurological disease cases and % ( % ci %- %) of fatal respiratory disease cases attended any hospital, including surveillance hospitals (fig ) . including other hospitals that were attended by cases in the surveillance system could have increased the overall case detection probability by % (absolute increase) for severe neurological disease cases and % for fatal respiratory disease cases. the capacity to detect outbreaks would have increased, so that outbreaks containing four severe neurological or eight fatal respiratory disease cases would have been detected with ! % probability for any distance in the range - km from the original surveillance hospital, compared to and cases, respectively, with the current system ( fig. f in s text) . however, since individuals who attended any hospital had similar characteristics in terms of sex, age, and socioeconomic status as those attending surveillance hospitals (fig. g in s text), this expansion would not have increased disease detection in key groups such as the lowest socioeconomic group. only with the informal sector incorporated in the surveillance system would cases in such groups be detected. we described an analytic approach for evaluating the sensitivity and representativeness of hospital-based surveillance systems and applied it to surveillance for severe neurological diseases and fatal respiratory infectious diseases in bangladesh. we quantified the proportion of cases detected and the probability that the surveillance system would detect different sized outbreaks by distance from the surveillance hospital. finally, we characterized biases in surveillance statistics and identified potential improvements to the surveillance platform. we estimated that approximately one-quarter of severe neurological disease cases and onefifth of fatal respiratory disease cases occurring km from a surveillance hospital would be detected with current surveillance. the proportion of cases attending a surveillance hospital declined significantly with increasing distance between individuals' residence and the surveillance hospital, substantially faster for fatal respiratory disease than for severe neurological disease. these low detection probabilities mean that hospital-based surveillance in bangladesh (like in most other resource-poor countries presumably) would likely miss a high proportion of single-case public health events. of greater relevance is that surveillance system capacity to detect outbreaks and detection probabilities increased substantially with the number of cases. the required number of cases to detect outbreaks with high probability varied with disease type and distance from the surveillance hospital. it could be as low as about ten cases if the outbreak occurred < km from the surveillance hospital but increased quickly with distance for evaluating hospital-based surveillance fatal respiratory disease. for outbreaks defined as a single detected case, we found that more than half of outbreaks with ten cases of fatal respiratory disease would be missed if the outbreak occurred > km from the hospital. such detailed quantification of outbreak detection probability is essential to ascertain the likelihood that an emerging threat can be detected early enough to be contained [ ] . in some circumstances, authorities may have to wait until more than a single case is detected to recognize that an outbreak is occurring. in particular, difficult differential diagnoses and lack of appropriate diagnostic tests mean that only when a number of cases are detected from the same area and over a short time frame will an outbreak be identified and further investigations conducted. in addition, where a low background level of transmission is expected (such as with endemic diseases), public health authorities may wait until a particular threshold is exceeded before declaring an outbreak. in both of these scenarios, where multiple cases need to be detected by the hospital before an outbreak is recognized, the optimal number of detected cases and their spatial and temporal separation will depend on the disease system. we can incorporate this information into our flexible framework and provide examples where we calculate the size an outbreak needs to be for scenarios where at least two or five cases need to be detected (fig b and c ). in particular, this demonstrates that if an outbreak is identified only once five cases are detected at the surveillance hospital, the size of the outbreak would have to be substantially larger (e.g., nearly total cases of a fatal respiratory disease at km from a surveillance hospital) for there to be a % chance of an outbreak being identified. this highlights the possibility that, by the time an outbreak reaches sufficient size to be detected by the system, outbreak control measures may be much less effective at controlling spread. thresholds for case counts that trigger an outbreak response should be crafted taking this possibility into account. low detection probabilities for outbreaks that occur far from surveillance hospitals are an important concern because pathogens with high case fatality such as japanese encephalitis and nipah virus are nearly exclusively found in rural communities in bangladesh [ , ] , and evaluating hospital-based surveillance these communities are usually located far from surveillance hospitals. rural environments are also considered to be at highest risk for the emergence of novel pathogens [ , ] . population distribution maps suggest that % of the population in bangladesh live in communities > km from a surveillance hospital (representing million individuals) and % live > km from a surveillance hospital (representing million people) (fig b) . strengthening healthcare-based surveillance in these areas should be a priority, and cost-effective approaches to achieving surveillance targets need to be identified. there is increasing recognition of the value of novel data sources to improve the sensitivity of infectious disease surveillance, some of which can provide crucial information in remote areas [ ] . novel approaches include surveillance for media reports of disease clusters, as used for various infectious diseases in bangladesh [ , ] , and training of local drug sellers to recognize and report disease symptoms, as rolled out nationally to enhance tuberculosis surveillance in ghana [ ] . other surveillance data streams, such as monitoring over-the-counter medication sales, telephone triage, and webbased queries, have been successfully integrated in surveillance systems in resource-rich settings [ ] . we found that cases attending surveillance hospitals were not necessarily representative of all cases in the community. in particular, the youngest severe neurological disease cases and the oldest fatal respiratory disease cases were less likely to attend surveillance hospitals, and attendance was also lower among cases in the lowest socioeconomic group. similar variation in hospital attendance has been reported in other resource-poor settings [ , , ] , indicating that hospital-based surveillance in these countries may have comparable limitations. disease statistics obtained through hospital-based surveillance have to be interpreted in the light of detected biases, and correction factors may need to be applied. for example, underestimating severe neurological disease among young children may mislead any future japanese encephalitis vaccination strategy [ , ] . differential surveillance hospital attendance may also influence the capacity to detect emerging infections, such as the avian influenza a (h n ) virus that emerged in in china with observed cases mainly among elderly men [ ] . overall, access to appropriate care was poor-over % of community cases with severe disease or who died in our study never saw a qualified provider. such low access is a common problem in low-income settings and means that a large proportion of the population, and particularly subgroups that are potentially at highest need, do not receive the required medical attention [ ] [ ] [ ] [ ] . for example, difficulties accessing qualified healthcare providers for elderly people, who are often at greatest risk of respiratory disease, can have severe consequences for the outcome of disease. previous studies have demonstrated that accessibility to healthcare is a significant predictor of morbidity and mortality among elderly individuals with respiratory disease [ ] . the study showed that healthcare utilization behavior varied by disease type, which may be due to different characteristics of cases such as their age, socioeconomic status, and geographic location (fig. a in s text) . the majority of fatal respiratory disease cases were ! y old and may have faced limitations in mobility; moreover, rapid progression of disease to death may have prevented cases in this age group from seeking appropriate care. cases and their family members in general may have also perceived neurological symptoms as more severe, resulting in higher motivation to attend a qualified healthcare provider [ ] . we evaluated potential improvements of surveillance by analyzing healthcare seeking behavior among cases identified in communities. while the majority of individuals did seek care, much of this was in the informal sector, which cannot easily be incorporated into surveillance activity. nevertheless, including other hospitals attended by cases in the surveillance system (the exact location and number of these hospitals was unfortunately not identified during surveys) would double case detection probabilities and allow detection of medium-sized outbreaks (< cases) in a wider geographic area. however, in the case of bangladesh, such extension is likely to be prohibitively expensive. mapping other hospitals in bangladesh that may serve as surveillance sites would allow testing of various surveillance scenarios to identify the optimal location of surveillance sites while keeping the same total number or to quantify the number of sites needed to achieve a target surveillance coverage [ ] . many emerging infectious diseases originate as spillover infections of zoonotic diseases into the human population [ ] . therefore, mapping the occurrence of relevant zoonotic diseases (e.g., avian influenza) and combining such maps with the estimated outbreak detection probabilities would allow highlighting of surveillance gaps for particular types of emerging infectious diseases. the capacity of surveillance systems to detect outbreaks will depend not only on the probability that a case attends a surveillance hospital, but also on whether the case undergoes confirmatory laboratory testing and is subsequently reported through the surveillance system by the hospital. here we assumed a "best-case scenario" with a fully functional surveillance system at the hospital level, where each case who attends the surveillance hospital is ultimately recognized and confirmed as a case. case detection at the hospital may however be incomplete, since case definitions at hospitals may differ from syndromic definitions, a surveillance sampling frame may be applied, or resources and trained personnel for the diagnosis and reporting of cases may be limited [ ] . the calculation of case and outbreak detection probabilities may be adjusted for misdiagnosis and underreporting at hospitals if such information is available. we further assumed complete detection of cases in communities during surveys. although a few cases may have been missed, this assumption is justified as we investigated severe disease conditions that are easily remembered by family and community members. moreover, survey procedures combining interviews of key informants and house-to-house visits were specifically designed to capture near-complete case information. further, any missed cases are unlikely to impact our estimates, as such impacts would occur only if there was differential healthcare seeking between those detected and those missed. we investigated spatial differences in hospital attendance based on the straight-line distance of communities from the surveillance hospital. if available, other distance measures such as travel distance or travel time may provide a more accurate indicator of distance from the surveillance hospital. in some cases, these measures may strongly vary with the season, and it would be interesting to explore how that may impact the probability of detecting an outbreak. we assumed that cases did not visit other surveillance hospitals than the catchment hospital. given the poor road infrastructure in the country, it would be very unusual to travel to a tertiary care hospital that was not the closest one. it is possible that some individuals traveled to dhaka; however, these are likely to be wealthier individuals who would visit small private healthcare facilities that are not part of the surveillance network. the surveillance hospital in dhaka was not included in our study. this is unlikely to have biased our assessment of the performance of the surveillance system outside the capital. indeed, this would introduce a bias only under the unlikely scenario that many cases in our study who did not attend the nearest surveillance hospital (and were therefore not captured there) instead attended the surveillance hospital in dhaka (and were captured there). surveillance system performance in the capital city may however differ from elsewhere, and a comprehensive assessment of the national surveillance system would therefore have to include dhaka. moreover, hospital-based surveillance is only one surveillance type in bangladesh, and other data sources need to be considered to assess the country's overall capacity to detect public health events. the described methodology is applicable to assessing surveillance for other severe diseases in resource-poor settings, keeping in mind practical constraints. conducting community surveys may be labor intensive, time consuming, and expensive depending on the setting and may be particularly challenging in densely populated areas such as dhaka. nonetheless, such surveys are valuable tools for obtaining external reference data and simultaneously assess heterogeneities in healthcare access. the effectiveness of community networking may depend on the social structures in the study area; where social links are weaker (e.g., in urban areas), house-to-house surveys, even though more labor intensive, may be more suitable for the identification of cases in the community. the proposed strategy is valid for diseases of sufficient severity to require medical attention and to be remembered by cases and family members. the approach is syndromic (i.e., disease types are classified based on a set of symptoms), and the classification specificity may vary by disease. in conclusion, this study allowed us to quantify the sensitivity and representativeness of hospital-based surveillance and to identify weaknesses, particularly in detecting small-to medium-sized 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the novel avian influenza a h n virus in humans pneumonia and influenza hospitalizations in elderly people with dementia optimizing provider recruitment for influenza surveillance networks global trends in emerging infectious diseases hospitalization records as a tool for evaluating performance of food-and water-borne disease surveillance systems: a massachusetts case study the international centre for diarrhoeal disease research, bangladesh (icddr,b) acknowledges with gratitude the commitment of the us centers for disease control and prevention to its research efforts. icddr,b is also grateful to the governments of bangladesh, canada, sweden, and the uk for providing core/unrestricted support. conceptualization: bn hs sc esg. key: cord- -begnpodw authors: yeasmin, sabina; banik, rajon; hossain, sorif; hossain, md. nazmul; mahumud, raju; salma, nahid; hossain, md. moyazzem title: impact of covid- pandemic on the mental health of children in bangladesh: a cross-sectional study date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: begnpodw covid- pandemic poses a significant mental health threat among children in bangladesh. this study aims to explore the impact of covid- on the mental health of children aged< years during the lockdown in bangladesh. an online cross-sectional study was conducted from th april to th may among parents having at least one child aged less than years using non-probability sampling. k-means clustering used to group children according to mental health score and confirmatory factor analysis (cfa) performed to identify the relationship among the parental behavior and child mental health, and also these associations were assessed through chi-square test. children were classified into four groups where % of child had subthreshold mental disturbances (mean major depressive disorder (mdd)- ; . ), . % had mild (mean mdd- ; . ), . % suffered moderately (mean mdd- ; . ), and . % of child suffered from severe disturbances (mean mdd- ; . ). the higher percentage of mental health disturbances of children with the higher education level of parents, relative infected by covid- (yes), parents still need to go the workplace (yes), and parent’s abnormal behavior but lower to their counterparts. this paper demonstrates large proportions of children are suffering from mental health disturbances in bangladesh during the period of lockdown. implementation of psychological intervention strategies and improvement in house-hold financial conditions, literacy of parents, taking care of children, and job security may help in improving the psychological/mental status of children and the authors believe that the findings will be beneficial to accelerate the rate of achieving the sustainable development goal (sdg) linked to health status in bangladesh. the outbreak of novel coronavirus disease has emerged in china, which rapidly spread the oddment of the world, and who declared it as a pandemic . the pandemic has been escalating and threatening the welfare of human beings globally and already transmitted to more than million people around the globe with at least , deaths as of july , (world health organization, a . to halt the covid- transmission and cease the burden on health systems all most all of the countries have brought unprecedented efforts to institute the practice of "social distancing", as a result, many schools have been closed (lancker & parolin, ) and classes are shifted to home-based distance-learning models (golberstein et al., ) . children are not beyond the grasp of this pandemic, and also the most vulnerable to the drastic effects of it, as they are forced to stay home for extended periods due to lockdown and school closure, resulting in minimal interaction with peers and decreased the opportunities for exploration and physical activities (jiao et al., ) . all of these adversely impact children's mental health and welfare, leading to a wide variety of mental health issues, such as anxiety, stress, depression, and sleeping difficulties (dunleavy, ; galvin, ; rawstrone, ) . to prevent the outbreak of covid- , bangladesh have been closed the academic institutions, therefore, about . million students and more than a million teachers are staying at home . although the scientific controversy is unremitting concerning the effectiveness of school closures on virus transmission (lancker & parolin, ) . schools play an emergent role, not just in supplying educational resources to children, but also in offering students an opportunity to communicate with teachers and receive psychological counseling (brazendale et al., ) . moreover, evidence shows that whenever children are beyond schooling (e.g. weekends and summer payday's), they become physically less active, have much-prolonged screen time, irregular sleep schedules and less healthy diets, resulted in excess weight and lack of cardiorespiratory performance (brazendale et al., ) . furthermore, pandemic stressors such as terror of infection, dissatisfaction and boredom, lack of knowledge, lack of personal space at home, and family's financial loss may have even more troublesome and enduring impacts on children mental health (brooks et al., ) . to assess the impact of home quarantine on children's mental health, a study was performed among , chinese children and identified that one in five children ( percent) in china was either suffering from depression or anxiety, or both (dunleavy, ) . also, mental health issues remain fairly elevated among u.s. children due to the covid- pandemic. according to the centers for disease control and prevention, . million children between the ages of to years have been diagnosed with anxiety and . million have been identified with depression because of home quarantine due to . moreover, about three in four children having depression along with anxiety (galvin, ) . the effect of the covid- pandemic on children's mental well-being is worrying % of parents, according to a survey by parents with primary-aged children and % reported that their children were missing school and less than half stated that their children were feeling lonely, which altogether affects their children's mental health and wellbeing (rawstrone, ) . in bangladesh, as the number of covid- cases continues to rise thus an immediate public health response is urgently needed (banik et al., ) . consequently, the government of bangladesh enforced full lockdown and all schools were closed from may , (kamruzzaman & sakib, ) , which negatively impact children's wellbeing through interruption of their health care, nutrition, security, education, and overall mental health (joining force bangladesh, ). yet, there is no literature available in bangladesh on the long-term impact of covid- pandemic on children's mental health. thus, it becomes important to determine how extended school closures, stringent social distancing steps and the pandemic itself have impacts on the mental health status of children. therefore, this study aimed to investigate the impact of the covid- pandemic on mental health and determining the associated factors among children of bangladesh. this study was conducted among parents having children in bangladesh through an online survey between th april to th may, after completing days of home-quarantine following lockdown declaration on th march by the government of bangladesh (world health organization, b). here, non-probability sampling (purposive sampling) techniques were used to collect the primary data from participants. firstly, parents who had at least one child aged between - years, known to the researchers by their facebook friends were invited to complete the survey by filling the questionnaire. we have calculated the sample size using the following where, we considered z = . and d = . confidence interval as . . the sample proportion was assumed as . since this value provide the maximum sample size. hence, the required sample size was . however, a total of respondents completed the survey and after cleaning the incomplete responses participants were taken for final analysis. the primary data was collected via an online questionnaire as the face-to-face interview had to be avoided due to ongoing lockdown. the questionnaire was pilot-tested in a sample of subjects before the final study initiation. we sent the link of designed google form to the parents randomly and the inclusion criteria were having at least one child aged between - years. the questionnaire consisting of several parts such as (i) socio-demographic information (age, sex, educational level, place of living, number of earning members in the family, average monthly family income, knowledge about covid- , and any family member/relatives/neighbor of the respondent was corona positive or not), (ii) financial and lifestyle information of parents, (iii) information related to child's activity and attitude of parents toward child and (iv) mental health related information of child. participants were given no economic motivation, and anonymity was maintained to make sure data confidentiality. first of all, asking the consent of participating in the survey and it was also notified that at any time, participants could revoke from the survey without giving any justification. this study was carried out online in full conformity with the provisions of the helsinki declaration on human participant research. the -item revised child anxiety and depression scale (rcads) (chorpita et al., ) includes the -item depression total scale in order to measure children's major depressive disorder (i.e., the child feels sad or empty, nothing is much fun, trouble in sleeping, problems with appetite, no energy for things, tired a lot, cannot think, feels worthless, doesn't want to move, & feels restless). children's anxiety was assessed by the generalized anxiety disorder (gad) scale with the help of spence child anxiety scale for parents (scas-p) (nauta et al., ) . also, gad is a -item questionnaire (e.g. my child worries about things, complains of having a funny feeling in his/her stomach, complains of feeling afraid, heart beating fast, child worries that something bad will happen, & feels shaky). parent-reported child behavior checklist (cbcl) (achenbach & edelbrock, ) , a questionnaire to assess children's behavior/emotional problems at ages of - years. a "sleep problem scale" was ascertained by six items from the cbcl ("experiences nightmares," "sleeps less than most children," "sleeps more than most children," "talks or walks in sleep," "trouble sleeping," and "overtired"). the mdd- and gad- scales are evaluated at -points ( =never, = once in a week, = - times in a week, & = everyday) which gives a total score of to and to respectively. moreover, sds- used a -point scale ( =not true; =sometimes true; =very true/often true) which gives a total score of to . the higher scores indicate higher level of depression, anxiety, and sleeping disorder. the acceptable reliability test was performed and the value of cronbach alpha was . which is more than the acceptable value of . . firstly, descriptive statistics were performed to describe the basic demographic characteristics of the respondents. secondly, k-means clustering analysis was applied to cluster depression, anxiety, and sleeping disorder scores (kang et al., ) of a child. the chi-square test was used to measure the association of socio-demographic variables, parental behavior towards children, and child mental health scores among the cluster. thirdly, a confirmatory factor analysis (cfa) was constructed to explore the components associated with child mental health. finally, a structural model was developed using the identified components of child mental health (hu & bentler, ) . the significance level is set at a p-value< . here. data analysis is performed using ibm spss among the participants, there are ( . %) female and ( . %) male respondents. the majority of the participants tended to be aged - years ( . %), had an educational level of post-graduation ( . %), and lived in the urban areas ( . %). a total of . % of the respondents were involved in a job during the lockdown, where . % of participants needed to go to the table ]. [ table here] the depression, anxiety, and sleeping disorder scores of children were classified into groups (sub-threshold, mild, moderate, and severe disturbance) using k-means clustering. results depict that % of child had subthreshold mental health disturbances (mean depression: . , anxiety: , and sleeping disorder: ), . % had mild disturbances (mean depression: . , anxiety: . , and sleeping disorder: ), . % suffered from moderate disturbances (mean depression: . , anxiety: . , and sleeping: ), and . % suffered from severe disturbances (mean depression: . , anxiety: . , and sleeping disorder: ). significant differences found in the depression, anxiety, and sleeping disorder scores of the child among the four groups using the chi-square test, as shown in table . [ table here] the chi-square test was used to find significant differences in several characteristics among the four groups. results reported that there were no significant differences in sex and age of the parents among the four groups. but significant differences found in the educational level of parents, place of living, any relative/neighbor of child having status positive or not by corona virus among the four groups. in the severe disturbance group, most of the child's parents were graduated family lived in the urban areas ( . %). the child had higher mental health disturbance scores who had higher corona positive relative/ neighbor [ table ]. [ table here] the result also showed that there was a significant difference in parents needed to go to the workplace or not, any chance of losing the job, and did smoke or not among the four groups. higher the number of parents of the child needed to go to the workplace ( %), had a smoking habit ( . %) and had the chance of losing their job ( . %) higher the score of depression, anxiety, and sleeping disorder of child. the score was also found higher for the child who fights frequently with each other, child who watched the cartoon and played the game - hours using a smartphone or other electronic device in a day, child whose parents didn't take any action to keep them busy, child who complained their parents remained busy, child whose parents called them by name that they (children) didn't like, child whose parents threatened them to be punished, child whose parents screamed and hit them (child) during the home-quarantine period [ table ]. the average score of depression, anxiety and sleeping disorder by different groups are presented in figure and it can be seen that the average score of depression, anxiety, and sleeping disorder of child is increased gradually from subthreshold disturbance group to sever disturbance group [ figure coefficients may also be interpreted. [ figure here] the chi-square test of the model fit yielded a value of . , with degrees of freedom= , p-value< . the results of chi-square test, rmsea = . , cfi = . , and tli= . . signaling that the model is well-fitted to data and hence, it is concluded that the assumed model is correct. the results disclosed that the child mental health is affected by the parental mental health as well as parents' attitudes towards child. the results are presented in figure and table . [ table here] [ figure here] mental health is an essential part of any country and ignored particularly in low and middle-income countries (patel, ) . bangladesh is a relatively small country according to area however having huge population with inadequate mental health care facilities for children and most hospitals use outpatient services. the largest part of the respondents was aged between to years and most of them were living in the urban areas and majorities are males ( table ). in this study, children's mental health (depression, anxiety, and sleeping disorder) scores were classified into four groups: sub-threshold, mild, moderate, and severe disturbance. the highest percentage of children are suffering from sub-threshold disturbance ( %), and . % had mild disturbances, . % had moderate disturbances, and . % had severe disturbances ( table ). the education level of parents of children, place of living, relatives/neighbors infected with covid- , still need to go to the workplace of parents, the chance of losing jobs of parents, the smoking habit of parents, hours watching the cartoon by children, children playing games, child fight, keeping busy with other works, acting of the child, children complain about parent's busyness, parent's abnormal behavior to children (call dumb, threat, scream, hit the child), and parent's knowledge about child abuse were significantly associated with children mental status ( table ) . children who live in urban areas with their parents were more prone to suffer mental healthrelated problems as compared to the rural area's child. perhaps the reason behind this scenario is that the lockdown was perfectly maintained in urban areas and children were forced to stay home anyway (the business standard, ). on the contrary, children in rural areas are free to move and can play with their relatives/friends (ranscombe, ) . children brought up in a rural environment, encompassed by animals and bacteria, grow stronger immune systems and might be at minor risk of mental illness than without pet-city inhabitants, as indicated in a study (hindustan times, ). usually, educated parents remain busy with their jobs as compared to uneducated ones even during this lockdown period in bangladesh, especially the government officials . as a result, they cannot manage time to communicate with their children as they demand. a bunch of social and personal adjustments is necessary to cope with this situation (poduval & poduval, ). if the work time of mother is longer, then the risks of children who are matured from one to five tended to increase child risks of experiencing psychological distress tended to increase the child risks of experiencing psychological distress as a young adult. the findings of this paper are also congruent with a previous study (poduval & poduval, ). parents who want to income more or who have higher family income need to give more time to their jobs or company even if they feel pressure to manage the company's activities like workers' activity, managerial team activity, and so on (mendez et al., ) . a longer period of part-time job mothers reduced the children's educational attainment and increase their child's mental distress but this effect was lower as compared to full-time employment mothers (saha et al., ) . in our study, it is also found that the children of higher-income parents are more likely to have mental disorders than others. parents who still need to go to the workplace and have a chance of losing jobs tended to increase the level of mental disorders of their children whereas it decreases for their counterparts. besides, parents whose feelings bored were tended to be more mental disturbances of their children as compared to their counterparts ( table ). the pressure that guardians bring home from their occupations can diminish their child-rearing abilities, sabotage the climate in the home, and in this way bring worry into kids' lives. moreover, children also feel pressure from their parents and becoming mentally sick (heinrich, ) . unfortunately, low-income parents are most apparent to work in stressful, lowquality jobs that prominence low pay, little autonomy, inflexible hours, and few or no benefits (heinrich, ) . it is well known that there is a strong association between a parent's smoking habits and child development behavior. since cigarette smoking is additionally connected with sadness, there are numerous unanswered inquiries regarding the interrelationship of these mental issues of children (shimomura et al., ) . the findings of this study also showed that parental depression and smoking behavior also linked to child mental disorder ( table ) . the children's mental depression was relatively low who was busy with some works as compared to who was not ( table ) , which is very usual. engaging with some works or encouraging daily exercise will help children to reduce depression (hurley, ) . children, who fight with others and get threats, scream and hit from their parents were much mentally disordered and increased severe mental disturbances as compared to their counterparts. because paternal and maternal behavior have an adjustment to children's mental health (elgar et al., ) . parents who threats, scream, or hit to their children are depressive and these depressive symptoms of parents and emotional behavior affect the child's mental health (gutierrez-galve et al., ) . again, children who act normal were in less mental disturbances as compared to others where the percentage increased gradually from less mental disturbances to severe mental disturbances. because if the children's sadness becomes interferes with social activities or regular life, it indicates that he or she has a depressive illness (lima et al., ) . this research has some limitations. firstly, considering health threats, a face-to-face interview was avoided whereas compared to face-to-face interviews, self-reporting has certain limitations. secondly, this study did not track the efficacy of psychological services as a cross-sectional study. finally, it would be better to have a larger sample size to validate the results but due to the current situation, it was not possible to collect samples on a large scale. the results demonstrate that large proportions of children are suffering from mental health disturbances in bangladesh during the lockdown period. mothers', as well as fathers' ability to forestall their emotional pain or manifestation of depression from influencing their role as a parent, might be a significant source of resilience for their children. the vulnerable cohorts for this study are children with the urban areas, higher educated parents, both higher and lower family income, smoking status (yes), parental depressive symptoms (threat, scream, hit, etc.), and the abnormal acting of the child. implementation of proper psychological intervention strategies and improvement in house-hold financial conditions, literacy of parents, taking proper care of children, and increasing job security and flexibility of parents may help in improving the psychological/mental status of children in bangladesh and the authors believe that the findings will be beneficial to accelerate the rate of achieving the sustainable development goals (sdgs) linked to public health in bangladesh. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. authors are grateful to all the participants who voluntarily offered their time, conscientiously provided honest and thoughtful responses and the personnel who supported data collection of this study. this study is considered a primary data set and the participants were given no economic motivation, and anonymity was maintained to make sure data confidentiality and reliability. it was also notified that at any time, participants could withdraw from the survey without giving any justification. the participants also provide their consent for publishing the analyzed results of this survey without their identifiable information. this study was carried out online in full conformity with the provisions of the helsinki declaration on human participant research. manual for the child behavior checklist : and revised child behavior profile managing schools, learning and student wellbeing during covid- . the daily star lockdown in the context of bangladesh covid- and bangladesh: challenges and how to address them covid- in bangladesh: public awareness and insufficient health facilities remain key challenges understanding differences between summer vs . school obesogenic behaviors of children : the structured days hypothesis the psychological impact of quarantine and how to reduce it : rapid review of the evidence parents' employment and children's wellbeing. the future of children assessment of symptoms of dsm-iv anxiety and depression in children: a revised child anxiety and depression 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much mothers, and where is the womanhood? covid- : we can ward off some of the negative impacts on children rural areas at risk during covid- pandemic. the lancet infectious diseases survey reveals impact of lockdown on children status of mental health among left behind wives of migrant workers in north-east part of bangladesh association between problematic behaviors and individual/environmental factors in difficult children areas in dhaka under partial or complete lockdown fragile families and child wellbeing ten-year secular trends in sleep/wake patterns in shanghai and hong kong school-aged children: a tale of two cities mitigate the effects of home confinement on children during the covid- outbreak coronavirus disease (covid- ) covid- key: cord- -ctet mun authors: mamun, mohammed a.; naher, shabnam; moonajilin, mst. sabrina; jobayar, ahsanul mahbub; rayhan, istihak; kircaburun, kagan; griffiths, mark d. title: depression literacy and awareness programs among bangladeshi students: an online survey date: - - journal: heliyon doi: . /j.heliyon. .e sha: doc_id: cord_uid: ctet mun background: preventing depression and helping individuals to become more resilient to depression, awareness-related programs have been suggested. to implement such programs, depression literacy (d-lit) assessment is needed. however, little information is known about it in bangladesh, and this gap was addressed - in the present study. methods: an online-based cross-sectional survey was carried out among university students ( . % male; . % undergraduates, mean age = . ± . years). the survey included questions asking about socio-demographics, personal and family depression history, its' stigma and related programs, and the -item bangla depression literacy questionnaire. results: the results showed a mean score of . (sd = . ; out of total scores) on the bangla d-lit scale. participants had very limited knowledge of the psychotic symptoms, impact, and management subscales. moreover, nine items out of the total twenty-items were answered correctly by at least % of the participants. there were no significant d-lit score differences based on gender and past-year personal history, and family depression history. structural equation modeling indicated that having knowledge about depression and attending depression seminars were positively related to elevated depression literacy. limitations: the study has some limitations due to its cross-sectional study nature and modest sample size. in addition, there the assessment of depression did not use a validated psychometric instrument and the d-lit comprises multiple-choice responses so the real rate of depression literacy may be even lower than that found because participants could have guessed answers that they did not know. conclusions: findings from this study suggest that depression literacy was low in the population studied and the findings here will help to facilitate mental health literacy awareness programs in the context of bangladeshi students as well as those outside the country. mental health literacy (mhl) arises from the concept of health literacy that is concerned with mental health issues. mhl was first coined by jorm and colleagues in , which was later defined to be the knowledge and beliefs of mental disorders which help to recognize first aid, treatment seeking behavior, and other support (jorm, ) . therefore, mhl is a very important aspect in enhancing the awareness, knowledge, and belief that facilitates the management and improvement of mental disorders' whereas poor mhl may increase the risk of mental health suffering (see gabriel and violato [ ] for a review). consequently, mhl has been studied globally as a prerequisite to the implementation of mental health awareness programs and is reported to have had positive influences on minimizing such suffering (gabriel and violato, ) . in bangladesh (where the present study was carried out), there has been a gradual improvement in health and education, but in the case of health literacy, it has been disappointing (arafat et al., a) . depression is the second most burdensome disease globally and affects more than million people worldwide (world health organization [who] , ). the common features included in depression are mood disturbance, lack of pleasure, sleep problems, weight changes, feelings of guilt, attention and concentration impairment, impairment of the daily functioning, and in extreme cases, suicide (disu et al., ; mamun et al., a; who, ) . students in bangladesh are highly prone to suffer from depression (i.e., the rate is more than %; e.g., alim et al., ; bhuiyan et al., ; hossain et al., ; mamun and griffiths, ; mamun et al., b mamun et al., , c d; sakib et al., ) . furthermore, common mental disorders (such as depression, traumatic disorder) are reported to be suicidality risk factor (jahan et al., ; mamun and griffiths, a, b; sakib et al., ) . these disorders directly or indirectly account for % of suicidality and suicides (mamun and griffiths, c, d; mamun and ullah, ) ; whereas up to % of individuals with suicide ideation are depressed in bangladesh (arafat et al., b) . although the extreme severity of mental disorders is well established, there are still stigmas in many societies like bangladesh; therefore, individuals find it difficult to seek professional treatment (masud et al., ) . in this regard, programs that raise awareness and promote health education are needed to help to reduce the stigma as well as make this vulnerable cohort more self-resilient to mental health suffering (mamun et al., b; griffiths et al., ; who, ) . at present, the implementation of mental health promotion programs and mhl assessment is inadequate and still has been addressed as a neglected issue in the country (i.e., only four previous studies have assessed mhl; i.e., arafat et al., a arafat et al., , bhuiyan et al., ; mali et al., ) . consequently, there is a huge knowledge gap concerning mhl generally and depression literacy specifically. moreover, there is a lack of data on whether having personal experience of depression impacts depression literacy, although it is expected that individuals exposed to depression will have higher literacy (lincoln et al., ; maneze et al., ) . similarly, attending depression or mental health-related seminars, workshops, or other programs are likely to positively influence depression literacy (ruble et al., ; yap and jorm, ) . these issues have not been investigated in the context of bangladesh to date. therefore, the present study examined depression literacy in relation to basic socio-demographic factors (i.e., gender, marital status, education level, residence, etc.). a cross-sectional survey study was conducted via online platforms (e.g., facebook pages, groups, etc.) from february to march , , after ensuring that the selected participants were all students (either undergraduate or postgraduate). an online survey was utilized in this study because of its advantages in epidemiological studies (increased confidentiality and anonymity, larger response rates, increased honesty of responses, etc.; van gelder et al., ) . after clicking on the survey link, the participants were able to begin the online survey once they had given their informed consent, and had read statements following the helsinki declaration . the study was approved by the local institutional review board. approximately students were approached via social media platforms to participate in the study, and students began the survey. of these, participants did not complete the full survey, therefore, a total of respondents' data were selected for final analysis. the first part of the survey included questions concerning sociodemographic variables (i.e., age, gender, study status, study area). two types of students (i.e., undergraduate and postgraduate) were approached, who were recruited from several study areas including basic sciences, business studies, social sciences, biological sciences, medical sciences, and allied medical sciences. the survey also included questions on whether the participant had experienced depression over the past year (yes/no), and whether anyone in their family had experienced depression over the past year (yes/no). one question relating to depression stigma were also asked (i.e., 'depression is like other physical illnesses'). participants were asked if they had heard about any seminars, workshops, or other programs related to depression or mental health during the past year (from friends, social media, etc.) and if they had attended any such events. in the present study, depression literacy based on symptomatology (i.e., biological, cognitive, behavioral, and psychotic symptoms), impacts, and management, was assessed using the bangla version of the depression literacy scale (bangla d-lit; arafat et al., ) . although the original version comprised items (griffiths et al., ) , the bangla d-lit has only items. each item has three response options (i.e., 'true', 'false', and 'don't know'), and one point is awarded for each correct response (whereas ' ' is given for incorrect and 'don't know' responses). based on this scoring, the scale has a score range of - , where higher scores indicate having higher depression literacy. previously, the scale has demonstrated acceptable reliability (cronbach's alpha ¼ . ; arafat et al., ) . cronbach's alpha in the present study was good ( . ). the data were analyzed using ibm statistical package for social sciences (spss) version . . descriptive statistics such as frequency and percentage were used along with the anova tests to test for d-lit mean differences with the variables. the level of statistical significance was p < . for all tests. frequency and descriptive statistics were used to determine mean scores and standard deviations of the study variables. a pearson correlation test was utilized to determine correlation coefficients among the study variables. structural equation modeling was applied to identify the associations among the study variables. the direct effects of the independent and control variables on the outcome variable were calculated via using the bootstrapping method with % bias-corrected confidence intervals and , bootstrap samples. the tested model was evaluated using the goodness of fit criteria. accordingly, root mean square residuals (rmsea) and standardized root mean square residuals (srmr) should be below . , and comparative fit index (cfi) and goodness of fit index (gfi) should be above . for a good fit. rmsea and srmr lower than . , and cfi and gfi higher than . are thresholds for acceptable fit (hu and bentler, ) . the distribution of socio-demographics is reported in table . most of the participants were males ( . %; n ¼ ) and were undergraduate students ( . %; n ¼ ) with a mean age of . years (sd ¼ . ). approximately three-quarters of the participants ( . %; n ¼ ) reported themselves as having experienced depression during the past year, and . % reported that at least one family member had depression in the past year. nearly two-thirds of participants ( . %) reported that depression was just like other physical illnesses. although more than half of the participants ( %, n ¼ ) had heard about mental health-related programs (i.e., seminars, symposia, workshops, etc.) in the past year, only . % had attended such programs (n ¼ ). the mean total bangla d-lit score was . out of (sd ¼ . ; see table ). there was no significant gender difference on overall d-lit scale score as well as other subscales, except for biological symptoms (i.e., findings also indicated that students studying in health-related disciplines had higher depression literacy levels compared to students studying non-health-related disciplines. additionally, there were no significant differences in depression literacy scores between those who reported that they had experienced depression in the past year or those that reported at least one family member had experienced depression in the past year (compared to those who had not experienced depression or did not have family members with depression). moreover, the stigma-related issue (i.e., 'depression is like other physical illnesses') was also not significantly associated with literacy scores ( (table ) . mean scores, standard deviations, and correlation coefficients of the study variables are shown in table . depression literacy total score was negatively and weakly correlated with seminar awareness (r ¼ - . , p < . ), seminar attendance (r ¼ - . , p < . ), and positively with age (r ¼ . , p < . ) and all subdimensions of depression literacy including biological (r ¼ . , p < . ), cognitive (r ¼ . , p < . ), psychotic (r ¼ . , p < . ), behavior (r ¼ . , p < . ), impact (r ¼ . , p < . ), and management (r ¼ . , p < . ). finally, structural equation modeling was used to examine the predictive role of depression-related variables on depression literacy while controlling for gender, age, discipline study area, and study level (figure ) having good mental health literacy has been suggested as having preventative benefits from potential mental health suffering (gabriel and violato, ) . there is still a knowledge gap in this aspect in the context of bangladesh. therefore, the present study attempted to address the depression literacy gap among university-level students in bangladesh. the overall mean d-lit score in the present sample was . (sd ¼ . ) out of a total of . this was lower than that of medical graduates ( . ), nurses ( . ), and spinal cord injury patients ( . ) scores reported in bangladesh (arafat et al., a; mali et al., ) . however, it was higher than other bangladeshi cohorts that have been studied [e.g., private university graduates ( . ), depressed patients ( . ) (arafat et al., a) , university freshers ( . ) (arafat et al., ) , and pre-university students ( . ) ]. as the bangla d-lit questionnaire comprised of items (rather than the original items), the findings are not compared with the studies conducted in outside bangladesh. the present study also found that nine items on the bangle d-lit were correctly reported by at least % of the respondents. consequently, the present study's correct response rate was higher than most of the previous scores reported among bangladeshi samples (i.e., five correct items among fresher university students, seven correct items among preuniversity students, six correct items among depressed patients); however, equal to graduate students (nine correct items), and lower than medical students and professionals ( correct items), nurses ( correct items), and spinal cord injured patients' responses ( correct items) (arafat et al., a; arafat et al., ; bhuiyan et al., ; mali et al., ) . the present study found no gender-based difference concerning overall d-lit scores. however, previous studies [e.g., conducted among australian students and university staff (reavley et al., ) , british general population (swami, ) ] reported higher mental health literacy among males. other studies have reported us female students to have a higher ability to recognize mental health issues such as depression compared to male students (coles et al., ) . previous studies conducted in bangladesh did not report any significant gender differences concerning d-lit scores [i.e., among pre-university students , among university freshers (arafat et al., ) ]. generally, compared to males, females are more prone to suffering mental disorders (as well as higher suicidal thoughts and suicide attempts), therefore increasing mental health literacy among this target group is warranted (schrijvers et al., ; wilhelm, ) . it is well-established that the more educated someone is (with or without exposure to health-related education such as medical and nursing education) the higher their depression literacy level (arafat et al., a; fonseca et al., ; lauber et al., ) also reported that students from medical science and psychology had higher depression literacy than other types of students. similarly, this assertion is also supported by the present study's findings (i.e., students from non-health-related study areas had lower depression literacy compared to students from medical or allied health sciences). moreover, correct recognition of depression increased with higher levels of education (i.e., postgraduates scored more correct answers than undergraduates). this has been reported in previous studies (e.g., reavley et al., ; yap and jorm, ) . however, it is simply a function of age with older individuals having more years of education. latent variables are represented in the model by circles while observed variables are represented by rectangles. depression-own ¼ experienced depression over the past year (yes/no), depression-family ¼ family member experienced depression over the past year (yes/no), depression-stigma ¼ i think depression is an illness like other physical illnesses (yes/no). seminar-aware ¼ heard about any seminars (yes/no), seminar-attend ¼ attended any seminars (yes/no). level ¼ academic level (undergraduate/postgraduate); area ¼ study area (basic/business/social/biological/nursing/medical). *p < . , **p < . , ***p < . . it was hypothesized that participants who had experienced personal or family depression during the past year would have higher depression literacy compared to those that had no personal experience of depression (i.e., those who had experienced or had exposure to first-hand depression may have been expected to know more about the features of depression, and have more knowledge). however, the present study found no significant differences. similar findings were reported in a very recent study of bangladesh, where there was no difference in depression literacy scores between those students who suffered from mental issues (i.e., depression and anxiety) and those who did not . however, it should be noted that participants' experiences of depression were only based on their perceptions rather than any formal diagnosis of themselves or others. so, it could have been the case that some of the participants (and/or their family members) had not experienced clinical depression and neither did not necessarily know what true depression entails. knowledge awareness programs are therefore recommended for all individuals even those who have personal experiences of depression (i.e., themselves and/or family members) which may be beneficial in early prevention of depression, and also may help in developing resilience to these psychiatric issues gabriel and violato, ; ruble et al., ) . as has been reported globally, mental health programs increase mental health literacy. however, there was a lack of data available in the context of bangladesh. higher depression knowledge was reported by those participants who attended seminars, workshops, or other programs related to depression or mental health, and/or simply heard about these programs from friends and social media. the sem analysis indicated that seminar awareness and seminar attendance were the best predictors of d-lit. however, most of the participants who had heard about arranging these programs did not attend them (i.e., . % heard about, but only . % had attended such an event). therefore, program organizers need to consider the factors as to why most individuals who heard about these types of programs did not attend them. such factors are related with the target audience (i.e., if the programs are not student-focused), attendance cost, the day of the event (students may not be able to attend on weekdays due to class attendance), and event location and distance from their home, unwillingness to participate and so on. knowing the barriers is vital to why individuals do not attend worthwhile events, even when they are aware of its importance, so that the organizers can come to facilitate program attendance and promote mental wellbeing effectively. the present study has several limitations. the study was crosssectional, and the sample size was modest. additionally, personal and family history of depression was assessed with single questions rather than the use of a validated psychometric instrument. furthermore, there is also the possibility of self-selection bias with those of experience of depression being more likely to participate (although based on the d-lit scores, there does not appear to be any evidence of such bias). there are also inherent biases in any self-report methodology (such as recall biases and social desirability biases). however, it should also be highlighted that compared to offline surveys, online surveys (i) increase confidentiality, (ii) increase anonymity, (iii) have better response rates, and (iv) have higher levels of honesty (van gelder et al., ) . it should also be noted that the d-lit scale comprises a multiple-choice response format (as opposed to being free recall). consequently, the percentage of correct responses could have been artificially higher because some answers could have been guessed correctly. despite these limitations, the present findings contribute to addressing the information gap in the bangladeshi context. the present findings suggest that the level of depression literacy was low in the investigated population. this should be addressed as soon as possible given the high levels of depression in bangladesh compared to other countries internationally. the study also provides beneficial data to mental health program developers and organizers to focus depression knowledge on areas that are much less known about by university students such as psychotic symptoms (e.g., auditory hallucinations, irrelevant speech, and reckless behavior), the impact of depression (e.g., impairment due to mild depression), and management of depression (e.g., the role of psychologist, antidepressants addictive properties, duration of action, the timing of stopping antidepressants, the role of vitamins, and other treatment options). such education-related programs should be implemented nationally, and special focus should be paid to non-science students whose depression literacy appears to be substantially lower than that of science students. author contribution statement m. a. mamun: conceived and designed the experiments; analyzed and interpreted the data; wrote the paper. a. m. jobayar, i. rayhan: performed the experiments. k. kircaburun: analyzed and interpreted the data. s. naher: contributed reagents, materials, analysis tools or data; wrote the paper. m. d. griffiths, m. s. moonajilin: contributed reagents, materials, analysis tools or data. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. assessment of depression, anxiety and stress among first year mbbs students of a public medical college psychiatric morbidities and risk factors of suicidal ideation among patients attending for psychiatric services at a tertiary teaching hospital in bangladesh depression literacy status in bangladesh: a crosssectional comparative observation depression literacy among first-year university students: a cross-sectional study in bangladesh adaptation and validation of the bangla version of the depression literacy questionnaire depression literacy among bangladeshi pre-university students: differences based on gender, educational attainment, depression, and anxiety adolescent mental health literacy: young people's knowledge of depression and social anxiety disorder risk factors of geriatric depression among elderly bangladeshi people: a pilot interview study depression literacy and awareness of psychopathological symptoms during the perinatal period depression literacy among patients and the public: a literature review effect of webbased depression literacy and cognitive-behavioural therapy interventions on stigmatising attitudes to depression: randomised controlled trial impacts of sociocultural environment and lifestyle factors on the psychological health of university students in bangladesh: a longitudinal study cutoff criteria for fit indexes in covariance structural analysis: conventional criteria versus new alternatives depression and suicidal behaviors among bangladeshi mothers of children with autism spectrum disorder: a comparative study we need to move from 'mental health literacy' to 'mental health action'. ment. health prev mental health literacy in an educational elite-an online survey among university students impact of health literacy on depressive symptoms and mental health-related quality of life among adults with addiction depression literacy among nurses: a cross-sectional observation in a tertiary care hospital of bangladesh the influence of health literacy and depression on diabetes self-management: a cross-sectional study the association between facebook addiction and depression: a pilot survey study among bangladeshi students ptsd-related suicide six years after the rana plaza collapse in bangladesh a rare case of bangladeshi student suicide by gunshot due to unusual multiple causalities first covid- suicide case in bangladesh due to fear of covid- and xenophobia: possible suicide prevention strategies mandatory junior school certificate exams and young teenage suicides in bangladesh: a response to arafat ( ) mental health problems and associated predictors among bangladeshi students problematic internet use in bangladeshi students: the role of sociodemographic factors, depression, anxiety, and stress prevalence of depression among bangladeshi village women subsequent to a natural disaster: a pilot study covid- suicides in pakistan, dying off not covid- fear but poverty? -the forthcoming economic challenges for a developing country prevalence and psychiatric risk factors of excessive internet use among northern bangladeshi job-seeking graduate students: a pilot study unobtrusive monitoring of behavior and movement patterns to detect clinical depression severity level via smartphone mental health literacy in higher education students depression knowledge in high school students: effectiveness of the adolescent depression awareness program depression and suicidality among bangladeshi students: subject selection reasons and learning environment as potential risk factors the gender paradox in suicidal behavior and its impact on the suicidal process mental health literacy of depression: gender differences and attitudinal antecedents in a representative british sample web-based questionnaires: the future in epidemiology? men and depression depression and other common mental disorders: global health estimates. world health organization young people's mental health first aid intentions and beliefs prospectively predict their actions: findings from an australian national survey of youth the authors would like to thanks md. mahmudul hasan (research assistant of the undergraduate research organization, dhaka, bangladesh) for his immense support throughout the study implementation. besides, gausul azam ranju is also acknowledged for his initial support to this study. the authors declare no conflict of interest. no additional information is available for this paper. key: cord- -ycjzitlk authors: simons, robin r. l.; gale, paul; horigan, verity; snary, emma l.; breed, andrew c. title: potential for introduction of bat-borne zoonotic viruses into the eu: a review date: - - journal: viruses doi: . /v sha: doc_id: cord_uid: ycjzitlk bat-borne viruses can pose a serious threat to human health, with examples including nipah virus (niv) in bangladesh and malaysia, and marburg virus (marv) in africa. to date, significant human outbreaks of such viruses have not been reported in the european union (eu). however, eu countries have strong historical links with many of the countries where niv and marv are present and a corresponding high volume of commercial trade and human travel, which poses a potential risk of introduction of these viruses into the eu. in assessing the risks of introduction of these bat-borne zoonotic viruses to the eu, it is important to consider the location and range of bat species known to be susceptible to infection, together with the virus prevalence, seasonality of viral pulses, duration of infection and titre of virus in different bat tissues. in this paper, we review the current scientific knowledge of all these factors, in relation to the introduction of niv and marv into the eu. bat-borne viruses with pandemic potential have been identified as the origin of a number of recent human disease outbreaks. examples include the paramyxoviruses nipah virus (niv) in malaysia and [ ] and the filoviruses ebola (ebov) and marburg viruses (marv) in africa [ ] . bats have also been linked with the more recent middle east respiratory syndrome coronavirus (mers-cov) [ , ] . nipah virus, in particular, has been suggested to have pandemic potential as it is capable of limited human-human transmission and rna viruses in general have particularly high mutation rates. a human-adapted strain of niv, were it to emerge in asia, could spread rapidly due to high population densities and global interconnectedness [ ] . a large, and still increasing, number of different viruses have been isolated from bats, many of which are asymptomatic in the host and are closely related to human pathogens. these viruses have the potential for cross-species transmission (i.e., -spillover‖) to other mammalian species, for example, marv in monkeys [ ] and niv in pigs [ ] , and to directly or indirectly infect humans [ ] . a recent paper describes the infection of a wildlife biologist with a novel paramyxovirus during a field trip to south sudan and uganda [ ] . a recent study found that bats have, on average, significantly more zoonotic viruses per species than rodents, which are also known to host a large range of viruses [ ] . additionally, the authors estimated that viruses had a broader host range in bats, averaging . host species per virus. bat-borne paramyxoviruses have been identified in various bat species across africa, australia, south america and asia and recently the detection and characterization of paramyxoviruses in free-ranging european bats has also been reported [ ] . further to this, recent evidence places bats as tentative hosts at ancestral nodes to paramyxoviridae and pneumoviridae [ ] . bat species can have very broad geographic ranges [ , ] and multiple species can share the same habitats and even roost sites [ ] . studies of pteropus bats in australia and asia found they could travel hundreds of kilometers between roosting sites with their home ranges extending across national boundaries and over sea [ , ] . factors that affect the degree and rate of contact between animals and humans are important for spillover of any zoonotic emerging infectious disease. most human outbreaks of bat-borne zoonotic diseases have been suggested to be as a consequence of human activities. for example, outbreaks of marv in africa have been linked to human contact with bat caves, for reasons such as mining operations [ ] or tourism [ , ] . deforestation has also led to bat colonies moving closer to areas inhabited by humans in search of food and roosting sites [ ] . bats are known to have varying degrees of contact with domestic animals and commercial food crops [ , ] , in particular contact of pteropus giganteus bats with date palm sap producing trees in bangladesh is considered a risk factor for human niv infection [ ] . livestock can act as an intermediate host between bats and humans. the outbreak of niv in malaysia in was linked to infection of pigs via fruit bats and resulted in the culling of over one million pigs and the deaths of over people [ ] . similarly, in australia hendra virus is transmitted to humans via horses; to date horses and seven people have been infected (four people have died). bats themselves are a known food source for humans in some areas of africa [ ] and asia [ , ] . while bats in the european union (eu) are known to harbor zoonotic viruses that can be transmitted via close contact, such as the european bat lyssaviruses and (eblv and ), there is currently no confirmation of the presence of viruses with pandemic potential in bats in the eu (i.e., at least capable of sustained human-human transmission). however, it is important to note that this should not be taken as proof of absence of such viruses, but rather that they have not been detected during surveillance of bat populations in the eu to date. historically, the first reports of human marv cases were in laboratory workers in germany and yugoslavia in , through direct contact with blood from african green monkeys (cercopithecus aethiops) imported from uganda [ , ] . however, more recent cases of bat-borne viruses affecting humans in the eu have been isolated incidents, notably the case of a dutch tourist returning from uganda after visiting a bat cave in which marv-infected bats roost [ , ] . similarly, as of november , cases of mers-cov have been detected in europe [ ] , several clusters of which represent chains of transmission in which the primary case had been infected in the middle east. previous studies have demonstrated the presence of similar viruses in eu bat populations, suggesting there is a risk of spillover of related viruses in the future. the first filovirus discovered in europe that was not directly imported from an endemic area of africa was lloviu virus (llov), detected in dead insectivorous bats in massive bat die-offs in caves in spain in [ ] . simultaneous bat die-offs were observed in portugal and france, although a causal relationship between llov and mortality was not shown. countries in the eu have strong historical links with many of the countries where zoonotic bat-borne viruses such as niv and marv are present and, consequently, commercial trade and human travel pose a potential route of introduction of such viruses into the eu. many patients in the ebov outbreak in uganda presented with mild clinical symptoms raising concerns that travel is possible whilst infected, [ ] . other factors, such as the importation of bushmeat, including bats and body parts of primates [ ] , could be potential routes of virus introduction. a qualitative risk assessment for the introduction of henipaviruses to the uk concluded that there was a low level of risk from southern asia, south-east asia and australia, through import of fruit and bushmeat and a very low level of risk through import of bat meat, horses and companion animals and through human travel [ ] . however, the assessment highlighted the high levels of uncertainty, reflecting the limited data and specific details of the routes involved. a risk assessment for niv establishing in australia also identified a lack of relevant data in various areas, reflected in the high levels of uncertainty in the risk estimates [ ] . in this paper we review the scientific literature relating to the risk of introduction of niv and marv into the eu, but do not formally assess the risk. we begin by reviewing the current evidence for the geographical location of the viruses and thus where a potential risk of introduction to eu member states (mss) may exist. next, we review the evidence for factors which may affect the probability of an eu introduction via the various routes, such as prevalence and transmission dynamics in bat species and survival and transmission potential of the viruses. finally we review the evidence directly relating to potential routes for introduction into the eu. the main routes we consider in detail are human travel, trade of fruit and pig products and illegal importation of bushmeat. other routes such as bat migration, the unintentional introduction of living or dead bats by aircraft and the effect of climate change are also given consideration. identification of countries which have had human cases of niv or marv is important for assessing the risk of introduction to the eu, as it identifies the areas from which human travel may be a particular risk. knowledge of the risk factors regarding human infection in these countries is also of relevance as they may suggest other potential routes of introduction, highlight similar factors which are present in the eu and may facilitate spread of the viruses, or indicate potential control measures. niv: studies suggest that human outbreaks are linked to one of two distinct nipah virus strains; niv-malaysia or niv-bangladesh [ ] [ ] [ ] . the malaysian strain emerged in with an outbreak in commercially farmed pigs, resulting in > human cases reported in malaysia and singapore with a case-fatality rate approaching % [ ] . pteropus vampyrus and pteropus hypomelanus were subsequently identified as likely natural reservoir hosts for the virus [ , ] . in this instance, pigs were implicated as amplifier hosts with viral isolates from both sick pigs and humans showing identical nucleotide sequences [ ] . the presence of large commercial pig farms with fruit trees in the vicinity meant that foraging bats could drop partially eaten fruit contaminated with niv into pig farms. pigs could then have access to this fruit and become infected with niv [ ] . transmission was attributed to direct contact with infective excretions and secretions and viral spread among pig farms was due to movement of pigs [ ] . there were no reported incidences of human-human transmission and there have been no further acute human cases attributed to niv-malaysia since , although relapsed and late onset cases have been reported [ ] . laws in malaysia preventing fruit farming in pig farming areas may have prevented further niv outbreaks. in contrast, there have been regular seasonal outbreaks of niv-bangladesh since its apparent emergence in , predominantly in bangladesh, although two outbreaks have also been reported in west bengal, india, close to the border of bangladesh [ ] . up to january , there have been reported human cases linked to niv-bangladesh with deaths, giving a reported case fatality rate of % [ , ].this appears much higher than the case-fatality rate of niv-malaysia, although direct comparison may be complicated by various biases such as method of surveillance and reporting. while human-human transmission is considered a major pathway for human infection with this strain [ ] , studies in india and bangladesh suggest the main risk factor is consumption of raw date palm sap [ , , ] . date palm sap is harvested from december through to march by cutting into the tree trunk and allowing the sap to flow overnight into an open clay pot [ ] . infrared camera studies have demonstrated that p. giganteus bats frequently visit date palm sap trees and lick the sap during collection [ ] , potentially contaminating it with niv from saliva and/or urine. other reported risk factors for human infection include consumption of alcoholic beverages made from date palm sap [ , ] , climbing trees and contact with other niv infected patients [ ] or animals [ ] . a recent study investigating the role of landscape factors in niv spillover risk in bangladesh [ ] found a significant correlation between niv spillover and villages with higher human population density, more fragmented forest cover and p. giganteus roost sites containing the tree species polyalithia longifolia or bombax ceiba. the geographical distribution of cases within bangladesh is shown in figure . cases generally occur in areas near inland water, predominantly the ganges, which provides a suitable habitat for date palm trees. in , there were cases reported from districts, more than in any other year, but generally only a few cases per district; the largest number was five cases reported from manikganj [ ] . the pattern of cases suggests multiple small outbreaks in different regions, rather than large outbreaks caused by one source. [ , ] . initial laboratory investigations at the time of the niv outbreak in siliguri (india) in did not identify an infectious agent. retrospective analysis, however, identified the presence of niv antibodies in serum samples by enzyme-linked immunosorbent assay (elisa) and rna by real-time pcr (rt-pcr) in (stored) urine samples [ , ] . sequence analysis confirmed that the pcr products were more closely related to the bangladesh strain ( . % identity) than the malaysia strain. to date, there is no reported evidence of niv outbreaks in humans emerging in other parts of india or in any other countries. however, given the delay in identification of the siliguri outbreak and large distribution of bats that can carry niv, it is possible that more human cases have occurred where niv has not been detected or reported. additionally, surveillance for niv in bangladesh may be more sensitive due to the previous cases reported to the authorities each year. as such, wider geographical distribution of human cases of niv should not be ruled out. marv: since the outbreak of marv in laboratory workers in europe [ ] , outbreaks have been confined to sub-saharan africa, although there have been reported cases of individuals acquiring infection in uganda and then travelling to the netherlands [ ] and the usa [ ] . human cases of filovirus infection in africa have been associated with hunting fruit bats for meat and with entry to mines or caves where large populations of fruit bat species, such as rousettus aegyptiacus, are present [ , , ] . it has been suggested that human infection could be through exposure to the excretions from bats roosting in the caves [ ] , although an experimental study on r. aegyptiacus bats inoculated with the hogan marv strain (originally from the south africa outbreak [ ] ) did not detect virus in the faeces of infected bats [ ] . one study reported -working as a miner‖ as a significant risk factor for a positive antibody result to marv, with % of the population who tested positive for marburg antibodies working in the local gold mines [ ] . there has not been a direct food consumption transmission route reported for marv, although index cases of filovirus infection have often had suspected contact with dead primates found in the forest, with exposure thought to occur during the butchering process [ , ] and the hunting process, which may involve the use of shotguns, potentially causing spray of body tissue and fluids [ ] . identification of countries where niv and marv have been detected in bats is important to understand the potential for infected bats from these areas to directly enter the eu, contaminated trade products destined for the eu, or infected humans who may travel to the eu. knowledge of the species of bats that are susceptible to niv and marv is also a relevant factor for assessing the susceptibility of bat species present in the eu. there is a growing body of literature on the geographical distribution and range of niv and marv in animal species with particular reference to bats. a complicating factor in defining the range is that studies in bats typically report serological or rna detection results, rather than detection of infectious virus. while a seropositive result is strong evidence of historical exposure to a virus, there may be cross reactivity with related viruses, precluding exact identification of the virus to which exposure has occurred, as seen for niv and hev in australasia [ ] . detection of rna demonstrates the presence of genetic material, but does not prove current presence of infectious virus. additionally, there can be difficulties in using serological assays outside their original, validated scope, for example when an existing assay is used with samples from an alternative species [ ] . here, the absence of positive and negative control samples and -gold standard‖ diagnostic assays makes it hard to determine an appropriate cutoff point to distinguish between seropositive and seronegative individuals [ ] . as such, positive identifications do not confirm active virus infection at the current time and, in some cases, could only be an indication of historical exposure to a related virus. in the absence of virus isolation or full genomic characterization, it cannot, therefore, be definitely confirmed whether the virus is currently present. niv: table shows a summary of reported testing for niv in bat species. niv is predominately associated with asian fruit bats of the genus pteropus, which have been suggested as the natural reservoir for henipaviruses [ ] . only a few studies have successfully isolated niv virus from bats. isolation has been reported from the urine of p. vampyrus [ ] and p. hypomelanus [ ] in malaysia and p. lylei in cambodia [ ] , but at very low prevalence, with only / samples yielding a virus isolate in the cambodia study. such low prevalence could be a factor for the inability to isolate niv in test samples of bats in other studies. rna positive pcr results have been obtained for p. vampyrus in indonesia [ ] and p. lylei in thailand [ ] , which identified both niv-malaysia and niv-bangladesh rna sequences. niv rna has also been detected in p. giganteus in india [ ] and p. vampyrus and rousettus amplexicaudatus in east timor [ ] . of particular interest to the eu is the identification of henipavirus antibodies in myotis daubentonii in china [ ] , as this species is also found across much of europe, although it should be noted that niv specific rna was not detected in this study and virus isolation was not attempted. while niv is predominantly associated with asia there is increasing evidence for the presence of related viruses in africa. paramyxovirus rna related to hev and niv has been detected in eidolon helvum bushmeat in the republic of congo [ ] and in the faeces and urine from roosting e. helvum bats in ghana [ , ] . viral concentrations were estimated to be low using rt-pcr assays [ ] . other studies have identified henipavirus antibodies in eidolon dupreanum and pteropus rufus in madagascar [ ] . a recent study combined genetic and serological analyses to determine the extent of connectivity among e. helvum populations across central africa. antibodies to henipaviruses were present in bats from all locations with henipavirus seroprevalences reported to be between %- . %, with an overall average of . % [ ] . however, the presence of infection on isolated islands suggested that large population size and connectivity may not be responsible for viral persistence. these studies do not confirm the specific presence of infectious niv virus in bats in continental africa and madagascar, but they now constitute a reasonably substantial body of work, from a number of independent sources, which suggest increasingly strong evidence for the presence of henipaviruses in bats that have a geographical range outside of asia and oceania. marv: table shows a summary of reported testing for marv in bat species. there are several studies reporting the prevalence of marv in bats in caves in africa including the countries of gabon, uganda and the democratic republic of congo (drc) [ , [ ] [ ] [ ] [ ] [ ] . marv is now considered endemic in r. aegyptiacus bats in gabon [ ] and, in general, those bat species which serve as potential reservoirs for marv are endemic to regions of central africa. there is little evidence for the potential of marv to occur outside africa at this point, although there are few published reports of testing for this virus on other continents; a study in india showed that none of bats tested, including p. giganteus (n = ), cynopterus sphinx (n = ) and megaderma lyra (n = ), were positive by pcr for marv rna [ ] . within africa, there are also reports of antibody or rna evidence of marv infection in bat species other than r. aegyptiacus, such as rhinolophus eloquens, miniopterus inflatus [ ] and hypsignatus monstrosus [ ] , but reports are less frequent. this highlights the importance of knowledge on the exact species of bats for the purpose of risk assessment, suggesting the main zoonotic risk is likely from r. aegyptiacus. in an experimental study, marv was found to be present in the blood and saliva of viraemic r. aegyptiacus bats but not in their faeces or urine [ ] , suggesting that close contact between adjacent bats of the same species within the roost may be important for marv transmission. marv rna has also been reported in a pooled liver, spleen, lung extract from a female r. aegyptiacus fruit bat in kenya in , although tissues from other bats including r. aegyptiacus from two locations were negative [ ] . from an eu perspective, r. aegyptiacus are known to be present in cyprus [ ] and turkey [ ] and populations were found in the wild in tenerife in the early s, as a result of escaped captive animals [ ] , before being effectively eradicated by . there is no reported evidence to suggest presence (or absence) of marv in these populations. bat host heterogeneity of virus prevalence is important both in terms of further spread of infection within the roost and spill-over to humans, e.g., through being hunted for bushmeat. some fruit bat colonies in trees in ghana have up to million bats, so the prevalence may vary spatially within the colony [ ] . fruit bat colonies in caves with more than , r. aegyptiacus bats are structured with juveniles more likely to be exposed to bat droppings due to their peripheral positions within the colony [ ] . a study on active infection of marv in a bat cave in uganda found a higher prevalence in older juvenile bats ( . %) than younger juveniles ( . %) or adults ( . %), the older juveniles were six months old at the time of capture and younger juveniles three months old [ ] . thus, an important consideration is whether juveniles and adult bats have different behaviors that would affect the onward transmission of marv. for example, are older juvenile bats and non-breeding adult bats more likely to range further in migration (and hence spread disease to other hosts) than younger juveniles or the breeding adults, or to be caught by bushmeat hunters (as they are less experienced in survival)? based on data gathered in tables - , those countries of the world where there is evidence of recent niv or marv infection in humans or bats are highlighted in figure . we define that a country is positive for human infection only if it has had a reported human case in the last years (i.e., since ). such a period of time without a reported case suggests that while there may still be potential for a human case in the country itself, the risk of import to the eu is extremely low. thus, malaysia and singapore are not considered positive for niv and south africa and kenya are not considered positive for marv. given the issues regarding use of serological positive results as an indicator of current virus presence, we do not consider serological positive results alone to be an indication of current viral presence in bats for this analysis. information from the iucn red list website is used to determine the geographical range of those bat species known to have been naturally infected [ ] , as there is a potential for undetected viral presence in these countries. it can be seen that while recent human infections of both niv and marv appear to be limited in geographical range (the red areas in figure ), there are a number of countries where bats have been identified as having the virus, but no human infection has been reported. it is also noted that the full geographical range of these bat species is extensive and in the case of r. aegyptiacus encroaches on the south-east boundary of europe, although the range of pteropus bats is much further east. however, if species serologically positive for henipaviruses are considered then m. daubentonii would be included and the geographical range would be much wider, encompassing europe and australia. viral load is a measure of the number of viral particles present in an organism or bodily fluid, e.g., the mass/volume of bat faeces, urine, saliva or bushmeat. the virus may be quantified in a number of ways including plaque-forming units (pfu), tissue culture infectious dose % units (tcid ) or number of genome copies. currently there are no published dose-response curves that convert pfu or tcid units in to risk of infection in humans or livestock animals. furthermore, the genomic copies may not all be equally infectious (due to the mutant spectrum) and some may be defective. it is not clear whether dispersion of the virions lowers the risk of transmission. however, the viral load is an important factor in a release assessment for any virus because it directly affects the risk of transmission. niv: while the studies mentioned previously demonstrate the likelihood of a continual reservoir of niv in many countries, the actual prevalence of bats currently shedding virus may be very low. as such, data on viral load is limited. however, with the application of real-time pcr, henipavirus-related sequences ranging from to , genome copies per . cm and . × per ml of bat urine have been reported [ ] . experimental studies have also been conducted in other animals. titres of up to pfu/ml from brain and basal turbinates and pfu/ml from trachea swabs were obtained from niv infected piglets [ ] , with lower levels found in lung and spleen and shedding peaks during the first week post inoculation. titre data are also available for niv strains from bangladesh and malaysia in experimentally infected rodents [ , ] . marv: one study reported that no viraemia or presence of marv rna could be detected in various tissues collected from r. aegyptiacus bats experimentally inoculated through oral or nasal routes [ ] , but subcutaneous and intraperitoneal inoculation resulted in high levels detected in plasma ( to tcid /ml) for five to nine days post inoculation, with titres up to . and . tcid /g in the liver and spleen respectively. virus was also occasionally detected in lung, heart, kidney and salivary glands with loads up to . tcid /g. ranges for tcid /ml of marv in tissues of naturally-infected r. aegyptiacus in uganda have also been derived from a standard curve of diluted stock virus using q-rt-pcr [ ] . high values of , - , , tcid /ml were obtained from liver, spleen and lung whilst values of - tcid /ml were obtained from multiple tissues including blood and intestines. a potential factor affecting the prevalence of viruses, regarding the risk of zoonotic transmission, is seasonal pulsing, or oscillations of prevalence, with peaks in prevalence at specific times of the year. periods of higher risk are relevant to eu incursion as they will affect factors such as the probability of eu tourists contacting an infected bat and thus impact on routes such as human travel to and from niv and marv areas. indeed, seasonal pulses of marv circulation in juvenile r. aegyptiacus bats coincide with periods of increased risk of human infection [ ] . the influx of susceptible young is a crucial driver of infection dynamics and bat reproduction and survival are thought to be major drivers of bat disease dynamics [ ] . many bat species exhibit highly synchronised parturition which can dramatically alter population contact rates and susceptibilities. sex differences in behaviour and distribution of bats during times of the year when the potential for disease transmission is greatest may also have important implications for disease dynamics [ , ] . the role of bat torpor in infection dynamics is largely unstudied [ ] . torpor typically reduces pathogen replication rates and hence lengthens the incubation periods. a study found a clear indication for torpor being a key factor in allowing perpetuation of rabies virus through the hibernation period, through prolonged incubation period and reduced mortality [ ] . this enabled the virus to persist in the population until susceptible individuals from the annual birth pulse could become infected and continue the cycle. migration and coloniality may also be important drivers of disease dynamics [ ] , altered migration behaviour may result in declining immunity within specific colonies which could lead to more explosive hev epidemics [ ] . niv: there is evidence of a seasonal pattern for spillover of niv to humans; a review of all human outbreaks of niv between and found that, except for the initial event in malaysia, they all occurred in the first five months of the year [ ] . a longitudinal study in thailand found the bangladesh strain of niv was dominant in the urine of p. lylei bats, with highest recovery of rna in may [ ] . in two sites, the bangladesh strain was almost exclusively detected between april and june while the malaysian strain was found dispersed during december to june. breeding of the bats (including mating and birthing) occurs in december to april, and may not be the only factor involved in bat transmission. there is some evidence that pregnant and lactating pteropus scapulatus and p. conspicillatus females had a significantly higher risk of hev infection [ , ] resulting in a seasonal pattern due to seasonality of reproduction of these bats. a study on an orchard in new south wales investigated the legal shooting of pteropus poliocephalus [ ] , found that the majority of bats shot were female (ratio : . ) and that % of these females were lactating. this suggests that pregnant and/or lactating females are more likely to be foraging for food and coming into contact with crops/orchards, which could not only be eaten by horses, but also could contribute to seasonality of human spillover for viruses such as niv bangladesh, for which oral transmission to humans through date palm sap is a route. the wild date palm produces sap seasonally from mid-october to mid-march and winter (december to early february) is the traditional date palm sap gathering season in bangladesh. outbreaks of niv generally coincide with this season, appearing between december and may. marv: a study of marv in r. aegyptiacus in the python cave in uganda predicted an oscillating biannual pattern of bat prevalence in the cave, with peaks in february and march. these peaks in prevalence coincided with the birthing seasons of the bats in the cave and the temporal clustering of previous reported spillover events of marv into humans [ ] . pcr data showed distinct oscillating pulses of marv infection in older juvenile bats (~six months of age) peaking in february and august that temporarily coincided with the peak twice-yearly birthing seasons. the authors speculate that the marv pulses reflect the pulses of newly weaned bats which populate the -low-lying‖ roosting areas where they are infected and may pass infection amongst themselves [ ] . as they age, and are recruited into the adult population, their colony positions are taken by the next generation of juvenile bats. it is not clear whether the oscillation peaks in juvenile bats coincide with other environmental/ecological factors affecting the bats such as local shortage of fruit or migration. knowledge of survival of virus in different media and under different environmental conditions is important for assessing the concentrations of virus on contaminated fruit and infected bushmeat over time and ultimately the risk to humans. this can be used to predict the concentrations of virus on the surface of fruit after export by taking into account the duration of transport to the eu. duration of infection in both humans and bats is also important when considering the probability of shedding infectious virus on arrival in the eu. niv: the incubation period for niv in humans has been reported to be as much as days [ ] . surveillance in bangladesh in found that among secondary cases, who had a single exposure to niv, the delay between exposure to onset of illness ranged from - days, with a median incubation period of nine days [ ] . the incubation period following a single intake of raw date palm sap to onset of illness varied between - days, with a median of seven days. a laboratory study on persistence of henipaviruses under various environmental conditions found that they were sensitive to ph, temperature and desiccation [ ] . the study showed a - log inactivation of henipaviruses in fruit juice (lychee, pawpaw and mango) over three to four days, although titres were still detectable after three days. there were also large variations in the half-life of the virus at different temperatures and ph values; e.g., in mango flesh, the half-life of niv was . hours for ph . at °c but . hours for ph at °c. for the purpose of risk assessment it is the rate of inactivation which is important, rather than the limit of survival, which depends on the starting titre. marv: investigation of the outbreak of marv in germany suggested that the incubation period could be as much as nine days [ ] . an experimental study on the effects of marv on the common marmoset (callithrix jacchus) found that animals became febrile after - days [ ] . an experimental study looking at marv, zaire ebolavirus (zebov) and reston ebolavirus (rebov), demonstrated survival for long periods in liquid media at both room temperature and °c, with virus recoverable from glass and plastic surfaces over three weeks after the start of the experiment [ ] . similar decay rates were found for marv and zebov, while rebov had significantly better survival within an aerosol. although data for survival of filoviruses on fruit are not available, a study looking at survival of poliovirus, simian rotavirus and feline calicivirus in the uk found prolonged periods of survival on fresh fruit and vegetable produce at refrigeration temperatures ( - °c), extending beyond the shelf life of the product [ ] . survival at °c was poorer, but some viruses remained viable for over a week. removal of viruses using conventional chlorine washing could give more than log reduction, but was only < log for poliovirus. however, it should be noted that these are non-enveloped viruses, and may, therefore, have different survival properties to the enveloped filoviruses. human-human transmission has been identified for both niv and marv. this, combined with incubation periods that could be over a week [ , ] , suggest that human travel could be an important route for transmission of bat-borne zoonotic viruses into the eu. the recent mers-cov cases in the eu highlight the risk of virus introduction from human travel [ ] . there has been one high profile case of tourism leading to an introduction of marv into the eu [ , ] . a similar, but non-fatal, incident from a person who visited the same bat cave in uganda also occurred in the usa [ ] . neither incident resulted in identified infection in other individuals. data from eurostat show that there are large numbers of people travelling between the eu and areas where niv and marv have been reported, both by air and by sea [ ] . the number of immigrants from these areas settling in eu countries is generally increasing and they will naturally have strong ties to their homeland. for example, the uk censuses of and show an increase in both number and percentage of the population of england reporting to be of indian, pakistani, bangladeshi and african ethnicity [ ] . combined, the indian, pakistani and bangladeshi ethnicity groups make up . % of the england population and % of the population of london in and similar data show that there has been an increase in the number of people reporting to be born in these countries [ ] . one could generally expect the individuals and their friends and families to have frequent trips to and from their native countries. data from the uk in suggested that out of , trips to the uk made by individuals using a bangladeshi passport, , were made by people returning after a temporary leave of absence [ ] . figure shows the migration into the eu from the niv and marv countries identified in figure . it is apparent that, in terms of migration from niv countries, the uk has the highest influx of migrants of all eu countries, while from marv countries it is france. further analysis showed that the majority of bangladeshi migrants go to the uk. this might suggest that when considering the risk from humans entering the eu from bangladesh, the uk is more likely to be at risk (before considering the impact of border control measures). previous research suggests that historically the bangladeshis that travelled to the eu were predominantly from sylhet [ ] , an area in the north east with very few reports of human niv cases, although more recently this may no longer be the case. it should be noted that some airports, such as heathrow, london, act as hubs for passengers going on to other destinations, which may lead to an overestimate for individual mss. however, an infected individual may be a risk even if only passing through the airport, as they will still likely have contact with airport staff and other passengers. a study looking at the risk of human-human transmission of viral haemorrhagic fevers (vhf), including marv, on airplanes found only a few events of vhf cases in the literature and no documented infection in follow up contacts [ ] . the study suggested that contact trace back should be undertaken for passengers and crew with direct contact with an infected individual, passengers seated within one seat of the case and cleaning staff responsible for cleaning the section occupied by the case. however, trace back of passengers seated more than one seat away from the infected individual was not considered necessary. this suggests that close contact is thought necessary for human-human transmission and so not everyone on an aircraft with an infected individual is likely to be at risk. as such, this would mean that spread of the virus to multiple locations in an eu ms, due to the dispersion of multiple individuals infected during the flight, is unlikely. however, the lack of data regarding vhf on flights and subsequent reliance on expert opinion in this study suggests that there is fairly high uncertainty surrounding the conclusions and further evidence should be sought, particular with regard to other viruses; factors such as stronger capability for airborne transmission could lead to different conclusions. tourism may have specific risks independent of other human travel. people who travel to foreign countries on holiday are likely to be there for only short periods of time, e.g., - weeks and some, particularly ecotourists, may visit bat caves or colonies, returning home soon afterwards. entering such areas carries the potential risk of direct contact with infected bats and contamination of shoes and clothing with potentially contaminated bat guano/faeces. there is a documented incident, in the python cave in uganda, of this leading to marv infection [ , ] , but there are numerous unofficial reports of similar such events. tourists are perhaps also more likely to be unaware of the risks of virus transmission, and therefore unaware of the appropriate precautionary measures. an author of this paper recently returned from west africa where they witnessed tourists entering an occupied bat cave and having contact with fresh bat guano. the tourists were not aware of the potential risks of virus transmission. however, the recent case of infection of a wildlife biologist with a novel paramyxovirus highlights that there is still a risk for people who are aware of and carrying out appropriate safety precautions [ ] . the short duration that tourists generally spend away means that, if infected, it is likely that they will return to the eu before clinical symptoms have developed, and there is little time for decay of pathogens in guano or indeed loss of guano from the clothing or shoes. it is well established that foodborne zoonoses can pose a threat to human health. pathogens may be present in products destined for human consumption either through infection of the source product in the natural environment (e.g., contamination of growing crops by infected animals or infection of animal tissues to be consumed while the animal was alive) or cross contamination of the product during processing, typically with urine or faeces. for viruses such as niv and marv, while cross-contamination during transportation could result in the presence of virus in other products, the most likely products to be contaminated are those that are associated with outbreaks, i.e., fruit and pig meat. while pig meat has not been directly associated with human infection, live pigs were identified as the source of human infection in the niv-malaysia outbreak, although pigs in malaysia are now considered free of niv [ ] . marv has not been associated with infection in any livestock animals to our knowledge (marv is known to infect primates which have been found in bushmeat seizures [ ] , but in this section we only consider animal products that would be traded legally for food). drinking raw data palm sap, or alcoholic beverages made from it, have been identified as risk factors for human niv infection in bangladesh [ , , ] , primarily due to the risk of direct contamination of the sap by the local pteropus bats. we have found no evidence of official trade of either of these products to the eu, although it is possible that individuals may bring alcoholic beverages with them in their personal belongings (the raw date palm sap ferments very quickly so is less likely to be brought over to the eu). while there are a number of products that involve its use, such as palm sugar, there are no reports of human infection as a result of consumption of such products. this suggests that the processing that takes place during the preparation of such products, in the case of palm sugar the sap is generally boiled, mitigates the risk. fruit bats are known to feed on a wide range of crops and they are often considered pests due to feeding in commercial orchards, although their importance in pollination is recognized [ , ] . a study on a vineyard in india found the old world fruit bat c. sphinx was responsible for > % damage to crops at the periphery of the vineyard [ ] . as such, it is common practice to protect commercial crops through the use of measures such as netting or shooting; one study on a stone fruit orchard in sydney, australia, consisting of four hectares of nectarine trees, where shooting was known to occur in order to protect the orchard, found a total of dead or injured flying foxes over days at the time when the nectarine crop was ripening and being harvested [ ] . niv-malaysia was isolated from fruit on tioman island, and contamination of fruit by bats is thought to be a potential route for the infection of pigs during the malaysian niv outbreak [ ] . a number of outbreaks in bangladesh have been linked with consumption of date palm sap [ ] , with the sap likely being contaminated with bat urine or saliva. while the date palm sap is the only identified foodborne source of human niv infection in bangladesh, bats could potentially have contact with, and contaminate with saliva or urine, any unprotected fruit grown in the region. while unlikely, if these crops are exported, there could be a risk of virus introduction into the eu. transport times can be less than hours by air travel, not long enough to allow significant decay of the virus. this route is less likely for marv as, to date, it has not been detected in the faeces or urine of either experimentally or naturally infected r. aegyptiacus bats [ , ] . faostat databases contain details of volumes of trade between eu mss and extra eu countries [ ] . the eu has strong trade links with the niv and marv identified areas in figure . while these databases show that there is little trade of pig products from niv and marv regions to the eu there is trade of fruit products (e.g., dates, apples, fruit juice). figure shows the relative volume of trade of fruit products from these areas and eu mss. the biggest importers from these areas are the netherlands and the uk, with germany having a relatively high volume from niv areas and france from marv areas. as with the human travel, it should be noted that some countries may act as hubs for trade products, with subsequent further distribution to other destinations. figure . trade data from faostat [ ] . trade of infected animals for non-food purposes could also pose a risk of viral introduction. marv has been identified in the african green monkey (cercopithecus aethiops), which have historically been traded for research purposes. there is considerable movement of horses around the world, primarily for sporting events. horses are known to be susceptible to hev with infections in australia [ ] , but to date there have been no reported cases of niv in horses. pet travel could also be a risk as the pets could potentially be infected with bat-borne zoonotic viruses in endemic countries. recently a kitten, infected with rabies virus, entered france from morocco demonstrating that such events can occur, even though the accompanying certificate of good health did not meet the regulatory provisions for the import of domestic carnivores from morocco [ ] . data from traces suggests that movement of live animals such as pets between niv or marv countries (as defined in figure ) and the eu are primarily animals not considered a risk of carrying the viruses (e.g., tropical fish) [ ] . however, there are a number of movements of cats and dogs. an experimental infection study of two cats with the malaysian strain of niv found that they started to develop clinical symptoms after five days [ ] . one cat developed acute clinical disease while the other recovered. virus was recovered from the tonsils and urine up to eight days post inoculation. while a very small sample size, and being aware that the experimental challenge dose is likely much higher than would be received in nature, this demonstrates that there is a potential risk of pets bringing the virus back into the eu. there is currently no quarantine regulation for third country pets, although the risk of bringing in pets from niv and hev areas is recognized by at least some mss [ ] . bat guano is also a potential trade product; it is sold for use as a fertilizer in several countries including thailand, indonesia, mexico, cuba and jamaica [ ] , and in theory could be imported into the eu. one study reported four of bat guano samples from a bat cave in ratchaburi province, thailand, were positive for group c betacoronavirus rna, although none contained niv rna [ ] . the legal importation of bats could also be a risk. the emergence of wild r. aegyptiacus bats in tenerife was believed to be a result of the escape of captive bats [ ] . there are no instances of live bat imports into the eu from niv countries on traces, but there are many instances of bats used in scientific research and zoos. r. aegyptiacus bats, known to be susceptible to marv, have been kept in zoo's in the eu; in two such bats died of rabies after being imported from a dutch zoo to a danish zoo [ ] . additionally there are reports of r. aegyptiacus being kept as pets. however, given the low numbers and the likely increased testing/surveillance of animals destined for these purposes the risk of importation from this route is likely very low. bushmeat is a term used to capture a variety of raw, smoked or partially processed meat that originates from the hunting of a variety of wild animals, including bats. it is well documented that bushmeat is illegally imported into both europe and the usa [ , , ] and, as such, it could act as a conduit for pathogen spread. in a recent study, illegal bushmeat imported into the united states was found to contain retroviruses and/or herpesviruses [ ] and henipavirus-like rna has been detected in internal organs of bat bushmeat sampled in the republic of congo [ ] . the perception of bushmeat as having zoonotic potential is not well recognized among bushmeat hunters, traders and consumers; one study reported that only % of bushmeat hunters in sierra leone are aware of the zoonotic disease risk [ ] and in a survey on bushmeat in the usa, participants in a focus group considered bushmeat to be a wholesome healthy and safe alternative to commercially produced meat from a shop [ ] . in an experimental study of r. aegyptiacus bats, marv was not detected in muscle, brain or skin tissues collected after cardiac exsanguination [ ] . this suggests that these tissues (including muscle) are not heavily infected, and that positive results in liver, spleen and kidney were not due to the presence of blood. if confirmed to be the case in naturally occurring infections, it could mitigate the risk of marv infection from the consumption of bushmeat if internal organs are not eaten. hunting of wildlife for food is a widely distributed practice in many parts of the world and constitutes an important source of animal protein for some rural communities. one paper reported that . % of households in brazzaville, congo consumed bushmeat [ ] and a survey of municipal markets identified different animals species, nine of which it is prohibited to hunt [ ] . economic recession over the past years has driven the commercialisation of bushmeat as a trade item; bushmeat now reaches the international markets as part of the $ billion annual global wildlife trade. the commercial trade in bushmeat occurs across almost all of tropical africa, asia and the neotropics, notably in the densely forested regions of west africa [ ] . estimates of bush meat harvests in ghana are around , tons annually [ ] . the bushmeat markets across west africa are nowadays dominated by small bodied, fast reproducing species such as rodents like the grasscutter (thryonomys swinderianus) [ ] . there is little officially reported information on the use of bats as bushmeat, a review of survey papers on bushmeat did not report anything on bats [ ] , but unofficial reports and eye witness accounts suggest it is not uncommon to see bats for sale in african markets. it is possible that bats do not follow a typical bushmeat commodity chain and amounts are therefore underestimated in standard bushmeat surveys [ ] . bats are often hunted for pre-arranged orders and regular customers rather than sale through wholesalers who may prefer to concentrate on larger animals with a higher value-to-weight ratio. one study estimates that , e. helvum are sold each year in southern ghana [ ] . this involves a commodity chain stretching up to km and involving multiple vendors. no official data regarding the size of the bushmeat trade exist as much of the trade is informal or illegal. while much trade is intra-country, trans-border trade does occur through known trade routes throughout the region and there is a limited amount of inter-continental trade from africa to europe [ ] . recently a quantity of bushmeat thought to be from the central african republic was seized by french police, and was reported to include bats, although the species were not named [ ] . imports of bushmeat into the uk do occur and mostly take place from those parts of africa with which the uk has close historical connections, in particular west africa [ ] . residents of the uk who have their ethnic and cultural origins in central and west africa and who are returning from a visit there often bring bushmeat into the uk for their own consumption. in comparison with the domestic market in bushmeat in central and west africa the amount of bushmeat coming into the uk represents only a very tiny fraction of the total turnover [ ] . a wildlife policy briefing report, which sets out bushmeat preferences in urban liberia provides a good indication of the sort of bushmeat likely to be imported into the uk, since returnees and visitors to the uk are most likely to buy their bushmeat in urban markets and are likely to reflect current local preferences [ ] . the list comprises ungulates, rodents, primates and pangolins. bats do not feature in the most preferred animals for taste from urban communities in west africa or in the more generic list of animal involved in the bushmeat trade in west africa. chaber et al. sampled passengers from flights from central and west africa to france over days in june [ ] . fifty-five passengers were found to be carrying fish or domestic meat and nine were carrying bushmeat. average individual consignments of bushmeat were over kg, compared with and kg for livestock and fish. most illegal imports detected by uk border agency are small amounts and continue to be typically gifts by travellers visiting family (or returning from visiting family abroad), or seizures from tourists, business people and students travelling to the uk for the first time. most do not involve deliberately smuggled goods but are made from passengers who are not aware of the current rules and prohibitions in place for products of animal origin (poao) imports [ ] . as well as personal carriage, bushmeat may be imported either by postal carriage or commercial freight to the eu. hm revenue and customs found bushmeat to constitute % of poao customs seizures for the period - . some bushmeat samples entering eu states from africa do so from european transit flights, as under the single market goods can travel freely from one member state to another without checks. thus the situation in any specific member state depends on the effectiveness of border controls in other member states. the bushmeat from animals hunted in tropical forests destined to be carried to the eu is likely to be preserved in some form for the duration of the journey. the bushmeat consumed in the uk imported from west africa is most often either smoked, dried or salted [ ] . because of this processing the initial load of viable organisms on the bushmeat would be expected to be reduced significantly. the average duration of smoking of bushmeat was found to be about hours minutes per day at a maximum temperature of . °c [ ] . to preserve the bushmeat it may be frozen on arrival in the uk. freezing in general promotes virus survival and a laboratory study suggested long survival times of marv at °c [ ] . throughout africa and asia, bats have been used in zootherapy, which is the treatment of human ailments with remedies made from animals and their products. around % of the population in africa uses traditional medicine and there is also a growing interest in many developed nations [ ] . there is evidence of bats being used for specific ailments in zootherapy and it is possible that they may still be used by migrants in european countries. treatment of ailments with bats include disorientation in patients with mental illness [ ] , fertility medicines and post birthing remedies, [ ] , the use of bat droppings of p. giganteus to treat patients with alcohol and drug addiction, [ ] , and night blindness [ ] . in asia, asthma is the most frequently cited disease for which bats are used as a remedy [ ] [ ] [ ] . these therapies are frequently practiced in countries where there is evidence of niv infection in bats. kanda tribal healers in bangladesh use p. giganteus in formulations for the treatment of fever [ ] , one pharmaceutical company in vietnam reportedly imported tonnes of faeces of rhinolophus bats [ ] . in a survey of asthma patients in singapore primary care clinics on the use of complimentary therapies, patients ( . %) had used complimentary medicine out of which ( . %) used animal products, ( . %) of which had used fruit bats [ , ] . whilst there is evidence that bats, as bushmeat, are eaten extensively in africa and asia there is little evidence of them being internationally traded or brought to the eu in personal possessions; a number of studies have investigated illegal imports of bushmeat, but rarely have bats been among the samples seized. however, these are relatively small studies and do not confirm the extent to which bats are exported as bushmeat. additionally, other animals, such as monkeys, were identified in the seized samples and are known to be susceptible to viruses such as marv. a review of possible microbiological hazards associated with the illegal importation of bushmeat concluded that although there was a lack of quantitative data relating to the microbiological risks, the risk of foodborne illness from consumption of bushmeat appeared to be very low and the risk of foodborne illness from cross contamination was also minimal [ ] . normal cooking would probably destroy any viruses and bacteria present although there were no data presented to verify this. the risk from use of bats in zootherapy is not as well understood. however, while the risk of contaminated bushmeat may be low, the consequence could be very high. migration is a seasonal, usually two-way movement from one place or habitat to another, to avoid unfavourable climatic conditions and/or to seek more favourable energetic conditions [ ] . some bat species are known to migrate large distances and cross national borders [ ] . such behaviour will connect seemingly distant bat populations, and an infected individual could therefore act as a vector to introduce a new virus into a naï ve population. bat flights are generally short distances for the purpose of foraging, hunting, changing roost sites or social behaviour. indeed, the majority of bat species in the world are sedentary. some bats, however, particularly those in the temperate regions of the world, perform annual long distance flights [ ] . bat migration typically occurs along rivers, as shown for bats in poland and central slovakia [ , ] and tends to avoid mountainous areas [ ] . with regards to bat species and geographical areas relevant to niv and marv, in congo a massive annual fruit bat migration takes place up the lulua river with hunting of the bats by villagers. direct exposure to the fruit bats may have led to an outbreak of ebov in [ ] . regular mass long-distance migrations have not been reported for r. aegyptiacus [ ] and a sedentary life history for r. aegyptiacus is also supported by the morphological record [ ] . in contrast, some e. helvum individuals migrate more than km [ ] , in some cases following the seasonal fluctuation in fruit abundance [ ] . thus, one study reported that that out of ( %) e. helvum ( %) were migratory, although % ( of ) were non-migratory [ ] . the median travel distance of the non-migratory bats was km (compared to km for the migratory bats) and similar to the observed daily commuting distances of r. aegyptiacus [ ] . based on available data and their own capture information, it was assumed that e. helvum has a core distribution in equatorial africa, with migrations in the northern direction, e.g., mauritania and niger from may to september and towards the south e.g., tanzania, zimbabwe and zambia during the months of october and december [ ] . thus, e. helvum from regions of africa north of the equator will generally migrate south in the autumn, away from europe. there is no evidence to suggest that the return migration routes in the spring would take the bats north of the sahara desert or that bats that might accidentally fly north (instead of south) in the autumn and reach europe. a review of data collected over years from banding of some one million bats within europe, provides information on which bats cross national borders [ ] . these data suggest there are a number of european bat species which migrate seasonally in the range of a few hundred kilometers and four species that are considered long distance migrants (regularly to km in one return flight). the migration routes are generally limited to europe, with the general trend from north-east to south-west europe. however, there are data showing movements of nyctalus noctula from russia into bulgaria [ ] and it is reported that pipistrellus nathusii killed in summer and autumn at german wind turbines originated from estonia or russia [ ] . an occurrence of vespertilio murinus on a north sea drilling rig confirmed that bats can fly across large bodies of sea [ ] . this raises the question of whether migration of bats from africa to europe can occur, for example, across the strait of gibraltar. there have been studies in relation to the genetic diversity in ibero-moroccan bats, but this does not address the frequency of vagrant african bats flying from morocco into southern europe. colonies of r. aegyptiacus, known hosts of marv, occur in cyprus and southern turkey. no banding studies have been done and existing knowledge is based on field observations in europe [ ] . in cyprus, no long distance flights are known, but seasonal altitudinal shifts have been observed [ ] , which could alter contact rates with other bat species. thus, despite the growing evidence on migration of bat species within europe, there are no data to suggest whether migration of bats into europe from niv or marv endemic areas (as outlined in figure ) could occur. a longer term risk factor is the gradual spatial creep of viruses due to transmission to previously uninfected species whose habitat spatially overlaps that of known infected species. for example p. vampyrus are known hosts of niv. they are not found outside of asia, according to iucn red list (see figure ), but have been reported in the shaanxi region of china, close to where m. daubentonii have also been recorded [ ] . m. daubentonii are also known to be present across europe and there is a report of henipavirus antibodies in three of four myotis bat species at a location in yunnan province, southern china in and . this included nine of m. daubentonii bats [ ] . although pteropid bats are not widespread in china, henipaviruses could be introduced to china by other susceptible bat species whose habitats and ranges overlap those of pteropid bats in neighbouring countries. this raises the question of whether henipaviruses could eventually emerge in european bats. however, there are a number of additional factors that may delay and/or prevent this from occurring, such as mountainous areas providing geographical barriers to interaction of neighbouring bat populations. indeed according to the iucn redlist the populations of m. daubentonii in china and europe are not contiguous. it would be interesting to know if bats in south-east asia migrate in a north-westerly direction to the same regions as those migrant european bat species to give a -virus cross-roads‖. the risk of eu bat infection with marv due to overlapping species populations is potentially higher than niv, due to shorter geographical distances, r. aegyptiacus are already present in some european countries where their range may overlap with some migratory european bat species, and the fact that some african fruit bat species (e.g., e. helvum) migrate large distances, although generally within the sub-saharan african continent [ ] . however, marv has not been isolated from any bats in cyprus or indeed northern africa, although there have been few published reports of attempts to find marv outside its normal range. additionally, marv has not been isolated from as many different bat species as henipaviruses, so the risk of virus transfer between species may be more limited. this may reflect the ubiquity of molecular receptors for henipaviruses among mammal species. there are a number of less obvious routes by which bat carcasses or products could enter europe. for example a bat strike on a long haul aircraft may result in the carcass of the bat being carried long distances across international boundaries. the remains of a bat were found in the wing flap of a boeing that had flown from heathrow (uk) to ben-gurion airport in israel [ ] . the plane had previously flown from ghana to london and pcr was used to identify the bat as having highest similarity with e. helvum. flying foxes and other bats were the animal species most often involved in aircraft strikes in australia between and with the majority of air strikes occurring at locations on the east coast of australia [ ] . for the year period ( - ) , strikes were reported to the united states federal aviation authority of which bats were involved in . % [ ] . this raises the question of what happens to the bat carcass remains and in particular how it is disposed of. in theory it could drop off the plane on coming into land at the destination airport as the carcass thaws or the wing flaps change position. this raises the possibility of the carcass being eaten by scavenging animals or even pet dogs or cats. accidental translocations of bats between land masses by ships or aircraft have also been known to occur, almost certainly with a far greater frequency than is actually reported [ ] . as some viruses such as coronaviruses can survive for long periods in water [ ] , bat guano or even dead bats transported in bilge waters of ships could, in theory, serve as route of transport of bat viruses around the world. another route, again involving aircraft, is where the bat is a stowaway either in the aircraft hold, or even the cabin itself. for example, in , a bat flew through the cabin of a commercial airliner minutes after takeoff during an early morning flight from wisconsin to georgia [ ] . the emergence of new viruses typically reflect change and combinations of events [ , ] . in this respect, anthropogenic changes, and in particularly globalization, are drivers. other changes including farming practice, environmental and climate change not only affect land use but also influence zoological and ecological factors including habitat and food supply. thus, over time, there may be changes in both the range and distribution of species and intensity and nature of species' interactions. climate change is associated with extreme weather events such as drought and flood. it is most likely to be linked to the geographical distribution of fruit bats through availability of food sources; the species p. nathusii has been observed to be adapting its range in response to recent climate changes [ , ] . this raises the question of how the range and population of fruit bats will change; ultimately, warming could convert forests to grassland savannas which are unsuitable habitats. a shift in the range of pteropid bats due to climate change could have an impact on the circulation of henipaviruses, by putting bats under stress [ ] . pteropus spp. may excrete viruses more often than usual in stressful situations such as when their food is destroyed by climatic events and extreme stress can result in immune suppression which can facilitate increased shedding of the virus [ ] . bats may also spread the virus between regions if they search for food in areas unaffected by flooding. additionally one study found a significant association with the dry season for spillover events [ ] . in this paper we have discussed factors that should be considered when assessing the risk of introduction of two bat-borne viruses, nipah virus and marburg virus, into the eu. the routes considered to pose a significant risk of introduction into europe include human travel, legal trade and illegal importation of bushmeat. a number of other potential routes should also be considered, including, bat strikes on aircraft and bat migration, although migration may not be significant as currently there is little evidence of significant migration pathways into europe. however, it is unclear whether the absence of knowledge of migration routes into the eu from the countries identified as having infection in bats from figure is because they do not exist or because their existence has not been comprehensively investigated. additionally, if niv or marv were to spread to areas on a european migration route, such as russia, then bat migration could become a greater risk. another, more long term risk for introduction to the eu could be transmission between bat species with overlapping distributions; r. aegyptiacus are hosts of marv and present in cyprus (although marv is not known to be present in bats in cyprus), where the range of this species may overlap with some migratory european bat species. it should also be noted that migration could pose a risk for other bat viruses which may be present on these migration routes. the two viruses discussed in this paper were chosen as they are not known to be present in eu bat populations, but published literature indicates their potential for causing large scale human outbreaks. there are many other bat-borne viruses of similar potential that we do not cover in detail here, but also require in depth consideration, such as ebola virus, hendra virus and mers-cov. at the time of writing there was limited and not conclusive evidence that mers-cov was a bat-borne virus [ , ] . while the risks of introduction of other bat borne zoonotic viruses should be considered on a case by case basis, there will likely be a degree of commonality with the factors and routes discussed in this paper, especially for viruses within the same family as marv or niv, namely filoviruses such as ebov and paramyxoviruses such as hev. while there is serological evidence of henipaviruses and filoviruses on multiple continents, the isolation of infectious virus in either bats or humans is currently limited to more confined geographical areas; niv in asia and marv in central africa. human infection of niv in particular is currently limited to bangladesh and west bengal in india. given the more widespread identification of niv amongst bat species and countries in asia, it is not clear why human outbreaks appear to be confined to this region. this could reflect the route of transmission, sensitivity of surveillance and also perhaps the greater titre of niv-bangladesh in bat saliva or urine compared to niv-malaysia [ ] . further knowledge of why these viruses do not currently seem to be spreading further, could help in assessing the risk of further spread, including the risk of reaching the eu. while a number of studies report high serological prevalence, actual virus infection in bats is rarely detected. this could explain why human spillover events of niv-bangladesh are fairly localised. p. giganteus roosts have been identified within km of villages in bangladesh and can consist of around individual bats [ ] , so even a low prevalence of infection within the roost can mean that there are still sufficient numbers of infected individuals able to contaminate local food sources such as date palm sap. in this paper we have discussed risks posed by bats, regarding entry of zoonotic viruses to eu, but the ecological importance of bats should also be recognized. insectivorous bats are responsible for controlling populations of other species considered to be pests such as mosquitoes and other insects, while fruit bats feed on nectar and pollen and so provide an important function as pollinators and/or seed dispersers [ ] . while the mass culling of pigs in malaysia undoubtedly helped to control the niv outbreak there, culling, or relocation, of wild bats could potentially increase levels of infection [ ] . for example, research in peru found that culling campaigns failed to reduce the seroprevalence of rabies among the studied vampire bat colonies [ ] . additionally culling of bats is considered by many to be unethical and methods are unavailable that comply with current standards of animal welfare. there are many alternative methods to help control virus disease, such as the use of bamboo skirts to prevent niv contamination of data palm sap in bangladesh [ , ] , limiting potential for indirect contact between livestock and bats at a local level, use of personal protective equipment by investigators dealing with suspect cases and a vaccine against hev in horses in australia [ , ] . this review identifies those routes which could provide a potential for introduction of niv and marv into the eu, but does not formally assess the risk associated with each route. for niv we have shown that, of the eu mss, the uk has the highest volume of relevant human travel (figure ), but the netherlands has the highest volume of relevant trade (figure ) , suggesting that the most probable route for introduction may vary between eu mss. however, to formally assess this it will be important to also take into account virus specific factors such as prevalence, titre and survival and ms specific factors such as border inspections or controls. therefore, it would be preferential to develop a quantitative risk assessment (qra), which would require large amounts of data. this review suggests that while data may be lacking to fully assess the risk for routes such as bushmeat, or indeed any other illegal activity, there are sufficient data available to assess legal routes such as volume of trade and human travel. in general, we found no evidence to suggest that the risk of niv release to the uk has changed from that reported in a previous qualitative risk assessment [ ] . reported human cases of niv continue to be limited to bangladesh and an increase in the number of those cases may be due to enhanced awareness and surveillance. a number of human cases of marv have been reported in uganda recently, but again this could be attributed to better surveillance. while there is evidence to suggest henipavirus infection of m. daubentonii in china and the presence of r. aegyptiacus in the eu country of cyprus, these are not sufficient factors on their own to warrant undue concern. however, it should be noted that there is a lack of research and surveillance in this area and the evidence for absence of niv or marv in bats present in the eu is limited. human migration patterns continue to change across some areas of the eu, suggesting the frequency of human travel to niv or marv areas and corresponding illegal imports of products such as bushmeat may change. this could increase the probability of a -rare event‖ occurring, such as importation of a bushmeat sample contaminated with virus and, as has been observed in the past, a single introduction event can be enough to cause an outbreak of disease in humans. a better understanding of surveillance sensitivity and biases in reporting, and further investigations of the presence and prevalence of these viruses in both bats and humans should be carried out, as high uncertainty remains about the risks associated with these diseases and how best to prevent or limit the risk of an introduction event. this work was funded by the european union fp project antigone (anticipating global onset of novel epidemics ) and the uk department for environment, food and rural affairs (defra) project se . the authors would also like to thank trevor drew and 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disease emergence: the past, present, and future drivers of nipah virus emergence the effect of bat (rousettus aegyptiacus) dispersal on seed-germination in eastern mediterranean habitats flying foxes carrying hendra virus in queensland pose a potential problem for other states ecological and anthropogenic drivers of rabies exposure in vampire bats: implications for transmission and control piloting the use of indigenous methods to prevent nipah virus infection by interrupting bats' access to date palm sap in bangladesh guidelines for veterinarians handling potential hendra virus infection in horses the authors declare no conflict of interest. key: cord- -o ig sde authors: rahman, md mostafizur; bodrud-doza, md; griffiths, mark d; mamun, mohammed a title: biomedical waste amid covid- : perspectives from bangladesh date: - - journal: the lancet. global health doi: . /s - x( ) - sha: doc_id: cord_uid: o ig sde nan bangladesh was already struggling with poor medical waste management before the covid- pandemic and has now been hit hard by a sudden increase in the volume of medical waste. in bangladesh, there are around government hospitals and private hospitals and clinics with beds in total, along with an additional diagnostic centre beds, all of which lead to the generation of huge amounts of biomedical waste. the average medical waste generation rate is · - · kg per bed per day in dhaka, the capital of bangladesh. in april , at least tonnes of waste from health care was generated across the country because of covid- , which has undoubtedly increased due to the increasing infection rate. also, on average, tonnes of medical waste are produced because of covid- per day in dhaka alone. this poorly managed waste poses a large environmental threat and might create a prolonged and unwanted public health hazard and be a potential source of re-emerging infection. in bangladesh, despite the introduction of the medical waste management and processing rules in , no safe system has yet been developed to manage the health-care waste generated daily in hospitals, clinics, and households. waste generated inside bangladeshi hospitals is often collected without any separation by untrained, unprotected, and unaware cleaners, and disposed of in unauthorised places without any separation or proper treatment. approximately informal waste collectors working across the country are at high risk of getting infected by sars-cov- because they work without adequate protection. there might be a serious risk of spreading sars-cov- if used masks, gloves, and other personal protective equipment are not managed and disposed of properly. additionally, household waste (eg, tissues, masks, gloves) puts waste management workers at increased health risk. in bangladesh, hospital waste is mainly managed by city corporations, third-party organisations, and nongovernmental organisations. however, the capacities of these stakeholders do not comply with the requirements of a proper, environmentally safe medical waste disposal mechanism. a policy-level paradigm shift into a strategic, state-of-the-art medical waste management system is required. failing to tackle the huge surge in medical waste amid covid- is likely to put bangladesh at further environmental and public health risk. poor medical waste management will increase infections reverse logistics network design for effective management of medical waste in epidemic outbreaks: insights from the coronavirus disease (covid- ) outbreak in wuhan (china) survey on quantitative and qualitative assessment of medical waste generation and management in dhaka north city corporation and dhaka south city corporation world environment day: medical waste prolonging covid- , threatening biodiversity · tonnes of covid- wastes produced in dhaka a day: study. the business standard medical waste management (mwm) in dhaka, bangladesh: it's a review covid- : , tons waste generated, waste collector halved in a month we declare no competing interests. a bangla translation of this correspondence is available in the appendix. we thank ismail hosen, firoj al mamun, and mehedee hasan, research fellows at the key: cord- -hhmd ilk authors: islam, abu reza md. towfiqul; hasanuzzaman, md.; shammi, mashura; salam, roquia; bodrud-doza, md.; rahman, md. mostafizur; mannan, md. abdul; huq, saleemul title: are meteorological factors enhancing covid- transmission in bangladesh? novel findings from a compound poisson generalized linear modeling approach date: - - journal: environ sci pollut res int doi: . /s - - - sha: doc_id: cord_uid: hhmd ilk novel coronavirus (sars-cov- ) causing covid- disease has arisen to be a pandemic. since there is a close association between other viral infection cases by epidemics and environmental factors, this study intends to unveil meteorological effects on the outbreak of covid- across eight divisions of bangladesh from march to april . a compound poisson generalized linear modeling (cpglm), along with a monte-carlo method and random forest (rf) model, was employed to explore how meteorological factors affecting the covid- transmission in bangladesh. results showed that subtropical climate (mean temperature about . °c, mean relative humidity (mrh) %, and rainfall approximately mm) enhanced covd- onset. the cpglm model revealed that every mm increase in rainfall elevated by . % ( % ci . %, − . %) covid- cases, while an increase of °c of diurnal temperature (tdn) declined the confirmed cases by − . % ( % ci . %, − . %) on the lag and lag , respectively. in addition, nrh and mrh had the highest increase ( . % ( % ci . %, . %) and . % ( % ci: . %, . %)) of covid- cased in lag . the results of the rf model indicated that tdn and ah (absolute humidity) influence the covid- cases most. in the dhaka division, mrh is the most vital meteorological factor that affects covid- deaths. this study indicates the humidity and rainfall are crucial factors affecting the covid- case, which is contrary to many previous studies in other countries. these outcomes can have policy formulation for the suppression of the covid- outbreak in bangladesh. novel coronavirus (sars-cov- ) causing covid- disease has arisen to be a pandemic and a dangerous component in strategic planning, critical policymaking, and time-worthy decisions in public health sectors worldwide. one of the significant challenges fighting against the covid- virus was to understand the infective agent and its environmental behavior effectively. climatological and atmospheric factors are the crucial considerations that might have influenced the tendencies of respiratory infectious diseases leading to epidemics wu et al. ) . however, the consequence of meteorological variables on covid- remains debatable (wu et al. ) . for illustration, countries in temperate regions, epidemic peak timing, and intensity precision exceed % at and weeks before the forecasted epidemic peak, respectively, whereas the tropics and subtropics, epidemic forecasts are significantly less accurate for both peak timing and intensity (kramer and shaman ) . seasonally and spatially, the surges of influenza rise during the monsoon season in tropical climates, while during the dry and cold months of winter in temperate climates (peci et al. ) . low humidity and temperature enhance many types of flu virus transmission; its impact on mortality remains unclear (kudo et al. ) . a study on influenza viruses revealed that humidity was found to be a controlling factor. for example, in temperate areas of the world, the seasonality of influenza virus attack along with the survival of the virus is strongly related to the decline in humidity (barreca and shimshack ; kudo et al. ) . a recent study reported that absolute humidity (ah) is more significant than relative humidity (rh) in regulating observed climate patterns (marr et al. ) . ah was a critical factor of observed influenza mortality, even after governing for temperature. temperature modestly affected influenza mortality as well, although outcomes were less robust (barreca and shimshack ) . the blending of temperature and rh is likewise acceptable as ah as a predictor, as upper levels of ah are only potential at elevated temperatures. at elevated temperatures, it is established that virus decline is swifter. in climatological data, outside ah substitutes for inside rh in temperate climate regions during the winter period (marr et al. ) . furthermore, recently, the influenza epidemic might be associated with environmental air pollution and low temperature, and the outcome is an excess of mortality in milan, italy (murtas and russo ) . likewise, in temperate regions, the risk of influenza frequency was significantly heightened with low daily temperatures of - °c and low ( - %) or high ( %) rh. a strong correlation between diurnal temperature and influenza incidence was found in south korea (park et al. ) . from the chinese study, it shows that both low ah and high ah are the reasons for other viral diseases such as pneumonia and influenza-related deaths among the elderly (qi et al. a) . studies related to covid- deaths and the relationship among meteorological and environmental factors are increasing, and at the same time, are crucial. several cited works have been found concerning covid- infection, mortality, and environmental factors. for instance, wu et al. ( ) stated that the temperature and rh were both negatively associated with daily new cases and mortality. a °c increase in temperature and a % increase in rh is related to . % death rate reduction and . % reduction of daily new cases of covid- infection (wu et al. ) . qi et al. ( b) used the generalized additive model (gam) to compute the province-specific relations among climatological factors and daily cases of covid- in china. the study found that temperature and humidity presented negative associations with covid- , while a significant association between temperature and humidity existed. temperate countries and regions with low humidity should be taken more considerate (qi et al. b) . ma et al. ( ) established a daily number of covid- death with meteorological variables and air pollutant datasets in wuhan, china, which was the starting point of the global pandemic. another study conducted by from cities across china, established the epidemiological and experimental research on ambient temperature and covid- infectious disease. surrounding temperature is an essential factor affecting the transmission and survival of coronavirus (zhu and xie ) . the mechanisms by which meteorological factors increase the rates of covid- confirmed cases are still overlooked. based on the available literature, it can be said that the concrete conclusion is yet to be drawn on the potential role of meteorological factors on covid- worldwide. therefore, it warrants more research on this topic in different regions of the world, including bangladesh. bangladesh is a subtropical country of high population density that ranks th in the world and a climatevulnerable country in the world (bodrud-doza et al. ; shammi et al. a ). the first covid- infection case was reported in bangladesh on march , (iedcr ; shammi et al. b) . from then on september , , the confirmed cases of infection and deaths are increasing exponentially (fig. ) . however, we do not know the potential impacts of meteorological factors on the disease transmission and mortality in this country. thus, the objectives of the current study were to investigate the effects of meteorological factors on covid- confirmed cases and deaths in bangladesh using compound poisson generalized linear modeling (cpglm), a unique approach across the eight divisions of bangladesh along with the monte-carlo method and random forest (rf) model. the findings will add some unique insights into the possible correlations between the covid- and meteorological factors. the uniqueness of the study is the first report from bangladesh on the potential relationships between meteorological factors and covid- confirmed cases. bangladesh is a low-lying riverine deltaic country that is positioned in south asia ). most of the land surface (about %) is a floodplain, except for some parts in the northeastern and southeastern portions (hills, hillocks). bangladesh experiences a subtropical monsoon humid climate with distinct spatial variation . three main seasons prevail in this country that are the pre-monsoon, monsoon, and post-monsoon. the monsoon is a crucial driver of climatic variability in bangladesh (rahman and islam ) . most of the precipitation (more than %) occurred in this season. the average maximum, minimum temperatures, and relative humidity over the nation are . °c, . °c, and %, respectively. the spatial distribution of the number of covid- cases (at district level) up to september , where there are now more than , covid- cases in bangladesh (fig. ) . bangladesh meteorological department (bmd) has weather stations across the country. the daily minimum temperature (t min ) (°c), maximum temperature (t max ) (°c), day relative humidity (drh) (%), night relative humidity (nrh) (%), and rainfall (mm) datasets of stations from march to april , were collected from bmd . diurnal temperature (tdn) (°c) and mean temperature (mt) were calculated from t min to t max . mean relative humidity (%) (mrh) was also derived from day and night relative humidity (%). there were no missing data in the climatic datasets of march and april data ( ). at first, stations meteorological data were collected from bmd. then, these aggregated station-wise datasets were demarcated into eight divisional cities in this work. finally, divisional city data were averaged and used for further analysis. data on daily confirmed and mortality cases from covid- in march and april across bangladesh, which can be found in the following link: https://corona.gov.bd. until april , , the confirmed cases were , and deaths were (iedcr ). weather variable data of bangladesh in the study period were collected from bmd in the official site: https://bmd.gov.bd. calculation procedure of absolute humidity ah can be calculated from several formulas. one of them, the absolute humidity is estimated by the eq. ( ) (snyder ) : where ah is the absolute humidity (g/m ), e is vapor pressure (kpa), and t mean is the mean temperature (°c). the detailed procedure of calculating vapor pressure can be found in the paper of snyder ( ) . we employed the compound poisson generalized linear model (cpglms) for exploring the relationship between daily meteorological variables (tdn, mt, nhr, mrh, ah, and rainfall), and daily confirmed cases from covid- across bangladesh from march to april , . first, meteorological variables were not considered during model development. most of the time-series data have continuous variables with exactly zero. to resolve this problem, a special form of the poisson distribution should be implemented where the response is assumed to be generated as a random sum of individual random variables with positive support. compound poisson distribution, a mixture probability model takes this advantage to degenerate and continuous distribution found in the origin and positive real line, respectively. it is effective in which continuous data with exact zeros regularly arise. it handles effectively hierarchical structures or extra zero inflation. it is also a robust tool for the zero-inflated model (zhang ) . the cpglm function was established from the core model which was proposed by jørgensen ( ) in the following eq. ( ): in the model, pois () symbolizes a poisson random variable with mean, and ga (,) symbolizes a gamma random parameter with mean and variance equal to and, respectively. x i is the identically distributed random variable. here, if t = then y = thereby allowing the distribution to have a probability mass at the origin. when t > , the response parameter y is the sum of t i.i.d gamma random parameters, implying that y l t ga (,). in this study, covid- confirmed cases set as the response parameter and all other weather parameters (tdn, mt, nrh, mrh, ah, and rainfall) were counted as independent parameters. to visualize, the lag-wise effect of climatic variables on covid- confirmed cases after developing the core model and then evaluated the probable lagged effects. in this case, we choose days in lag for single lag days (lag , days - ; lag , - ; lag , - ; lag , - ; lag , - ; and lag , - ) and cumulative days were selected in multiple-day lag (lag - ; lag , days - ; lag , - ; lag , - ; lag , - ; and lag , - ; march to april in calendar time). we removed lag (days - ) in multiple days which represents a single -ay lag. both studies considered the lag from march as before this date no mortality case was reported for considering lag days. this cpglm analysis was performed in r (version . . ) with 'cplm' (version . - ) package (zhang ) . up to . was considered statistically significant. the effect was denoted as the slope changes and the coefficients of % significance levels of daily covid- confirmed cases are in association with the climatic variables per -unit increase. breiman ( ) proposed the tree-based machine learning random forest (rf) model. it is applied for both predicting and regression problems. it is simple, as well as a robust model. rf model has been benefited from the two more powerful algorithms: bagging and random, which are called the powerhouse of this model. for developing the rf model number of trees and features in each split is essential. rf is a classifier, which comprises of an assortment of classifier trees f m (x) for m = , ……., m which relies on the parameters and every single tree casts a unit vote for input x. each tree generates an individual class, which then combined and the majority vote predicts the final results (pavey et al. ). the rf model has been benefited from two more powerful algorithms: bagging and random, which are called the powerhouse of this model and combining with arcing. this model is robust for avoiding outliers alone with noise. the present study optimized its accuracy with trees, execution slot, seeds, and with maximum depth . this model was performed for this study by using the package of 'randomforest' within the free r statistical software. several models exist, for instance, principal component analysis, which is used extensively for assessing the importance degree for the respective purposes. but now, scholars prefer machine learning algorithms of rf model for assessing the importance degree mainly in the fields of climate, hydrology, environment, etc. (rahman and islam ; salam and islam ; saha et al. ) . in this study, a rf model was used followed by rahman an islam et al. ( ) , salam and islam ( ) , saha et al. ( ) , islam et al. ( b) to explore the importance degree of climatic variables influencing covid- mortality cases across eight major divisional cities of bangladesh. monte-carlo simulation refers to the method by which the percentage of risks can be represented by histograms (cullen ) . this is the most used model for identifying the contribution of risks on a particular factor. this analysis was based on the following eq. ( ) (Ökten ) : where x j denotes the jth elements of the solution vector; h is the n × n matrix in jth element (e.g., h ji , h ji ) and b i is an ndimensional vector satisfying condition. generally, the monte-carlo method can be summarized as below: (a) creating many random variables for each stochastic input; (b) according to a special statistical distribution, these random variables could be transformed into the associated random variates; (c) storing the obtained stochastic variates in an array for each variable; (d) each variable would create a value, which is used as a deterministic input in the computation formula of the meteorological variable; (e) computing the meteorological variables based on a numerical model for each monte-carlo run; (f) the outputs of the meteorological variables would be stored; (g) repeating steps (a)-(f) for detailed monte-carlo run; and (h) analyzing the computation outcomes. monte-carlo simulation is a robust tool to solve the randomness and uncertainty within model operations. a more detailed description of this model can be found in the paper of Ökten ( ) . this study adopted this model for exploring the contribution percentage of climatic variables on the covid- outbreak in bangladesh. table reveals the statistical summary of daily detected cases of the covid- pandemic and meteorological variables in bangladesh. a total of confirmed cases and deaths were recorded during this study period (march -april ) with an average of . ± . and . ± . , respectively (iedcr ). with the increasing rate of covid- testing, the confirmed cases have also been increased over time. in this study, maximum (t max ) and minimum (t min ) temperatures ranged from . to . °c and . - . °c with their average of . ± . °c and . ± . °c respectively. tdn (diurnal temperature) had an average . ± . °c ( . - . °c) where the mean temperature (mt) was . ± . °c ( . °c - . °c). the relative humidity day (drh) and night (nrh) period had an average of ± . % and . ± . %, respectively. however, the mean relative humidity (mrh) and ah ranged between . and . % and . - . g/m , respectively. apart from this, rainfall had an average of ± mm ( . - . mm) during the study period. figure shows the temporal distribution of covid- daily confirmed cases and meteorological variables in bangladesh during the investigation period, demonstrating the confirmed cases/day of covid- distributed in a similar pattern with nrh, mrh, ah, and rainfall, except for tdn and mt, where both variables showed an irregular pattern with the daily confirmed cases of the covid- in bangladesh. figure reveals the temporal variations of meteorological factors at different eight divisions in bangladesh. the tdn had the highest change in sylhet ( °c) followed by the lowest in barishal division ( °c). rajshahi and rangpur have substantial regional differences as . °c and . °c, respectively. alternatively, the largest and lowest mt value was found in dhaka ( . °c) and rangpur ( . °c), respectively, where the most considerable differences were found in dhaka divisional city ( . - . °c). in humidity, nrh and ah both cases, the highest and lowest values were found in barishal ( . % and . g/m ) and sylhet ( . % and . g/ m ), respectively. the highest range value was found for nrh and ah in rangpur ( . - . %) and barishal ( . - . g/ m ), respectively. in mrh, the highest value and range were observed in the rangpur division ( . % and . - . %), where the lowest value was in dhaka ( %). in the rainfall variables, many outliers were detected in rajshahi, rangpur, khulna, and barishal divisions. the lowest rainfall was observed at the rajshahi division ( mm), whilethe highest rainfall was distributed at barishal division ( . mm). covid- mortality with variability in meteorological factors using cpglm modeling figure shows the slope changes of covid- confirmed counts per -unit elevation in climatic factors with various lags ( - ) using the cpglms modeling. in single lag, both per unit raise in all factors such as mt, nrh, mrh, ah, and rainfall, except for tdn were connected to increased covid- confirmed cases in lag , with the highest increase ( . % ( % ci . %, − . %); . % ( % ci . %, − . %); . % (ci . %, − . %); . % ( % ci . %, − . %); and . % ( % ci . %, − . %)] respectively. as for tdn each °c increase was associated with a . % ( % ci . %, − . %) rise in covid- confirmed counts in only lag . in contrast, in the case of multiple lags, each unit increase in mt and ah was the highest association with . % ( % ci . %, . %) and . % ( % ci . %, . %) enhancement in the covid- confirmed counts in both lag (fig. ) . a mm increase in rainfall raised by . % ( % ci . %, − . %) covid- confirmed cases while an increase of °c of tdn declined the confirmed cases by − . % ( % ci . %, − . %) on the lag and lag , respectively. nrh and mrh had the highest increase ( . % ( % ci . %, . %) and . % ( % ci . %, . %)) of covid- cased in lag . the monte-carlo simulation method was used to identify the most influential meteorological variables that affect covid- confirmed cases of count and contribute most to the total covid- mortality cases over bangladesh (fig. ) . the results indicated that among the nine climatic variables, the most driving variable was nrh, which had a score of . . the second and third most influential variables were the mrh, and drh, which had a score of . and . , respectively. the other meteorological variables such as rainfall, absolute ah, mt, tdn, t min , and t max had less than . score, which was comparatively non-significant. to perform the significance degree analysis for the contributing meteorological factors, rf tool was applied. it assisted for determining the order of contribution status of several climatic multiple modes exist. the smallest value is shown fig. the association of slope changes between covid- daily confirmed cases with -unit increase in meteorological factors for the effects of singlelag days based on the cpglm models across bangladesh at % confidence interval variables affecting the covid- mortality cases based on the rfm model in divisions across bangladesh (fig. ) . the yellow and light green columns of the histogram showing the tdn and ah, respectively. tdn and ah found as the highest contributing variables, indicating that these two variables influence the covid- cases most in divisions of mymensingh, rangpur, sylhet, barishal, and chattogram (table and fig. ) . table depicts that among the eight divisions of bangladesh, three divisions show tdn and three divisions represent ah as the highest contributing factor. ah comprised almost . % of divisions, which were identified mostly in northeastern (mymensingh), followed by northern (rangpur) and southwestern coastal climatic regions (khulna). in addition, tdn consisted of nearly . % of the fig. the association of slope changes between covid- daily confirmed cases with -unit increase in meteorological factors for the effects of multiple-lag days based on the cpglm models across bangladesh at % confidence interval fig. contribution percentage of meteorological factors on covid- outbreak in bangladesh using monte-carlo simulation total area, which was detected mainly in the eastern (sylhet), followed by southcentral (barishal) and southeastern (chattogram) . mrh was to be found as the second-highest contributing variable affecting % of the total covid- mortality cases distributed mostly in northeastern regions (mymensingh), eastern (sylhet), southcentral (barishal), and southwestern (khulna) of bangladesh (fig. ) . it is observed that mt and rainfall are the lowest contributing variables in fig. bar diagram in the map shows the importance degree of climatic variables on covid- confirm cases in eight division of bangladesh from march , to april , affecting the daily mortality cases. in the dhaka division, mrh is the most vital factor that affects covid- deaths. therefore, the results imply that ah, tdn, and mrh are the key contributing climatic variables for daily covid- cases across bangladesh. the role of mt and rh in day-to-day new infections and case fatalities due to covid- should be dealt with many other possible and unprecedented controlling factors which are not yet established. for instance, the potential factors such as wind (speed and direction), national population age groupings, the density of population, and global indices (global health security index; ghsi, and human development index; hdi) should be considered the confounding factors for the covid- transmission (wu et al. ) . meteorological factors such as humidity, temperature, and rainfall are critical drivers for controlling infectious diseases in different parts of the world (sahin ; islam et al. c) . for example, elevated temperatures may prevent the outbreak of droplets that transmit coronavirus, likely via rapid evaporation. simultaneously, other factors like humidity may enhance the covid- survival time in atmosphere possibly also influence the infection rate, which is shown in fig. . these outcomes can be considered with caution. previous studies indicate that humidity affects the infection rates of covid- outbreak (oliveiros et al. ; wu et al. ; demongeot et al. ; wang et al. ) . it is unknown whether increases in seasonal temperatures will decrease the rate, which deserves further investigation. in fact, to date, role of environmental factors in the transmission of covid- is not established. concrete and evidenced-based proofs are needed to be explored, besides the probabilistic determination methods could help to obtain potential clues. we run a cpglm, permitting us for parameters specific to the contagious sars-cov perspectives (imai et al. ) . however, these drivers may behave differently for the daily mortality cases due to infectious diseases in different climatic zones as well as socio-demographic settings. for example, in tropical brazil, high mean temperature and intermediate rh may be responsible for the covid- outbreak (auler et al. ) , and the current disease situation in this country is the worst with severe death tolls. in turkey, the key weather factors might control the spread of covid- is considered temperature (°c), dew point (°c), humidity (%), and wind speed (mph). due to variant incubation periods of covid- ( to days), spearman's correlation coefficients revealed that wind speed and temperature had a direct relationship with covid- cases in turkey (sahin ). ma et al. ( ) reported that rh had a reverse association with covid- mortality cases/day (r = − . ), with the highest reduction in lag (− . % ( % ci − . %, − . %). another study stated that every % rise in rh, confirmed cases/days of covid- lowered by . % (with the ci %, . %, . %), and mortality/day lowered by . % ( % ci . %, . %) in the countries (wu et al. ). contrary to these cited works, our result found that in the single-lag days, every % rise in mean rh, confirmed case/ day of the covid- raised by . % (ci . %, − . %) in bangladesh. similarly, every mm increase in rainfall elevated by . % ( % ci . %, − . %) covid- cases in lags and . the conflicting outcomes may be due to their studies were conducted at the global scale, and the temperature and humidity ranges were large and different climatic and geographic settings. however, in either case, more studies are warranted to draw a precise conclusion to assure the contribution of meteorological impacts on covid- cases. a recent study in china stated that daily covid- cases elevated by . % for every °c increase in mt (zhu and xie ) when the mt was fallen °c. this result echoes our outcomes. each °c increase in mt was corroborated with the elevated covid- confirmed cases in lag , with the highest growth of . % ( % ci . %, − . %), but it should be kept in mind that this increased transmission majorly comes from contact and community media. ma et al. ( ) explored the daily mortality of covid- in wuhan, china. they found that diurnal temperature ranges had a significant positive association with daily covid- mortality, which is in disagreement with our study. however, this result was unstable because the temperature was associated with a decline in covid- mortality in lags and . the other reason is that they may be used in the various characteristics of the participants and multiple methods (prata et al. ) . the probable elucidation of our results is that meteorological factors such as temperature, humidity, and rainfall are critical factors in living conditions that play a vital role in the status of human health according to pandemic induction and prevention (mcmichael et al. ; salam et al. ) . a set of definite meteorological factors that suitable fits favor coronavirus and that specific climatic variables like humidity contribute to the outbreak because it exists when the susceptibility rises. it clearly indicates about the virus particle survival state under variant meteorological conditions rather than direct transmission. therefore, the onset of summer can be favorable to enhance the spread out of the covid- cases. our findings accord with those published cited reported worldwide, exhibiting how the number of confirmed cases increases above °c and linearly increased afterward. several studies have stated that the virus (sars-cov- ) is sensitive to temperature and humidity (luo et al. ; ma et al. ; sajadi et al. ; liu et al. ; benvenuto et al. ; tobías and molina ) . moreover, a recent study by benvenuto et al. ( ) showed that the variability of sars-cov- was similar to that of sars-cov under different experimental settings. chan et al. ( ) showed that the temperature up to °c and relative humidity of more than %, dried out sars-cov could survive for more than week on smooth surfaces. however, the stability of sars-cov increased when the relative humidity and rainfall increased. the sars-cov- might be more stable at high-rainfall and high-humid conditions. the moisture in the bioaerosols evaporates quickly in high relative humidity, creating a tiny droplet in the air for a long time, thereby enhancing the probability of pathogen outbreak (tellier ) . however, our immunity system is not compromised in high-humidity systems (oliveiros et al. ) . thus, the human body is at an elevated risk of infection by viruses in high-temperature, high-rainfall, and high-humid conditions. in this study, the change in daily covid- cases has a strong association with ah and rh, which move southward to increase easterlies. our findings showed that the overall covid- pandemic in bangladesh can be affected by the change of humidity mostly. many studies have reported that temperature and relative humidity are the most contributing climatic variables influencing covid- cases in other countries shi et al. ) . this study also is confirmed that five meteorological variables included, where ah and dt are the most contributing factor, and the rh is the second-highest influencing factor in the variability of daily covid- cases. ma et al. ( ) found that a positive association is found between daily death counts of covid- and tdn. contrary to our study, zhu and xie ( ) reported that case counts of covid- could decline when the weather becomes warmer when the temperature is above °c. the possible key meteorological driver of the covid- mortality cases in bangladesh might be the ah and rh as well as other climatic factors such as tdn, mt, and rainfall (oliveiros et al. ; qi et al. b; shi et al. ; wu et al. ; zhu and xie ) . the rf model showed that mt and rainfall are the lowest contributing factors affecting the daily mortality cases in bangladesh. in the dhaka division, mrh is the most vital factor that affects covid- deaths. the findings of wu et al. ( ) provided preliminary insights for the potential association between the virus and the climatic parameters. whatever is the association being, there is no alternative to control the infections, transmissions, and therefore spread of covid- . a possible mechanism of particulate matter pm concentration upon covid- diseases was evaluated in italy, considering the airborne virus diffusion based on pm as a vector. covid- infection cases can influence the association between air pollutants and humaninduced aerosols. however, direct correlations between the presence of high quantities of pm and the diffusion of the covid- virus were not evident (bontempi ) . though our study gives a strong clue to meteorological factors that might have an association with covid- confirmed cases and mortality, the following limitations are observed. first, other variables such as environmental pollutants, air quality, and uv radiations must perform a comprehensive study of covid- infectious disease. second, the association of pm . , air pollutants, and human-induced aerosols may be influenced by the covid- infection cases. next, many parameters including immunity, social and physical distancing, nutritional status, and accessibility of healthcare facilities affect the covid- cases/mortality (shammi et al. a (shammi et al. , b . this study did not consider socioeconomic factors such as population movement and population density. finally, epidemiological data should be dealt with more cautiously and systematically to differentiate the number of infected cases and local death rates require to be deserved in further investigation. in the entire bangladesh, air quality index, along with other factors, should be considered to risk assessment on daily new cases of infections and mortality. policymakers should think about the meteorological variables, especially ah and rh along with environmental factors such as air pollution for taking necessary measures to manage and prevent new infections. we found that the confirmed cases of covid- were distributed in a similar pattern with meteorological factors such as nrh, mrh, ah, and rainfall except for tdn and mt, where both the factors showed an irregular pattern with the daily confirmed cases of the covid- in bangladesh. the result also disclosed that both per unit increase in nrh, mrh, ah, and rainfall were related to the increased covid- confirmed cases in lag , with the highest increase ( . % ( % ci . %, − . %); . % (ci . %, − . %); . % ( % ci . %, − . %); and . % ( % ci . %, − . %)) respectively. in contrast, in the case of multiple lags, nrh and mrh had the highest increase ( . % ( % ci . %, . %) and . % ( % ci . %, . %)) of covid- cased in lag while mm increase in rainfall elevated by . % ( % ci . %, − . %) covid- infections on lag and lag respectively. the humidity (nrh, mrh, drh) and rainfall are the most influential meteorological factors to the covid- cases. in the dhaka division, the mean relative humidity is the most vital factor that affects covid- cases. the outcomes of the rf model demonstrated that the humidity and diurnal temperature are vital factors influencing the covid- confirmed cases. as infection cases are still rising in bangladesh, this study recommends that sectoral policies, actions, and preventive measures should be implemented considering the environmental factors to reduce transmission and strengthen the healthcare system in bangladesh. the government will not capable to alleviate this worse situation alone, specific efforts from the people, active participation of the country's healthcare specialists, and international aid are immediately required. evidence that high temperatures and intermediate relative humidity might favor the spread of covid- in tropical climate: a case study for the most affected brazilian cities absolute humidity, temperature, and influenza mortality: years of county-level evidence from the united states the -new coronavirus epidemic: evidence for virus evolution psychosocial and socio-economic crisis in bangladesh due to covid- pandemic: a perception-based assessment first data analysis about possible covid- virus airborne diffusion due to air particulate matter (pm): the case of lombardy (italy) random forests the effects of temperature and relative humidity on the viability of the sars coronavirus monte carlo simulation for quantitative health risk analysis. wiley encyclopedia of operations research and management science demongeot j, flet-berliac y, seligmann h ( ) temperature decreases spread parameters of the new covidd- case dynamics time series regression model for infectious disease and weather disease control and research (iedcr) ( ) covid- status bangladesh assessing recent impacts of climate change on design water requirement of boro rice season in bangladesh spatiotemporal trends in the frequency of daily rainfall in bangladesh during - 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qvvkvk authors: shammi, mashura; bodrud-doza, md.; islam, abu reza md. towfiqul; rahman, md. mostafizur title: strategic assessment of covid- pandemic in bangladesh: comparative lockdown scenario analysis, public perception, and management for sustainability date: - - journal: environ dev sustain doi: . /s - - -y sha: doc_id: cord_uid: qvvkvk abstract: community transmission of covid- is happening in bangladesh—the country which did not have a noteworthy health policy and legislative structures to combat a pandemic like covid- . early strategic planning and groundwork for evolving and established challenges are crucial to assemble resources and react in an appropriate timely manner. this article, therefore, focuses on the public perception of comparative lockdown scenario analysis and how they may affect the sustainable development goals (sdgs) and the strategic management regime of covid- pandemic in bangladesh socio-economically as well as the implications of the withdrawal of partial lockdown plan. scenario-based public perceptions were collected via a purposive sampling survey method through a questionnaire. datasets were analysed through a set of statistical techniques including classical test theory, principal component analysis, hierarchical cluster analysis, pearson’s correlation matrix and linear regression analysis. there were good associations among the lockdown scenarios and response strategies to be formulated. scenario describes how the death and infection rate will increase if the bangladesh government withdraws the existing partial lockdown. scenario outlines that limited people’s movement will enable low-level community transmission of covid- with the infection and death rate will increase slowly (r = . , p < . ). moreover, there will be less supply of necessities of daily use with a price hike (r = . , p < . ). in scenario , full lockdown will reduce community transmission and death from covid- (r = . , p < . ). however, along with the other problems gender discrimination and gender-based violence will increase rapidly (r = . , p < . ). due to full lockdown, the formal and informal business, economy, and education sector will be hampered severely (r = . ). subsequently, there was a strong association between the loss of livelihood and the unemployment rate which will increase due to business shutdown (p < . ). this will lead to the severe sufferings of poor and vulnerable communities in both urban and rural areas (p < . ). all these will further aggravate the humanitarian needs of the most vulnerable groups in the country in the coming months to be followed which will undoubtedly affect the bangladesh targets to achieve the sdgs of and other development plans that need to be adjusted. from our analysis, it was apparent that maintaining partial lockdown with business and economic activities with social distancing and public health guidelines is the best strategy to maintain. however, as the government withdrew the partial lockdown, inclusive and transparent risk communication towards the public should be followed. recovery and strengthening of the health sector, economy, industry, agriculture, and food security should be focused on under the “new normal standard of life” following health guidelines and social distancing. proper response plans and strategic management are necessary for the sustainability of the nation. graphic abstract: [image: see text] electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. performed is , which is tests/ million (iecdr ; worldometer ) . the number is one of the lowest in the world (table ) . it is predictable that during a pandemic, a humanitarian crisis may arise in a developing country like bangladesh. in most incidents, it will be the combined effects of a variety of shortages that will likely culminate in the worst outcomes (truog et al. ). this can lead to a shortage of basic needs including foods, goods, and services such as job loss, economic and financial loss, food insecurity, famine, social conflicts, and deaths. besides, an impact on the psychosocial and socio-economic and health and well-being of the citizens may be affected which we had shown in our previous study . while predicting all the subsequent impact of the covid- pandemic is challenging, early strategic planning and groundwork for the evolving and established challenges will be crucial to assemble resources and react in an appropriate timely manner. moreover, as the gob has lifted the lockdown without flattening the curve of the pandemic what should be the socio-economic management strategy for the government at this stage. this article, therefore, focuses on the public perception of comparative lockdown scenario analysis and the strategic management regime of covid- pandemic in bangladesh. as there is no such prediction on how long the situation prevails, the absence/lack of management strategy for an epidemiological and socio-economic emergency response might be a tool to assess the forthcoming situation under a set of specific scenarios. therefore, the objective of this study is to analyse long-term strategic management of the pandemic in three different lengths of scenarios in a resource-limited setting of the so-called lockdown of the country. the outcome can play a crucial role to formulate emergency response strategy to tackle the covid- considering the impact of current socio-economic lockdown for flattening the curve of covid- infection in bangladesh, this study identifies three scenarios of lockdown based on literature review, the lockdown situation in bangladesh, and the global lockdown practices in different countries. a total of statements were used to develop the questionnaire to understand the scenario-based impact assessment and management of covid- outbreak in bangladesh. we had taken expert suggestions, consultations, and cross-validation of statements for getting perceptions from a different group of people. we have used google form to prepare the questionnaire and conduct the survey online. an online database of target bangladeshi participants was prepared by reviewing different online social platforms of different expert groups in bangladesh, considering their current activities, responsibilities, and engagement related to covid- response in socio-economic sectors, planning, and policymaking. the prepared questionnaire with an introductory paragraph outlining the objective of the study was then shared through email, facebook, messenger, linkedin, and whatsapp with selective and relevant people considering the purposive sampling method. the questionnaire survey was conducted from april to april . a five-point ( - ) scenario-based likert scale was employed to test whether each respondent understands the statements described ranging from strongly disagree to strongly agree. the target population was general bangladeshi citizens age years and older. the inclusion of the respondents was different social groups like university faculty and scholars, government officials, non-government officials, development workers or practitioners, doctors, engineers and technologists, youth leaders and students, businessmen and industry officials, banking and finance corporates, researchers, and others. the answers to the survey questionnaires were the voluntary basis. a total of responses were recorded during the survey. according to the survey findings, the ratio of male to female participants was (n = ): (n = ). the composition of age groups was % ( - years old), % ( - years old), and % ( - years old), respectively. however, the average age of the respondents (n = ) was . years (sd ± . ). % of the youth leader was mostly students as they are the dynamic group in the society, also involved in covid- response, volunteer social works, job seeking, research and reporting activities. rest of the % participants belonged to various professions of doctors, civil service officials, development practitioners, non-government officials, expert panels, and university scholars. the descriptive statistics (e.g. frequencies, percentages, and student t test) were used to understand the participant's characteristics. applying the statistical package for the social science (spss) v. . , datasets were analysed via a set of statistical tools such as principal component analysis (pca), hierarchical cluster analysis (hca), pearson's correlation coefficient (pcc), multiple regression analysis (mra), and classical test theory (ctt) analysis. pca is one of the population data reduction techniques that indicate each potentiality of variables and their significance level in a huge sample size. before conducting the pca, kaiser-maier-olkin (kmo) and bartlett's sphericity tests were applied to confirm the necessity of this analysis. the results of the kmo > . (the kmo value was . in this research) and the significance of bartlett's sphericity test at p < . verified our datasets to be fitted for the pca ). the number of factors chosen was based on the kaiser's normalization principle, where the only factors with eigenvalues > . were regarded. from ctt analysis, cronbach's alpha was employed to test the consistency and reliability of the factor loadings in this study. cronbach's alpha validation values ranged from . to . (the cronbach's alpha reliability value was . indicating that these statements are appropriate in social science study (table ) (devellis ). the hierarchical cluster analysis (hca) is a crucial means of identifying relationships among all socioenvironmental variables. the hca assists to classify a population into different groups based on the similar characteristics of a set of the dataset that may show causes, effects, and or the source of any undetected socio-environmental crisis. furthermore, hierarchical clustering was adopted to determine the possible number of clusters. the one-way anova test was conducted to confirm the significant differences in the variance at p < . . participants were informed of the specific purpose of the study. participants' consent was taken before the survey and they remained anonymous. the survey was completed only once, and the survey could be completed/terminated whenever they wished. the survey content and procedure were reviewed and approved by the department of public health and informatics, jahangirnagar university. reductions of covid- pandemic have been linked with the cessation of public transport, educational institutions, the closing of entertainment and business centres, and the prohibition of public meetings. averagely, cities that carried out control measures of lockdown within the first week of the outbreak reported fewer cases compared to the cities which started control later (tian et al. ) . vietnam, the communist country bordering china with a population of million, has been an under-reported low-cost success story of the pandemic, which has had just coronavirus cases and no deaths due to strong public health systems, good governance and transparent communication, strict quarantine approach, and contact tracing. from the first-known international cases on january , vietnam quarantined anyone who arrived from the high-risk area and closed its porous -km border with china to all but essential trade and travel. in february, it quarantined more than , people in the son loi village due to infections. it also closed all schools, colleges, universities, and all other educational institutions beginning in february. on march , the vietnamese government suspended all foreign entries (wef a). it also decided early on to impose a -day quarantine on anyone arriving in vietnam from a high-risk area. on april , vietnam eased its lockdown effort. unfortunately, in the european region such as worst-affected italy, france, and uk, the region in the americas such as the usa and now brazil experienced most deaths due to the failure to understand the disease and keep continuing their activities such as travelling and tourism which spiked the death rates, or delayed lockdown efforts (table ). the case of new zealand is interesting in the sense that it pursued an eradication tactic historically based on a mitigation model and focused on slower arrival of the virus, followed by a range of measures to flatten the curve of cases and deaths (cousins ) . the measures include increased testing, screening, strict quarantine of the infected person, contact tracing, and surveillance. the same measures have been adopted by south korea, taiwan, and many successful countries. luo ( ) , of singapore university of technology and design (http://www.sutd.edu. sg) forecasted using a data-driven model that by may , % of the infection case will end, while % will end by july for bangladesh. however, the forecast does not seem to be valid considering the present context in bangladesh. at this background, a scenario-based assessment under different assumptive situation considering the socio-economic and cultural attitude of the country could better identify the impacts. the later section of the article mainly focused on the different scenario and their possible management and their way forwards. in our study, we have considered global lockdown practice, country situation analysis, and expert suggestions to set three scenarios for impact analysis and possible management strategies which are: lockdown scenario : withdraw the existing partial lockdown (ls ) lockdown scenario : continue the existing partial lockdown (ls ) lockdown scenario : full lockdown/shutdown with an exit plan (ls ) a total of scenario-based statements were set, and perception-based statistical analysis was performed. the descriptive statistics are presented in table , which exhibits the percentage, mean, and standard deviation (sd), describing the responses of participants to the related scenarios for all statements from each of the respondents and the direction of each statement in the studied survey datasets. sect. . - . discusses the impacts of different lockdown scenarios. considering the withdrawal of existing partial lockdown, the results of ctt analysis and the corrected inter-item correlation analysis reveal that eight statements have low corrected item-total correlation values (< . ). this includes, people will start moving towards table (continued) table (continued) regular life (ls s : . ); massive movement and a mass gathering of people will be started again (ls s : . ); community transmission of covid- will increase due to people's movement and mass gathering (ls s : . ); and the number of infected populations will increase (ls s : . ). bangladesh is entering into this scenario without having any signs of flattening the infection curve. from pearson correlation analysis, a strong significant positive relationship was observed between people will start moving towards regular life (ls s ) and the formal and informal economic activities will be started (ls s ) (r = . , p < . ) ( table ) . linear regression analysis reveals that the community transmission of covid- will increase due to people's movement and mass gathering (ls s ) as people will start moving towards regular life (ls s , p < . ), and crime will rise and more people will die (ls s , p < . ) exhibited a statistically significant high correlation with the number of infected populations will increase (ls s ) ( table ). in addition, more unemployment and loss of livelihood (ls s ) and more people will die (ls s ) statistically pose a significant positive impact on an irreversible loss to the economy (p < . ) of bangladesh. from ctt analysis, continue the existing partial lockdown (ls m : . ); limited people's movement will enable low-level community transmission of covid- (ls s : . ); infection and death rate will increase slowly (ls s : . ); increased facilities to the healthcare system for covid- treatment will be able to provide health services to the infected peoples (ls s : . ). from pearson correlation (table ) , a significant positive relationship was found between the limited people's movement will enable low-level community transmission of covid- (ls s ) with the infection, and the death rate will increase slowly (ls s ) (r = . , p < . ). also, there will be less supply of basic products for daily use (ls s ) which posed a significant relationship with the price of most of the basic products will be higher than usual (ls s ) (r = . , p < . ). from the linear regression model (table ) , the association between dependent statements limited people's movement will enable low-level community transmission of covid- (ls s , r = . , p < . ) with poor people will suffer from food and the nutritional deficiency (ls s ), and gender-based violence will increase (ls s ). based on management scenario , massive awareness and enforcement of proper lockdown and quarantine initiatives were strongly associated with limited people movement will enable low-level community transmission of covid- (ls s , p < . ). from the ctt analysis, among statements, the corrected inter-item correlation analysis showed that only one statement has low corrected item-total correlation values (< . ). this adds existing with increased facilities for covid- in the health system will be able to provide health services to the infected people (ls s : . ). the highest interitem correlated value is the loss of livelihood and the unemployment rate will increase due to business shutdown (ls s : . ), while the lowest value is the number of infections and death will be limited (ls s : . ). in the case of management of scenario , inter-item correlated values are more than . . the high inter-item correlation was observed in the synergy with government, law enforcement agencies, and private sector initiatives (ls m : . ) and long-term planning and implementation of policies regarding covid- , psychosocial, and socio-economic loss (ls m : . ). according to the results of the pearson correlation, there was a statistically significant correlation among scenario where gender discrimination will increase due to covid- outbreak with gender-based violence will increase rapidly (r = . , p < . ). besides, extremely limited people's movement will reduce the risk of community transmission of covid- with the number of infection and death will be limited (r = . , p < . ). for management purposes, synergy with government, law enforcement agencies, and private sector initiatives with coordinated emergency relief support (r = . , p < . ). also, microfinance support to small and medium enterprises is required for recovery (ls m , p < . ). for management strategies of scenario , deep analysis of the situation should be carried out and go for full lockdown with relief support to the poor and most vulnerable are urgently needed for decision-making in the county due to the rapid community transmission of covid- (p < . ). first of all, the government should come up with a comprehensive strategic plan accompanied by non-governmental and social organizations and law enforcement to analyse the spread of the virus, identifying the most vulnerable hosts, properly tracked the movement of general people, precise estimation of economic losses from different financial and industrial sectors, educational diminutions and professional and informal employment disruption to picture an integrated scenario of the current situation and future predictions by which the revival of the negative aspects of the country could be managed. there must be two types of the strategic plan on under the category of the emergency response plan (short-term) by ensuring basic supplies to all citizens who are in real needs, motivate and/or force the people to abide by the covid- guidelines by the gob and who, prepare a complete but robust list of vulnerable population in terms of covid- spreading, co-morbidities, and economic stress, activate all the local wings of the gob such as local government representatives at the village level, and construct a covid- response task force to monitor and handle the country situation through application of information and communication technologies (ict). the government should implement those plans with proper timing, transparency, and resources. the gob has already been taking a lot of initiatives to tackle covid- pandemic, but there seems lacking proper risk assessment and weak coordination among stakeholders from medical to social welfare. another plan must be focused on the reconstruction or rebuild (long-term) and must follow the guidelines of the sendai framework. the sendai framework for disaster risk reduction - recognizes health at the heart of disaster risk management (drm) at the global policy level (wright et al. ). this sendai framework has given the rise of the health-emergency disaster risk management (health-edrm) framework an umbrella term used by who ( ). health-edrm thus refers to the "systematic analysis and management of health risks, posed by emergencies and disasters, through a combination of ( ) hazard and vulnerability reduction to prevent and mitigate risks, ( ) preparedness, ( ) response and ( ) recovery measures" (djalante et al. ). this also includes build back the healthcare sector, industrial sector, education, agriculture, research, environment, and finance. however, deep research complied with massive surveillance could help in making decisions whether the lockdown must be further carried on or not and this must have to be based on evidence. miscommunication and miscalculation of the strategy may trigger worsen the situation. communicating the disease risk in the local language is also necessary to increase awareness about the diseases. moreover, in sects. ( . . - . . ) we have analysed emergency management issues including short to medium-term measures as well as long-term management strategies of covid- pandemic lockdown scenarios in bangladesh based on our research outcomes. "lockdown" is an unfamiliar word or term to the people of bangladesh. according to scenario , a partial lockdown is a hoax. people recommended to use a more familiar term "curfew" (legal section ) to maintain strict and there is no alternative to reduce covid- transmission. in bangladesh, section of the penal code prohibits assembly of five or more people, holding of public meetings, and carrying of firearms and this law can be invoked for up to two months (minlaw/gob ). this law could have been a much more effective strategy to contain the infection. in total, . % of the participants agreed that community transmission of covid- will increase due to the people's movement and mass gathering, . % agreed to continue the existing partial lockdown, whereas approximately % of respondents agreed that deep analysis of the situation is required and go for full lockdown with the relief support to the poor and the most vulnerable. overall, the participants had a positive view about lockdown scenario to possibly spread out of covid- at the community level. many people expressed their disappointment towards the extreme corruption of the healthcare sector and that it has collapsed before the covid- pandemic. respondents advocated the government to consider biomedical waste management for reducing further environmental transmission and that efficient incinerator to be built for hospital waste management. however, the responders also suggested the government to sustain the retail and wholesale kitchen market/bazaar of any area maintaining the health guideline and social distancing. this approach could have positive feedback as already experience in different upazilas in bangladesh with the help of local administrative authorities, magistrates, and police forces. after the days of the partial lockdown, the federation of bangladesh chambers of commerce and industries recommended the opening of the industrial sectors with some guidelines (fbcci ). moreover, the fbcci taskforce demanded the covid- incentive financial package in a more gettable way from the gob. it could be a very crucial decision to be taken considering the covid- contagions and the business development to protect the exports. to maintain livelihood, industrial workers resumed their work from april . however, the gob weakened the lockdown and resumed the industrial activities without proper guidelines or the scientific basis for such a risky decision. the question is why the gob was in hurry to weakening the lockdown and withdraw it without eradicating the disease? predictably, there might be a strong business/financial association to withdraw the lockdown when life and livelihood matters for the poor and middle-class people and to run the country's economy. although gob provided healthcare guidelines and social distancing during work, the infection rates surged significantly among the workers in the industrial zones. most of the covid- clusters are majorly distributed in dhaka city, chittagong city, narayanganj, cumilla, gazipur, and the peripheral cities (iedcr ; tbs news b). finally, this study confirms that the withdrawal of the partial lockdown will not become positive in terms of covid- management in bangladesh, because still, we do not have enough evidence even after the days of lockdown that the transmission is reducing from the peak. overall, the participants had a positive view about lockdown scenario to stop/slow down the spreading out of covid- pandemic in bangladesh. in total, . % of respondents in this study agreed that existing health facilities will not be able to provide adequate services to the number of covid- patients due to limited community transmission, while . % strongly agreed that there will be a need for emergency food and financial support to the poor communities. about . % strongly agreed that emergency relief to the poor communities in both urban and rural areas should be provided ensuring transparency. around million people, or . % of the population, live below the poverty line and based on the current rate of poverty reduction, bangladesh is projected to eliminate extreme poverty by (chaudhury ). yet, as covid- pandemic hit the country within weeks poverty rate in bangladesh rose to . % as % of family incomes fell (the financial express a). so, it was the choice between life versus livelihood (hussain ) . the poor community always lacks food and nutrition due to the injustice and corruption by the local or regional level of political stakeholders in bangladesh. by nature, people of bangladesh are quite unaware and kind of ignorant or does not like to abide by rules. moreover, the public is not confident somehow with the administrative decisions, policies, and their implementation of covid- emergency response such as lockdown on their livelihoods. there was also a lack of coordination among the different government stakeholders to tackle emergency healthcare and crisis management in the field. for instance, people usually made different excuses to go outside and a regular crowd was common in the kitchen market, streets, and small bazaars. only the government, semi-government, autonomous institutes/organizations, and educational institutions were maintaining the rules/guidelines. this situation is well visualized in different mass media that people are in movement for relief, road blockage, corruption by the government representatives, mismanagement in relief distribution, biases to party supporters, bureaucratic administrators to look after the response activities, and so on. likewise, the potential danger of covid- pandemic from the very beginning has been overlooked by the people due to the presence of misinformation in the social and mass media that it was general flue, and that the virus cannot infect in a humid country like bangladesh. so, the government should try to implement a stringent policy of risk communication and media communication during this emergency to the most vulnerable communities. the vulnerable groups such as disable and disadvantaged persons, young children and orphans, and aged citizens should be taken under protection for their well-being (undp a). right now, doctors, bankers, grocers, police, and armed forces are the most vulnerable profession to the covid- infection. until may , % doctors, % nurse and % frontline healthcare workers were covid- -infected. of the infected, police personnel had so far died, while more than others are in either isolation or in quarantine (the daily star ). although the extension of partial lockdown was not a solution in bangladesh, it could have been an effective option continued to slower the infection rate. the lockdown should have been partially continued with necessary financial support for the vulnerable. it would have been a crisis for a short time, but it would be a saviour for the future (shammi and bodrud-doza ). however, to run the economy, the hotspots of the infection and the cluster areas could remain lockdown, while economic activities could have maintained by strongly abiding public health guidelines and social distancing. moreover, for the next couple of years, it will be extremely hard for the country especially as far as the financial issues are concerned to achieve the current development as well as sdg targets and reaching to middle-income countries (undp a). gob should declare the delayed beginning of its th five-year national plan due to the covid- pandemic as a large part of it seems to be irrelevant at this stage, according to his proposals (the financial express b). increasing surveillance as well as the reallocation of the budget, the distribution of direct cash, and private sector engagement could be some of the options to alleviate the crisis. in total, . % of the respondents in this study agreed that due to full lockdown, the formal and informal business, economic and education sector will be hampered severely. . % agreed that the poor and vulnerable communities both in urban and rural areas will be affected severely. for management purposes, % of the respondents thought that coordinated emergency relief support is required. overall, the respondents had a positive viewpoint about lockdown scenario due to the covid- outbreak in bangladesh. if we have no other options, a strategic plan and policy should be taken for the revival of the health sector, economy, and education. it is speculative that a full lockdown might end up with famine and starvation. according to the world bank report ( ) prolonged and broad national lockdowns will bring a negative growth rate of the economy in bangladesh and other south asian countries in due to the covid- pandemic. this negative growth rate will continue in with growth projected to hover between . and . %, down from the previous . % estimate. a more serious issue that will arise due to the progress of the pandemic is the rate of suicide as a long-term effect on the vulnerable population due to fear and economic hardships (mamun and griffiths ) . preventing suicide and counselling mental health issues are therefore be considered by the authority (gunnell et al. ) . moreover, the authority should take proper steps to meet the basic emergency services and maintain the basic supply-demand of the daily needs of urban and rural people by transporting the crops and vegetable production from the farms. due to the lockdown, the farmers should not face any crop loss and they should be also brought under the financial and other stimulus plans so they can continue their productions for the future. if the needed government should give them free seeds, fertilizers, electricity for irrigations, and water and other incentives such as no-interest agricultural loans for future food security. the government already declared a financial recovery package with a clear disparity towards the agricultural sector. the financial stimulus package mainly focused on large and export-oriented businesses such as the readymade garment sector (rmg). it seems that this package has arrived a little earlier without any participatory strategic assessment. a strong collaborative need-based assessment is required to tackle the short-term and long-term needs to properly distribute the stimulus package. in this emergency response, the local government must have to come forward with full strength and capacities to implement the work plan for the gob. for overall relationship assessment for effective management of policy implications, governance, and developmental effects, pca (fig. ) , cluster analysis (fig. ) , and pearson correlation (table and supplementary table ) significantly show the relationships. pca showed a significant level of controlling factors in bangladesh covid- pandemic and how these statements are associated with the various scenarios (table ) . nine principal components (pcs) were originated based on standard eigenvalues (surpassed ) that extracted . % of the total variance as outlined in table . however, before pca applying in the tested data, the kaiser-meyer-olkin (kmo) and bartlett's tests of sphericity were conducted to appropriateness for this study. the findings of the kmo value in this research were . (> . ), the confidence level of bartlett's sphericity (bs) test was zero at p < . , suggesting the tested data were fit for pca analysis. the scree plot was used to identify the number of pcs to be retained to the understanding of the inherent variable structure (fig. ) . the loading scores were classified into three groups of weak ( . - . ), moderate ( . - . ), and strong (> . ), respectively (liu et al. ; islam et al. ) . the pc (first) explained . % of the variance as it covered a significance level of strong positive loading of the lockdown scenarios and management in bangladesh (ls s : . and ls s : . ). similarly, moderate positively loaded of the lockdown scenarios in bangladesh (ls s : . ls s -s : . - . ). the pc (second) explained . % of the total variance and was loaded with moderate positive loading of lock drown scenarios (ls s - : - . and ls s : . ). the pc (third) elucidated . % of the variance and was strong positively loaded of massive awareness and enforcement of proper lockdown and quarantine initiatives (ls m : . ) and provide emergency relief to the poor communities both in urban and rural areas ensuring transparency (ls m : . ). furthermore, management scenario and scenario were observed moderate positive loading of pc (ls m : . ; ls m : . , ls m : . and ls m : . ). the pc (four) accounted for . % of the total variance and was strong positively loaded of poor people who will suffer food and the nutritional deficiency (ls s : . ) and moderately loaded in scenario (ls s -s : . - . and ls s : . ). the pc (five) explained . % of the variance and was strong positively loaded of deep analysis of the situation and continue this existing partial lockdown (ls m : . ) and with moderately loaded in the management scenario (ls m : . and ls m : . ). pc (six) accounted for . of the total variances and were strong positive loading of existing with increased facilities for covid- in the health system will be able to provide health services to the infected peoples and number of infection and death will be limited (ls s : . and ls s : . ) and with moderately loaded of very limited peoples movement will reduce the risk of community transmission of covid- (ls s : . ). pc (seven) explained for . % of the variance and was strong positively loaded with gender-based violence will increase (ls s : . ) and gender discrimination will increase (ls s : . ). pc (eight) was responsible for . % of the variance and was strong positively loaded with people will start moving towards regular life and formal (ls s : . ) and informal economical activities will be started (ls s : . ) and moderate positively loaded of massive movement and a mass gathering of people will be started again (ls s : . ). cluster analysis (ca) further recognized the total status of scenario variations and how these scenarios influence the socio-economic and development impacts (fig. ) . all the statements were categorized into five major classes: cluster (c ), cluster (c ), cluster (c ), cluster (c ), and cluster (c ). c consisted of five sub-clusters of c -a, b, and c; c -a composed of an irreversible loss to the economy and more people will die (ls s -ls s ) c -b comprised of community transmission of covid- will increase due to people's movement and mass gathering and panic will rise in the mass communities (ls s -s ). c -c is comprised of the possibility of the full lockdown of the whole system again and no basic services will be available (ls s and ls s ). c consisted of three sub-clusters of c -a, and b. c -a consists of continue the existing partial lockdown and deep analysis of the situation and go for full lockdown with relief support to the poor and most vulnerable (ls m -m ) c -b consists of people will start moving towards regular life and massive movement and a mass gathering of people will be started again (ls s -ls s ). c consisted of three sub-clusters of c -a, b, and c. c -a contained an existing increase in the health facilities involving private sectors and implement inclusive sustainable quick plan and policies to revive the economy and employment (ls m -m ). c -b consisted of lack of support and improper management will lead to the psychosocial and socio-economic crisis and long-term planning and implementation of policies regarding covid- , psychosocial, and socio-economic loss (ls s and ls m ), while c -c composed of continuous situation analysis of disease outbreak and implement the full lockdown with relief and basic support for human survival and loan support for business and economic recovery (ls m -m ). cluster consisted of three sub-clusters of c -a due to full lockdown, the formal and informal business, economic, and education sector will be hampered severely, loss of livelihood and unemployment rate will increase due to business shutdown, and poor communities in both urban and rural areas will be affected severely (ls s - ); c -b supply and access to basic daily products in urban areas will be reduced drastically, the extreme need for relief and financial support in the urban and rural communities will increase, and people will be involved with conflict and crime to access the basic needs (ls s - ); and c -c there will be less supply of basic products for daily use and price of most of the basic products will be higher than usual (ls s -s ). c -d indicates poor people living from hand to mouth will be severely affected and the formal education system will be hampered. c consisted of two sub-clusters of c -a, b, and c. c -a contained gender-based violence will increase and gender discrimination and violence will increase ls s and ls s . c -b comprised of limited people's movement will enable low-level community transmission of covid- and infection and death rate will increase slowly (ls s -s ). c -c contained limited people movement will reduce the risk of community transmission of covid- and the number of infections will be limited ls s -s . the covid- pandemic has the most effects on vulnerable populations, ranging from good health and well-being (sdg ) to quality education (sdg ) worldwide. disruptions in the routine health care, poverty, and access to food and nutrition will culminate into unavoidable shocks and health system collapse which will increase child mortality and maternal deaths as well as many unwanted deaths (roberton et al. ) . the crises in achieving clean water and sanitation targets (sdg ), weak economic development and the absence of decent jobs (sdg ), overall inequality (sdg ), and above all, no poverty (sdg ), and food insecurity (sdg ) will be aggravated in many developing countries. the world bank reports that about million people will be forced into poverty by the crisis (wef b). according to undp ( b), revenue losses in developing countries are estimated to reach $ billion. the losses would be consequences of the education, human rights, and, in the most extreme cases, fundamental food security and nutrition, with an estimated % of the global population not having access to social protection. wider socio-economic effects will likely continue for several months to years across the world which will also significantly impact the economy of bangladesh. global food security will be hampered as one-third of the world's population is in lockdown (galanakis ) . both the import of important goods and exports related to the readymade garment sector and others likely will be affected for income and employment. financial protection during outbreak matters. at the initial stage of the covid- epidemic, out-of-pocket expenditure posed a substantial financial burden for the poor populations with severe symptoms, even for those under coverage by the social health insurance scheme (wang and tang ) . people marginally above the poverty level particularly low-income families, daily and informal low wedge earners, ethnic community groups, people with disabilities, and returnee migrant workers are already started falling below the poverty line due to loss of income and employment. brac an international bangladeshi ngo survey report confirmed to increase a % rise in poverty amidst the covid- pandemic (brac ). the intake of foods, vegetables, and herbs can boost the immune system against the infection disease, while it can stimulate the transmission through the food chain (galanakis ) . again, the lack of food will rise to malnutrition, hunger, and famine. approximately , million people worldwide will be suffering from acute hunger projected by the un world food programme (wef c). ready-made garment (rmg) sector is going to suffer a serious shortfall as until march , orders of rmg products from garment factories worth us$ . billion was cancelled. this is the sector where almost million low-income people-of whom over % are women-work and another similar number of people indirectly depend on the downstream and upstream services required by the rmg value chain (dhaka tribune a). as the lockdown continues to ensure public health and safety, many rmg workers already lost their jobs and did not receive their salary of the previous months, some of them have been sacked already. food security and social and economic recovery package of the government should focus on immediate response during the lockdown period and outbreak and post-lockdown support mechanisms. in this condition, middle-income families are relying on their savings available. the negative coping mechanism includes skipping meals and nutrition and distressing the whole family. in the prolonged lockdown scenario, they need government and other support measures to continue their lives under lockdown. due to lockdown, the agricultural products in the urban areas are selling at a high price, while the farmers are not getting the fair price of the product in agricultural districts. it was due to the proper decisions and policy of the gob that aman paddy was timely harvested ensuring the safety of migrant workers. otherwise, it would have likely imposed a bigger social and economic implications such as heavy rainfall triggering natural flash flooding. moreover, due to the lockdown transport of animal, poultry and fish feed are hampered. likewise, due to the closure of local restaurants and hotels, the market demand for eggs and chicken had lowered. all this will likely impose further impacts on food production and crop supply chains. to protect the country from famine, the bangladesh government should consider the stimulus package for the farmers with % agricultural loan to continue cropping and agricultural production. receiving education has stopped for most of the students in bangladesh. the government of bangladesh postponed all academic and public exams until the indefinite period, considering the growing public concern. distance learning education of the national curriculum through air transmission in the national tv had started though. while urban children can attend virtual classes through the internet, rural and marginalized children are deprived due to limited resources. students from marginalized backgrounds particularly with disabilities will lose out more on their education. considering this, gob should prepare special educational package including counselling for marginalized and disadvantaged students. the severe infection of covid- pandemic has devastated the healthcare systems across the globe from a shortage of n masks, and personal protective equipment (ppes) for the healthcare workers and putting occupational health risk, allocations of ventilators, icus, and hospital beds to a patient who can benefit most from treatment while letting the older persons to death. the peaked disparity between supply and demand for healthcare properties raised a normative query of equitable resource allocation during the covid- pandemic (emanuel et al. ). thousands of healthcare workers have already been infected worldwide (gan et al. ) , and the administrative and managerial departments are likely to place increased burdens and stresses on the frontline healthcare workers (willan et al. ). bangladesh has no exceptional scenario. on may , gob lifted its partial lockdown after days of general holidays. the gob claimed the withdrawal of lockdown as a test for next days from may to june , but it was decided without having the designated committees' opinion rather only considering the economic considerations. the gob is planning to divide areas around the country that are affected by the covid- into three zones based on colour as red, yellow, and green indicating the severity of cluster infections and to prevent the disease spread (the daily star ). at present bangladesh is at number considering the infections and mortality from covid- (worldometer ) . the overall attack rate among the bangladeshi population is . / million and more than % positive cases have been identified in the recent days reported in the who situation report on th may (who c). among the countries of india, pakistan, nepal, bhutan, sri lanka, thailand and vietnam, bangladesh is at the bottom in terms of the number of covid- tests done per million population (newage ) . the maldives and bhutan are on the top of the list with each conducting , tests per millions of people (tbs news c). the testing laboratories are situated in the urban metropolitan areas and often due to fear and social stigma the patients do not want to test. moreover, the incidences of a false negative in one laboratory while positive in another laboratory had been reported in mass media. in addition, the mortality rate from covid- infection remains a puzzle which just cannot be explained by the gdp of the country, strength of healthcare governance and availability of equipment like icu or ventilators. the trend of screening and testing ( / million population) and contact tracing the covid- patients in bangladesh is not quite enough to conclude that the curve is flattening, or the peak of the curve has reached. thus, at this point, the database does not seems to be robust and it could be chaotic from the epidemiological point of view. after the lockdown is withdrawn, it was speculated that the number of infections will increase as the life and livelihood needed to sustain. on st may , bangladesh recorded deaths from covid- and new infections (iedcr ). at this stage, gob should increase the icu numbers and strengthen the healthcare departments by recruiting more doctors, nurses, and technicians. rapid testing, screening and diagnosis should be increased which was the advice of who from the beginning. along with isolation, clinical management, and infection prevention and risk communication should be continued to the public. the gob should engage public and private hospital authorities for the treatment of covid- infected patients and resume treatment of other critical-care patients who are being deprived of any treatment at present. moreover, as the infection from dengue is also rising government should take special emphasis for dengue treatment and management also. in fig. we have outlined the overall impact and management analysis of the three scenarios: scenario , scenario , and the scenario after the withdrawn of partial lockdown. community health workers can support pandemic preparation earlier to the epidemics by increasing access to the healthcare services and the healthcare products within the communities. they can communicate disease risks and increase awareness in the comparative lockdown scenarios with impact and management analysis for bangladesh due to covid- pandemic respected area in cultural language whereas reducing the weights of the formal healthcare systems. community healthcare workers can also contribute to pandemic preparedness by acting as community-level educators and mobilizers, contributing to surveillance systems, and filling health service gaps (boyce and katz ) . it is critical to detect cluster surveillance of covid- to better allocate resources and improve decision-making as the outbreaks continue to grow in different districts of bangladesh to improve resource allocation, faster testing stations, stricter quarantines and city/block lockdowns as well as travel bans (desjardins et al. ) . it is predictable that environmentally the decrease in air pollution reduces preventable communicable and non-communicable diseases such as covid- (dutheil et al. ) . likewise, ma et al. ( ) mentioned that the warmer season and lockdown activities were the keys to reduce exposure to novel coronavirus on humans in china. although the relationship between the infection rate and climatic variables is not confirmed in bangladesh, as the partial lockdown failed and continued, the number of infections over the past days indicates that gob should have ensured proper implementation of the lockdown scenario with limited public movement in the hotspots, resulting in lower community transmission of the virus and a slower death rate, while continuing economic activity with strict guidelines. gob was looking forward to exiting from partial lockdown beginning of may, yet no specific exit plans were executed by the government which should be scientifically rational and practically achieved. the exit plans from the lockdown should have been well communicated to the public ensuring transparency. without ensuring safety and security the partial lockdown was withdrawn. public transportation started on may without maintaining any health guideline (tbs news d). coordination among the different stakeholders of the government is necessary, along with increased surveillance and resource allocation to the needy ones, to ensure supply of daily necessities, control price hikes, and reduce the loss of livelihood and unemployment. moreover, very recently cyclone amphan hit bangladesh on may , living the coastal districts flooded and in the mayhem. preliminary losses were estimated to be worth bdt , crores (dhaka tribune b). at this stage detection of covid- hotspots by increased testing facilities all over the country must be ensured. the poor and vulnerable communities always lack food and nutrition due to injustice and corruption by local political stakeholders. the vulnerable groups, such as disabled and disadvantaged persons, young children and orphans, and elderly citizens, should be taken under protection for their well-being. they should be provided with food and nutrition for the time being. covid- pandemics cause environmental, economic, and social attributes which have only partially been described in bangladesh. to fight this pandemic, it requires remarkable tasks and partnership development in the local and global level. the world must prepare for the likelihood that mitigation measures might fail because lockdown periods in different countries took different times to prevent or suspend the spread of covid- (gautam and hens ) . collective responsibility is required from the public as well to protect themselves by abiding general health guideline, maintaining hygiene and social distancing, and avoiding going to crowded places and meetings. extremely coordinated and effective planning and strategies for both the ongoing and afterwards response are required from the gob to manage this pandemic and take it as a new "standard of normal". considering the global hard-hit economy, depression, unemployment, job loss, shortfall of rmg export and incoming remittances, the socio-economic and development impacts along with the food insecurity as well as rising poverty due to covid- at the community level need to be coordinated in bangladesh. at present, as the lockdown is withdrawn, both lives and livelihoods are in danger which is a long-debate that is going on. along with the pandemic disease, the upcoming seasons of natural disasters from cyclones, tidal floods, flash floods, and landslides of monsoon seasons should be considered to prepare for the emergencies. all these will further aggravate the humanitarian needs of the most vulnerable groups in the country in the coming months to be followed. as the health sector is the most strained at present, it will affect the targets of sustainable development goals of . in addition, quality education will be hampered in the country. the government of bangladesh has already mobilized a noteworthy stimulus package to support the affected industries and community which needs to be coordinated over a longer period of - months and may be incorporated in the upcoming th -year plans with substantial revising. however, this package should also include research and innovation, recovery of education. there is no alternative to strengthen the health care facilities and preparedness for the potential humanitarian crisis. moreover, humanitarian support should reach the most vulnerable communities which need to be targeted, outlined, and delivered. finally, economic implications should be subjected to the spatial and geographical locations based on the vulnerabilities. hotspots identified in the delta plan can be considered here. the long-term strategic plan can be integrated into perspective plan and bangladesh delta plans , for better strategic management. whatever will be the lockdown scenario, the basic supports to the mass people must be ensured and that is not so easy without strong strategic planning and multisectoral collaboration for sustainability including 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jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge all the frontline doctors, healthcare workers, emergency responders, security, and armed forces fighting this pandemic.funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord- -sn ike authors: jakariya, md.; alam, md. sajadul; rahman, md. abir; ahmed, silvia; elahi, m. m. lutfe; khan, abu mohammad shabbir; saad, saman; tamim, h. m.; ishtiak, taoseef; sayem, sheikh mohammad; ali, mirza shawkat; akter, dilruba title: assessing climate-induced agricultural vulnerable coastal communities of bangladesh using machine learning techniques date: - - journal: sci total environ doi: . /j.scitotenv. . sha: doc_id: cord_uid: sn ike abstract the agricultural arena in the coastal regions of south-east asian countries is experiencing the mounting pressures of the adverse effects of climate change. controlling and predicting climatic factors are difficult and require expensive solutions. the study focuses on identifying issues other than climatic factors using the livelihood vulnerability index (lvi) to measure agricultural vulnerability. factors such as monthly savings of the farmers, income opportunities, damage to cultivable lands, and water availability had significant impacts on increasing community vulnerability with regards to agricultural practice. the study also identified the need for assessing vulnerability after certain intervals, specifically owing to the dynamic nature of the coastal region where the factors were found to vary among the different study areas. the development of a climate-resilient livelihood vulnerability assessment tool to detect the most significant factors to assess agricultural vulnerability was done using machine learning (ml) techniques. the ml techniques identified nine significant factors out of based on the minimum level of standard deviation ( . ). a practical application of the outcome of the study was the development of a mobile application. custom rest apis (application programming interface) were developed on the backend to seamlessly sync the app to a server, thus ensuring the acquisition of future data without much effort and resources. the paper provides a methodology for a unique vulnerability assessment technique using a mobile application, which can be used for the planning and management of resources by different stakeholders in a sustainable way. the intergovernmental panel on climate change (ipcc) highlights that the vast low-lying coastal region of bangladesh is particularly vulnerable to risks from climate change (ipcc, ) . increase in temperatures, changing rainfall patterns, sea-level rise, and increase in frequency and intensity of extreme climatic events are negatively impacting agriculture, water resources, human health, and the ecosystem (wheeler and von braun, ) . climate change has already had major impacts on the lives and livelihoods of the people in the coastal areas of bangladesh (gob, (gob, , . the greater reliance of the people on the agricultural sector has made it more challenging today as a sustainable livelihood. agriculture will become even more susceptible in the future due to changes in climate variables (ipcc, ; islam et al., ) . one predominant impact of climate change will be fluctuations in crop yield due to frequent changes in climatic variables (mendelsohn & dinar, ) . moreover, extreme climatic events, soil salinity in coastal areas, and incidence of pests and diseases due to the increased temperature and humidity may result in additional adverse effects on the agriculture sector (rosenzweig et al., ) . despite technological development, climatic factors are still fundamental dominators of agricultural productivity. addressing the issues to find solutions to reduce agricultural vulnerability would require an integrated and comprehensive management plan with particular consideration for hazard vulnerability and the resilience of the coastal population to climate change (sajjad & chan, ) . the authors recognize that long-term measures will be required to address the climatic factors of vulnerability and, therefore, the paper suggests methods to find the second most significant factors that can be addressed more easily and can reduce agricultural vulnerability in the short run. an effort was made to find the crop yield vulnerability of the farmers of the three coastal districts of bangladesh by identifying the significant factors that have increased effects on the vulnerability score by machine learning models. this was done by first calculating the vulnerability livelihood index of agriculture for each of the study areas. vulnerability indicators help monitor and keep track of the changing vulnerability over time and space (shah et al., ) . the three components that characterize vulnerability include j o u r n a l p r e -p r o o f to cope with vulnerabilities related to rice production that would be specific for each region and could be managed locally with the help of mobile applications. developing such technology-based solutions has become extremely important, especially considering the scarcity of global resources and, more importantly, the recent covid- pandemic, which has emphasized the need to address the issue further. bangladesh, as a country, with its unique geographical location, is prone to natural disasters and climatic effects. therefore, at a time of such disasters, be it geographical or in the health-sector when mobility needs to be limited, it becomes next to impossible to maintain proper resource management. the work in this paper thus presents a complete system for the coastal areas of bangladesh that work with data acquisition using mobile applications, data processing using machine learning techniques, and interpretation through web-based interfaces. in addition, the architecture that was designed for this system is quite generalized and can be adopted for work in other domains as well, with minimal modifications. three coastal districts of bangladesh, namely, patuakhali, kutubdia, and khulna were selected for this research study. the maps of the study area are shown in figure . the vulnerability assessment method used in the study was based on the vulnerability assessment method of giz vulnerability sourcebook (fritzsche et al., ) , which is built upon the ipcc framework. it should be noted that the giz study only addressed specific methods of the vulnerability score calculation, but this study goes a step further and puts forth a practical application and usability of the score, giving policymakers a chance to apply the vulnerability information for functional purposes. moreover, while giz only identified the main components of vulnerability (e.g., exposure, sensitivity, and potential impacts), this research project identified the significant factors for all components of vulnerability, as shown in figure through engaging in extensive discussions with local communities. ( ), ( ), and ( ) below: ( ) where, w = weight and n = total number of factors. the categories assigned for the vulnerability score is shown in table . the regions were assigned into a category of low, medium, and high vulnerability based on the vulnerability score along with consultations with experts and local villagers (schiffman & kanuk, ). random sampling methods were used to select the study areas and study population (bernard, h.r. ) . a total of households were selected to collect preliminary data in order to get a general overview of the study area. broadly, socio-economic, climatic, water and sanitation, and disaster management related issues were covered in the questionnaire. a separate set of samples were chosen from the preliminary selection of households to assess agricultural production and related vulnerability issues. the average vulnerability index and the spatial distribution of the houses according to vulnerability were prepared using j o u r n a l p r e -p r o o f of each respondent, stores the result in a database and sends the data to a web dashboard. the web dashboard summarizes results for all respondents and also provides individual level vulnerability scores. administrators can use information from this dashboard to determine how resources can be optimally allocated to provide personalized help to each vulnerable individual. the factors related to three different variables of vulnerability, e.g., exposure, sensitivity, and adaptive capacity, were identified through focus group discussions (fgd) with the local farmers in each village. climate change-related exposures are global issues, whereas sensitivity and adaptive capacity are location-specific and can be addressed with local interventions (wilbanks, ; hess, et al., ) . the results of the fgds are presented in the vulnerability weights reflect the perception of farmers regarding the factors related to vulnerability in the study areas. weights measured from the ranking exercise conducted with farmers are displayed in table . across the coastal region of bangladesh, the climatic conditions were amongst the factors with the highest weights, which illustrate their importance to assess vulnerability levels. the climatic conditions include average rainfall, average humidity, and average temperature (weight = . ), which holds a weight of particular importance that could disrupt farming activities. during fgd sessions, farmers often mentioned price and market conditions as vital factors for sustaining livelihoods. the factors shown in table are location-specific and were collected through focus group discussions with the local farmers. the parameters with the highest vulnerability weights belong to exposure: average rainfall community response variations about different vulnerability factors in the three districts are shown in figure . among the parameters for sensitivity, the parameter with the highest weight in cox's bazar and patuakhali that affects agricultural productivity is rain availability (weight = . , weight = . respectively), whereas, in khulna and patuakhali, the parameter that holds the highest weight in the vulnerability calculation is the percentage of damaged crops (weight = . ). the factors of adaptive capacity help to overcome the exposure and sensitivity factors when measuring the vulnerability of a community or household. the factors that hold the highest weight in the vulnerability calculation for cox's bazar were education level and seasonal crop diseases (weight = . ). the adaptive capacity factor with the highest weight in khulna was also observed to be seasonal crop diseases (weight = . ). in patuakhali, the factor with the highest weight for adaptive capacity was the education level (weight = . ). table shows the state of crop yield vulnerability of the three coastal regions of bangladesh, which is reflected in the vulnerability scores of different villages in the study area. each village's vulnerability score was derived from analyzing the individual score of each household. every household's individual score was then examined and the cumulative score was achieved to obtain the vulnerability score. the maps in figure of three coastal regions show geographical areas of vulnerability, which is the subject matter of the study. the spatial map shows the vulnerability level of the villagers according to the household survey. similar to hazard maps, the vulnerability maps in figure highlight the zones where farmers and farming land are most vulnerable to a variety of factors, which include social, physical, and economic aspects of rice production, as discussed above. (bathrellos et al., (bathrellos et al., , (bathrellos et al., & ). the overall average vulnerability level was found to be relatively moderate in all three study areas. this shows an overall similar vulnerability situation in the coastal region of the country. however, slight variations in terms of vulnerability were seen in maheswaripur it is apparent from the study that the vulnerability in the crop yield sector varies according to regional and temporal variations of natural disasters in the coastal areas of bangladesh. it was observed that among the farmers, about %, %, and % were vulnerable to the risk of humidity, temperature, and precipitation, respectively. all the significant factors for vulnerability assessment were filtered using two different methods of statistical analysis and machine learning methods. later, a comparative analysis of both the methods identified the best method to use for developing the mobile application. it was done with an understanding to develop a mobile application that was simple and convenient for the users in terms of handling fewer vulnerability factors for input. the following sections discuss both methods. the multivariate logistic regression model was performed to screen out the non-significant factors of sensitivity and adaptive capacity (tolles & meurer, ; brunner & giannini, ) . the goodness of fit of the model was high because the value of r is . (draper & smith, ) . on the basis of the wald test, five variables for sensitivity and five variables for adaptive capacity showed significance (p-value < . ) out of a total of variables, which were considered initially for the vulnerability score calculation (fahrmeir et al. ; j o u r n a l p r e -p r o o f ward & ahlquist, ) . the vulnerability score was measured by integrating the significant factors related to sensitivity and adaptive capacity without influencing the original score (table ) . though the statistical analysis gave a primary list of important variables, the correlation of the vulnerability scores generated only using these variables with those generated using the full list of variables under the giz framework was not high (r = . ). so, using machine learning, we opted to find a better approach that would generate vulnerability scores closer to the original ones with fewer variables. the distribution of individual vulnerabilities, calculated as per the giz method, is plotted in figure . it can be seen that vulnerability follows a normal distribution and that there are no extreme vulnerability scores. it was assumed that the distribution is such because the agriculture-dependent coastal people are generally more or less vulnerable. of the data points that were collected, three had null values for different factors, which might have been caused by erroneous data entries. since the number of erroneous data points was very small, they were simply dropped and the remaining data points were considered for the ml models. moreover, in the dataset, there were only three distinct values for temperature, humidity, and precipitation. this occurred because each district was given a single value for each of these factors. as a result, there was minimal variance in the data for these factors and thus, was excluded from the ml models. finally, to check whether any factor had little influence in predicting vulnerability, a column with random floating-point values taken from the half-open interval [ , ) was added, entitled "random". the intention was to make an importance ranking of the factors where any factor ranked below "random" could easily be disregarded. thus, in the end, data points having actual factors and one random factor were considered. randomly chosen, % of these data points were kept for training the models and the remaining % for testing the performance of the models. before training the models, to ensure that there were no factors with high correlation, the spearman's rank correlation coefficient between each pair of factors in the training set was calculated and no two factors with high correlation were found. later, the vulnerability scores obtained by using the giz formula were taken as ground truths and five different regressors j o u r n a l p r e -p r o o f were tested to generate vulnerability scores as close as possible to the ones attainted using the giz method. the models and their respective performances are shown in table . it can be seen that linear regression and bayesian ridge regression performed well in predicting vulnerability scores while random forest regression, xgb regression, and extremely randomized trees regression overfitted the training data. the hyperparameters for the random forest, xgb, and extremely randomized trees regression (breiman, ; chen and guestrin, ; geurts, et al., ) through bayesian optimization were attempted to be tuned but were not successful in reducing the variance of these models without reducing their predictive capacity on the test set. this might be attributed to the fact that, in this case, these models are too complex for the small dataset being used. linear regression and bayesian ridge regression, on the other hand, did not require any hyperparameter tuning. as these models were functioning well, they were finally selected to generate the importance ranking of different factors. in order to obtain the importance scores of different vulnerability factors, permutation importance was used, which works by measuring the r score on the original set of factors for a model and then calculating the decrease in r by randomly permutating the values of each of the factors one at a time (altmann et al., ) . in this way, the factors with a larger decrease in r value are considered to be more important. figure although linear regression and bayesian ridge regression did not produce the same rankings, it was noticed that the two ranking schemes were similar in putting the same factors in higher or lower positions. to get a unified ranking, the ranks produced by the two regression models were summed up and sorted, with the factors in ascending order according to their sum of ranks. later, the factors with smaller sums of ranks were considered more important than those with bigger sums of ranks. this unified ranking is shown in table . the vulnerability factors with the lowest rank to the second-highest rank and so on were dropped one by one and trained new linear and bayesian ridge regression models with continuously reducing sets of factors. table lists how the new models performed with the reduced sets of factors. it was noted that the factor "random" was already dropped from our dataset before training the new models because it was no longer necessary. it can be seen from table that up to factors can be dropped and the vulnerability scores that have under . standard deviation from the original vulnerability scores while retaining a pearson correlation coefficient of . can still be predicted. since temperature, humidity, and precipitation were not included in the ml model like the original vulnerability calculation, it can be stated that, in actuality, up to factors can be reduced and reasonable predictive capacity of vulnerability scores can still be maintained by asking only questions. the ml method demonstrated successfully in identifying significant factors for vulnerability score calculation than that of the statistical approach. the ml method also demonstrated that it could strategically identify the significant vulnerability factors with the highest rank for designing program intervention without considering all significant factors to reduce a specific community vulnerability in a resource constraint situation. a mobile application was developed after a successful reduction of non-significant factors, which later was used to assess the vulnerability scores. the design of the user interface (ui) and user experience (ux) were heavily considered while developing the mobile application so that people of any age with little educational background can use it. farmers can log into this mobile application and answer the questions corresponding to the top vulnerability factors, which were discussed in the previous section. to avoid any false input data, unrealistically large integer numbers of any input field can be filtered. later, the responses of each individual will be sent to the central virtual server and vulnerability scores will be calculated for each individual household using the bayesian ridge regression model. to reduce agricultural vulnerability, it is important to consider the factors identified as being significant, such as soil and existence of groundwater, crop diseases, etc. along with the physical process of the area which provided issues related to agricultural vulnerability and this ultimately would help planners and policymakers to develop sustainable agricultural planning for the coastal communities of bangladesh (bathrellos et al., ) . vulnerability assessment and planning are highly inter-dependent. in order to become more accurate in assessing farmers' vulnerability, it is important to consider environmental, social, economic, and other relevant factors such as culture, ethical issues, the proper understanding of the static relationships between man and nature, etc. while designing such an intervention (ford et al., , bathrellos et al., . a proper method of data collection, journal pre-proof j o u r n a l p r e -p r o o f such as, if possible, an anthropogenic approach, could be applied for collecting such important information from the villagers. if the significant factors for vulnerability are identified properly, it would be easier for policymakers and planners to allocate scarce resources in a sustainable way. the mobile application, for example, provided a dynamic vulnerability score. the score, in reality, is not static and changes continuously. the application also allows scores to be upgraded as frequently as required by relevant stakeholders to address a particular situation. as the application will be available to farmers for data input, the collected information will be more accurate while keeping expenses low as there will be no physical involvement for data collection and storage activities. the method of a mobile application-based quick vulnerability assessment technique can also be applied to assess other livelihood aspects simply by identifying significant factors responsible for vulnerability as the factors responsible for vulnerability are highly location and subjectspecific. agricultural production in the coastal regions of bangladesh is highly vulnerable to changes in weather conditions. the prevailing situation demands the development of a dynamic agricultural plan that considers the future consequences of climatic change and vulnerability to natural hazards. the study identified the most vulnerable agriculture-dependent households using a rapid and cost-effective method. the study focused on the development of a practical and community-friendly application to assess the vulnerability scores to aid local government institutions and other similar organizations with planning and management. spatial maps were also prepared to show the locations of vulnerable households along with the extent to which they were vulnerable (tambe et al., ) . the study also provided a description for the application of the vulnerability scores, which can later be used to understand the vulnerability issues of certain livelihood options, such as agriculture, fishermen, health, etc. climate change-related exposures are global issues, whereas sensitivity and adaptive capacity are local issues and can be addressed with local interventions (wilbanks, ; hess, et al., ) . community response to the identified vulnerability factors of sensitivity and adaptive capacity varied significantly due to the diverse developmental profile and geographical characteristics of the study areas. statistical and machine learning methods were initially used to filter the most significant factors. the ml method was more successful in this aspect and was used to develop a mobile application that helped in vulnerability assessment by figuring out the factors which require immediate government intervention. the climate resilient vulnerability assessment tool, which provides an authentic and faster process of identifying vulnerability, would be able to bring about a revolutionary change in resource distribution and, more importantly, the allocation of scarce resources in a sustainable way. the vulnerability assessment process is usually highly technical, whereas the mobile application, which is based on a built-in system, provides a more user-friendly approach and can be used independently. the research findings provided an important starting point for directing future research into crop yield vulnerability to climate variability and change. it is expected that the output of the study can be used by policymakers and other stakeholders for better designing and targeting climate change adaptation policies and programs to ensure sustainability. permutation importance: a corrected feature importance measure potential suitability for urban planning and industry development by using natural hazard maps and geological -geomorphological parameters assessment of rural community and agricultural development using geomorphological -geological factors and gis in the trikala prefecture suitability estimation for urban development using multi-hazard assessment map random forest trial design, measurement, and analysis of clinical investigations study on livelihood systems assessment, vulnerable groups profiling, and livelihood adaptation to climate hazard and long-term climate change in drought prone areas of north-west bangladesh. centre for environmental geographic information services (cegis) and food and agricultural organization of the united nations (fao) proceedings of the nd acm sigkdd international conference on knowledge discovery and data mining -kdd ' applied regression analysis the dynamics of vulnerability: locating coping strategies in kenya and tanzania regression: models, methods, and applications vulnerability and its discontents: the past, present, and future of climate change vulnerability research the vulnerability sourcebook: concept and guidelines for standardised vulnerability assessments. bonn and eschborn: deutsche gesellschaft für internationale zusammenarbeit (giz) gmbh extremely randomized trees climate change climate change climate variations: farming systems and livelihoods in the high barind tract and coastal areas of bangladesh total vulnerability of the littoral zone to climate change-driven natural hazards in north brittany climate, water, and agriculture climate change and extreme weather events: implications for food production, plant diseases, and pests. global change and human health risk assessment for the sustainability of coastal communities: a preliminary study consumer behavior this research was supported and funded by the climate change trust fund (cctf), the government of the people's republic of bangladesh and the department of environment (doe). the authors declare that there is no conflict of interest.. journal pre-proof j o u r n a l p r e -p r o o f key: cord- -mtjk rp authors: al-zaman, md. sayeed title: healthcare crisis in bangladesh during the covid- pandemic date: - - journal: am j trop med hyg doi: . /ajtmh. - sha: doc_id: cord_uid: mtjk rp the covid- pandemic has had a severe impact worldwide. developed countries, such as the united states, united kingdom, italy, and spain, had their highly efficient medical infrastructure greatly stressed and suffered from high death tolls. similarly, bangladesh, a poverty-stricken south asian country, is losing its battle against the pandemic, but mainly because of its incompetent healthcare system. the casualties are escalating and public sufferings are becoming unimaginable. on this backdrop, this perspective piece discusses the healthcare crisis in bangladesh during the pandemic. this article also identifies three responsible issues for the country’s deteriorating health care: ) poor governance and increased corruption, ) inadequate healthcare facilities, and ) weak public health communication. surprisingly, whereas many developed countries, including the united states, the united kingdom, italy, and spain, have suffered greatly during the covid- pandemic even with their highly efficient healthcare systems, many less developed countries with inadequate healthcare systems are surviving the crisis more easily. where is the magic? unfortunately, no magic is there. rather, behind this mysterious façade, the reality tells a different tale. this pandemic reveals the incompetent health care of many less developed countries engulfed by intense corruption, and bangladesh is one of them. as one of the world's most densely populated countries ( , people/km ) with . % of people living below the poverty line, bangladesh has a healthcare system that lacks reliability, responsiveness, and empathy, and that has already been proved inadequate to deliver proper health care to the public on many occasions. , moreover, medical facilities are concentrated in urban areas that create a healthcare divide depriving rural areas. , amid such a situation, the covid- pandemic reveals many loopholes in the healthcare system that can be summarized under three themes: ) poor governance and increased corruption, ) inadequate healthcare facilities, and ) weak public health communication. after detecting the first covid- case on march, in the following weeks, more than . million overseas workers entered the country without proper screening, facilitating community transmission. furthermore, a few of the government's delayed decisions were found less effective that worsened the pandemic situation. for example, the government declared a general holiday for days from march , to april , without restricting transportations and public movement. as a result, a crowd of more than million people left dhaka immediately after the notice that expedited the community transmission. moreover, none of the two existing laws, disaster management act and infectious disease (prevention, control, and elimination) act , were brought into action properly to control such massive mass mobilizations and gatherings. in such a situation, many private medicals around the country were either unwilling or abstained from treating covid- patients, and thus healthcare denial intensified. , a survey found that . % of patients receive healthcare facilities from private medicals. consequently, a large share of the population suffered, and many of them died without proper medical supports. improper synchronization among the responsible bodies, the ministry of health and family welfare (mohfw), the directorate general of health services, and test laboratories' executives and workers, could be a reason for such mismanagements. with the deteriorating covid- situation in bangladesh, corruption surged. as a great initiative, prime minister sheikh hasina promptly declared incentive packages of usd . billion to ameliorate people's sufferings from the pandemic. but it is a matter of concern how effective these measures could be amid the intensifying nationwide corruption. whereas mismanagements were paralyzing the health sector, increased corruption worsened the situation to a greater degree. the media reported relief-related corruption incidents from march , to june , , and most of the convicts were the government officials, public representatives, and ruling party leaders and activists. they either expropriated the public's relief or counterfeited the budgets of medical equipment and health services. , in july, a hospital owner along with a few responsible persons was convicted for trading with fake covid- test certificates (for more fake covid- test news, see https://tinyurl.com/ y abr o). more investigations reveal similar incidents, including the case of two doctors who threw thousands of patients' samples in the garbage and provided them imaginary results (for a few notable examples, see table ). , despite the rampant irregularities and corruptions, a government promulgation on august , restricted law enforcement's investigations in hospitals: specialists suggest that it would exacerbate health-related corruption. healthcare preparation and capacity against covid- might explain the pandemic situation in bangladesh more precisely. the coronavirus testing rate in bangladesh ( . %) is the second lowest in south asia only after afghanistan, a war-torn nation ( table ). its main reasons could be the limited number of testing laboratories ( laboratories) and kits, and their uneven distributions across the country, expensive coronavirus tests in private medicals (usd - /test), the fewer number of medical workers, and unregulated testing system (elites get preferences). , , moreover, many testing kits were preserved by corrupt businessmen to initiate an artificial crisis. recently, the mohfw imposed a fee on covid- test in state-run laboratories too that dramatically reduced the average per day tests. thanks to the lower test rate, , people died undiagnosed with coronavirus symptoms from march to may . it hints about the possible discrepancies in the coronavirus's official statistics of bangladesh. medical facilities, such as beds, intensive care units, and ventilators, are far fewer than the required amount in both government and private hospitals. therefore, to manage a seat in the country's finest hospitals, patients often need to have connections. also, many patients prefer to remain at home fearing maltreatment in hospitals. a report reveals that % of patients stay at home and get treatment over the phone. in bangladesh, only . physicians and . nurses serve every , people on average, which is insufficient for the pandemic situation. moreover, medical workers were provided lower quality medical equipment, such as masks and personal protective equipment. consequently, many doctors got infected and some died, making the doctors' mortality rate of bangladesh highest in the world. inadequate information flow and communication networks make the healthcare system more vulnerable and incompetent. because of health-related uncertainty, information scarcity, the absence of reliable information sources, and defected flow of reliable information amid the pandemic, rumors became prevalent. in such a situation, national media outlets failed to successfully deliver reliable information to a large number of audiences, letting the more personalized and internet-based media occupy the communication space. as a result, around covid- -related online rumors spread across the country from march to july (for the complete list of rumors, see http://bdfactcheck.com, a nonprofit award-winning fact-checking website of bangladesh). as a timely step, the government started detaining rumor-producers and rumorspreaders to reduce the covid- crisis to some degree. however, along with the perpetrators, as many human rights activists and organizations believe thanks to a few recent incidents, political dissidents and the government's critics may be suppressed. , meanwhile, government officials are ordered "not to like, share or comment on social media posts" that criticize the government's policies. these steps may breed fear among the online communities and hamper the positive health-related communication. in june after a visit, a team of chinese physicians expressed their concerns about bangladesh's disorganized health sector: this article already discussed the key selected discrepancies. this situation may be controlled by taking a few steps. first, corruption in the health sector is mandatory as this will help improve the proper utilization of allocated resources. second, more tests should be conducted to identify the infected persons to provide them better treatment. third, hospitals should be well equipped with updated and efficient medical supplies such as oxygen and medications to provide supportive treatment for covid- . fourth, doctors and other medical workers must be protected from infection. moreover, infected doctors and nurses could be super-spreaders of the virus. fifth, thanks to higher population density and lower health awareness, social distancing in public spaces is virtually impossible in bangladesh. therefore, some sort of strict regulations for such spaces may be imposed. sixth, healthy information flow is a must for the current covid- situation in bangladesh to reduce the health-related confusions and uncertainties. battling the covid- pandemic without organized strategies and an effective healthcare system would be like an attempt to kill a lion with bare hands. received july , . accepted for publication august , . published online august , . the proposed expenditure was usd . million that was at least times higher than the actual expenditure. also, the products were of poor quality. the proposed expenditure was usd . million, and the original expenditure was usd . computer software the proposed expenditure was usd . million, and the original expenditure was usd . million. the proposed expenditure was usd /piece, and the market price was usd /piece. audio clips the proposed expenditure was usd . million, which was unevenly higher than the market price. personal protective equipment the proposed expenditure was usd /piece, and the original market price was less than usd /piece. five hundred physicians' food and living cost for month why south asia's covid- numbers are so low (for now) bangladesh: one in five people live below poverty line diabetes fact: bangladesh perspective patient satisfaction with health services in bangladesh bangladesh. global health workforce alliance the challanges of good governance to combat covid- people leave dhaka with high coronavirus risk. new age coronavirus: bangladeshi private hospitals unable to treat coronavirus patients. the business standard covid- and healthcare denial covid- : bangladesh hospitals forced to turn away patients institute for defence studies and analyses bangladesh arrests hospital owner over fake coronavirus results covid- fake certificates scam: jkg healthcare's chairman dr. sabrina held how much the permission-based investigation in hospitals would be effective. bbc news bangla coronavirus: testing crisis because of lab and kit scarcity govt imposes fees on covid- tests at staterun hospitals unb news, . , died with coronavirus symptoms: cgs. united news of bangladesh (unb) covid- : a reality check for bangladesh's healthcare system % of patients get treatment over the phone. daily prothom alo coronavirus: doctors' mortality rate in bangladesh 'highest in the world bangladesh: alarming crackdown on freedom of expression during coronavirus pandemic. article bangladeshi lecturer arrested over facebook coronavirus post bangladesh's measures in covid- battle disappoint chinese experts acknowledgment: publication charges for this article were waived due key: cord- -b ra j authors: rahaman khan, md hasinur; hossain, ahmed title: covid- outbreak situations in bangladesh: an empirical analysis date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: b ra j covid- disease, as popularly known as coronavirus disease, has been emerged from wuhan, china in december and now is a pandemic for almost every nation in the earth. it affects every country without considering country's race, nationality and economic status. this paper aims at analysing primarily the current situations of bangladesh and predicting infections and deaths for moderated term intervals by a proposed projection technique called infection trajectory-pathway strategy (itps) and for short term intervals prediction for total infections, deaths along with total number of severe patients and intensive care unit (icu) patients by polynomial regression modeling approach. since april , bangladesh has started to face critical situations as the number of infections has accelerated very fast in the following days. however, the fatality rate decreases considerably from . on april to . on april , which is still high among the south asian countries. of the cases reported on april , almost % are the male, % are from the capital dhaka. we have found that the potential pathway of infections for bangldesh would be the similar pathways that are experienced by austria, netherlands, israel, france and united kingdom. these countries are ahead a number of weeks and days in terms of infection cases since their -th confirmed cases. our proposed projection method itps suggests that by may , bangladesh will cross incidences and deaths which, by may will be and respectively. on the other hand, the regression model suggests that by the end of april, total number of infections, deaths, severe patients and icu patients will be , , , and respectively. this study will be favorable for the administrative units of bangladesh to plan for the next few weeks and to consider various aspects related to the control of covid- outspread in bangladesh and local or international flight bans etc. for slowing down the spreading. bangladesh followed shutting down schools and colleges on march and one week later from march the all offices remain close resulting national lockdown. as of april , number of covid- infections is and that has already spread in districts of districts (iecdr, ) . but for people in one of the densest countries on earth, it is difficult task to maintain social distancing, despite closing of educational institutes, offices, and markets may contribute considerably to reducing spread, while commuting in crowded public transport or even living in cheek by jowl urban slums. besides, public healthcare system in bangladesh is not sufficient, rather is overburdened. according to world bank data (wb, ) , bangaldesh in has . hospital beds for every , people; by way of comparison, the india has . ( ), the pakistan has . ( ), the srilanka has . ( ), us has . ( ) while china has . ( ) beds per , people. currently, hospitals in bangladesh have total , icu beds of which are in government hospital and the remaining in the private hospitals against a population of milion ("the daily dhakatribune", march , ). total number of icu beds in a hospital should be between % and % depending on the care given by the hospital [ (kennedy & pronovost, ) , (nafseen, ) ]. in - , the total number of beds in hospitals were , , , among them , were in governmental hospitals and , were in private hospitals [(nafseen, ) , (ministry of health and family welfare, ) ]. currently, bangladesh has total , hospital beds ("the daily dhakatribune", march , ), which is . beds for every , people. amid of the scarcity in basic health care facilities, has bangladesh acted accordingly to cope up with the ongoing covid- threats despite facing the underlying economic threats and uncertainty. if so, then how much preparation the country need to take for facing the potential management crisis. is the country alien to viral outbreaks like covid- , having suffered counntry's worst recorded case of dengue outbreak in and at the same time despite having a three-month head start since the outbreak began in china? this paper will help to know the answers to these questions in both directly and indirectly. as of today, we have found very few research works on covid- that have been conducted using bangladesh data. recently, islam et al. ( ) proposed a model to . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . measure the risk of infectious disease and predict the risk of covid- transmission using bangladesh data along with other four countries-united states, australia, canada and china. paul et al. ( ) proposed a seir epidemic model that accommodates the effects of lockdown and individual based precautionary measures and used it to estimate model parameters from the epidemic data for three south asian countries-bangladesh, india and pakistan. paul et al. ( ) used bangladesh data up to nd april, by which, bangladesh has only infection cases and deaths. however, their prediction model for bangladesh may not give reasonable results because of sufficiently small sample. mamun and grith ( ) discussed possible suicide prevention strategies while the first covid- suicide case in bangladesh took place due to fear of covid- and xenophobia. neither of the three research works dealt with the analysis of current covid- situations in bangladesh and to make direct projections for incidence, deaths, hospital icu beds, number of severe patients etc that are the main goals of this paper. these statistics may help government to take proper preparation to tackle the potential unprecidented situations in bangladesh. there is a number of models available in literature to model infectious diseases of which a few models has been used primarily for the countries where number of cases is very high like china, italy, spain, uk, germany and usa. particularly, a number of study works [kucharski et al. ( ) ihme covid- health service utilization forecasting team ( ), phua et al. ( ) and phua et al. ( ) ] has used various mathematical models to determine the spread of the disease, predict the number of incidence, health care faciities in tackling covid- spread. we will use polynomial regression model to predict the infected people, deaths and other healthcare faciities. however, it was also claimed that bangladesh's existing healthcare infrastructure is not very strong as per the who guide-lines [ ] and in case of community spread, the bangladesh government may find it difficult to manage the spread in light with the predicted statisstics. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint the data used for the current study has been from the esri living atla (dong & gardner, ) . this is the data repository maintained by the johns hopkins university [johns hopkins university ( b), johns hopkins university ( a)]. in the current study, we have used other countriy's (including bangladesh) temporal data of confirmed and death cases till -th april, . for projection we have used only april month's data i.e. from april to as there is sufficient daily cases from the begining of april. we have also used several other secondary data sources such as the iedcr (iecdr, ), world in data (max roser & ortiz-ospina, ) and world bank (wb, ). for basic statistical analysis, we have used the basic statistical tools that include the trend line charts, correlation, t-tests etc. for projection of infections and deaths, we have fitted the incidence and deaths of covid- disease in bangladesh by higher order polynomial regression. the second order polynomial regression is used with confirming orthogonality that helps to get uncorrelated regression coefficient. the two degree polynomial regression modell is given by we have obtained also % confidence interval estimates. polynomial regression has been used in forcasting covid- diseases along with for fitting trends by many researches [pandeya et al. ( ), johannes ( ) , howard ( ) ]. in bangladesh, the first covid- case has been detected on march , and the national lockdown was announced after days on th march by the gov-ernment of bangladesh. this lock down was called well ahead as compared to many other countries including india and pakistan with a hope of narrow downing the spread of infection. even . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . before the lockdown majority of the schools, colleges, markets, cinema halls, etc. were already shut down in dhaka and other parts of the country. current, the lockdown has been extended until april and government banning all the movements and restricting and urging peole to stay at home. the citizens were allowed to step out only in emergency situations. all these steps were taken in the hope of flattening the curve of infected cases and to limit the exponential growth of the patients in bangladesh. the number of infected cases, deaths and active case are reported in figure . there are infected cases, deaths reported in bangladesh as on -th april with . % cases being active which is much higher compared to global percentage of active case % (dong & gardner, ) . more than % cases are from dhaka division (iecdr, ) of which almost % are from the capital city dhaka. the sex ratio (males to females) among the infected population is found to in every cases as of april , . since april , the number of infections and deaths has been increased significantly with much higher rates. during april to , the average doubling time for infections and deaths is found . and . respectively (see figure (b)). figure shows the case fatality rate (cfr) and growth rate of infections. cfr is the ratio between the number of confirmed deaths and the number of confirmed cases from covid- . bangladesh had very high cfr rates during april to with average almost %. compared to south asian countries india, srilanka and pakistan the cfr rate in bangladesh is still the highest (see figure ). however the current cfr is much lower . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . than the glober cfr which is over as on april . in the early days of identification the count was in single digits, so the growth rate was comparatively high, so as the cfr values. but in the weeks that followed, the cfr particularly declined, reaching as low as . % as on april , . the growth rate has consistently positive since april and that has been hovering around % till april . testing is the only effective window onto the covid- pandemic and how it is spreading. when disease becomes pandemic, testing for it early leads to quick identifica- . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . tion of cases, quick treatment for those people and immediate isolation to prevent spread and to trace their contacts. early testing also helps to identify anyone who came into contact with infected people so they too can be quickly treated. china, south korea, taiwan have followed this procedure to use it as one of our most important tools in the fight to slow and reduce the spread and impact of the virus. as expected, very strong positive correlation is found between the number of tests conducted in last hours and the reported infections in bangladesh (see figure (a)). the correlation coefficient is . based on the data reported as on april , . as on april , bangladesh has tested only , case samples which is in a rate per milion and which is much lower than many countries (max roser & ortiz-ospina, ). bangladesh is one of the countries who have passed the threshold of confirmed cases, with many more countries on the cusp (max roser & ortiz-ospina, ). we have presented in figure , the infection trajectory for the countries, based on the data reported as on april , who have crossed the case mark and have experience, being well ahead bangladesh, the pathways that bangladesh is likely to experience in future. by comparing such trajectories, we would be able to see a clearer picture of how quickly the virus may spread in future in bangladesh who is on the same track but well behind . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . the track and also how quickly the virus spread within the countries who are on the same trajectory line. we call this procedure as the itps (infection trajectory-pathway strategy). bangladesh crossed case mark on april exactly one month after the first case that was identified on april . however, figure shows that bangladesh could follow the same pathway of infection trajectory (between and days to double the cases) that is experienced by any of the five countries-austria who is days ahead, isreal who is days ahead, netherlands who is days ahead, france who is days ahead and united kingdom who is days ahead. these lead to the projected infections for bangladesh as reported in table . this table also shows the projected deaths estimated based on the global cfr value which is about (johns hopkins university, b) as on april , . this projection method suggests that bangladesh could cross , case mark and deaths, in worst scenario, by may while infection and death toll could cross , and respectively around in may . the projections for infected people, severe patients, icu patients and deaths for short term have been made using the polynomial regression. table shows the projected numbers with their % confidence intervals. according to (phua et al., ) , % . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . (phua et al., ) . the deaths are projected from the infected people by assuming that bangladesh will follow the similar global case fatality rate which is stated as almost as of april , our projection believes that total infected people and deaths in the bangladesh will be more than and almost respectively by the end of april, while the number of severe and icu patients will be and respectively. those figures are estimated to be , , and respectively by april . we have not considered the relationship between deaths and country's intensive care bed capacity in calculating the potential deaths in our projection, but we believe that the actual projected deaths could be higher than the predicted numbers since the bangladesh will not have enough beds and intensive care unit (icu) beds to meet demand ["the daily dhakatribune" (march , ), nafseen ( )]. this paper presented the basic analysis results of the current covid- situations in bangladesh. the paper also proposed an ad-hoc projection strategy known as itps (infection trajectory-pathway strategy) for projecting total infections and deaths suiitable for a moderated period of time like one month or one and half months. the itps is . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . table : projected infected people, severe patients, icu patients and deaths of covid- in bangladesh by polynomial regression method a new of its kind in predicting infectee people while it assumes the projected country will follow the similar infection trajectory line or indirectly the similar growth rates of the countries who are already in advanced level of common experiences like infectios and deaths. as reported in table , according to itps bangladesh will have similar number of infections like , by austria who is days ahead, , by isreal who is days ahead, , by netherlands who is days ahead, , by france who is days ahead and , by united kingdom who is days ahead. this paper also presented the projection results by the polynomial regression model which is suitable for short period of time. as reported in table , bangladesh will cross infection cases and deaths mark by april , while the country will cross cases and almost deaths mark by april . the number of severe and icu patients will exceed the and marks by april , which by the end of april will be and respectively. the world grapples with the containment of the covid- outbreak but bangladesh . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . may not be doing so as the number of tests done as of april is over just , which is not a good number compared to even neibourhood countries such as india, pakistan. despite having very strong positive correlation ( . ) between the daily tests and number of infected people, the growth rate of tests in bangladesh is considerably low. capacity of tests needs to increase rapidly for detecting the infected people within quick time. this will help to restrict the spread by isolating the infected people and quaranting the susceptible people. our projected number of severe and icu patients might help the government of bangladesh to prepare the number of hospital beds including icu beds, health staff to tackle the potential demand of covid- patients. however, our findings provide an indication of the challenges that the bangladesh health care system will face if the covid- epidemic progresses unabated. for giving tratment to critical patients fully functional icu beds are crucial. the icu beds are not useful in the absence of an adequate number of trained critical health-care workers, medical supplies like personal protective equipment (ppe) that are needed for crisis management. therefor, the government, hospital administrators, and policy makers must work with icu doctors and nurses to prepare for a substantial increase in critical care bed capacity. goverment must protect in unprecedented ways the health-care workers from nosocomial transmission and physical exhaustion including several mental health issues. we believe this study will help the government and health-care workers in preparing their plans for the next two or three weeks. our predictions by both methods are suitable for both short-term and medium-term interval, and these models can be tuned for forecasting in long-term intervals. we declare that we have no competing interests. there is no funding for this study. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://www.iedcr.gov.bd., accessed april . ihme covid- health service utilization forecasting team. ( ). forecasting covid- impact on hospital bed-days, icu-days, ventilator-days and deaths by us state in the next months. medrxiv , doi: . / . . . . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . risk assessment of novel coronavirus covid- outbreaks outside the effect of travel restrictions on the spread of the novel corona-virus the daily dhakatribune an interactive web-based dashboard to track covid- in real time. the lancet infectious diseases critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency re-sponse fitting polynomial trends to seasonal data by the method of least squares the continuing -ncov epidemic threat of novel coronaviruses to global health-the latest novel coronavirus outbreak in wuhan, china institute of epidemiology disease control and research modeling risk of infectious diseases: a case of coronavirus outbreak in four countries smoothing time series with local polynomial regression on time coronavirus map novel coronavirus covid- ( -ncov) data repository by johns hopkins csse shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the st century early dynamics of transmission and control of covid- : a mathemati-cal modelling study. the lancet infectious diseases fundamental principles of epidemic spread highlight the immediate need for large-scale serological surveys to assess the stage of the sars-cov- epidemic coronavirus disease (covid- government of the people's republic of bangladesh prediction on covid- epidemic for different countries: focusing on south asia under various precautionary measures intensive care management of coronavirus disease (covid- ): challenges and recommendations real-time forecasts of the covid- epidemic in china from the world bank data coronavirus disease (covid- ) situation reports. situation report critical care crisis and some recommendations during the covid- epidemic in china mhrk carried out the statistical analysis and contributed to draft the manuscript. ah arranged the datasets and contributed to finalize the manuscript. key: cord- -y p bmph authors: akter, shahina; banu, tanjina akhtar; goswami, barna; osman, eshrar; uzzaman, mohammad samir; habib, m. ahashan; jahan, iffat; mahmud, abu sayeed mohammad; sarker, m. murshed hasan; hossain, m. saddam; shamsuzzaman, a. k. mohammad; nafisa, tasnim; molla, m. maruf ahmed; yeasmin, mahmuda; ghosh, asish kumar; al din, sheikh m. selim; ray, utpal chandra; sajib, salek ahmed; hossain, maqsud; khan, m. salim title: coding-complete genome sequences of three sars-cov- strains from bangladesh date: - - journal: microbiol resour announc doi: . /mra. - sha: doc_id: cord_uid: y p bmph we report the sequencing of three severe acute respiratory syndrome coronavirus (sars-cov- ) genomes from bangladesh. we have identified a unique mutation (nsp _v i) in one of the sequenced genomes (isolate hcov- /bangladesh/bcsir-nilmrc- / ) compared to the sequences available in the global initiative on sharing all influenza data (gisaid) database. the data from this analysis will contribute to advancing our understanding of the epidemiology of sars-cov- in bangladesh as well as worldwide at the molecular level and will identify potential new targets for interventions. s evere acute respiratory syndrome coronavirus (sars-cov- ) belongs to the genus betacoronavirus, family coronaviridae, and is the causative agent of the ongoing coronavirus disease (covid- ) pandemic (https://coronavirus.jhu.edu/map.html). sars-cov- was first reported in bangladesh in march , and since then the country has experienced a steady rise in infections, resulting in ϳ , cases and , deaths as of june (https://corona.gov.bd/?gclid). here, we report the complete sequences of three sars-cov- isolates from patients who tested positive using quantitative pcr (qpcr) in the national institute of laboratory medicine and referral center (nilmrc). qpcr was performed using a sansure biotech novel coronavirus ( -ncov) nucleic acid diagnostic kit according to the manufacturer's instructions. the threshold cycle (c t ) values of the n gene of the three positive samples were . , . , and . , and the c t values of the open reading frame (orf) genes were . , . , and . , respectively. the study was approved by the ethics committee of nilmrc (bangladesh). the samples were taken with the consent of all patients, and they provided informed written consent consistent with the experiment. to understand the molecular epidemiology of sars-cov- viruses in bangladesh, we carried out whole-genome sequencing of three isolates (hcov- /bangladesh/bcsir_nilmrc_ / [bcsir_nilmrc_ ], hcov- /bangladesh/bcsir_nilmrc_ / [bcsir_nilmrc_ ], and hcov- /bangladesh/bcsir_nilmrc_ / [bcsir_nilmrc_ ]) collected directly from nasopharyngeal swabs from three patients in bangladesh. viral rna was extracted using a purelink viral rna/dna minikit (catalog no. ; thermo fisher scientific, usa). the cdna of all three samples was used to prepare paired-end libraries with the nextera dna flex library preparation kit according to the manufacturer's instructions (illumina, inc., san diego, ca). the extracted viral rna was converted into cdna using the goscript reverse transcription system protocol according to the manufacturer's instruction. the library pool of three samples was sequenced using a nextseq highoutput kit with an illumina nextseq instrument in paired-end format (read length, bp). the library generated , , , , , , and , , reads, of which , , , , , , and , , unique reads, respectively, were found after excluding duplicate marked reads using basespace dragen rna pathogen detection software version . . ( ). sequence trimming and quality control were done using the basespace dragen app. quality control examination of the sequencing reads revealed that Ͼ % of the sequencing data yielded a phred score of or above. we did not identify any overrepresented adapter sequences in the sequencing libraries. after generating a fasta file from the fastq files using the dragen software, it was found that the complete genome sequences of the bangladeshi sars-cov- strains (bcsir_ nilmrc_ , bcsir_nilmrc_ , and bcsir_nilmrc_ ) have linear rnas of , bp, , bp, and , bp, respectively, with an average gc content of %. data for the three samples were uploaded to the global initiative on sharing all influenza data (gisaid) database on may ( ) . phylogenetic analysis of these three virus genomes grouped them in sars-cov- clade b (fig. ) . this phylogeny shows the evolutionary relationships of human coronavirus (hcov- ; or sars-cov- ) viruses from the ongoing covid- pandemic. the results show an initial emergence in bangladesh in may and june , followed by sustained human-to-human transmission, leading to the sampled infections. compared with hcov- /wuhan/wiv / , for strain bcsir-nilmrc- , we found eight mutations, including nsp _g s, n_r k, n_g r, nsp _q r, spike_d g, nsp _i f, nsp _p l, and nsp _v i. six mutations were found in bcsir-nilmrc- , spike_d g, n_r k, n_g r, nsp _k n, nsp _i f, and nsp _p l. in bcsir-nilmrc- , the genome mutations spike_d g, n_r k, n_g r, nsp _i f, nsp _p l, and nsp _p s were observed (table ) . a unique mutation (nsp _v i) was observed in the bcsir-nilmrc- genome sequence compared to the genome sequences available in the gisaid covsurver (gisaid initiative_covsurver_files). data availability. the sequences of these sars-cov- genomes from bangladesh were submitted to the gisaid database (accession no. epi_isl_ , epi_isl_ , and epi_isl_ ) and genbank (accession no. mt , mt , and mt ). the raw reads have been deposited in the basespace cloud and were also submitted to the ncbi sra under accession no. prjna , prjna , and prjna for strains bcsir_nilmrc_ , bcsir_nilmrc_ , and bcsir_ nilmrc_ , respectively. idseq-an open source cloudbased pipeline and analysis service for metagenomic pathogen detection and monitoring gisaid: global initiative on sharing all influenza data: from vision to reality nextstrain: real-time tracking of pathogen evolution this project is financed by the government of the people's republic of bangladesh. we extend special thanks to architect yeafesh osman, honorable minister of science and technology. we thank m. anwar hossain, senior secretary, ministry of science and technology. we are very grateful to the chairman of bcsir for his continuous support to the team. key: cord- -zi qm authors: ara, tasnim; rahman, md. mahabubur; hossain, md. abir; ahmed, amir title: identifying the associated risk factors of sleep disturbance during the covid- lockdown in bangladesh: a web-based survey date: - - journal: front psychiatry doi: . /fpsyt. . sha: doc_id: cord_uid: zi qm background: bangladesh, a developing country with a lower-middle-income and one of the world’s most densely populated areas, has been severely affected by covid- . this global epidemic is not only affecting the physical health of the patients but also causing severe psychological effects among those who have not yet been infected. sleep disturbance is one of the key symptoms of major depression and one of the proven risk factors for suicide. the objective of this study is to identify the risk factors associated with sleep disturbance which has developed as a general impact of covid- and new normal life during the lockdown (a measure to control the spread of covid- ) in bangladesh. methods: demographic characteristics, covid- , and lockdown related information have been collected from , individuals by conducting a web-based survey. respondent’s perspective regarding sleep disturbance during covid- lockdown is considered as the outcome of interest which is dichotomous. descriptive statistics methods have been applied to explore the distribution of respondent’s demographic characteristics. pearson’s chi-square tests have been performed to relate the sleep disturbance status of the respondents to their demographic, personal, and covid- related information. furthermore, a multivariable logistic regression model has been adopted to identify the significant association of sleep disturbance with the demographic, covid- , and lockdown related information of respondents during the covid- lockdown in bangladesh. findings: the prevalence of sleep disturbance during the covid- lockdown is found to be higher among participants aged – years. gender disparity has also been observed in favor of male participants, whereas no significant regional heterogeneity has been found. working from home or doing online classes during the lockdown has been found as a potential predictive factor of sleep disturbance. losing a job has been considered as an adverse economic effect of covid- , which also induces sleep disturbance. perception regarding the risk of getting infected and anxiety triggered the chance of developing sleep disturbance. the sleeping schedule is also found as a risk factor for sleep disturbance. conclusion: evidence-based policies are required to combat psychological challenges that have arisen due to covid- , primarily targeting the groups who are largely suffering from sleep disturbance. background: bangladesh, a developing country with a lower-middle-income and one of the world's most densely populated areas, has been severely affected by covid- . this global epidemic is not only affecting the physical health of the patients but also causing severe psychological effects among those who have not yet been infected. sleep disturbance is one of the key symptoms of major depression and one of the proven risk factors for suicide. the objective of this study is to identify the risk factors associated with sleep disturbance which has developed as a general impact of covid- and new normal life during the lockdown (a measure to control the spread of covid- ) in bangladesh. methods: demographic characteristics, covid- , and lockdown related information have been collected from , individuals by conducting a web-based survey. respondent's perspective regarding sleep disturbance during covid- lockdown is considered as the outcome of interest which is dichotomous. descriptive statistics methods have been applied to explore the distribution of respondent's demographic characteristics. pearson's chi-square tests have been performed to relate the sleep disturbance status of the respondents to their demographic, personal, and covid- related information. furthermore, a multivariable logistic regression model has been adopted to identify the significant association of sleep disturbance with the demographic, covid- , and lockdown related information of respondents during the covid- lockdown in bangladesh. findings: the prevalence of sleep disturbance during the covid- lockdown is found to be higher among participants aged - years. gender disparity has also been observed in favor of male participants, whereas no significant regional heterogeneity has been found. working from home or doing online classes during the lockdown has been found as a potential predictive factor of sleep disturbance. losing a job has been considered as an adverse economic effect of covid- , which also induces sleep disturbance. perception regarding the risk of getting infected and anxiety triggered the the emergence of a cluster of acute respiratory illnesses that occurred by exposure to sars-cov- is officially identified as covid- , which was first observed in december in wuhan, hubei province of china ( - ). the who declared the covid- outbreak as a "pandemic" on march , as the virus spreads increasingly worldwide ( ) . as of june , , countries and territories around the world are affected by the sars-cov- , and a total of , , covid- cases in the world have been confirmed, and , deaths have occurred worldwide from the disease ( ) . almost all countries are adopting preventive measures such as remote office activities, international travel bans, mandatory lockdowns, and physical distancing. bangladesh, a developing country with a lower-middle-income and one of the world's most densely populated areas, is also trying to stop the spread of the disease with its limited resources. the country confirmed the first covid- case on march ( ) . there are , total confirmed cases and , total deaths in bangladesh as of june , ( ) . the government of bangladesh declared the enforcement of lockdown on march to prevent the spreading of this infectious virus ( ) . there is a considerable relation between mental health and poverty ( ) . low and middle-income countries have a higher burden of mental disorders than economically developed countries ( , ) . mental health resources include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. in low-and middleincome countries, mental health services are highly insufficient, and the available resources for mental health are still scarce, inequitably distributed, and inefficiently utilized ( , ) . compared to australia and canada (two high capacity countries in terms of mental health response), bangladesh is more than fold behind in terms of the number of psychiatrists per , population ( ) . the rate of occupational therapists per , population is in bangladesh, whereas this rate is respectively . and . in australia and canada ( ) . in australia and canada, people with mental disorders pay at least % of the cost of mental health care, whereas in bangladesh patients pay entirely out of their own pocket to receive the service ( ) . the only nationally representative survey conducted between and illustrated the high burden of mental disorders in bangladesh ( ) . notedly, mental health services are virtually non-existent at the primary care level throughout the country ( , ) . there is a considerable lack of an adequate number of psychiatrists, and they are mostly located in big cities which makes the burden heavier ( ) . in such a situation, mental health issues during the covid- pandemic might be severe in bangladesh. the mass home confinement since the covid- outbreak in december has developed a stressful situation for many across the globe. covid- not only affects the physical health of the population but also has a serious impact on mental health ( , ) . in addition, symptoms of anxiety and depression and self-reported stress are common psychological effects of the covid- pandemic ( ) . previous studies have also shown that the prevalence of novel infectious diseases, such as severe acute respiratory syndrome (sars) can increase anxiety, depression, and stress levels in the general population ( ) . being forced to stay at home, work from home, do homeschooling for children, severely reduced social interaction, work many more hours in stressful situations, and health risks can have a severe impact on daily activities and nighttime sleep ( ) . even if people under lockdown have less possibility to develop an infection they often suffer from negative psychological effects, which may disrupt the sleep quality ( ) . sleep plays a fundamental role in emotion regulation ( ) ( ) ( ) ( ) . many cross-sectional epidemiological studies have indicated that sleep disturbance is closely associated with new-onset of poor mental health status and lasting poor mental health status ( ) ( ) ( ) ( ) ( ) . disturbed sleep is also considered as a causal factor in the occurrence of many mental health disorders ( ) . several studies have shown that proper quality sleep not only reduces the risk of non-communicable diseases (ncds) ( ) ( ) ( ) ( ) ( ) ( ) but also helps to improve immunity to viral infection ( , ) . thus, through good quality sleep, a better immune system can be developed which in turn may have an impact on the susceptibility of covid- infection. psychological wellbeing and sleep are affected by several socio-economic factors such as economic burden, family support, and social support ( ) . recently, several studies have investigated the influence of social factors and factors related to covid- on sleep quality in china and european countries ( , , ) . this paper attempts to assess the risk factors associated with sleep disturbance in the context of covid- and new normal life during the lockdown in bangladesh. a web-based self-reported cross-sectional survey has been conducted to collect the data. this web-based survey was intended to reach as many individuals as possible. thus, rather than using the official psychological tools to respond to questions about sleep disorder or anxiety, to keep the questionnaire easy and understandable to the respondents and to make the interview duration shorter, we constructed a self-reporting questionnaire. this is the most widely used tool in community surveys for physical and mental health evaluation ( ) ( ) ( ) . features that might be related to sleep quality evaluated by previous studies were included in the questionnaire ( ) ( ) ( ) . moreover, some hypothesized risk factors of sleep disturbance in the context of covid- and new normal life during the lockdown were also included in the questionnaire. the survey questionnaire with the consent form was shared on the internet through different social networking and messaging site (facebook, whatsapp, viber, imo, etc.) and e-mail, sms. all bangladeshi people using these tools may see this survey and may answer the questionnaire by clicking the relevant link. this web-based questionnaire was completely voluntary and non-commercial. participants answered the questionnaires anonymously on the internet from may , , to may , . all subjects reported their demographic data, covid- related information, and questions related to sleep quality. to ensure the quality of this survey, questions were provided in both bengali and english language and encouraged participants to answer carefully through questionnaire explanations. a total of , individuals have participated in the survey and among them, , individuals have completed the questionnaire. incomplete responses have been excluded from the analysis. demographic variables include administrative division, place of residence ("urban", "rural"), religion, age, gender, marital status, educational level, employment status, and income level. in addition, family-size and body mass index (bmi) of the participants have also been included. individuals were asked about different pieces of information regarding covid- and their new normal life during the lockdown. this information includes whether they are following the social distancing rule; whether they or their family members, relatives, friends, or neighbors got infected by covid- ; whether they are working from home/doing online classes; whether they have to go to the workplace during the lockdown; whether any of the family members including respondent have lost their job; exercise status, whether food consumption dominates the new normal life during the lockdown, daily internet usage, perception regarding the risk of getting infected by covid- , anxiety, sleeping schedule, etc. sleep disturbance was considered as a binary outcome of interest. individuals were asked whether they are facing any kind of problems or disturbances in their sleep during the lockdown period or not. descriptive statistical methods have been applied to assess the distribution of the demographic characteristics of the bangladeshi population. then, pearson's chi-square tests ( ) were used to find associations between independent variables and sleep disturbance, with those variables showing an association of . selected to be the part of the model. a multivariable logistic regression ( , ) has been carried out to find associations between the independent variables, the dependent variable, and adjust for confounders. the adjusted odds ratio (aor) and % confidence interval ( % ci) have been obtained from the logistic regression model. in the logistic regression model, coefficients with p-values ( -sided tests) less than or equal to . have been considered as statistically significant ( % level of significance). as a measure of model performance, the area under the curve (auc) of the receiving operating characteristic (roc) has been calculated along with its standard error by using its equivalence to the wilcoxon statistic ( , ) . all data were analyzed using r (version . . , rstudio version: . . ) and stata version . (stata se , stata corp, college station, tx, usa). the socio-demographic information of the respondents is presented in table . the analysis was based on a sample of , respondents (male . % and female . %). the majority of the respondents ( . %) were from the second age group ( - years). there was found to be a higher response ( . %) from the dhaka division. the responses were the highest ( . %) from urban areas. more than half of the participants ( . %) were students, and . % have passed the bachelor or equivalent level. the marital status of % of respondents is "single". around % of the respondents have income less than ten thousand tk. the prevalence of sleep disturbance by the demographic and personal information of the respondents is presented in table . from this web-based survey, it has been observed that . % of the participants claimed to have sleep disturbance during the covid- lockdown. after performing pearson's chi-square test of association, it has been observed that place of residence, age, gender, and marital status have a statistically significant association with sleep disturbance. table displays that sleep disturbance during this pandemic situation is more common among respondents of urban areas ( . %) compared to rural areas ( . %). the highest prevalence of sleep disturbance has been found among respondents aged - years. among females, a higher prevalence of sleep disturbance ( . %) has been observed compared to males ( . %). the sleep disturbance significantly varies with the marital status of the respondents. among respondents who were in a relationship, about % are suffering from sleep disturbance, whereas the prevalence of sleep disturbance is the lowest ( . %) among "single" respondents. table explores how sleep quality is disrupted during the covid- lockdown. a higher prevalence of sleep disturbance has been observed among respondents whose family member/relative/ friend/neighbor or him/herself has got infected with covid- . among respondents who were working from home or doing online courses (during the lockdown) through the internet, . % have developed sleep disturbance. the prevalence of sleep disturbance varies considerably by internet usage. table indicates that the prevalence of sleep disturbance is the highest among respondents whose daily internet use is more than h. losing the job of any of the family members (including respondents) increases the prevalence of sleep disturbance. among respondents who thought to be at a high risk of getting infected by covid- , . % had a sleep disturbance. it has been observed that about % of respondents have claimed to develop anxiety during the lockdown, while . % of them have also claimed to develop sleep disturbance, which is higher than those who do not think finally, the estimated effects from the logistic regression model for the factors associated with sleep disturbance are presented in table . the odds of having sleep disturbance is % higher among the respondents who are working from home or taking online classes through the internet than those who are not doing so (aor: . , ci: . - . ). sleep disturbance is . times higher among respondents who or anyone from his/her family had lost their job than among the respondents who or anyone from his/her family did not lose their job during lock-down. it has been observed that a respondent who thinks to be at a high risk of getting infected by lastly, the area under the curve (auc) of the receiving operating characteristic (roc) curve has been calculated as a measure of model performance, which explains the model's performance by evaluating sensitivity versus specificity. figure displays that there is a . % chance that the final fitted model will be able to distinguish between the positive and negative class of sleep disturbance. further, statistically significant evidence (pvalue <. ) has been found that the model performance measure auc of the final fitted model is greater than . . according to worldometers, a total of , covid- cases were identified, and the death rate was . % over the cumulative number of closed cases up to th march when the first shutdown starts in bangladesh ( , ) . as of the end of march, infections remained low, but a steep rise had been observed in april ( ) . new cases in bangladesh grew by , % in the week ending on th april, which is the highest in asia, ahead of indonesia, with % ( , ) . this web-based survey shows a high prevalence ( . %) of sleep disturbance and anxiety ( . %) during the covid- outbreak. studies on the italian population showed a . % prevalence of sleep problems with . % anxiety disorders ( ) . the italian study partitioned their region into three geographical segments and revealed sleep disturbance by using official psychological tools. the majority of their respondents ( . %) were female. they explore the influence of demographic factors and knowledge of people affected by covid- in determining risk for sleep quality. on the other hand, our study assesses how covid- and new normal life during the lockdown disrupts sleep quality. furthermore, it is impossible to differentiate whether the results of the italian study are due to the fear of the pandemic or the restrictive measures imposed by the government of italy. however, the different demographic characteristics of the sample and different aspects of the italian study made a statistical comparison quite impossible. our study indicates that younger participants of age less than years were less likely to develop sleep disturbance compared to older people of age more than years during this lockdown. around % of the respondents aged - years were living in urban areas where population density is much higher compared to rural areas. as a result, a higher percentage of them ( . %) thought to be at a high risk of getting infected by covid- . this risk of getting infected may disrupt their sleep quality. women's triple burden is depicted across three broad categories of productive, reproductive, and community work ( ) . disease outbreak, disaster, or other crises predominantly increase women's workloads and decrease the ability to balance their time ( ) ( ) ( ) ( ) . burdens associated with covid- are figure | performance measure for predicting sleep disturbance using last fitted multivariable logistic regression model. strenuous, perilous, and likewise gendered. understanding the extent to which covid- home confinement measures affect women and men differently is fundamental for understanding the broader impact of this disease. during the lockdown, families are at home more which has intensified women's existing triple burden ( ) and fears of violent domestic abusers ( ) . a recent study has explored women's triple burden during covid- in three asian countries ( ) . home confinement may have increased household (including caretaking of elderly family members) responsibilities, which may disproportionately affect women. in addition to other jobs, this potential increase in responsibilities during the pandemic may have exacerbated adverse mental health for women in particular. several studies have reported a higher prevalence of sleep disturbance among women compared to males ( , , , ) . a recent study in the context of covid- conducted on bangladeshi people also found a higher prevalence of general anxiety disorder among females ( ) . similar to other studies, it has been observed in our study that the odds of getting anxious during the lockdown is about % higher among female participants than among males. this high prevalence of anxiety and a greater burden in the household increase the stress of females, which may result in a higher prevalence of sleep disturbance. it has been observed that sleep disturbance is more common among the participants who are working from home or taking online classes through the internet. one possible explanation behind observing a higher prevalence is that the majority of them ( . %) are using the internet for more than h a day. previous studies have identified excessive usage of the internet as a potential source of sleep disorders ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . besides this, around % of the respondents who were working from home or taking online classes through the internet were female, which also provides the rationale for observing a higher prevalence among them. readymade garments and other export-oriented sectors of bangladesh had faced a huge shock due to orders cancellation of worth $ . billion ( ) . more than a million have already been fired or furloughed as global fashion companies have canceled or suspended their orders in bangladesh due to the corona virus crisis ( ) . the tourism industry of bangladesh will face a loss of about tk billion (usd million) this year, whereas this sector directly provided a livelihood for . million people ( ) . around lakh transport workers had become temporarily unemployed ( ) . it seems that this pandemic now turns into a severe economic crisis as a huge percentage of people have already lost their jobs. among the participants, % stated that their family members or they themselves lost jobs during this lockdown. the finding of this study implies that there is a greater prevalence of sleep disturbance among participants who or anyone from their family members lost jobs during this pandemic as losing jobs create massive insecurity of meeting livelihoods. the results of this survey have displayed that . % of the participants think that they are at high risk of getting infected. the results of multivariable logistic regression have suggested that the odds of developing sleep disturbance is higher among participants who thought to be at high risk of getting infected. due to the lockdown, people have been confined to their homes, which results in a severe reduction of their daily social interaction. this lack of social interaction and home confinement may contribute to developing anxiety. expectedly, it has been observed from the study results that the presence of anxiousness triggers sleep disturbance. in several studies, anxiety had also been found as a potential risk factor of sleep disturbance ( ) ( ) ( ) ( ) ( ) ( ) ( ) . in this study, no statistically significant association (pearson's chi-square value = . , p-value = . ) has been found between respondent's anxiety and age. before the covid- lockdown, the sleeping schedule was more dependent on a person's working shift. several studies have found that sleep disorders are more common in night-shift workers compared with day workers ( ) ( ) ( ) . during lockdown, people have been confined to their homes, which moderately shifts the working hours and work responsibilities. participants of this study were mainly students ( . %) and in general, they can have erratic sleep schedules as they have no defined hours to do their work. the results of this study have suggested that sleeping schedule has a statistically significant impact on developing sleep disturbance in favor of participants who slept more at night ( pm- am) than those who slept more at daytime ( am- pm). the findings of this study suggest that the factors highlighted above can be the potential risk factors of developing sleep disturbance, as previously reported for the chinese population and accordingly with other studies on epidemic and quarantine conditions ( ) ( ) ( ) ( ) . the findings of this study should be interpreted in the context of the study's design and limitations. the study used a web-based nonprobabilistic convenience sampling method as it was impossible to take personal interviews due to covid- confinement restrictions. it is always very much difficult to obtain a nationally representative sample through a web-based survey. expectedly, we have observed more responses from urban areas and comparatively younger groups of bangladeshi population (mainly students) as they are more active in digital platforms than the people of rural areas and elderly people of bangladesh. approximately half of the responses have been obtained from the dhaka division, which results in failing to capture the regional psychological behavior of the respondents. since the study is a cross-sectional one, it can only point toward associations. a more robust design such as cohort or case-control is recommended to corroborate causation and generalization. the results of this study could have been more robust if we could have included the information regarding the previous history of sleep disturbance (insomnia), depression, and other mental health conditions (bipolar disorder), the previous history of anxiety disorder, chronic diseases/chronic pain conditions, consumption of medications associated with insomnia. the survey was basic, with clear categories outlined and no need for official psychological tools, making it easy for respondents to quickly go through the survey. the survey reached people through a variety of digital platforms, making it more accessible and meeting people where they already are (aside from the fact that this was not available in person). notwithstanding all the limitations, this study explores a relevant topic, mental health and associated conditions like sleeping disorders, which have been identified as one of the secondary effects of the pandemic. to the best of our knowledge, this will be the first study in bangladesh that assesses the association between sleep disturbance and variables associated with the lockdown prompted by covid- . fortunately, many strong national measures have been taken by the bangladesh government to avoid further spread of the covid- outbreak. however, the public's psychological problems during the covid- outbreak are still overlooked. this study attempts to fill this research gap by analyzing the prevalence of sleep disturbance as sleep disturbance is one of the key symptoms of major depression and one of the proven risk factors for suicide ( ) ( ) ( ) . the findings of this study suggest that sleep disturbance during the lockdown is dependent on both demographic characteristics and the covid- related information of the respondents. in conclusion, this study found that variables associated with the lockdown prompted by covid- such as working from home or doing online classes through the internet, job loss, anxiety, fear of infection with covid- , and (day) sleeping schedule were predictive factors for developing sleeping disorders in the bangladeshi population. we anticipate that this framework will help the policymakers to initiate government programs to diagnose and treat mental health disorders due to the secondary impact of the pandemic. we suggest arranging cognitive-behavioral therapy (cbt) which is the most widely-used therapy for sleep disorders and may be conducted individually in a group of people with similar sleeping problems, or even online ( ) ( ) ( ) . as well as changing the way one's thinking regarding sleep, 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distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- - qoyrqmj authors: huq, samin; biswas, raaj kishore title: covid- in bangladesh: data deficiency to delayed decision date: - - journal: journal of global health doi: . /jogh. . sha: doc_id: cord_uid: qoyrqmj nan l ower middle-income countries are not heavily presented in global media on covid- . bangladesh, a densely populated nation, have conducted only tests in last one month with reported deaths. the decisions of cluster-wise lockdown or social distancing, or even preparing the health system to respond to the pandemic are made without the availability of adequate data. this is fuelling panic in local community and giving an obscure picture in the global data. with major discussions around covid- pandemic focused on china, usa and europe, few media reports have acknowledged that it has also silently paved its way into lower middle-income countries. in bangladesh, as per the th of april , only diagnosed cases and deaths have been associated with covid- with first case detected on the th of march [ ] . as of the st of april, the number of tests conducted was since the detection of the first covid- case. in a country of million and with overseas arrivals between the th of march and the th of april, which included some hard-hit countries such as italy, a total of less than tests in the first weeks of transmission were likely insufficient to illustrate the viral transmission in bangladesh [ ] . although scarcity of test kits and lack of awareness from the general public certainly contributed to the crisis, bangladesh is one of the few countries which had more than two months to prepare for covid- crisis. it could have been both aware and prepared, because of its close business ties with china. due to the shortage of test kits, authorities had to set strict eligibility parameters for the test. thus, only those with direct contact with foreign returnees were tested. there was a refusal to consider the possibility of any community transmission, which created confusion. furthermore, there was a rather strong opposition to the development of rapid diagnostic kits on diagnostics attributes such as sensitivity and specificity, without careful consideration on affordability and subsequent accessibility. this problem has contributed to a reduced availability of baseline information on the degree of transmission of covid- in bangladesh. the situation forced the government to enforce measures without being able to rely on substantial data. in bangladesh, the covid- crisis was therefore a game of "catching up". the government has undertaken measures iteratively, in response to the situational development in the country. it promoted hand hygiene and other protective measures, such as social distancing, airport screening, quarantine wherever necessary, and restricted movement during government holidays [ ] . as the final step, the government decided on a nation-wide shutdown, with army deployed to ensure a proper lockdown. the crisis has already started in the form of limited availability of disinfectants and personal protective equipment in the health care facilities. this led to el-covid- in bangladesh: data deficiency to delayed decision samin huq , raaj kishore biswas evated perceived risk on covid- infection in the hospitals. many facilities are now refusing to admit patients who suffer from other routine complications. lack of testing also limited quarantines of close contacts of the suspected cases. these resulted to country-wide fear and an avalanche of reports on deaths with pneumonia/flu-like symptoms. the fear soon turned to a panic, as some villages or entire local areas were locked down by local authorities over untested possible covid - related deaths. the only testing facility during the first weeks of the crisis (the th to the th march) received over phone calls to request testing, but was only able to test . % of those who raised a concern over their status [ ] . this shows the extent of the burden that the authorities in bangladesh had to deal with. the lack of information fuelled the panic. on the th of march, the government extended testing to multiple facilities following a supply of test kits from china. however, the rush towards testing in absence of a careful planning within these facilities for sample collection and diagnosis created more confusion. this is because some facilities with test kits did not have laboratories with biosafety level or no trained personnel who could adhere to a standardized protocol [ ] . the crisis worsened with increases in prices due to shortages of essential items. such a scenario can result in limited affordability in a capitalistic economy, where families are dependent upon the single-wage earners. in the era of free-flowing online information, "discoveries" based on weak evidence and related comments had a massive influence on the decision making at the individual level. this led to, for example, overstocking of medications such as hydroxychloroquine and azithromycin, which created an artificial scarcity. partial lockdown aimed at social distancing may allow virus containment for a period of time [ ] . however, it comes at a cost as resource-intensive and demands meticulous contact testing. furthermore, widespread testing becomes difficult to replicate in a resource-limited health care infrastructure. bangladesh has inequitable distribution of health care workforce concentrated in the major urban areas. this is coupled with one of the lowest availability of health care workforce in the world, with only . skilled workers per population [ ] . aligning the situation with the dimension of access by penchasky and thomas [ ] , limited availability coupled with reduced accessibility in the peri-urban and rural health care settings may contribute to a health care catastrophe in addressing the control of covid- . the recent surge of daily testing has managed to uncover more cases and traces of transmission at the community level. despite the surge, the testing rate is too low to uncover the true burden of covid- in bangladesh, considering the population size ( tests per million) [ ] . on the other hand, the surge on daily testing has only managed to expose some hotspots which were already known to be the densely populated areas of the capital. therefore, the recent opening of the manufacturing industries, with subsequent closure due to criticism, contributed to migration to the overcrowded areas of the city [ ] . such initiatives can lead to a dual burden of risk transmission, to both the rural community and the urban community. this happens at a greater pace, owing to the mass migration of the factory workers. also, decision making based on the current prevalence of covid- can undermine the photo: the distribution of positive covid- cases across the districts of bangladesh ( april ), data source: https://iedcr.gov.bd/. the lack of data has led to unplanned decision making and contributed to skewing global data. issue of the health system preparedness without a careful understanding of the dynamics of covid- evidenced worldwide. it can include premature lifting of restricted movement and sanctions and lower concentration of testing and contact tracing in the rural areas. these can impact not only the health system planning and response in terms of financial input, but also appropriate service delivery and required supply to address the covid- due to the changing dynamics of population density in the event of reduced sanctions. additionally, it can lead to a surge on heightened risk of exposure due to minimized health response priorities, efforts and initiatives -such as contact tracing and testing in the rural areas and considering their movement to the urban areas. while pandemics hardly give opportunities to many countries to prepare, developed nations will have the data to at least trace their progress and assess their position on the curve. unfortunately, the curve for bangladesh seems flat with only one case detected in a period of hours (the th to the th march). this could be because either bangladesh is extremely lucky, or this scarcity of databased on appropriate testing now obscures an ominous death toll that is to follow. directorate of health services goverment of bangladesh directorate of health services goverment of bangladesh. daily and monthly call report situation analysis of novel covid- feasibility of controlling covid- outbreaks by isolation of cases and contacts world health organization. the global health observatory data repository the concept of access: definition and relationship to consumer satisfaction coronavirus cases rmg workers asked to go back from factory gates no funding source to declare.authorship contributions: sh reviewed literature, compiled data and drafted the manuscript. rkb conceptualised the study, coded the map, critically reviewed and revised the manuscript. both authors read and approved the final manuscript. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest. key: cord- -j glby authors: bodrud-doza, md.; shammi, mashura; bahlman, laura; islam, abu reza md. towfiqul; rahman, md. mostafizur title: psychosocial and socio-economic crisis in bangladesh due to covid- pandemic: a perception-based assessment date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: j glby background: the spread of the covid- pandemic, the partial lockdown, the disease intensity, weak governance in the healthcare system, insufficient medical facilities, unawareness, and the sharing of misinformation in the mass media has led to people experiencing fear and anxiety. the present study intended to conduct a perception-based analysis to get an idea of people's psychosocial and socio-economic crisis, and the possible environmental crisis, amidst the covid- pandemic in bangladesh. methods: a perception-based questionnaire was put online for bangladeshi citizens of years and/or older. the sample size was , respondents. datasets were analyzed through a set of statistical techniques including principal component and hierarchical cluster analysis. results: there was a positive significant association between fear of the covid- outbreak with the struggling healthcare system (p < . ) of the country. also, there was a negative association between the fragile health system of bangladesh and the government's ability to deal with the pandemic (p < . ), revealing the poor governance in the healthcare system. a positive association of shutdown and social distancing with the fear of losing one's own or a family members' life, influenced by a lack of healthcare treatment (p < . ), reveals that, due to the decision of shutting down normal activities, people may be experiencing mental and economic stress. however, a positive association of the socio-economic impact of the shutdown with poor people's suffering, the price hike of basic essentials, the hindering of formal education (p < . ), and the possibility of a severe socio-economic and health crisis will be aggravated. moreover, there is a possibility of a climate change-induced disaster and infectious diseases like dengue during/after the covid- situation, which will create severe food insecurity (p < . ) and a further healthcare crisis. conclusions: the partial lockdown in bangladesh due to the covid- pandemic increased community transmission and worsened the healthcare crisis, economic burden, and loss of gdp despite the resuming of industrial operations. in society, it has created psychosocial and socio-economic insecurity among people due to the loss of lives and livelihoods. the government should take proper inclusive steps for risk assessment, communications, and financial stimulus toward the public to alleviate their fear and anxiety, and to take proper action to boost mental health and well-being. the novel coronavirus disease (covid- ) began spreading in november , in wuhan, china. following this, the world health organization (who) announced covid- as a global pandemic on march th, ( ) . covid- has advanced into a pandemic, starting initially as small clusters of transmission that combined into larger clusters in many countries, subsequently resulting in a widespread transmission ( ) . social isolation, institutional and home quarantine, social distancing, and community containment measures were applied without delay ( ) . through quick administrative action and raising awareness for individuals on social-distancing, stringent steps were taken to manage the spread of the disease by canceling thousands of locations that involved social gathering including offices, classrooms, reception centers, clubs, transport services, and travel restrictions, leaving many countries in complete lockdown ( ) . the remarkable actions and ventures in public health to quarantine mass numbers has prevented this virus from spreading exponentially between humans in china, singapore, hong kong, and south korea, despite initial cases ( , ) . however, a surge of covid- outbreaks in all inhabitable continents, with , deaths alone in the usa, indicates that the infection had passed the tipping point ( , ) . today, as of the th of may , total global covid- cases have risen to , , , with the total number of deaths escalating to , , ( ) . the accelerating spread of covid- and its outcomes around the world has led people to experiencing fear, panic, concern, anxiety, stigma, depression, racism, and xenophobia ( ) . bangladesh confirmed their first covid- case on the th of march ( ), followed by a nationwide lockdown from march which had been extended several times until th may to prevent human transmission. the government deployed armed forces to facilitate social distancing on march th. emergency healthcare services and law enforcement were exempt from this announcement. yet more than million people left dhaka to return to their home districts and thus helped spread the diseases nationwide. moreover, from the th of april , all ready-made-garment (rmg) factories, industries, private offices, and business centers were allowed to open, leading to a "partial lockdown" in the country. the migration of rmg workers to the industrial districts and less community awareness about the disease has increased the transmission among millions of people. the institute of epidemiology disease control and research (iedcr), under the ministry of health and family welfare (mfhw) and directorate general of health services (dghs), is responsible for researching epidemiological and communicable diseases such as covid- in bangladesh, as well as disease control and surveillance. initially, iedcr was the single and centralized laboratory for covid- testing in bangladesh ( ) . the dghs, on the other hand, is the responsible body for the coordination of testing and sample collections of covid- patients ( ) . as of the th of may , according to iedcr, the total number of covid- positive cases stands at , with deaths (figures a,b) . according to iedcr, those aged between and are with the highest number of cases ( %), while those aged above have had fatal cases of the disease ( %). at present, the fatality rate in bangladesh is . % ( th may ) which was initially . % ( th april ) ( ) . although the number of laboratories for covid- testing has increased to , all these labs are in major urban areas of bangladesh and to get tested requires long waiting hours. more often the tests have been done after the patients had died. very recently, more than % of those tested daily have tested as positive (figure c) , and the ratio of testing is , / million people. in addition, it also takes a long time to get the result of the tests. furthermore, there are only , intensive care unit (icu) beds in the country, of which beds are in government hospitals and in private hospitals. it is predicted that as the number of patients rise, the required number of icu facilities will not be adequate ( ) . in addition, the healthcare staff and doctors were given low quality/no personal protective equipment (ppe) which has caused a high infection rate among them ( ) . moreover, as laboratory staff, healthcare staff, and doctors have become increasingly infected, there is also a shortage of specialized trained personal to perform covid- tests, meaning patient treatment will be disrupted. amidst the lockdown, due to the fear of contact transmission, private hospitals and clinics are not providing any services ( ) . the shortage of healthcare facilities for primary and critical care patients have therefore been depleted. the healthcare workers who have treated patients and become infected have been criticized socially and have faced social stigma from local people. in many locations public protests were observed against the establishment of quarantine facilities, covid- care hospitals, and clinics. social humiliation was a common practice of law enforcement authorities and government officials. on many occasions, family members left the infected and the deceased in the hospitals. the deceased were even denied burials in local graveyards, which are basic cultural rights as a muslim ( ) . moreover, the lockdown hit hard for those who earn daily wages and low and middle-income people who lost their jobs and their income source. the anxiety and fear of death from hunger or death from infection led to several suicide cases ( ) . predictably, any contagious epidemic outbreak has harmful effects on individuals and society ( ) . considering the population density, educational status, social structure, cultural norms, healthcare capacity, and often flawed policies taken by the government of bangladesh, it is hard to lock down a country of million people. moreover, bangladesh hosts the largest refugee camps in the world in the cox's bazar district. the rohingya refugees who fled from myanmar reside in the camps of cox's bazar. confirmed cases were found in the camps while the district had reported confirmed cases ( ) . this depicts the scenario of public anxiety which should be immediately dealt with by the government, along with the alliance groups, with proper information. amidst the current societal levels of anxiety and fear, the possibility of natural disasters such as tropical cyclones and monsoon floods and the potential for a dengue outbreak, seasonal influenza, or other infections are potentially overlooked. furthermore, the consequences of incorrect disposal of used personal protective equipment (ppe) from covid- hospitals without proper treatment in landfill sites has the potential for further disease transmission among the waste management personal and further environmental transmission. considering the given circumstance, this study was designed to analyze the psychosocial, socio-economic, and possible environmental crisis based on public perception in bangladesh due to the covid- outbreak. this assessment may inform the government and policymakers of countries with a similar socioeconomic and cultural structure to bangladesh. to understand the possible psychosocial, socio-economic, and environmental impact of the covid- outbreak in bangladesh, we considered and identified several relevant and possible items based on the socio-economic situation, political analysis, the existing healthcare system, environmental analysis, possible emerging issues utilized from scenario developments, analysis of local and global reports of the covid- pandemic from the print and electronic media, and a literature review. we prepared the questionnaire considering the demographic characteristics of bangladesh, societal mental health conditions (mh), the healthcare system in bangladesh (hsb), governance and political issues (gpi), socio-economic issues (sei), immediate emerging issues (iei) and enduring emerging issues (eei). a total of items were considered in the drafted questionnaires to understand people's perception of the covid- outbreak in bangladesh. furthermore, expert consultation was considered to set and validate these items. we prepared the online-based questionnaire through google to operate the survey nationwide. an introductory paragraph describing the objective of the questionnaire was shared with the respondents through email and through social platforms commonly used by bangladeshi groups on facebook, messenger, linkedin, and whatsapp. relevant people were selected for targeted sampling. an online database of target participants was prepared by reviewing relevant websites and online social platforms of different groups in bangladesh. the sample group was targeted considering bangladeshi citizenship, their age, current activities, occupation, social and economic responsibilities, and engagement related to covid- response, planning, and policymaking. the questionnaire survey was conducted from march to march during the lockdown period. the respondents belonged to different social categories, such as university faculty members and scholars, government officials, development workers or practitioners, doctors, engineers and technologists, youth leaders and students, businessmen and industry officials, banking and finance corporates, and independent researchers, among others. the answers to the survey questionnaire were voluntary. data from respondents were collected through this online survey initially using the simple random sampling method following keeble et al. ( ) . following the removal of incomplete questionnaires, , responses were finally retained for this study. a five-point ( to ) likert scale was used for testing the statement descriptions that ranged from strongly disagree to strongly agree with the statements ( table ) . there was a limitation of the rapid assessment on the publicperception on the psychosocial and socio-economic crisis in bangladesh due to the covid- pandemic. as the study was conducted during the lockdown period, it was not possible to reach to general people physically. therefore, we had to keep our samples limited to internet users only. there are more than million mobile internet users in bangladesh and, as a youthdividend country, the majority of the mobile internet users are young educated people. the descriptive statistics [e.g., frequencies, percentages, and ttest (data provided in supplementary tables)] were employed to understand respondents' characteristics. an investigation of psychometric characteristics was included in the classical test theory (ctt) analysis. a set of statistical techniques, including linear regression analysis (lra), principal component analysis (pca), and hierarchical cluster analysis (ca), were applied to explore the association between the items. pca is a data reduction tool that demonstrates each potentiality of parameters and their confidence level in large sample datasets. before conducting the pca, kaiser-maier-olkin (kmo) and bartlett's sphericity tests were applied to confirm the necessity of this analysis. the results of the kmo at > . (the kmo value was . in this work) and the significance of bartlett's sphericity test at p < . supported our datasets to be fitted for the pca ( ) . the number of factors chosen was based on the kaiser's principle, where the only factors with eigenvalues> . were considered. cronbach's alpha was employed to test the consistency and reliability of the factor loadings in this study. cronbach's alpha values at > . (the cronbach's alpha value was . ) are regarded to be suitable in social science research ( ) . the ca is a crucial means of detecting associations among many psychosocial and environmental parameters. ca assists to demarcate a population into various groups based on the same feature of a set of the dataset that may reveal causes, effects, and/or the source of any unidentified relationships among the items. furthermore, hierarchical clustering was used to determine the probable number of clusters. statistical package for the social sciences (spss) v. . was used for the analysis of the datasets. the consent of the respondents was taken before the survey, and their anonymity was guaranteed. all the participants were informed about the specific objective of this study before proceeding to the questionnaire. participants were able to complete the survey only once and could terminate the survey at any time they desired. anonymity and confidentiality of the data were ensured. formal ethical permission of this study was taken from the respective authority. a total of , (=n) responses were recorded in this study. the proportion of male to female respondents was : [males (n = ; . %) and females (n = ; . %)]. the composition of age groups of the respondents was as follows: . % ( - years old), . % ( - years old), . % ( - years old), . % ( - years old), and . % (> years old). the average age of the respondents was . years (sd ± . ). on average, the respondents had . years of formal education (sd ± . ). % of the youth group were mostly students or at the brink of finishing their studies. the remaining % of the respondents were from various professions, including doctors and healthcare workers, civil service officials, non-government officials (ngos), teachers and scholars, policymakers, researchers, and businessmen. the descriptive statistics containing the statements are shown in table . the category of statements were grouped as follows: mental health condition (mh) comprised five statements (mh - ), the healthcare system of bangladesh (hsb) comprised ten statements (hsb - ), the governance and political issues (gpi) comprised statements (gpi - ), the socio-economic issues comprised statements (sei - ), the immediate emerging issues comprised statements (iei - ), and for enduring emerging issues statements were considered (eei - ). in the following section of mental health status, healthcare system, governance and political perspective, socio-economic aspects, and emerging issues, we have discussed the descriptive statistics. in the statement of "i am afraid of the recent outbreak of coronavirus in bangladesh" (mh ) . % of the respondents strongly agreed, followed with a mean of . ± . . in the second statement (mh ), "i am afraid of getting infected with coronavirus" the difference among strongly agreed ( . %) and agreed ( . %) statement with a mean value of . ± . . for statement three, . % of the respondents strongly agreed to the (mh ) "i am afraid of losing my life or my relatives' life due to this outbreak" with a mean value of . ± . . in the fourth % of the respondents strongly agreed to the statement that the healthcare system of bangladesh is fragile and unable to deal with the recent outbreak of covid- (hsb ), with a mean value of . ± . . for the second statement, % of respondents with a mean value of . ± . strongly agreed that "a huge population is a pressure to the existing healthcare system to deal with covid- " (hsb ). % of the respondents with a mean value of . ± . strongly agreed that "there is a lack of awareness of basic healthcare issues in most of the citizens of bangladesh" (hsb ). moreover, % of the respondents with a mean value of . ± . strongly agreed that there is "a lack of trained doctors and healthcare professionals to deal with the covid- " (hsb ). with a mean value of . ± . , . % of the respondents strongly agreed that "the lack of healthcare facilities will be unable to combat the covid- outbreak in bangladesh" (hsb ). again, % of respondent with a mean of . ± . strongly agreed with "the lack of healthcare infrastructure to deal with covid- " (hsb ). for statement seven, . % of respondents with a mean value of . ± . strongly agreed that "there is a severe lack of bio-medical and hospital waste management facilities in bangladesh" (hsb ). moreover, % of respondents with a mean value of . ± . strongly agreed that "there is a lack of covid- testing facility in bangladesh" (hsb ). . % of respondents ( . ± . ) strongly agreed that "the budget is inadequate or there is a lack of financial support to respond to this outbreak" (hsb ). finally, . % of respondents with a mean value of . ± . strongly agreed that "most of the poor people will not have access to the existing healthcare facilities if they are infected with covid- " (hsb ). regarding the statement of "the bangladesh government can deal with this outbreak" (gpi ), the public opinion did not vary significantly with a mean value of . ± . . similar responses were also found in response to "the government is taking this outbreak seriously" (gpi ) with a mean value of . ± . and "the government is taking proper decisions at the right time" (gpi ) with a mean value of . ± . . . % of respondents strongly agreed that "the government needs support from the general public to reduce the impact of covid- " (gpi ) with a mean value of . ± . and that "the government needs to formulate a policy and action plan and implement it immediately" (gpi ) with a mean value of . ± . . about . % of respondents agreed that "developed nations are going to support bangladesh in response to covid- " (gpi ) with a mean value of . ± . . nearly - % of respondents strongly agreed that "the shut down or lockdown of regular activities was a good decision to reduce the chance of infection of covid- " (sei ) (mean . ± . ), "this will have an economic and social impact in the future" (sei ) (mean . ± . ), and that "both formal and informal businesses will be hampered" (sei ) (mean . ± . ). for the fourth statement, . % of respondents strongly agreed that "poor people living off daily wages will be severely affected" (sei ) with a mean of . ± . , while . % strongly agreed that "most of the poor people living in urban areas have to leave the city due to not having any options for income" (sei ) (mean . ± . ). . % (mean . ± . ) of the respondents agreed that "many people will lose their livelihood/ jobs at this time" (sei ). a further . % (mean . ± . ) strongly agreed that "there will be a reduced supply of basic goods/ products for daily use" (sei ) and . % (mean . ± . ) strongly agreed that "there was or will be increased prices for basic products" (sei ). consequently, "poor people will suffer food and nutritional deficiency" (sei ) was strongly agreed with by . % respondents (mean value of . ± . ). "the shutdown of education institutes will hamper those currently receiving formal education" (sei ), to which % respondents strongly agreed (mean value of . ± . ). for "if there is a chance of social conflict due to this outbreak" (sei ), the mean response was . ± . . . % (mean . ± . ) of respondents strongly considered that "there is a chance of community transmission of covid- in bangladesh" (iei ) and that "a huge number of people will be infected" (iei ) with a mean value of . ± . . moreover, % of the respondents strongly agreed (mean value . ± . ) that "there is a chance that many infected patients will not be detected due to a lack of testing facilities and this will not show the actual number of infected cases" (iei ). approximately - % of the respondents strongly agreed that "there is a chance of an increasing numbers of deaths from infection due to a lack of proper health facilities" (iei ) with a mean value of . ± . . "a lack of bio-medical waste management facilities in the hospitals will create further transmission" (iei ) received a mean value of . ± . . for the sixth statement, . % of respondents (mean value of . ± . ) strongly agreed that "there will be many people psychosocially shocked due to this outbreak" (iei ) and that "the general public will lose trust in the government" (iei ) was strongly agreed with by . % respondents with a mean value of . ± . . we have considered emerging enduring issues (eei), such as potential natural calamities and infectious disease outbreaks, as the monsoon season is approaching. six statements were considered for enduring emerging issues (eei - ). regarding the statement that "there is a chance of a disaster such as a flood, cyclone, or drought in considering the vulnerability of bangladesh to climate change" (eei ), there was a mean response of . ± . . but the statement "if any disaster (flood, cyclone, landslide) occurs after/during covid- , the situation will create a double burden to the country" (eei ) was strongly agreed with by % of respondents with a mean of . ± . . . % of respondents agreed with a mean of . ± . that "there is a chance of severe food scarcity in the country due to these events (covid- + disasters)" (eei ). a strong agreement from participants (varied from to %) was observed for the statements: "there is a high possibility of huge economical loss" (eei ) with a mean value of . ± . , "there is a high possibility of increasing poverty level" (eei ) with a mean value of . ± . , and "there is a high possibility of severe socio-economic and health crisis" (eei ) with a mean value of . ± . . the association of affected psychosocial wellbeing and the fragile healthcare system during covid- outbreak from the regression analysis, among the variables, only five variables showed statistically significant associations with the fragile healthcare system of bangladesh (hsb ) to deal with the recent outbreak of covid- in the country ( table ) . hsb , hsb , and iei statistically pose a significant positive effect on the fragile healthcare system of bangladesh (p < . ). this relationship implies that a huge population and a lack of healthcare facilities are contributing to the community transmission of covid- in bangladesh. the presence of community transmission in bangladesh within a short time is present as predicted by the iedcr, who announced a mildlevel community transmission possibility in bangladesh on st april in their press release ( ). this assumption is further validated by the number of deaths from covid- reported in the news, after the announcement of the partial lockdown, and the opening of rmg factories from april . the number of covid- patients increased significantly in industrial zones. there was also a positive significant association between the fear of the covid- outbreak (mh ) with the struggling healthcare system (p < . ). also, the negative association between hsb and government political decision gpi (p < . ) reveals that the government is unable to make proper decisions at the right time due to the poor governance in the existing healthcare system. the results of linear regression showed that among the variables, only variables showed statistically significant associations with fear of the covid- outbreak ( table ) . for instance, mental health variables mh , mh , and mh statistically pose a significant positive effect on fear of the covid- outbreak (p < . ). on the other hand, there is a statistically positive association between fear of the covid- outbreak (p < . )and the healthcare system in bangladesh (hsb and hsb ), due to the lack of testing facilities and a fragile healthcare system contributing to the fear that has been experienced due to the covid- pandemic in bangladesh. the socioeconomic issues (sei ) and immediate emerging issues (iei ) have a statistically significant positive impact (p < . ), e.g., obstruction to the formal education system, and the potentiality of a huge number of people becoming infected may contribute to the fear development of the covid- outbreak in this country. there was also a positive significant association between the chance of community transmission of covid- for immediate emerging issues (iei ) with fear of the covid- outbreak (p < . ). results from the regression analysis further showed eight variables have a significant statistical association with the governance and political capacity to deal with the covid- outbreak in bangladesh (gpi ). a significant positive association was found among the governance and political issues (gpi with gpi and gpi ) and socioeconomic issues (sei ) (p < . ), implying that the government's decision to lockdown activities was at the proper time and has enhanced the people's perception of the capacity of government to deal with the covid- outbreak ( table ). however, the negative association between governance and political issues (gpi ) and the healthcare system of bangladesh (hsb ) (p < . ) shows that a perceived lack of budget created a gap in the response to covid- ( table ) . moreover, a negative association of governance and political issues (gpi ) with the healthcare system of bangladesh (hsb ) and socioeconomic issues (sei ) (p < . ) shows a perceived lack of trained doctors and healthcare professionals, and that a hampering of formal and informal business activities are reducing the government's capacity to deal with the covid- outbreak. nevertheless, a positive association of governance and political issues gpi with socioeconomic issues sei (p < . ) and governance and political issues gpi (p < . ) shows that there is a perceived possibility of social conflict due to this outbreak if not managed properly, and that the bangladesh government will need support from developed nations and allied forces to deal with this outbreak. it should be mentioned here that containment, risk mitigation, and suppression plans must be as inclusive as possible or risk undermining response efforts. the regression analysis showed that, among the variables, nine showed a significant statistical association with the future impacts of implementing lockdown and social-distancing activities (sei ). a significant positive association of socioeconomic issues (sei ) with governance and political issues (gpi ) and socioeconomic issues (sei ) (p < . ) shows that the government took the right decision by shutting down regular activities and implementing the social distancing approach ( table ) . but due to this initiative, the formal and informal business sectors and the economy will be hampered. again, a positive association of socioeconomic issues (sei ) with mental health (mh ) and healthcare services (hsb ) (p < . ) reveals that this decision of shutting down normal activities was imposed due to the fear of losing lives due to covid- and having a lack of healthcare facilities. however, a positive association of socioeconomic issues sei with sei , sei , sei , and enduring emerging issues eei (p < . ) shows that due to this shut down poor people will be severely affected, the price of the basic products will increase, the formal education system will be hampered, and the possibility of severe socio-economic and health crises will increase. in the regression analysis, eight variables are statistically associated with the possibility of community transmission of covid- (iei ). a significant positive association between mental health variables (mh , mh ), healthcare system variables (hsb , hsb ), socioeconomic variables (sei , sei ), and immediate emerging issues (iei , iei ) (p < . ) reveals that community transmission will increase the number of infected people which will create further fear and mental pressure of others of losing their lives due to covid- infection ( table ) . the fragile healthcare system of bangladesh will be unable to detect most of the infected patients due to a lack of health facilities, which leads to undermining the actual infected cases. as of the last day of the survey for this study on march , the testing rate of covid- was at its lowest in bangladesh compared to the other similar countries ( people/ million). however, as the laboratories increased, the number of testing has increased along with this, with people/ million. this is still inadequate compared to the population density. also, the inadequate disposal method of covid- hospital bio-medical waste management and associated facilities could increase community transmission. subsequently, due to the community transmission of covid- , many people will lose their lives and livelihoods, which might lead to creating social conflict, as a worst-case scenario. the regression analysis further identified nine variables that are significantly associated with the possibility of climate-induced extreme natural events (flood, cyclone, landslides, etc.) occurring during/after the covid- pandemic. the pandemic along with natural disasters may create a double burden to the country due to enduring emerging issues (eei ). the positive association between eei , sei , iei , eei , eei , and eei (p < . ) shows that there is a perceived possibility of a climate-change-induced disaster after the covid- situation which would create severe food insecurity ( table ) . poor people will suffer most from food and nutritional deficiency and the country will face enormous economic loss. also, after the covid- situation, a lack of bio-medical and solid waste management will add more problems. moreover, a positive association between eei , hsb , and eei reveals that, after the covid- emergency, existing poverty will create further socio-economic and health crises. overall relationship assessment among the variables from ctt, pca, and ca ctt and pca revealed a confidence level of controlling factors in bangladesh during the covid- outbreak and how these components are correlated to the psychosocial, socio-economic, and environmental crisis components (tables , ) . cluster analysis (ca) further detected the total status of regional variations, and how socio-economic and environmental crises influences psychosocial development (figure ) . from the ctt analysis, according to the corrected interitem correlation analysis, among variables, four variables have low corrected item-total correlations (i.e., the ability of the government to deal the outbreak, − . ; seriousness of the government, − . ; government is taking a proper decision, − . ; and other sectoral involvement to covid- , − . ). the remaining variables in the scale had an acceptable corrected item-total correlation ( . to . ) and the cronbach's alpha ( . ) was acceptable. from pca, nine principal components (pcs) were originally based on standard eigenvalues (surpassed ) that extracted . % of the total variance as displayed in table . the scree plot was adopted to detect the number of pcs to be retained to provide insight into the underlying variable internal structure (figure ) . the loading scores were demarcated into three groups of weak ( . - . ), moderate ( . - . ), and strong (> . ) ( ) ( ) ( ) . the pc (first) showed . % of variance as it encompassed a confidence level of weak positive loading of the healthcare system in bangladesh (hsb - : . - . ); with results being moderate positively loaded for the healthcare system in bangladesh (hsb - : . - . ). the pc (second) indicated . % of the variance and was loaded with moderate positive loading for socio-economic issues (sei - : . - . and sei : . ) and weak positively loaded for socio-economic issues (sei - : . - . and sei : . ). the pc (third) showed . % of the variance and was moderate positively loaded for immediate emerging issues iei - ( . - . ). the pc (four) indicated . % of the variance, and was loaded with a significant level of strong positive loadings for immediate emerging issues iei ( . ); results were moderate positively loaded for immediate emerging issues iei - ( . - . ) and immediate emerging issues iei - : . - . ), and were weak positively loaded for immediate emerging issues iei ( . ). the pc (five) and pc (six) indicated . and . % of the total variances, and loaded a significant level of strong positive loading for mental health issues mhi - ( . - . ) and government and political issues gpi - ( . - . ); results were moderate positively loaded for mental health issues mhi ( . ), mhi ( . ), government and political issues gpi ( . ), and gpi ( . ). results were weak positively loaded for mental health issues mhi ( . ) and government and political issues gpi ( . ). the pc (seven), pc (eight), and pc (nine) showed . , . , and . % of the total variances and were moderate positively loaded for government and political issues gpi - ( . - . ), socioeconomic issues sei ( . ), sei - ( . - . ), and immediate emerging issues (iei : . ); results were weak positively loaded for socio-economic issues sei ( . ), sei - ( . - . ), healthcare sector of bangladesh hsb - in the ca all the parameters were classified into four major groups: cluster- (c ), cluster- (c ), cluster- (c ), and cluster- (c ) (figure ) . c was composed of two sub-clusters of c -a and c -b; c -a was composed of issues surrounding an increase in the number of deaths due to not having proper health facilities, a lack of bio-medical waste management facilities in bangladesh that will create more problems, many people experiencing psychosocial issues due to this outbreak, with a large number of people becoming infected, and there being a chance of not detecting most of the infected patients due to the lack of health facilities leading to undervaluing the actual infected cases (iei - , iei - ). c -b was composed of socioeconomic issues that may lead to poor people suffering from a lack of food, thereby leading to nutritional deficiency (sei - and sei ). c consists of socio-economic issues (sei - ). c consisted of three sub-clusters of c -a, c -b, and c -c. c -a covered governance and political issues gpi - , and socioeconomic issues (sei ). c -b consisted of immediate emerging issues iei - , while c -c was composed of issues related to the healthcare system in bangladesh (hsb - ). cluster- consisted of three sub-clusters of the c -a health system in bangladesh and immediate emerging issues (hbs , iei ), c -b covered mental health issues (mhi - ), and c -c contained governance and political issues (gpi - and gpi ). this perception-based study tried to visualize the psychosocial as well as socioeconomic stresses due to the covid- pandemic in bangladesh. any major epidemic outbreak has negative effects on individuals and society ( ) , and people's fear due to covid- is rational in the sense that the fatality rate of the virus is around % and it can kill healthy adults along with the elderly or those with existing health problems ( ) . it is crucial to assess the covid- pandemic independently based on its attributes and not on past epidemics like sars or mers ( ) . more than covid- symptom-like deaths were reported from leading newspapers and electronic media from th of march to th of april . the reported case numbers certainly underestimate the actual number of infected persons given the limited number of urban testing centers, the shortage of test kits, and the long waiting times for tests and test results ( ) . the covid- outbreak caused other critical care and infectious disease patients to be deprived of basic healthcare facilities. patient-management decisions, early diagnosis, rapid testing, and detection are urgently needed ( , ) . the decentralization of testing and treatment facilities is required for the healthcare system to combat the pandemic. the government needs to aid in implementing testing facilities in both public and private clinical laboratories all over bangladesh. for a developing country, resources need to be assembled appropriately and promptly. with limited screening and testing of covid- in bangladesh, and the presence of only laboratories mostly located in urban areas, it is difficult to predict when transmission of the disease will peak and when the curve will flatten ( ) . predictably, community transmission in the country is happening and people are being infected and infecting their community, in some cases even without showing symptoms. it is further predicted that covid- and dengue together is a deadly combination. as the monsoon season approaches, the risk of dengue infection is on the rise. it is a timely step taken by the dghs to conduct dengue tests on suspected covid- patients, as both diseases share common symptoms (reported on may , by dghs in a daily press briefing on covid- ). successful governance is only possible with a competent early warning system, efficient analysis of the situation, and the interpretation, sharing, and use of relevant knowledge and information ( ) . public health instructions should be established based on scientific evidence to reduce the anxiety and distress caused by misinformation and rumors. epidemiological outcomes need to be informed on in time so that they can be accurately evaluated and explained ( ) . societies where underserved communities exist strongly fear government information and politics. public risk communications are therefore needed to prevent misinformation from social media and electronic media. the psychosocial risk (mental health impacts) for children in this situation are apparent, as they are out of touch with schools, classmates, and playmates, and deprived of physical activities and social activities; these issues need to be addressed. moreover, the isolation and quarantine of parent/s can mentally traumatize them and result in negligence, mistreatment, and abuse in the absence of parents/caregivers frontiers in public health | www.frontiersin.org ( ) . in addition, due to lockdown and the required maintenance of family hygiene, the burden of these activities is increased for women, considering the patriarchal nature of the country (where predominantly all household activities are performed by women). moreover, increased levels of violence against women and girls are experienced, as in the lockdown it is almost impossible for victims to escape those family members who are the perpetrators ( ) . furthermore, in the rohingya refugee camps, it will have catastrophic outcomes ( ) . these kinds of risks, awareness, and prevention methods should be effectively communicated to the public. as the pandemic continues, each new day brings in new conversations on social media and alarming developments of misinformation and propaganda, resulting in unnecessary psychological trauma and anxiety ( ) . moreover, religious tension, personal tension, job insecurity, financial loss, and social insecurity could leave some people feeling particularly vulnerable and mentally unstable ( ) . honest, transparent communication is vital for risk communication about the pandemic, while confusing or contradictory health messaging engenders mistrust and leads people to seek information from unreliable alternative sources and thus proliferates rumors ( ) . the fear of becoming infected or fear for vulnerable family members has amplified along with the administrative procedures of testing and reluctance of other private clinics and hospitals to admit patients. at the bbginning of this pandemic, bangladesh had only icu beds in five dedicated hospitals in dhaka for the treatment of covid- patients. there were no icu beds in hospitals outside dhaka ( ) . this is a sign of weak governance in the healthcare system of bangladesh. in this scenario, other critical care patients are denied admittance, experience negligence, and are often left to die without treatment. moreover, the administrative procedure for the covid- deceased, whether that be burial or cremation, has created more confusion and religious fear in the minds of the common people. often, family members of the deceased have denied claiming the body due to fear of infection. in those cases, government authorities have intervened. moreover, there is a rumor that the victims of covid- are buried without the muslim funeral procedures of bathing, which has created further religious tensions among people. it is, therefore, imperative that the government manages people's fear and anxiety. proper information should be circulated to reduce confusion. the bangladeshi electronic and print media is not acting responsibly to disseminate truthful information and are instead reporting misguided stories on social media. since the th of march, the government of bangladesh formed a division to monitor media to eradicate rumors or incorrect information being disseminated on social media platforms and in the mainstream media to protect the mental health of the people. the bangladesh meteorological department (bmd) had forecasted heavy rainfall events and intermittent nor'westers and cyclones at many places across the country during april and may ( ) . heavy rainfall and nor'westers related to high windspeed causes tremendous disasters by destroying standing crops and properties and cause death to people and livestock. fair and equitable sharing of health resources could mitigate further risks to public health by meeting community health needs and generating all-important trust and resilience ( ) during further climatic disasters. the development of resilience is significant to combat any disasters, even a pandemic. subsequently, to develop resilience in the healthcare systems and to tackle any pandemic, good governance is crucial, along with good coordination. in addition, it also requires financing, service delivery, medicines and equipment for health workers, and information ( ) . moreover, governments, institutions, healthcare facilities, and the general public all hold a social and ethical responsibility to assess and mitigate risks for the most vulnerable communities, including homeless people, people without adequate insurance or employment, indigenous communities, immigrant communities, people with disabilities, and certain frontline healthcare workers and emergency responders. prisons, nursing homes, orphanages, old care homes, homeless shelters, and refugee camps can become focuses for disease outbreaks as these settings often have inadequate access to basic healthcare facilities that increases the disease burden ( ) . the government should prepare policies and decisions on early recovery plans which should be inclusive to all ethnic groups, religious groups, minorities, and the wide range of vulnerable populations. april and may are the months of natural disasters like tropical cyclones, tornados, and early flooding in bangladesh, which may be evident within the coming days. therefore, utilization of the health-emergency disaster risk management (health-edrm) framework is important to implement. health-edrm refers to the "systematic analysis and management of health risks, posed by emergencies and disasters, through a combination of ( ) hazard and vulnerability reduction to prevent and mitigate risks, ( ) preparedness, ( ) response and ( ) recovery measures" ( ) . health-edrm is an umbrella term which the who uses to refer to the broad intersection of health and disaster risk management (drm). as the patients of other seasonal diseases such as dengue are rising, and the possibility of a natural disaster remains, the healthcare system should be coping with the changing scenario of the covid- outbreak in bangladesh, where resilience is very important. the hotspot areas of the disasters have already been identified in the bangladesh delta plan ( ) . vulnerable areas should be given special emphasis in the coming months for the protection of crops, risk reduction, relief preparation, and rehabilitation. biomedical waste should be disposed of following national and international guidelines on the disposal of infectious biological hazardous materials ( ) . when an exponentially rapid spread of a disease or infection breaks out, the generation of biomedical waste and other related healthcare hazards may be considerably increased within a noticeably short period. if improperly treated, this waste may accelerate the spread of disease and pose a significant risk to medical staff, patients, and waste management unit personnel. a complex short-term decision-making problem is required by the authorities to deal with the fast accumulation and transportation mode of the medical waste. healthcare centers can either directly transport the waste to the treatment centers or they can transfer and consolidate via a temporary transit center ( ) . the use of ppe should be distinguished by different risk factors to adopt different epidemic prevention measures and reduce the waste of personal protective equipment, as these resources are already in short supply ( ) . moreover, repeated use of disposable masks and not washing cloth masks could create further risk of infection that needs to be dealt with through proper information to the public ( ) . as the country does not have proper incineration facilities, the government should think of setting up mobile incinerator plants rapidly to responsibly manage bio-medical waste. as we have analyzed the scenario over the past months of partial, a loss of billion bdt a day to gdp is incurring. more than million people are becoming further marginalized due to the loss of wages and jobs ( ) . the dilemma of life vs. livelihoods has put people at high risk of community transmission in the industrial districts after the ready-made-garment (rmg) manufacturers trade organization bgmea decided to open the factories even before the end of lockdown. it was predicted that the government would not get support from the allied forces. weak governance and policy put emergency responders, such as medical doctors and healthcare staff, police, security forces, and army personnel, at risk of infection. already, thousands of doctors and members of the police force have been infected and died during this time. the socio-economic fall-out from this pandemic is already high, particularly for the disadvantaged poor communities, day laborers, wage earners, rmg-sector workers, and small and medium business start-ups. already the country's rmg sector has lost many global orders due to the pandemic, and the remittance flow is at its lowest. job insecurity and financial insecurity is foreseeable, and concerns of a global depression will affect the local market as well as investors. the prime minister of bangladesh already declared a stimulus package of , crore bdt, of which , crore bdt has been announced for the rmg sector, other large industries, and the service sector in an attempt to defeat the economic losses due to the coronavirus situation ( ) . however, on prioritybasis the financial incentives should be given to the povertystricken disadvantaged communities first, as well as insurance for healthcare professionals at the frontline, emergency responders, and caregivers responsible for emergency handling. purchasing intensive care unit (icu) beds, protective equipment, diagnostic test kits, mechanical ventilators, and additional supports is required for these mentally and physically affected persons who have survived covid- . it is also imperative to continue taking precautions, including screening, isolation of suspected cases, and social distancing, even after the pandemic is over. finally, combating the global pandemic is not easy. the statements that we have included in this analysis aid in identifying the associations among the psychosocial, socioeconomic, and possible environmental crisis based on public perception in bangladesh. risk mitigation measures concerning the psychosocial, socio-economic, and environmental components of the public are necessary to combat a global pandemic. therefore, with great advancements in the speed and power of science, international collaborations are required to provide knowledge about the virus and disease recovery. moreover, it is highly recommended by who and other stakeholders from the national level to raise the testing speed and facilities in bangladesh. multi-sectoral involvement and proper relief facilities for unprivileged populations must be ensured. without ensuring fundamental needs would be met, the lockdown due to covid- has imposed mental stress on the public. the weak governance in the healthcare systems and limited healthcare facilities exacerbated the general public's fear and anxiety. the centralized covid- testing facility and limitations of dedicated hospital units for covid- patients hampered other critical patients from receiving healthcare services. as a country vulnerable to climate change, there might be some additional risk factors of occurring natural disasters, such as a tropical cyclone, which may add further pressure on the country. the closure of all educational institutions may increase the number of mentally depressed young people. as the business centres (except for groceries, pharmacies, and other daily necessities) are closed, it has put further stress on the country's economy. an infectious outbreak of dengue might be on the way that may have a cumulative/synergistic negative impact with covid- on public health in bangladesh. however, numerous factors that can be considered in the context of the current covid- outbreak in bangladesh are as follows: risk of community transmission, healthcare capacity, governance coordination, relief for the low-income population, biomedical waste management, and preparation for possible natural disasters. the recommendations collected in the perception study can be summarized as a need to increase covid-testing rates and increase medical facilities. the decentralization of the covid- medical facilities is particularly important due to the forced migration of more than million people from dhaka city to districts of bangladesh after the announcement of partial lockdown. in addition, proper risk assessment and dependable risk communication, a multisectoral management taskforce development, care of biomedical waste, ensuring basic support to vulnerable people, and good governance was suggested to reduce the psychosocial and socioeconomic impact of the covid- outbreak in bangladesh. finally, this assessment process could help the government and policymakers to judge the public perceptions to deal with the covid- pandemic in densely populated lower-middleincome countries like bangladesh. covid- ) situation reports how will country-based mitigation measures influence the course of the covid- epidemic? managing covid- in low-and middleincome countries countries test tactics in 'war' against covid- covid- containment: china provides important lessons for global response covid- : surge in cases in italy and south korea makes pandemic look more likely the fear of covid- scale: development and initial validation mitigate the effects of home confinement on children during the covid- outbreak available online at available online at doctors at private hospitals left vulnerable. the daily star editorial ( ) hatred and stigmatization grip bangladesh amid covid- outbreak student suicide risk and gender: a retrospective study from bangladeshi press reports psychological interventions for people affected by the covid- epidemic choosing a method to reduce selection bi-as: a tool for researchers simultaneous comparison of modified-integrated water quality and entropy weighted indices: implication for safe drinking water in the coastal region of bangladesh scale development: theory and applications application of factor analysis in the assessment of groundwater quality in a blackfoot disease area in taiwan characterization of groundwater quality using water evaluation indices, multivariate statistics and geostatistics in central bangladesh characterizing groundwater quality ranks for drinking purposes in sylhet district, bangladesh, using entropy method, spatial autocorrelation index, and geostatistics responding to covid- -a once-in-a-century pandemic? a midpoint perspective on the covid- pandemic covid- and community mitigation strategies in a pandemic emergence of a novel coronavirus disease (covid- ) and the importance of diagnostic testing: why partnership between clinical laboratories, public health agencies, and industry is essential to control the outbreak to withdraw or not to withdraw? tbs news ( ) crippled community governance and suppressed scientific/professional communities: a critical assessment of failed early warning for the covid- outbreak in china taking the right measures to control covid- covid- : children at heightened risk of abuse, neglect, exploitation and violence amidst intensifying containment measures covid- and violence against women: what the health sector/system can do the covid- pandemic: making sense of rumor and fear covid- : control measures must be equitable and inclusive bangladesh has only icu beds to fight coronavirus! the business standard nor'wester likely this week. the daily star ( ) the resilience of the spanish health system against the covid- pandemic building resilience against biological hazards and pandemics: covid- and its implications for the sendai framework general economics division (ged) planning and provision of ecmo services for severe ards during the covid- pandemic and other outbreaks of emerging infectious diseases reverse logistics network design for effective management of medical waste in epidemic outbreaks: insights from the coronavirus disease (covid- ) outbreak in wuhan (china) rational use of face masks in the covid- pandemic to open or not to open: lockdown exit strategies can help how will the covid- stimulus package be implemented? the daily star ( ) available online at all datasets presented in this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by department of public health and informatics, jahangirnagar university, bangladesh. the patients/participants provided their written informed consent to participate in this study. mb-d, ms, and mr planned the studies and developed the questionnaire. informatics and data analysis and interpretation were maintained by mb-d, ai, ms, and mr. mb and lb revised and improved the manuscript as suggested by the reviewers. all authors reviewed and read the manuscript before final submission. the authors would like to acknowledge all the frontline doctors fighting this pandemic and all the researchers cited in the references. the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/ . /fpubh. . /full#supplementary-material the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © bodrud-doza, shammi, bahlman, islam and rahman. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- - fb xnil authors: weaver, anne m.; khatun‐e‐jannat, kaniz; cercone, emily; krytus, kimberly; sohel, badrul munir; ahmed, makhdum; rahman, mustafizur; azziz‐baumgartner, eduardo; yu, jihnhee; fry, alicia m.; luby, stephen p.; ram, pavani k. title: household‐level risk factors for secondary influenza‐like illness in a rural area of bangladesh date: - - journal: trop med int health doi: . /tmi. sha: doc_id: cord_uid: fb xnil objective: to describe household‐level risk factors for secondary influenza‐like illness (ili), an important public health concern in the low‐income population of bangladesh. methods: secondary analysis of control participants in a randomised controlled trial evaluating the effect of handwashing to prevent household ili transmission. we recruited index‐case patients with ili – fever (< years); fever, cough or sore throat (≥ years) – from health facilities, collected information on household factors and conducted syndromic surveillance among household contacts for days after resolution of index‐case patients’ symptoms. we evaluated the associations between household factors at baseline and secondary ili among household contacts using negative binomial regression, accounting for clustering by household. results: our sample was household contacts of index‐case patients. seventy‐one percentage reported that smoking occurred in their home, % shared a latrine with one other household and % shared a latrine with > other household. a total of household contacts ( . %) had symptoms of ili during follow‐up. smoking in the home (rr (adj) . , % ci: . , . ) and sharing a latrine with one household (rr (adj) . , % ci: . , . ) or > household (rr (adj) . , % ci: . – . ) were independently associated with increased risk of secondary ili. conclusion: tobacco use in homes could increase respiratory illness in bangladesh. the mechanism between use of shared latrines and household ili transmission is not clear. it is possible that respiratory pathogens could be transmitted through faecal contact or contaminated fomites in shared latrines. annual influenza epidemics occur worldwide with sporadic pandemics. influenza is an important aetiological agent for febrile illness and pneumonia among children in urban dhaka, bangladesh [ ] [ ] [ ] , where influenza incidence is approximately episodes per childyears, and an estimated % of childhood pneumonia episodes are influenza-associated [ ] . influenza-like illness (ili) refers to a syndrome with symptoms typical of influenza virus infection: fever with sore throat and/or cough [ ] . in community-based surveillance in bangladesh, % of all people who died during , excluding those who died from injury, suicide or homicide, had symptoms of ili within days before death [ ] . although was a pandemic year, which may have influenced mortality from influenza, hospital-based surveillance indicates a similar incidence of influenza-associated ili in ( cases per person-years), ( . cases of seasonal influenza and . cases of pandemic influenza per person-years) and ( cases per person-years) [ ] . in bangladesh, influenza and ili result in a high economic burden for families of ill individuals. families of individuals with influenza identified during surveillance paid a median of % of monthly household income in out-of-pocket costs for treatment of influenza-associated illness [ ] . many families reported reducing monthly food expenditures and/or borrowing money in order to pay for treatment [ , ] . ill individuals may be unable to work and/or attend school for several days, further increasing the financial burden on families [ , ] . annual vaccination is a key strategy for the prevention of influenza in high-and middle-income countries [ ] . in bangladesh, as in many low-income countries, vaccination against influenza viruses has not been widely promoted, likely due to high costs and competing priorities of the healthcare system [ ] . non-pharmaceutical interventions that modify influenza transmission risk factors would be particularly useful in such a setting. respiratory virus transmission has been demonstrated in hong kong and the united states to be common among household contacts [ , ] . household contacts are in frequent contact with infected individuals and have similar risk factors to infected household members [ , ] . crowding and poor hand hygiene, which are prevalent in low-income settings, facilitate transmission of influenza and other respiratory viruses [ ] [ ] [ ] [ ] . handwashing has been associated with a reduced risk of acute respiratory infections in children [ , ] and influenza transmission [ , ] in high-and low-income settings. exposure to indoor and ambient air pollution has been associated with an increased risk of all-cause acute respiratory infections [ ] [ ] [ ] [ ] . exposure to air pollution may damage lung tissue and compromise immunity, increasing susceptibility to respiratory infection [ , ] . air pollution concentrations in a home can be affected by tobacco smoking, biomass fuel use for cooking and proximity to biomass cookstoves [ , ] . influenza and ili carry a high disease burden and subsequent economic burden in bangladesh, a lower middle-income country where widespread pharmaceutical interventions may not be currently feasible or affordable for patients. however, most studies on non-pharmaceutical interventions for influenza have been conducted in high-income settings. it is, therefore, important to identify and address modifiable factors associated with secondary ili, defined as ili in another household compound member after the first patient has been identified, at the household level in bangladesh and other highburden, low-income settings in order to design interventions to reduce transmission. for this study, we aimed to identify household-level risk factors associated with secondary ili in rural bangladesh. we conducted this analysis using the control group of a randomised controlled trial, bangladesh interruption of secondary transmission of influenza study (bistis) [ ] . during the and influenza seasons, patients who sought care for respiratory symptoms at jahurul islam medical college hospital, two district health complexes, and six local pharmacies in rural kishoreganj district, bangladesh, were recruited as index-case patients. study physicians screened patients for the presence of influenzalike illness (ili), which was defined as fever in those less than years of age and fever with cough or sore throat in those years or older. as this study was investigating transmission of influenza at the household level, patients who were admitted to the hospital were ineligible to participate. consenting index-case patients were accompanied to their home by study staff. typically, residents of this area live with extended family members in compounds of several households, sometimes with a shared cooking space and a latrine. if at least two people other than the index-case patient intended to reside in the compound for the subsequent days, we sought to enumerate and enrol all members of the compound ( figure ). eligibility requirements of index-case patients varied during the study period [ ] . briefly, in , we recruited index-case patients who experienced symptom onset in the prior days, who lived within min travel time to the health facility, and had no ili among household compound members in the prior days (n = ). due to a lack of recruitment, after one month, we expanded this criteria to include those living within two hours' travel time and those with ili in other household compound members (n = ). in , in response to literature indicating that handwashing was effective against influenza transmission within h of symptom onset [ ] , we limited enrolment to index-case patients with symptom onset within h. we allowed recruitment of those compounds where individuals who did not live in the indexcase patient's home had ili (n = ). full details of the eligibility requirements are described elsewhere [ ] . household contacts who had fever at enrolment (n = ) were excluded from these analyses. randomisation to an intensive handwashing intervention or control arm was carried out at the compound level. details of the handwashing intervention are described elsewhere [ ] . the following analyses were conducted among participants randomised to the control group to reflect household-level risk factors for ili. at the initial healthcare facility visit of the index-case patient, a trained study physician procured specimens using a nasal swab and an oropharyngeal swab, which were batched and tested by rt-pcr for influenza viral rna using the world health organization protocol [ ] . after index-case patients were recruited and tested for influenza virus infection, study staff accompanied index-case patients to their homes and recruited members of their compounds into the study. a staff member then administered a questionnaire to the male or female head of each household in the compound to assess demographics, socio-economic factors and individual-and household-level characteristics. the staff member observed each household for certain factors such as presence of a handwashing station with soap and water, location of cooking area, type of fuel used, water source and latrine facilities. study staff visited each household compound daily until the tenth day after resolution of the index-case patient's symptoms to conduct surveillance for ili symptoms. any member of the compound with new ili symptoms during the follow-up period was considered a secondary ili case. after consent was obtained, the secondary ili case patients were tested for influenza in the same manner as the index-case patient. written informed consent for specimen collection was obtained from all adult index-case patients and secondary ili cases. if the index-case patient or secondary ili case was a child, written informed consent for specimen collection was obtained from a parent or guardian. written informed consent was obtained from the head of the compound (typically the eldest male) for all household data collection activities. all study procedures were approved by the international centre for diarrhoeal disease research, bangladesh (icddr,b) research and ethics review committees. as few (n = ) index-case patients had laboratory-confirmed influenza in the control arm, we included all index-case patients with ili and conducted analyses to determine household-level risk factors associated with secondary ili in household members. we examined the following household-level characteristics as potential risk factors for secondary ili: crowding, building materials of homes, exposure to indoor air pollution, presence of handwashing materials, water source, latrine quality and sharing, education of the household respondent and household wealth status. crowding was assessed as number of people per room (the number of people in the household divided by the number of rooms in the home, excluding latrine and kitchen). we assessed indicators of exposure to indoor air pollution, such as frequency of index-case patients with influenza-like illness (ili) identified at hospitals, health complexes, pharmacies, tested for influenza (n = ) household compound members of index-case patients recruited, baseline questionnaire given (n = ) handwashing intervention given at repeated visits household compound members with ili tested for influenza (n = ) all household compound members followed for ili for days after resolution of index-case patient's symptoms (n = household compound members) all household compound members followed for ili for days after resolution of index-case patient's symptoms (n = household compound members) household compound members with ili tested for influenza (n = ) exclude those with missing questionnaire data from final analysis (n = ) smoking in the home, cooking fuel use, building material of the home and the distance between the cooking and sleeping spaces. we observed handwashing materials, soap and/or water at a handwashing station [ ] . we defined latrine quality as improved (flush/pour flush to piped sewer system, septic tank or pit latrine; or pit latrine with slab) or unimproved (flush/pour flush to elsewhere, open pit latrine, bucket, hanging latrine or no facility/bush/field), according to the who/unicef joint monitoring programme for water supply and sanitation. for socio-economic status, we examined education level of the household respondent and developed a wealth index using principal component analysis of household assets [ ] . we used the first principal component as our wealth index and categorised it into quintiles. we also examined each household asset that weighed on the wealth index in principal components analysis as indicators of wealth. we reported household-level factors potentially associated with ili transmission at the household and individual levels. those factors with - % variability among all households were considered for multivariable analysis. we adjusted multivariable models for age of the indexcase patient (< years, ≥ years), as previous analyses showed age to be associated with ili transmission in bistis [ ] . we examined age of the susceptible contact as a potential confounder, both as a continuous variable and defined in the following categories: very young child (less than years), young child ( - years), older child ( - years), adult ( - years) and older adult ( years and older). we examined sex and wealth status of the susceptible household contact, as well as any factors associated with risk of ili in the bivariate models (p < . ) as potential confounders. since case definition varied by age, we conducted a sensitivity analysis in which we stratified analyses by age of the index-case patient (< years, ≥ years). we also examined bivariate associations between household factors associated with secondary ili and multiple daily interactions with the index-case patient (collected in ), as this was shown in our prior study to be associated with ili [ ] . we conducted mixed-effects log-binomial regression to evaluate the relationship between household-level factors and identification of a secondary case of ili, adjusting for age of the index-case patient and the susceptible household contact, and we accounted for clustering at the household level. in order to evaluate independent associations, we adjusted models for all other householdlevel factors associated with secondary ili in bivariate analyses (p < . ). we estimated the adjusted risk ratios of developing a secondary ili case among those who lived in households with factors of interest compared with those who lived in households without the factors of interest. among susceptible household contacts of index-case patients, seven individuals ( . %) from two households were excluded due to missing data. a total of ( . %) susceptible contacts developed ili symptoms during follow-up. among household contacts included in this analysis, household members were from index-case patient households and from households in the compound other than the indexcase patient's household (table ) . houses typically consisted of one ( %) or two ( %) rooms, were made of brick or concrete ( %) and had a separate cooking space outside of the main living area ( %). almost all households cooked with biomass fuels and used tube wells for drinking water. smoking occurred in approximately % of homes. of household contacts, ( %) reported smoking; ( %) of adult men were smokers vs. ( . %) of adult women (results not shown). most ( %) household respondents had eight or fewer years of education. our wealth index accounted for % of the variance in asset ownership. a total of ( %) of the secondary ili cases lived in the index-case patient's household (table ). in our final negative binomial regression models, we evaluated the independent associations between ever smoking in the home or sharing a latrine with one other household or more than one other household, and secondary ili, adjusting for age category of the index-case patient (< , ≥ years). models examining smoking in the home were also adjusted for shared latrine use, and models examining shared latrine use were also adjusted for smoking in the home. all other models adjusted for both smoking in the home and shared latrine use. sex and age of secondary contacts were not included as model covariates, as sex was not associated with risk of secondary ili in bivariate analysis, and addition of age of the secondary contact did not substantially change model estimates. addition of further covariates resulted in unstable models. in our final models, the risk of developing secondary ili was % ( % ci . - . ) greater in those who lived in a household in which smoking ever occurred, compared with those who lived in a household with no smoking. additional adjustment for education, wealth quintile and each individual asset that weighed on the wealth measure (ownership of a chair, table, mobile phone, watch or clock, sewing machine and electricity in the home) did not substantially change the estimates of the relative risk for ili among those who lived in a household where smoking occurred compared with those who did not (rr adj between . and . ). those who lived in a household with water at a handwashing station had a % lower risk of developing secondary ili compared with those without water at a handwashing station, but this association was not statistically significant ( % ci . - . ). after adjustment, having soap and water at a handwashing station was not associated with risk of secondary ili. compared with those living in a household with a private latrine, those who lived in households sharing their latrine with one other household were at a . -fold increased risk of developing secondary ili ( % ci: . , . ) and those who shared their latrine with more than one other household had a . -fold increased risk of developing secondary ili ( % ci: . , . ). additional adjustment for education, wealth quintile and each individual asset that weighed on the wealth measure did not substantially change the estimates of the relative risk for ili among those sharing a latrine with one other household (rr adj between . and . ) or among those sharing a latrine with more than one other household (rr adj between . and . ). living in the same household as an index-case patient, crowding (number of people per room), building material of home, water source and improved latrine use were not associated with risk of secondary ili. in stratified analysis, associations between household-level risk factors and risk of secondary ili did not substantially differ by age of index-case patient. sex of the secondary contact and relationship of the secondary contact to the index-case patient were not associated with risk of developing secondary ili in this analysis or in prior bistis analyses (results not shown) [ ] . multiple interactions with the index-case patient were not associated with shared latrine use or smoking in the home (results not shown). in this study of household-level risk factors for ili, we found that smoking in the home and sharing a latrine with other households were associated with increased risk of secondary ili among household contacts. these results suggest that exposure to environmental tobacco smoke increases the risk of secondary ili; there are several potential mechanisms for the increased risk of ili due to shared latrine use. both factors are potentially modifiable. our results support exposure to indoor air pollution from environmental tobacco smoke as a potential risk factor for ili. exposure to indoor air pollution is a wellestablished risk factor for all-cause acute respiratory infections, due to its detrimental effects on respiratory tissue and immune functioning in the respiratory tract [ ] [ ] [ ] . exposure to environmental tobacco smoke is also a well-established risk factor for numerous other conditions, including low birthweight, various cancers and chronic respiratory and cardiovascular diseases [ ] . the prevalence of smoking in the home was high in this study, highlighting the need for tobacco control measures in bangladesh. greater use of effective tobacco control measures, such as taxation, could help to reduce tobacco smoking prevalence in bangladesh [ ] . the global adult tobacco survey estimated that % of adult men in bangladesh smoke tobacco products [ ] . in contrast, only . % of adult women in bangladesh smoke. our study showed a lower proportion of men who smoke ( %) compared with the global adult tobacco survey. in our study, the household head reported tobacco smoking for all members of the household; it is possible that respondents may underreport smoking habits of other household members. although biomass fuels are considered to be the major source of indoor air pollution in low-and middle-income countries [ , , ] , we were unable to assess the effect of biomass fuel use on secondary ili, as nearly every participant ( . %) reported using biomass fuels for cooking. sharing a latrine with at least one other household was the strongest exposure associated with secondary ili observed in this study. although shared latrines have not previously been shown to be associated with respiratory infections, there is some evidence of an association between shared latrines and diarrhoeal disease [ , ] . shared latrines may not be cleaned as frequently as private latrines [ ] , so it is possible that pathogens remain present longer on surfaces in shared latrines compared with private latrines. contact transmission, by either direct contact with infected fluids or indirect contact via fomites, may be an important route of transmission for influenza and other respiratory pathogens [ , ] as well as diarrhoeal pathogens [ ] . contaminated fomites in shared latrines, such as doors and traditional pots used for anal washing after defecation, may provide a route of transmission for pathogens in bangladesh. as ili may be caused by many different pathogens, it is possible that shared latrines may expose users to a number of different pathogens that may cause ili symptoms. specifically, influenza viruses [ , ] and coronaviruses [ ] have been recovered from faeces of patients, suggesting that some respiratory viruses may be transmitted through faecal contact. interactions with people with influenza have been shown to be associated with risk of secondary influenza [ ] [ ] [ ] [ ] [ ] , and ili [ ] ; it is plausible that those who use shared sanitation may have increased interactivity due to a commonly used resource (latrine). we did not observe an association between multiple daily interactions with the index-case patient and shared latrine use. however, we were unable to thoroughly investigate this possibility due to limited data. it is also possible that the association between sharing a latrine and ili may be spurious or that latrine sharing represents a proxy for an unknown factor that is associated with ili, but the effect estimates did not change substantially when adjusted for measures of wealth, age or smoking making this a less likely explanation. nearly % of household contacts reported ili in this study. this proportion is similar to previous investigations of the burden of ili in the general population of bangladesh [ ] . although age of the index-case patient did not modify the effects of household-level risk factors on ili, in this analysis and our prior analysis, ili incidence was higher in susceptible contacts who were younger than years compared with those who were years or older [ ] . residing in the index-case patient's household was not associated with ili risk, indicating that all members of a compound in a densely populated area are at risk of contracting infectious diseases from their compound members or the community at large. important limitations of this study include lack of detail regarding intravs. extra-household transmission pathways. we do not know whether pathogens were transmitted between members of the same household compound, whether they were acquired outside of the compound or whether the index-case patient we identified is in fact the primary ili case in each compound. it is possible that control households had contact with intervention households and subsequently modified handwashing behaviour. however, our main study results do not suggest an association between handwashing and secondary ili, so contact with the intervention arm is unlikely to have affected our results. as few participants had influenza, we did not test for other pathogens, and our definition of ili for those under years was broad, our results may not be relevant to influenza transmission, but rather, transmission of respiratory pathogens more broadly. air pollution is a wellestablished household-level risk factor for respiratory illness [ ] [ ] [ ] , but reliable data on concentrations of household air pollutants are not available from this study. however, we did observe associations between indoor smoking, one proxy indicator of air pollution and secondary ili incidence. as this study recruited participants from selected healthcare facilities, our sample may not be representative of people who sought care elsewhere [ , ] . in addition, our sample may not be generalisable to urban bangladesh, where there may be more crowding and more accessible health care. smoking in the home and use of shared latrines are associated with an increased risk of secondary influenza-like illness in households in this study. our data highlight the possible benefit of efforts to reduce exposure to indoor air pollution from environmental tobacco smoke, including effective approaches to smoking cessation and clean air initiatives. interventions focused on improving access to private latrines may also be helpful in low-income countries. influenza a and b infection in children in urban slum influenza is a major contributor to childhood pneumonia in a tropical developing country incidence of influenza-like illness and severe acute respiratory infection during three influenza seasons in bangladesh household transmission of pandemic (h n ) influenza-associated mortality in in four sentinel sites in bangladesh economic burden of influenza-associated hospitalizations and outpatient visits in bangladesh 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impact of intensive handwashing promotion on secondary household influenza-like illness in rural bangladesh: findings from a randomized controlled trial world health organization. manual for the laboratory diagnosis and virological surveillance of influenza practical guidance for measuring handwashing behavior estimating wealth effects without expenditure data-or tears: an application to educational enrollments in states of india individual level risk factors for secondary transmission of influenza-like illness: secondary data analysis from the bangladesh interruption of secondary transmission of influenza study household air quality risk factors associated with childhood pneumonia in urban dhaka, bangladesh indoor air pollution in developing countries and acute lower respiratory infections in children effect of biomass smoke on pulmonary host defence mechanisms world health organization tobacco free initiative. international consultation on environmental tobacco smoke (ets) and child health. world health organization tobacco free initiative the price sensitivity of cigarette consumption in bangladesh: evidence from the international tobacco control (itc) bangladesh wave ( ) and wave ( ) surveys tobacco use in billion individuals from countries: an analysis of nationally representative cross-sectional household surveys indoor air pollution in developing countries: recommendations for research shared sanitation and the prevalence of diarrhea in young children: evidence from countries shared sanitation versus individual household latrines: a systematic review of health outcomes hand hygiene and risk of influenza virus infections in the community: a systematic review and meta-analysis pathogen survival in the external environment and the evolution of virulence influenza virus infection among pediatric patients reporting diarrhea and influenza-like illness influenza a/h n virus infection in humans in cambodia detection of human coronaviruses in simultaneously collected stool samples and nasopharyngeal swabs from hospitalized children with acute gastroenteritis measured dynamic social contact patterns explain the spread of h n v influenza what types of contacts are important for the spread of infections?: using contact survey data to explore european mixing patterns social contacts and mixing patterns relevant to the spread of infectious diseases social mixing patterns in rural and urban areas of southern china using data on social contacts to estimate age-specific transmission parameters for respiratory-spread infectious agents university at buffalo, school of public health and health professions first, we would like to thank the participants of bistis for their time and patience. we would like to thank our field staff for all of their hard work. this research study was funded by us centers for disease control and prevention. icddr,b acknowledges with gratitude the commitment of cdc to its research efforts. icddr,b also gratefully acknowledges the following donors who provide unrestricted support: government of the people's republic of bangladesh; global affairs canada; swedish international development cooperation agency and the department for international development. the findings and conclusions in his report are those of the authors and do not necessarily represent the official position of the centers for disease control and prevention. key: cord- - fjb iz authors: morshed, m. s.; mosabbir, a. a.; chowdhury, p.; ashadullah, s. m.; hossain, m. s. title: clinical manifestations of patients with coronavirus disease (covid- ) attending at hospitals in bangladesh date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: fjb iz bangladesh is in the rising phase of the ongoing coronavirus disease (covid- ) pandemic, caused by severe acute respiratory syndrome coronavirus- (sars-cov- ). however, the scientific literature on clinical manifestations of covid- patients from bangladesh is virtually absent. this is the first study aimed to report the sociodemographic and clinical characteristics of patients with covid- in bangladesh. we conducted a cross-sectional study at three dedicated covid- hospitals. a total of rt-pcr confirmed non-critical covid- patients were enrolled. sociodemographic factors, underlying disease conditions, clinical symptoms and vital signs including oxygen saturation were documented and analyzed. the median age of the patients was years (iqr: - ); most of the patients ( . %) were male. mild, moderate and severe illness were present in . %, . % and . % of patients respectively. more than half ( . %) patients had a co-morbidity, with hypertension being the most common ( %), followed by diabetes ( . %) and ischemic heart disease ( . %). fever ( . %), weakness ( %) and cough ( . %) were the most common clinical manifestations. other common symptoms included loss of appetite ( . %), difficulty breathing ( . %), altered sensation of taste or smell ( . %), headache ( %) and bodyache ( %). the median time from onset of symptom to attending hospitals was days (iqr - ). this study will help both the clinicians and epidemiologists to understand the magnitude and clinical spectrum of covid- patients in bangladesh. the world has been experiencing one of the most serious public health crises in the history of humankind. the ongoing pandemic of coronavirus disease (covid- ) is caused by severe acute respiratory syndrome coronavirus- (sars-cov- ). as of july , over million individuals have been infected with over , deaths worldwide [ ] . sars-cov- infection predominantly results in an acute respiratory illness. in addition, it can cause a myriad of extrapulmonary symptoms. the clinical spectrum ranges from asymptomatic or mildly symptomatic flu-like illness to potentially life-threatening critical conditions [ ] . recent studies suggest that the clinical spectrum of covid- can vary among different ethnicities and geographical locations across the world [ ] . owing to a population of over million, inadequate healthcare system, and poor personal hygiene among the general population, bangladesh is considered one of the high-risk countries for coronavirus spread. the first official case of covid- was reported on march , and the epidemic still appears to be in a growing phase. as of july , a total of , cases and deaths have been reported in bangladesh [ ] . however, the information on clinical manifestations from bangladesh is scarce in the literature. therefore, this study aimed to document the clinical spectrum of covid- patients attending fever clinics in bangladesh. this was a cross-sectional study conducted among rt-pcr confirmed covid- patients attending the fever clinic of a dedicated covid- hospital (kurmitola general hospital) in dhaka city of bangladesh and two upazila health complexes from different districts (jessore and jhenaidah) from july to july . diagnosis of sars-cov- infection and assessment of severity were done based on the who interim guidance [ ] . data were collected only from non-critical covid- patients as critical patients required immediate intensive care admission making them unable to respond to the questions. socio-demographic and clinical data were evaluated and collected by experienced clinicians using a pretested case record form. we used pearson's chi square test, fisher's exact test and kruskal wallis test to compare . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint differences between mild, moderate and severe patients where appropriate. logistic regression was used to study associations. p < . was set as statistically significant. a total of laboratory-confirmed covid- patients were enrolled. about % ( ) of cases presented with mild symptoms, followed by nearly % severe and % moderate cases. overall, the median age of the participants was years (iqr: - ); more than % of these patients were under years. ( table ). most of the patients were male ( . %). more than half of the patients ( . %) had at least one co-morbidity, including hypertension in ( %), diabetes in ( . %) and ischaemic heart disease in ( . %) patients. notably, around % of moderate and severe cases had comorbidity. the median time from onset of symptom to attending fever clinic was days (iqr - ). overall, the most common symptoms reported were fever ( . %), weakness ( %) and cough ( . %) followed by loss of appetite ( . %), difficulty breathing ( . %), altered sensation of taste or smell ( . %), headache ( %) and body ache ( %). less common symptoms included sore throat ( . %), diarrhoea ( . %) and chest pain ( . %). fever was the most prevalent symptom in all groups of patients. interestingly, % of moderate patients experienced difficulty breathing compared to . % severe patients. (table ). more than half of the severe cases had tachycardia ( . %) and tachypnoea ( . %) at presentation; their median oxygen saturation was . % (iqr . - . ). this study aimed to determine the clinical characteristics of rt-pcr confirmed patients with covid- attending fever clinics of government hospitals in bangladesh. to the best of our knowledge, this is the first hospital-based report presenting clinical features of covid- patients from bangladesh. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . other symptoms: vomiting ( . %), abdominal pain ( . %), dizziness ( . %), red eye ( . %) . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint the most prevalent symptoms of non-critical covid- patients in bangladesh consist of fever ( . %), fatigue ( %), and cough ( . %). similarly, in a meta-analysis from china, most prevalent symptoms were fever ( . %), cough ( . %) and fatigue ( %) (ref) . however, studies from china included both critical and non-critical patients. in contrast, one study from europe on mild to moderate patients reported that headache ( . %), loss of smell ( . %), nasal obstruction ( . %) were the most common symptoms; fever was reported by only . % of patients. interestingly, % of mild cases, % of moderate cases and . % of severe cases reported altered sensation of taste or smell in this study. while olfactory and gustatory dysfunctions were prevalent symptoms in european patients, they were only rarely reported in chinese patients [ , ] . in this study, about % cases were presented with severe symptoms. this is consistent with a summary report of , cases from china [ ]. as expected, most of the severe patients ( . %) had co-morbidity. age > years, patients with diabetes mellitus, ischemic heart disease and chronic kidney disease had significantly higher odds of developing the severe disease at presentation (supplementary table ). our study has some limitations. first, the sample size of this study was small. second, we could not include critical patients due to the requirement of emergency management. therefore, our findings could not be generalized in the context of bangladesh. our study reports the presenting symptoms of sars-cov- infections among the bangladeshi population. although there are certain similarities in the range of symptoms with the chinese population, where the pandemic originated, there are some unique findings like the high prevalence of olfactory and gustatory dysfunctions. this study will help both the clinicians and epidemiologists understand the magnitude and clinical spectrum of covid- patients in bangladesh. none of the authors have any conflict of interest to declare we are grateful to brigadier general jamil ahmad, director, kurmitola general hospital (kgh); dr. tania easmin, medical officer, kgh; dr. md. rashed al mamun, upazilla health . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint world health organization. coronavirus disease (covid- ) situation report- the epidemiology, diagnosis and treatment of covid- the impact of ethnicity on clinical outcomes in covid- : a systematic review world health organization, clinical management of covid- , interim guidance clinical characteristics of covid- patients: a meta-analysis clinical and epidemiological characteristics of european patients with mild-to-moderate coronavirus disease and family planning officer (uhfpo), shailkupa, jhenaidah and dr. md. alamgir, uhfpo, keshabpur, jessore for their generous support in data collection. key: cord- - lr th authors: shishir, tushar ahmed; naser, iftekhar bin; faruque, shah m. title: in silico comparative genomics of sars-cov- to determine the source and diversity of the pathogen in bangladesh date: - - journal: biorxiv doi: . / . . . sha: doc_id: cord_uid: lr th the covid pandemic caused by sars-cov- virus has severely affected most countries of the world including bangladesh. we conducted comparative analysis of publicly available whole-genome sequences of sars-cov- isolates in bangladesh and isolates from another countries to predict possible transmission routes of covid to bangladesh and genomic variations among the viruses. phylogenetic analysis indicated that the pathogen was imported in bangladesh from multiple countries. the viruses found in the southern district of chattogram were closely related to strains from saudi arabia whereas those in dhaka were similar to that of united kingdom and france. the sars-cov- sequences from bangladesh belonged to three clusters. compared to the ancestral sars-cov- sequence reported from china, the isolates in bangladesh had a total of mutations in the coding region of the genome, and of these were missense. among these, missense mutations ( %) were predicted to destabilize protein structures. remarkably, a mutation that leads to an i f change in the nsp protein and a mutation leading to d g change in the spike protein were prevalent in sars-cov- genomic sequences, and might have influenced the epidemiological properties of the virus in bangladesh. the pandemic of coronavirus disease referred to as covid- pandemic, which originated in wuhan, china in december is ongoing and has now spread to countries and territories. as of july , the pandemic has caused about million cases and over half a million death. this novel virus of the coronaviridae family and betacoronavirus genus ( , ) designated as severe acute respiratory syndrome coronavirus (sars-cov- ), is the causative agent of covid- . previously two other coronaviruses, namely sars-cov and mers-cov have demonstrated high pathogenicity and caused epidemic with mortality rate ~ % and ~ % respectively affecting more than countries each time ( ) ( ) ( ) . however, sars-cov- has proven to be highly infectious and caused pandemic spread to over countries and territories. besides its devastating impact in north america and europe, the disease is now rapidly spreading in south america including brazil, and in south asian countries particularly india, pakistan and bangladesh ( ) . the virus was first detected in bangladesh in march ( ) . although infections remained low until the end of march it began to rise steeply in april. by the end of june, new cases in bangladesh grew to nearly , and the rate of detection of cases compared to the total number of samples tested increased to about % which was highest in asia ( ) . sars-cov- is a positive-sense single-stranded rna virus with a genome size of nearly kb. the ' end of the genome codes for a polyprotein which is further cleaved to viral nonstructural proteins whereas the ' end encodes for structural proteins of the virus including surface glycoproteins spike (s), membrane protein (m), envelop protein (e) and nucleocapsid protein (n) ( ) . like other rna viruses, sars-cov- is also inherently prone to mutations due to high recombination frequency resulting in genomic diversity ( ) ( ) ( ) . due to the rapid evolution of the virus, development of vaccines and therapies may be challenging. to monitor the emergence of diversity, it is important to conduct comparative genomics of viruses isolated over time and in various geographical locations. comparative analysis of genome sequences of various isolates of sars-cov- would allow to identify and characterize the variable and conserved regions of the genome and this knowledge may be useful for developing effective vaccines, as well as in molecular epidemiological tracking. thousands of sars-cov- virus genomes have been sequenced and submitted in public databases for further study. this include sars-cov- genomic sequences submitted from bangladesh in the global initiative on sharing all influenza data (gisaid) database, till th june ( ) . we conducted comparative analysis of publicly available genome sequences of sars-cov- from countries to predict the origin of viruses in bangladesh by studying a time- resolved phylogenetic relationship. later, we analyzed the variants present in different isolates of bangladesh to understand the pattern of mutations in relation to the ancestral wuhan strain, find unique mutations, and possible effect of these mutations on the stability of encoded proteins, and selection pressure on genes. a total of whole genome sequences of sars-cov- including sequences isolated in bangladesh (detail information in s table) , and that of isolates of each month between january to may, isolated in different countries with high frequency of infection were included in this analysis. source and number of sequence are presented in table (detail information are provided in s table) . however, since only number of sequences were reported from different african countries, we included all sequences from the african countries and categorized collectively as african sequence ( ) . reference sequence included in various analysis was the sequence of the ancestral strain from wuhan, china (nc_ . ) ( ). selected sequences were annotated by viral annotation pipeline and identification (vapid) tool ( ) , and multiple sequence alignment was carried out using mafft algorithm ( ) . maximum likelihood phylogenetic tree was constructed with iq-tree ( ), the generated tree was reconstructed based on time-calibration by treetime ( ) , and visualized on itol server ( ) . for analysis of mutations, sequence were mapped with minimap ( ) , and variants were detected using samtools ( ) and snp-sites ( ) . a haplotype network was generated based on mutations in genome using popart ( ) . sequences were then put into different clades based on specific mutations proposed in gisaid ( ) and further classified as d g type ( , ) . subsequently, another phylogenetic tree and haplotype network containing only sars-cov- sequences from bangladeshi was constructed and categorized using the same tools, and additionally one step further clustered with treecluster ( ) . the direction of selection in sequences from bangladesh was calculated by the slac algorithm ( ) in the datamonkey server ( ) . finally, the effects of the mutations on protein stability were predicted using deepddg ( ). a total of genomic sequences of sars-cov- reported from various countries (table ) which included sequences from bangladesh and the sequence of the ancestral sars-cov- isolated in wuhan, china were analyzed in the time-resolved phylogenetic tree. sequences from bangladesh belonged to three different clusters of which one cluster carried of the sequences, and shared the same node with sequence from germany while they had a common ancestry with isolates from the united kingdom (fig ) . the remaining two clusters of sars-cov- sequences contained and sequences respectively from bangladesh, and they shared the same node with sequence of sars-cov- reported from india, and also shared a common ancestry with isolates from saudi arabia. besides, lone sequences that did not belong to any of these clusters were found to have similarity with sequences from europe including united kingdom, germany, france, italy, and russia. one of these sequences was closely related to sequence reported from the usa. subsequently, all sars-cov- sequences from representative countries were clustered based on some specific mutations sustained, into different clades as mentioned by gisaid. in this analysis, the sequences from bangladesh were found to be distributed in all clades except v (figs and ) . classification. in order to understand the evolutionary relationship and possible transmission dynamics of sars-cov- in bangladesh at a higher resolution, another time-resolved phylogenetic tree carrying only sequences of the pathogen isolated in various regions of bangladesh was generated using the sequence of the first sars-cov- reported from yuhan, china as a reference. of the three clusters produced in this analysis, cluster- included mostly isolates from chattogram and one isolate from dhaka, cluster- included isolates from dhaka, narayanganj and chattogram districts, whereas cluster- included isolates from chattogram only. as mentioned above, the isolates from bangladesh were found to be distributed in all gisaid clades based on specific mutations, except in clade v (fig ) . most isolates of dhaka and narayanganj ( of ) belonged to the gr clade, whereas those of chattogram belonged to five different gsid clades (g, gh, gr, o, and s). the major international airport in bangladesh is situated in the capital city dhaka, whereas the major seaport is located in chattogram. based on the phylogenetic analysis, all isolates of dhaka were the descendant of sars-cov- found in european countries, more specifically france and the united kingdom. on the other hand, most isolates of chattogram were found closely related to saudi arabian isolates. moreover, considering the gsid clades, the presence of s clade was absent among dhaka whereas most isolates of chattogram was found to belong to the s clade. clearly these two genomic variants of sars-cov- were initially imported by travelers from different countries, and the two variants initially spread in the two areas. that the isolates of narayanganj and two isolates of dhaka are closely related, indicates that the sars-cov- strain imported initially through international traveler to dhaka later spread to narayanganj, which is a densely populated city with river ports and large business centres. the sars-cov- sequences were also categorized according to d g type mutation (fig ) . this particular subtype with a non-silent (aspartate to glycine) mutation at th position of the spike protein is presumed to have rapidly outcompeted other preexisting subtypes, including the ancestral strain. the d g mutation generates an additional serine protease (elastase) cleavage site near the s -s junction of the spike protein ( ) . all but one sequence from dhaka and narayanganj were found to be of g type which carries glycine at position whereas sequences of chattogram carry sequences of both types (fig ) . in addition, the first sequence from bangladesh carried g type of surface glycoprotein, which indicate that this dominant variant was present since the first isolation of sars-cov- in bangladesh and the mutant virus might have been imported to the country from europe, and the presence of the mutation might have facilitated viral transmission. relationships among dna sequences within a population are often studied by constructing and visualizing a haplotype network. we constructed a haplotype network by the median joining algorithm and found that of sars-cov- sequences from representative countries were alike, therefore formed a large haplo group (fig a) . however, there were presences of a significant number of unique lineages too consisting of a single or multiple sars-cov- sequences (fig a) . this network demonstrated the closeness of the sequences and their pattern of mutation beyond the geographical boundary. several sars-cov- isolates appeared to have sustained certain common mutations along with certain unique mutations. although a large proportion of sequences from bangladesh belonged to the common cluster (fig a) , there was a significant number of unique nodes as well due to mutations overtime subsequent to being carried into bangladesh (fig a) . therefore analysis of the sequences from bangladesh provided further insight of their mutation patterns. the haplotype network revealed that viruses isolated in bangladesh had certain unique mutations in them, and as a result they belonged to different haplo groups and no significant cig group (fig. a) . most of the isolates sustained a significant number of mutations compared with each other. in addition it further confirms that most isolates from chattogram ( fig b) were not directly related to those isolated in dhaka or narayanganj. we detected the presence of point mutations in sars-cov- isolates from bangladesh when compared to the reference sequence from yuhan, china. in addition, isolates were found to have lost significant portions of their genome, and as a result lost sequences for some non-structural proteins such as orf and orf while other deletions were upstream or downstream gene variants (s table) . among the point mutations, mutations were in the non-coding region of the genome and were in coding regions. ten of the non-coding mutations were in upstream non-coding region and rest was in downstream non-coding region of the genome. seventy mutations in the coding region were synonymous and mutations predicted substituted amino acids. among twelve predicted orfs, orf ab which comprises approximately % of the genome encoding nonstructural proteins had more than percent of the total mutations while gene e encoding envelope protein and orf b were conserved and did not carry any mutation. though orf harbored the highest number of mutations, mutation density was highest in orf considering orf lengths. details and distribution of the mutations are presented in table and full analysis report is placed in s table. in sequences from bangladesh, c>t and c>t changes were the two most abundant mutations found in out of isolates, and often found simultaneously (table ) . position is located in the non-coding region whereas the mutation in position was synonymous. on the other hand, sequences were found to harbor c>t and a>g mutations which altered amino acid pro>leu and asp>gly respectively, and these two mutations were found to be present simultaneously as well. in addition, other co- fig ) . orf was predicted to have dn/ds value of . due to the presence of higher number of missense than synonymous mutations. this finding indicates that orf is rapidly evolving and is highly divergent. the orf protein is an accessory protein whose function is yet to be fully elucidated ( ) . the orf a and nucleocapsid phosphoprotein had dn/ds values . and . respectively which confer their strong evolution to cope up with challenges under positive selection pressure. orf is predicted to be conversed with dn/ds value while envelope protein and orf b did not harbor any mutation and was conserved. on the other hand, orf a and surface glycoprotein might approach toward positive selection pressure and evolve but rests of the proteins were under negative selection pressure. table ) . none of the mutations in structural proteins were predicted to increase stability. all mutations were synonymous and found this gene conserved in summary, mutation analysis revealed point mutations as well as deletion of base pairs. deletions of the base pairs were associated with missing non-structural proteins and predictably affected certain viral properties since orf a protein is the growth factor of the coronavirus family, induce apoptosis, and promotes viral encapsulation ( ) ( ) ( ) while orf is associated with viral adaptation by playing role in host-virus interaction ( , ) . furthermore, we have found that some genes are under positive selection pressure indicating that the virus is fast-evolving presumably to evade host cell's innate immunity; which should be taken into special consideration prior to vaccine development or other treatment strategies. finally, a missense mutation at a>t changing the amino acid isoleucine to phenylalanine in nsp protein was found uniquely among isolates in bangladesh. nsp is a methyltransferase like domain that interacts with phb and phb , and modulates the host cell survival strategy by affecting cellular differentiation, mitochondrial biogenesis, and cell cycle progression to escape from innate immunity ( , ) . this unique and high-frequency mutation might be a further interest of study, considering death rate against the infection rate in bangladesh. virus 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for detecting amino acid sites under selection datamonkey: rapid detection of selective pressure on individual sites of codon alignments deepddg: predicting the stability change of protein point mutations using neural networks aputativediacidicmotifinthesars-covorf proteininfluencesitssubcellularlocalizationandsuppressionofexpressionofco -transfectedexpressionconstructs sars-cov accessory protein a directly interacts with human lfa- severe acute respiratory syndrome coronavirus gene products contribute to virus-induced apoptosis severe acute respiratory syndrome coronavirus orf a inhibits bone marrow stromal antigen virion tethering through a novel mechanism of glycosylation interference the orf protein of sars-cov- mediates immune evasion through potently downregulating mhc-i. biorxiv the proteins of severe acute respiratory syndrome coronavirus- (sars cov- or n-cov ), the cause of covid- covid- : the role of the nsp and nsp in its pathogenesis key: cord- -li ng v authors: chowdhury, moyukh; stewart williams, jennifer; wertheim, heiman; khan, wasif ali; matin, abdul; kinsman, john title: rural community perceptions of antibiotic access and understanding of antimicrobial resistance: qualitative evidence from the health and demographic surveillance system site in matlab, bangladesh date: - - journal: global health action doi: . / . . sha: doc_id: cord_uid: li ng v background: the use of large quantities of antimicrobial drugs for human health and agriculture is advancing the predominance of drug resistant pathogens in the environment. antimicrobial resistance is now a major public health threat posing significant challenges for achieving the sustainable development goals. in bangladesh, where over one third of the population is below the poverty line, the achievement of safe and effective antibiotic medication use for human health is challenging. objective: to explore factors and practices around access and use of antibiotics and understanding of antimicrobial resistance in rural communities in bangladesh from a socio-cultural perspective. methods: this qualitative study comprises the second phase of the multi-country abacus (antibiotic access and use) project in matlab, bangladesh. information was collected through six focus group discussions and in-depth interviews. informants were selected from ten villages in four geographic locations using the health and demographic surveillance system database. the access to healthcare framework guided the interpretation and framing of the findings in terms of individuals’ abilities to: perceive, seek, reach, pay and engage with healthcare. results: village pharmacies were the preferred and trusted source of antibiotics for self-treatment. cultural and religious beliefs informed the use of herbal and other complementary medicines. advice on antibiotic use was also sourced from trusted friends and family members. access to government-run facilities required travel on poorly maintained roads. reports of structural corruption, stock-outs and patient safety risks eroded trust in the public sector. some expressed a willingness to learn about antibiotic resistance. conclusion: antimicrobial resistance is both a health and development issue. social and economic contexts shape medicine seeking, use and behaviours. multi-sectoral action is needed to confront the underlying social, economic, cultural and political drivers that impact on the access and use of antibiotic medicines in bangladesh. antimicrobial drugs include antibiotics, antifungals, antivirals and antimalarials. their use in medical and veterinary practice, animal husbandry and agriculture has reduced infectious agents by killing bacteria, fungi, viruses and parasites [ ] [ ] [ ] . exposure to antimicrobials is causing drug resistance. factors thought to account for this include the suboptimal use of drugs in hospitals, the community, veterinary practice and agriculture. the leakage of compounds into the environment creates pathways for antimicrobial resistance (amr) although evidence of their relative importance and contribution has not been established [ ] [ ] [ ] . amr presents significant challenges for achieving sustainable development goals (sdgs) such as sdg (poverty), sdg (good health and well-being), sdg (clean water and sanitation) and sdg (responsible consumption and production) [ ] . amr is both a health and development issue. tackling amr requires an 'adaptive approach' that acknowledges how and why antimicrobial use has become entrenched in the way of life in both rich and poor countries [ ] . the world bank estimates that by up to million people could be forced into extreme poverty due to amr [ ] . addressing amr requires acknowledgement of how and why antimicrobials are embedded in societies and economies [ ] . the covid- pandemic will further exacerbate this trend which is impacting disproportionately on low-and middle-income countries (lmics) [ ] . the drivers of antimicrobial use in human health are complex and multifaceted [ ] . individual behaviours that promote amr result from limited knowledge and understanding of potential consequences [ ] . a systematic review of studies on amr showed that addressing the social determinants of poverty is an essential yet neglected step in addressing amr [ ] . in lmics structural, social, political and economic barriers impede access to prescription medicines, and health system development challenges compromise intervention efforts [ , , ] . in a qualitative study among human and animal healthcare professionals in ethiopia, nigeria, sierra leone, india, vietnam and the philippines, amr awareness raising did not reduce prescribing [ ] . a study of amr in rural thailand concluded that the results of educational programs in high-income countries cannot be generalised to lmics where impoverished populations endure precarious existence under fragmented under-resourced health and social support systems [ ] . in many countries antibiotics are a 'quick fix' medicine [ , ] . balancing access and excess in lmics poses precarious ethical questions about the roles and responsibilities of users and prescribers [ ] . discussion in the literature has focused on measured 'use' and 'misuse' of antimicrobials. researchers in the social sciences remind us of the dangers of injecting subjective bias and unfair judgement into scientific debate [ , ] . anthropological studies of antibiotic use in sub-saharan africa and south-east asia used the 'drug bag' method to address conceptual and semantic issues [ ] . by 'appropriate' use we mean that if a medicine is used appropriately (in a clinical sense) it is safe and effective in treating the disease. conversely, 'inappropriate' use occurs when the medicine is not clinically effective in treating the disease. yet it is important to acknowledge that what is considered 'appropriate' from a biomedical perspective, may not be 'appropriate' from a socio-cultural perspective [ ] . each country's 'risk profile' for amr is contextually determined [ ] . bangladesh is a lower-middle-income economy in south-asia with a population of million https:// www.unfpa.org/data/world-population/bd. more than two thirds of the population live in rural areas where social and economic disadvantage and poverty is widespread [ , [ ] [ ] [ ] . despite the government's national drug policy, access to formal healthcare and medical prescribing is limited, and antibiotics are commonly purchased, without prescription, from vendors in pharmacies [ , , , ] . a systematic review of amr studies ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in bangladesh identified a high prevalence of resistance to most antibiotics and major gaps in surveillance [ ] . in a country where sixty seven percent of total healthcare expenses are out of pocket and thirty five percent of the population is below the poverty line, achieving safe and appropriate medication use for human health is challenging [ , ] . the access to healthcare framework articulated by levesque, harris and russell [ ] is used to guide the interpretation and framing of the findings in this study. the framework provides a theoretical underpinning because it offers a patient-centred perspective. it goes beyond conceptualising access in a one-dimensional space by presenting and articulating five interdependent dimensions and their corresponding abilities at the interface between the population and the health system. the same approach has been undertaken in other similarly designed studies of abr in lowresource settings [ ] . levesque et. al. [ ] propose five dimensions of access: ) approachability (transparency, outreach, information screening); ) acceptability (professional values, norms, culture, gender); ) availability (geographic location, accommodation, hours of opening, appointment mechanisms); ) affordability (direct costs, indirect costs, opportunity costs) and ) appropriateness (technical and interpersonal quality, adequacy, coordination, continuity). levesque et. al. [ ] proposed five corresponding conceptualisations of the ways in which peoples' abilities to interact with each of these dimensions are generated: ) ability to perceive (health literacy, health beliefs, trust, expectations); ) ability to seek (personal and social values, culture, gender, autonomy); ) ability to reach (living environments, transport, mobility, social support); ) ability to pay (income, assets, social capital, health insurance) and ) ability to engage (empowerment, information adherence, caregiver support). see figure . the objective of this study is to explore factors and practices around access and use of antibiotics and understanding of antimicrobial resistance in rural communities in bangladesh from a socio-cultural perspective. the study was conducted in the matlab site of the health and demographic surveillance system (hdss) in the chandpur district of bangladesh. the matlab hdss is an economically deprived rural area in southern bangladesh with an estimated population of , people in , households across villages. further information about matlab hdss is published elsewhere [ , [ ] [ ] [ ] [ ] http://ghdx. healthdata.org/record/bangladesh-matlab-health-anddemographic-surveillance-system. this qualitative exploratory cross-sectional study is one component in a larger multi-country research project abacus (antibiotic access and use) [ ] which assessed and compared community-based antibiotic access and use in bangladesh, south africa, ghana, vietnam, thailand and mozambique. http://www. indepth-network.org/projects/abacus. abacus was conducted in the six countries in two phases ( - ). the first phase involved identifying antibiotic resources by mapping suppliers and implementing inventories. in the second phase, factors that affect antibiotic access and use were explored using in-depth interviews (idis) and focus group discussions (fgds) with community members in each of the sites. this study reports the results of idis and six fgds conducted in the bangladesh matlab site in the second phase of the abacus project. supplementary file (sf) includes the preparatory in-depth interview guide, sf the in-depth questionnaire and sf the preparatory focus group guide. sampling and recruitment followed the abacus study protocol under the direction of the third author (hw) [ ] . fourth and fifth authors (wak and am respectively) were abacus study investigators in the matlab site. wak is a senior public health scientist and am is an anthropologist. in line with abacus protocols [ , , ] residents were 'randomly sampled' from different age and gender categories in ten villages across four different geographic areas identified in the matlab hdss database [ , ] . the same method applied in both idis and fgds. antibiotic suppliers and healthcare workers were not invited to participate. the sixteen idis (four men and women) and six fgds ( men and women) were conducted between march and april . four people (two men in the idis and one woman and one man in the fgds) declined to join the study. there were no drop-outs. see results section for details. the themes for the qualitative data collection instruments were informed by a review of the literature and developed by jk under the guidance of the abacus principal investigator (hw). local support was provided by wk and am. the interview and focus group questions were developed in english and translated into the bangla language by wak and am. the questions were divided into sections ) accessing treatment, ) the supplier/seller of medicines, ) the medicines. see sfs , and . references to specific medicines were made using international brand names which are commonly recognised both in clinical and community settings in bangladesh. all participants were familiar with the terms, concepts and brand names. the field workers ensured that there were no ambiguities. the fifth author (am) conducted all the interviews and discussions with the support of a trained field assistant. neither were known personally to the informants. all interviews and discussions were taperecorded. on average, the duration of the idis was minutes and the fgds minutes. the idis and fgds each had a different purpose. the idis were conducted in private homes. interviewees were encouraged to speak openly about their experiences and give personal opinions. in the fgds (held in community spaces in villages) there were many opinions being expressed on the same topic. participants interacted with one another and shared views and insights. both sets of data were analysed in the same manner. transcripts were recorded in bangla and translated to english for coding and analysis by the first author (mc) with input from the last author (jk). transcripts were not shared with the informants. data were analysed using a combined thematic approach. by this we mean that the approach was broadly inductive with the concept of access being central and a priori themes derived from the questions used in the fgds and idis. both sets of data (idis and fgds) were analysed in the same manner. we used braun and clarke's six thematic steps to: become familiar with the data; generate initial codes; search for themes; review potential themes; define themes, and produce a report [ , ] . codes were generated, assessed and clustered into emergent themes consistent with the access framework dimensions [ ] . atlas ti . software was used in coding all transcripts. we were critically aware of the importance of reflexivity during the collection and interpretation of data. the multidisciplinary nature of our team meant that we were cognisant of how different value systems can influence judgement and lead to biased processes and outcomes. the informants were fully informed about the backgrounds of the field workers with whom they had contact. all study informants were fully informed about the purpose of this study, the processes used to collect qualitative information, and the matlab study's relationship with the abacus project. informed written consent was a requirement for participation in the idis and fgds. approval for all abacus project sites was granted by the oxford university tropical research ethics committee, and the ethical review committee of the international centre for diarrhoeal disease research, bangladesh [ ] . over % of people in matlab live below the poverty line [ ] . according to the most recent ( ) matlab hdss household socio-economic census [ ] one in six households did not have access to improved water sources, most had mud flooring and tin was the predominant building material. the bicycle was the most common form of transportation. most men aged - years were working; the highest proportion of working women ( %) was in the age group - years. remittance payments were the main source of income for one third of households. twenty nine percent of females and % of males had not had any formal schooling. medical pluralism is an important characteristic of healthcare in matlab. residents access formal and informal services for both conventional and alternative medical care and advice. treatment seeking is influenced by social and cultural beliefs, previous experience and perceptions about the approachability, acceptability, availability, affordability and appropriateness of care [ ] . government-run services charge nominal fees [ ] . the most common reported acute illnesses are fever, diarrhoea/dysentery and aches/pains for which self-treatment is common. matlab's morbidity and mortality profile is changing from acute, infectious, and parasitic diseases to non-communicable conditions including cardiovascular and cerebrovascular diseases. longer duration illnesses are managed in government hospitals [ , ] . there were informants ( female and male) from different villages. the age range spanned - years. the average age of interviewees was years and the average age of focus group participants was . most of the men were employed and most of the women were engaged in full time home duties. islam was the dominant religious faith. none of the informants held health insurance (see tables and ). data are presented under the five thematic dimensions proposed by the access framework developed by levesque et. al. [ ] . as there were no substantial differences in the results of the idis and fgds, the findings are grouped togther. approachability/ability to perceive 'approachability' relates to how individuals perceive the existence of services they need. village pharmacies were directly approachable for primary treatment. young women sought treatment based on what they believed had worked well in the past. we usually go to the nearby pharmacies for primary treatment. if anything is serious then we travel to the upazilla (approximately nine kilometres). the treatment at the pharmacy works fine, that's why i barely go to the hospital. moreover, i get medicines in credit sometimes'. (idi -female, age , secondary education, homemaker). a mother commented that she used medications she could trust to provide a 'quick-fix'. if there is any trouble i take an extra dose of antibiotic. if i am having stomach-ache today, i will need a pill. so if i take one dose extra, then there will be no pain (idi -mother of child under five years, age , secondary education, homemaker). men referred to serious issues of structural violence in public sector facilities. in contrast, village pharmacies offered a safer trusted alternative. ' we go to private facilities because of the poor service in the public ones. even though the treatment is free in public facilities, they do not treat well without bribe or connection. moreover, often we do not even get free medicines. they just sell them outside. we are treated with negligence. if we go to the public healthcare centres, we might end up dying without treatment.' (fgd -male, age , secondary education, agriculture). women mentioned limited medicine supply as a further impediment. ' we do not have any government health facility in our area. there is one in our neighbouring village but the government ones do not always have a sufficient supply of medicines'. (fgd -female, age , primary education, homemaker). informants self-medicated with antibiotics for: wound healing, headache, lethargy, blood pressure control, urinary tract infection and stomach ache. commonly recognised brand names were: fimoxyl, zthrin, zmax, cephrad and cef- . health literacy and trust was built on familiar trusted brand names. there were several choices to make regarding where to seek acceptable healthcare. non-medical spiritual practices are important healing methods in the local belief system. these methods included 'jharfuk' (sorcery involving blowing holy verses), 'kabiraji' (treatment with herbal extracts), 'tabij' (an amulet containing verses from holy books believed to be protective and curative against diseases) and 'pani pora' (water with spell from the religious pastor which is believed to be curative). 'kabirajs do not give medicines, they give "tabij" instead, and people recover there. as we believe in religion, we believe that allah can cure us without medicines if he wants, he can save us without treatment'. (fgd -male, age , higher secondary education, service sector employment). younger people were aware of religious discrimination in government healthcare. this influenced their ability to seek healthcare. 'the hospital is in mnd which is a hindu area. so people from our area do not really prefer going there.' (fgd -male, , higher secondary education, business sector employment). medicines were obtained (free of charge) from friends, relatives and neighbours. having personal contacts with hospital or pharmacy experience enhanced self-efficacy. 'i do not need to visit doctors mostly as my neighbour works in the hospital and gets free medicines from there. i take antibiotics from her, even for my family members. she tells me how to take it'. (idimother of child under five years, age , undergraduate education, homemaker). a young wife had full confidence in her husband's advice because of his village pharmacy experience. ' in my family, my husband suggests which antibiotic is to be taken as he has a good knowledge about the ability to reach healthcare is related to the ability to seek healthcare. men aired complaints regarding the distance to hospitals. village based services were available and easy to reach. 'there is only a community clinic in our village. the nearest government hospital is there in ml (another village kilometers away from the village) and then matlab (sub-district centre kilometres from the village)'. (fgd -male, age , primary education, agriculture). public infrastructure was inadequate on multiple fronts -roads, facilities and the medical workforce. ' we do not have sufficient physicians in our area. for primary care, we need to go to dk (around kilometres away from his village). they are really far, moreover, look at the condition of the roads. we need more doctors and better facilities for treatment for our people'. (fgd -male, age , primary education, service sector employment). at the very least it was important to ensure that village residents could reach medical facilities to obtain treatment when needed. another male focus group informant made the following comment. 'government health facilities are far from here, also look at the condition of the roads. this is hard to travel. we need doctors and better treatment for our people'. (fgd -male, age , higher secondary education, business sector employment). even though most medicines are free of charge in government-run facilities, informants preferred to use trusted nearby village pharmacies where they could purchase medicines quickly over the counter. yet personal economic circumstances influenced ability to pay. men shared personal accounts of their healthcare expenditure and monthly earnings in the focus group. you have to accept the reality. if you earn bdt/ month ($us ) you cannot afford to pay healthcare costs at all if the problem is more than just a cold or a fever. many people in the village struggle with expenses for treatments. some people borrow money and others end up selling all their lands and properties to afford to pay treatment costs'. (fgd -male, age , higher secondary education, unemployed) pharmacy healthcare was appropriate. village residents were comfortable engaging with local salespersons in pharmacies. 'frankly speaking, our healthcare system is totally pharmacy-based.' (fgd -male, age , higher secondary education, service sector employment). pharmacy salespersons hold a level of authority and accountability with regard to medication advice. they are trusted and respected by both men and women. salespersons typically cut slits in the boxes to help those unable to read. three cuts, for example, can mean one pill three times a day. 'they (pharmacy salespersons) tell us how to take the medicines and we depend on this advice. if they give something wrong, they will be in trouble. they might not be mbbs doctors but they are from our area, so we trust their management.' (idi -mother of child under five years, age , secondary education, homemaker). antibiotics were perceived as being useful for treating infections. but there was also a belief that antibiotics could be used to treat non-infectious conditions such as hypertension and lethargy. some male and female focus group participants volunteered views on resistance. 'antibiotic resistance? i heard that antibiotics will be banned or something, on the tv news. it said around hundred companies were banned or something. i cannot remember correctly.' (fgd -male, age , postgraduate education, business sector employment). there was curiosity about correct dosages. 'yes, we have that habit. if we take antibiotics for two days and get well, we stop taking it. this causes the problem and the disease recurs. who knows? frequent use of antibiotics might turn out to be another disease.' (fgd -female, age , higher secondary education, homemaker). awareness raising activities were discussed. examples include audio-bulletins in villages, neighbourhood discussions, door-to-door promotions by community health workers, counselling by physicians and advertising in the media (television, radio and newspapers). treatment seeking was women's responsibility and their role was important in raising awareness about antibiotics and amr. 'i think the females of the community should be focused to educate about the issue as the males are usually busy. the female members of the family can teach them later'. (idi -female, age , primary education, unemployed). the findings of this qualitative study highlight multiple factors and practices around the access and use of antibiotics and the understanding of abr in matlab, bangladesh. healthcare seeking is embedded in social, economic, political and institutional structures and belief systems. individuals in resource-poor settings have limited capacity to make the same evidence-based choices that are available in more advantaged populations [ , , ] . 'structural violence' in government facilities inhibits access to the public sector for antibiotic medicines [ ] . local retail pharmacies and clinics are the accepted primary healthcare choice. advice regarding antibiotic medicines is based on common practice and reinforced by trust built on personal communication and local knowledge [ , , ] . according to the access to healthcare framework [ ] impediments to accessing prescription antibiotic medicines result from: the low density of facilities and the financial burden of purchasing antibiotics (availability/ability to reach and affordability/ability to pay); sociocultural factors and trust (acceptability/ability to seek and approachability/ability to perceive) and the abundance of unregulated services (appropriateness/ability to engage). enablers capture the willingness to learn (appropriateness/ability to engage). see figure . most were unaware of the term 'antibiotic resistance' or 'abr' although some understood the link between 'inappropriate' use and 'effectiveness'. many reported a willingness to engage in learning about amr. health literacy was built from past experience. 'trusted' brands that had provided a 'quick-fix' in the past were preferred. over sixty percent of patients' total healthcare expenditure is for pharmaceuticals, and over sixty percent of this is borne out of pocket [ ] . the average gross income per capita in bangladesh is only $us per day http://povertydata.worldbank.org/poverty/home/, the price per capsule of the three most popular antibiotics zithrin, (azithromycin), zmax (azithromycin) and cef- (cefixime) is about $us . . a standard course of any of these medicines costs between two and six $us. when medication costs impact on ability to pay there is an incentive to under-dose if this saves money. as is the case in most lmics, the informal sector in bangladesh provides the bulk of healthcare for the poor [ ] . a systematic review of the role of informal providers in developing counties cited convenience, affordability and social and cultural norms as the main reasons for their popularity [ ] . references to the informal sector, whether in housing, the labour market or healthcare are often made in a normative context, imposing unfair judgment and discrimination on disadvantaged and marginalised populations for whom these services offer the most affordable and suitable option [ ] . in this study, informants reported selfmedicating with antibiotics because they believed, in good faith, that these medicines would alleviate symptoms and lead to recovery [ ] . our findings illustrate how the acceptability of village pharmacies as providers of antibiotic medicines is embedded within the social and cultural fabric. people valued the accessibility of local stores and were reassured by the approachability and familiarity of trusted pharmacy salespersons. care seeking behaviours were motivated by good intent to remedy immediate health concerns in an expedient affordable manner [ ] . family budgets were constrained. healthcare was covered after providing food and shelter. even though antibiotics were nominally 'free of charge' when purchased from government facilities, there were service charges to consider. poorly maintained roads made people reluctant to travel to hospitals located several kilometres away when they could purchase medications and obtain healthcare advice locally. trust plays an important role in healthcare approachability [ ] . trust in government run services was eroded by perceptions of bribery, corruption, negligence and the scarcity of medicine supplies. some perceived patient safety to be at risk. informants therefore trusted pharmacy sales persons more than medical practitioners. it is essential for policy-makers to understand the underlying reasons for this trust imbalance. health sector reforms need to accommodate the roles played by both providers and seekers within a fractured pluralistic healthcare system [ ] . the availability and affordability of quality-assured medicines is an essential requirement for the delivery of primary healthcare [ ] . the commonly accepted purchasing of medicines from village pharmacies must be understood in context. the vulnerability of individuals due to circumstances such as hardship, poverty, and stress impacts on access to healthcare and medicines in ways that are often not well understood by policy-makers and regulators operating from positions of relative advantage and prosperity. the study was conducted in matlab, an hdss site since and home to numerous significant public health interventions in bangladesh [ , ] . the abacus project provides an empirical basis for understanding antibiotic use and informing context specific interventions in six lmics [ , , , , ] . the research infrastructure is well established, and we are confident that all ethical and scientific protocols were followed correctly over the course of this study. the data collection methods were standardised across the six-country study sites in the abacus project [ ] . although there were opportunities for some probing questions we followed the pre-defined topics. see sf , sf and sf . this study in matlab provides rich contextual insights into how and why people's medicine behaviours are as they are. however we do acknowledge that there may be a degree of fatigue due to the area being well-researched by the dhss over several decades. moreover, residents across matlab may be more astute about the issues discussed here than people in other rural parts of bangladesh. the findings are not intended to be representative, generalizable or comprehensive. antibiotic use in matlab villages reflects a fractured public healthcare system that remains out of touch with the issues that determine health seeking behaviours and oblivious to the erosion of trust in public infrastructure and services. future research in matlab might include ethnographic methods such as participant observation to explore further lines of enquiry regarding the way underlying social, economic and political determinants underpin behaviours [ ] . the focus on individual behaviour change needs to be complemented by attention to the dynamic complex processes responsible for knowledge acquisition. we need to understand more about the ways in which social, cultural and economic factors impact on the knowledge, attitudes, beliefs and behaviours of patients, health professionals and the broader public in regard to the use of antimicrobials in human health and agriculture [ , ] . cross discipline research, using mixed methods, is needed to focus on the dynamic interplay between contextual constraints, communication and behaviour change among the various agents involved in care seeking. informal providers are a neglected yet important group in amr research. there is a need for research to unpack the issues from the perspective of informal providers to help inform strategies to build community trust in government-run health services [ ] . awareness raising campaigns have had limited success in lmics because they have tended to focus on, and also judge, knowledge deficits [ , ] . yet mainstream public health education messages are not appropriate for those experiencing hardship and abject poverty on a daily basis [ ] . educational campaigns need to be complemented by upstream drivers of amr such as poverty and unemployment and structural violence [ , ] . at the national level, the implementation and enforcement of the bangladesh government's national drug policy must be strengthened [ , , , ] . the world health organization acknowledges the need to increase awareness and knowledge about antibiotic medicines and abr more broadly in society. specifically this means developing surveillance and research, enhancing infection control, optimizing the use of antimicrobials in human and animal health, and building sustainable investment in new medicines, diagnostic tools, and vaccines [ ] . progress will only be achieved by understanding human behaviours and actions in relation to norms, assumptions, beliefs and attitudes at the intersection between social and economic circumstances and political power structures. interventions aimed at mitigating amr must address the entrenched social, economic, political and cultural conditions in which people live, work and seek care [ , ] . sustainable solutions will require multi-sector national action plans with clear targets and lines of accountability to ensure that political will translates to effective action [ ] . accountability for amr lies with governments and global authorities both within and beyond the health sector [ , ] . developing a much stronger manuscript we learnt a lot from their feedback. the themes for the qualitative interviews were developed by jk under the guidance of hw and with support from wk and am. fieldwork was conducted by wak and am under the direction of hm as principal investigator for the abacus project. data analysis was undertaken by mc with assistance from wak, am and jsw and guidance from jk. the first draft was prepared by mc. jsw developed and finalised the draft, undertook the literature review and provided critical input for the submission and subsequent revision. all authors read and approved the final version. no potential conflict of interest was reported by the authors. the procedures followed in this study were approved by the oxford university tropical research ethics committee and the ethical review committee of the international centre for diarrhoeal disease research, bangladesh. the abacus project was funded by the wellcome trust [ ] major overseas programme; uk through indepth network. this paper is based on a master of public health thesis funded by the swedish institute. antimicrobial drugs (antifungals, antivirals and antimalarials) are public goods. inappropriate use promotes the spread of resistant pathogens and reduces treatment efficacy, thereby impacting on public health. in bangladesh, over sixty percent of patients' total healthcare expenditure is for pharmaceuticals, over sixty percent of 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peer review: . wellcome open res to sell or not to sell; the differences between regulatory and community demands regarding access to antibiotics in rural ghana community knowledge and practices regarding antibiotic use in rural mozambique: where is the starting point for prevention of antibiotic resistance? thematic analysis what can "thematic analysis" offer health and wellbeing researchers? antimicrobial resistance as a problem of values? views from three continents the spectre of superbugs: waste, structural violence and antimicrobial resistance in india what influences antibiotic sales in rural bangladesh? a drug dispensers' perspective informal allopathic provider knowledge and practice regarding hypertension in urban and rural bangladesh what is the role of informal healthcare providers in developing countries? a systematic review toward an epistemology of planning united nations children's fund. a vision for primary health care in the st century: towards universal health coverage and the sustainable development goal determinants of inappropriate antibiotics use in rural central ghana using a mixed methods approach. front public health antimicrobial resistance, inflammatory responses: a comparative analysis of pathogenicities, knowledge hybrids and the semantics of antibiotic use help seeking for antibiotics; is the influence of a personal social network relevant? prevention of antibiotic resistance -an epidemiological scoping review to identify research categories and knowledge gaps we are most grateful to the abacus team and the all of the informants who freely gave of their time to participate in the fgds and idis. we express our gratitude to the reviewers for their extensive commentaries. apart from key: cord- - ucemm authors: sazzad, hossain m.s.; hossain, m. jahangir; gurley, emily s.; ameen, kazi m.h.; parveen, shahana; islam, m. saiful; faruque, labib i.; podder, goutam; banu, sultana s.; lo, michael k.; rollin, pierre e.; rota, paul a.; daszak, peter; rahman, mahmudur; luby, stephen p. title: nipah virus infection outbreak with nosocomial and corpse-to-human transmission, bangladesh date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: ucemm active nipah virus encephalitis surveillance identified an encephalitis cluster and sporadic cases in faridpur, bangladesh, in january . we identified case-patients; of these patients died. for case-patient, the only known exposure was hugging a deceased patient with a probable case, while another case-patient’s exposure involved preparing the same corpse for burial by removing oral secretions and anogenital excreta with a cloth and bare hands. among persons with confirmed sporadic cases, died, including a physician who had physically examined encephalitis patients without gloves or a mask. nipah virus–infected patients were more likely than community-based controls to report drinking raw date palm sap and to have had physical contact with an encephalitis patient ( % vs. %, matched odds ratio undefined). efforts to prevent transmission should focus on reducing caregivers’ exposure to infected patients’ bodily secretions during care and traditional burial practices. in bangladesh, probable or confirmed cases of nipah virus (niv) infection in humans were identified from through ; ( %) were fatal ( ) . drinking raw date palm sap, contaminated by niv from urine or saliva of pteropus spp. fruit bats, has been identified as a vehicle for transmission of niv to humans in bangladesh ( , ) . niv, an rna paramyxovirus ( ), was isolated from human respiratory secretions, saliva, and urine during the outbreaks ( , ) . outbreak investigations in bangladesh and india have repeatedly implicated person-to-person transmission of niv, including health care-associated transmission in the siliguri, india, outbreak in ( ) ( ) ( ) ( ) . however, to our knowledge, no evidence of niv transmission to health care workers had been confirmed in bangladesh ( ) . in the area where niv outbreaks have been repeatedly identified (figure ), the institute for epidemiology, disease control and research (iedcr) of the government of bangladesh, in collaboration with icddr,b (formerly the international centre for diarrhoeal disease research in bangladesh) is conducting hospital-based encephalitis surveillance. to detect outbreaks of niv infection, the surveillance system identifies sporadic niv cases during january-march and clusters of encephalitis patients throughout the year. on january , , two cousins living in the faridpur district in bangladesh ( figure ) were admitted to faridpur medical college hospital (fmch) with fever and altered mental status. a team from iedcr and icddr,b initiated an investigation on january , . the objectives of the investigation were to identify the cause of the outbreak and to detect sporadic cases of niv infection. surveillance physicians maintained a registry of patients who sought treatment with fever or with history of fever with axillary temperature > . °c ( . °f), altered mental status, new onset of seizures, or a new neurologic deficit, either diffuse or localized to the brain ( ) . the physicians collected whole blood, cerebrospinal fluid, a throat swab specimen, and urine samples from patients admitted during january-march in of the active surveillance hospitals (faridpur, rajshahi, and rangpur medical college hospitals) and during january-april at faridpur medical college hospital. these samples were stored in liquid nitrogen in local hospitals and transported biweekly to the iedcr laboratory. we defined possible case-patients as persons with acute onset of fever living in the outbreak area with onset of illness from january through january , . we identified possible case-patients by conducting door-todoor visits of all homes and contacting local physicians in the affected villages. we defined probable case-patients as persons who met the possible case definition and who had new onset of altered mental status or new onset of breathing difficulty. we defined case-patients with laboratoryconfirmed niv infection as those with detectable serum igm against niv. to assess asymptomatic niv infection in the outbreak community, we asked community members who had close physical contact or had shared date palm sap from the same pot with probable or confirmed case-patients within the preceding month, to provide a blood specimen for serologic testing. we obtained a clinical history and information about exposures during the month before illness from each probable and confirmed case-patient. friends, relatives, and neighbors of deceased or unconscious case-patients served as proxy informants for interviews. the investigation team collected acute-phase and subsequent whole blood specimens from possible casepatients. samples were centrifuged in the local government community clinic, and the separated serum was stored and transported to the iedcr laboratory in liquid nitrogen. samples were stored at - °c. we tested serum samples at iedcr with an igm capture enzyme immunoassay that detects niv igm ( ) . we shipped an aliquot of serum, cerebrospinal fluid, throat swab specimens, and urine from patients with probable and confirmed cases of niv infection and from those with igm against niv to the centers for disease control and prevention (cdc), atlanta, georgia, usa, for confirmatory testing. we conducted in-depth interviews with families of casepatients to explore history of illness and exposures of casepatients. we also had informal discussions with neighbors of case-patients to explore possible modes of transmission. we conducted a matched case-control study to identify risk factors for transmission of niv. persons with probable and confirmed cases from the outbreak and with sporadic cases identified from surveillance were considered to be case-patients. the field team selected neighborhood controls for each case-patient, starting from the fourth closest courtyard to the case-patient's residence. the courtyards where other case-patients resided were excluded. in each courtyard, only the household closest to the main entry was selected. the age of every person in the selected household was recorded. then a control (only from each courtyard), whose age was closest to the case-patient's age, was selected. if that control was absent during the first visit, the team tried times to reach the control. if the team was unsuccessful, no control was selected from that household. this process was repeated at the next closest courtyard household until we had selected the required number of controls. all case-patients, except , were either too sick or too confused to respond or had died, so the field team selected multiple appropriate proxy respondents for interview. we used standardized, structured questionnaires in the bengali language. to estimate the association between each exposure and niv infection, we calculated the matched odds ratio (mor). we used conditional logistic regression and considered any association to be statistically significant if the p value was < . . we analyzed data in stata (stata corp., college station, tx, usa). legal guardians of study participants and healthy adult participants provided informed verbal consent for participation in this investigation. the ethical review committee of icddr,b reviewed and approved the protocol for niv surveillance and outbreak investigation. during january-april , surveillance physicians from the hospitals reported meningoencephalitis casepatients. of these, ( %) were reported by surveillance physicians in faridpur, including outbreak case-patients. ninety-seven ( %) serum samples were collected at the faridpur surveillance site. of these, had igm against niv ( %), including from the outbreak area. the outbreak investigation team identified possible niv-infected persons with febrile illness in the outbreak area during january - , . of these, persons gave a blood sample for niv laboratory diagnosis. one person's sample was positive for igm against niv and that person was classified as a confirmed niv-infected casepatient. we collected blood samples positive for igm against niv from probable case-patients. the remaining case-patients died before blood samples were collected. we defined these persons as probable niv-infected casepatients. all but case-patient had altered mental status, and two thirds of case-patients had breathing difficulty (table ) . seven ( %) of persons who met the case definition for probable or confirmed niv infection died. the onset of illness for all of case-patients occurred within days of exposure. four cases constituted an initial peak, and a second-generation outbreak of cases appeared after contact with the initial case-patients ( figure ). sporadic case-patients among patients with sporadic cases of niv infection, of whom died, had a history of drinking raw date palm sap in the month preceding illness onset, and of these were harvesters of date palm sap. one case-patient attended to a family member who was hospitalized at fmch with an illness unrelated to encephalitis for days, days before the onset of illness. while staying in the hospital, he spent the days talking with and caring for other patients and slept alongside them. another case-patient was a physician in training at fmch. from january through february , , he worked in the adult medicine and pediatric wards and clinically managed cases of meningoencephalitis in patients, including with confirmed niv infection and other severely ill febrile patients who had not been enrolled in niv surveillance. he performed physical examination, intravenous canalization, and nasogastric intubation for confirmed case-patient in the adult medicine unit > month before the onset of his illness. he also similarly treated the condition of confirmed niv case-patients in the pediatric unit days before his onset of illness. a handwashing station for physicians did not exist in either the adult medicine or pediatric wards, and his colleagues reported that he did not use gloves or a mask during patient care or wash his hands after patient care. his illness began on february , , with fever and myalgia. subsequently, he experienced coughing, respiratory distress, convulsions, altered mental status, and loss of consciousness. he died on march , . the duration between onset of illness of the physician and his contact with known niv-infected casepatients in the adult medicine ward was days, and the time from his contact with the children with niv infection to illness was - days. two niv genomic sequences, obtained from of meningoencephalitis patients that the physician had been in contact with, did not match the niv genomic sequence of the physician's isolates ( ) . case-patient a, a -year-old man with a probable case of niv infection, lived under a pteropus bat roost. he drank raw date palm sap from his own date palm tree during the last week of december , week before the onset of illness on january , . he had fever, headache, and myalgia, which progressed over days to drowsiness, convulsions, confusion, unconsciousness, and death. on january , three neighbors of case-patient a, from a single family (case-patients b, c, and d), bought and drank raw date palm sap from the village date palm sap harvester. all became ill on january , within hours of each other. none had any history of contact with any person who had symptoms similar to encephalitis. probable case-patients a and b died on january ; confirmed case-patients c and d died on january and ( figure ). among those with second-generation cases, casepatient e (confirmed case) was the wife of case-patient a and was involved in feeding, comforting, and transporting her husband to fmch and in bringing his dead body back home on january . she cleaned saliva from her husband using her bare hands and did not wash her hands afterwards. she also drank raw date palm sap with case-patient a in last week of december and did not get ill. on january , , a fever developed, but she did not have altered mental status. she recovered on the fourth day of illness and was a confirmed case-patient who survived. casepatient f (confirmed case) was a friend of case-patient a, who frequently visited case-patient a during case-patient a's illness. when case-patient a's condition deteriorated, case-patients e and f took him to the hospital. case-patient a had to be supported by case-patient f, and the distance between the faces of case-patients a and f was < foot while case-patient a was coughing, salivating, and having difficulty breathing. while bringing the dead body back from hospital by bus, case-patient a's head rested on the thigh of case-patient f. case-patient g (confirmed case) was the uncle of case-patient a who lived in the same village, and he never visited case-patient a during his illness. he had no contact with any other encephalitis case-patient. he arrived only after case-patient a died and had caressed the head of the corpse before the ritual corpse bathing. case-patient h (probable case), was a neighbor of casepatient a, who did not come into contact with case-patient a during his illness. he carried out the muslim practice of ritual purification by cleaning the body and washing it. he used pieces of cloth to clean the body orifices (anus, urethra, oral and nasal secretions) with an ungloved hand. he then washed the entire corpse with water. he took a bath hour after the ritual cleansing. case-patient g came in contact with the corpse of case-patient a hours after case-patient a's death, and case-patient h came in contact with the corpse of case-patient a hours after case-patient a's death. none of these case-patients (f, g, and h), who cared for case-patient a before or after his death, had drunk raw date palm sap in the preceding month. their illnesses began - days after contact with case-patient a, they had symptoms similar to those of case-patient a, and they died on january or january , , after - days of illness. the field team enrolled case-patients and controls ( table ). the mean age of the case-patients and controls was similar (mean age [±sd] ± years for casepatients vs. ± years for controls, t = - . , p = . ). among case-patients with niv infection and neighborhood controls, niv case-patients were more likely than controls to have consumed raw date palm sap during the month before the case-patient's illness ( % in case-patients vs. % in controls, matched odds ratio [mor] . , p = . ) and were more likely than controls to have been in the same room as case-patients ( % vs. %, mor undefined, p< . ) or to have touched ( % vs. %, mor undefined, p value undefined) case-patients. during , we identified an outbreak and several sporadic cases of encephalitis caused by niv infection. two case-patients from the outbreak and patients with sporadic cases had igm against niv in serum and niv rna in oropharyngeal swab samples by conventional and real-time reverse transcription pcr ( ) . we could not collect biological specimens from probable outbreak case-patients, including the source case-patient; however, the onsets of illness of patients with confirmed and probable cases were within weeks of each other in an area where niv outbreaks have been repeatedly confirmed over the past decade ( , , ( ) ( ) ( ) ( ) , ) . clinical features of fever, evidence of brain involvement, and rapid progression to death were also consistent with previous niv outbreaks ( , , - , ). the first case-patients of the initial phase of the outbreak, and of of the patients with sporadic cases, apparently contracted niv infection by drinking raw date ( , ) . the remaining case-patients from the outbreak probably acquired niv infection from physical contact with the source case-patient. such person-to-person transmission has been observed in prior niv outbreaks in bangladesh ( - ). the generations of transmission are reflected in the peaks in the epidemiologic curve ( figure ). among the second-generation cases, a novel finding was the transmission of niv from the corpse of the source case-patient to persons who had contact with the corpse before burial. this is the most plausible transmission pathway, because they did not have known exposures to living persons with encephalitis and had no history of drinking raw date palm sap. because niv is found in the respiratory secretions of niv case-patients ( ) , casepatient g may have had intimate hand and facial contact with the corpse's respiratory secretions while performing ritual purification. consistent with the culturally prescribed method of ritual bathing of a corpse, case-patient h did not wear a mask or gloves during cleansing of the corpse's orifices. he only used pieces of cloth and his bare hands, which then were almost certainly contaminated with niv. case-patient h also likely touched his face or nose during or after the ritual purification. persons commonly touch their own faces subconsciously, and videotaped observational study found that persons touched their own eyes, nostrils, and lips times per hour during normal activities ( ) . during muslim ritual bathing, water is poured on the body ( ) . thus, the water may have become contaminated with niv and came in contact with case-patient h's clothes and body. similar to other infectious diseases, including severe acute respiratory syndrome and measles, the transmission efficiency of individual niv case-patients varies ( , , ) . case-patient a was an unusually efficient spreader of niv, perhaps because of an unusually high concentration of niv in his oral secretions. the dead bodies of all niv-infected patients who are muslim in bangladesh have undergone the same process of ritual bathing, but to our knowledge, corpse-to-human transmission has not been previously recognized. in other niv outbreaks when niv infection developed in family members, many persons had contact with the source casepatient during illness and when preparing the corpse, so we were unable to separately assess corpse-to-person transmission. this investigation suggests that occasional niv transmission could occur during the muslim ritual purification of a corpse before burial. this study also documents the death of a physician in bangladesh from niv encephalitis after he cared for niv-infected patients with encephalitis in the surveillance hospital. the physician's colleagues and roommates did not report any history of his drinking raw date palm sap during the month preceding onset of illness. although the physician had contact with oral secretions of several meningoencephalitis patients during the outbreak, the genetic sequence of niv found in the physician was distinct from those of hospitalized niv-infected casepatients who were positive for niv by reverse transcription pcr ( ) . indeed, none of the hospitalized patients with confirmed niv infection was likely to have been the source of the physician's infection. the duration between onset of illness of the physician and his contact with confirmed niv case-patients was beyond the range of the -to day incubation period for niv ( , ) . during the assumed time of exposure to niv, he cared for patients in the adult medicine ward; some of them may have had niv infections that were missed by hospital surveillance. however, we did not identify any patient who met the case definition for meningoencephalitis in that ward - days before onset of the physician's illness. the clinical spectrum of human niv infection in bangladesh also includes patients who sought treatment with respiratory disease as the primary manifestation ( ) , and surveillance may have missed any niv-infected persons on the ward with this clinical manifestation. another line of evidence suggests that an unidentified niv-infected patient was hospitalized on that adult medicine ward at that time. one patient with a sporadic case, who visited fmch as a family caregiver, also provided care for several patients in the men's medicine ward during the same days that the physician attended to patients on that ward. this case-patient may have come in close physical contact with the same unidentified nivinfected case-patient as the physician. during , health care workers were infected by niv in siliguri, india. among infected persons, case-patients were hospital staff or family caregivers attending to the patients, and patients were infected from an unidentified, hospitalized index case-patient ( ) . however, during an niv outbreak in bangladesh in , health care providers (using minimal personal protective equipment [ppe] and with substantial exposure to niv case-patients) had no evidence of having acquired niv infection ( ) . during in faridpur, niv was transmitted from person to person in community and hospital settings. the observed differences in risk for person-to-person transmission between outbreaks suggest that niv strains may differ in their proclivity for personto-person transmission. because niv infection is not the major cause of acute meningoencephalitis in bangladesh, and because most persons who contract niv infection have died by the time a diagnosis is made, it is difficult to identify a strategy to prevent person-to-person transmission that could be consistently applied to niv-infected casepatients. strategies to reduce care providers' exposure to respiratory secretions could prevent a broad array of saliva-transmitted infections, including niv encephalitis. prevention approaches to reduce corpse-to-person transmission of niv and other potentially fatal respiratory secretion-transmitted viruses should focus on minimizing exposure to saliva and other bodily fluids from the body of a person who died of severe febrile illness. wearing gloves and a mask during the handling and washing of a dead body before burial would not be feasible in lowincome communities, where the annual total per capita spending on health is us $ per person per year ( ) . research to identify culturally acceptable cost-effective approaches that can be consistently implemented in lowincome settings, for example, washing hands thoroughly with soap and water immediately after corpse contact, could save lives. this report of nosocomial transmission of niv to a health care worker in bangladesh after caring for nivinfected patients highlights the risk of working without ppe. barriers to developing an appropriate prevention strategy for nosocomial transmission of niv in hospitals in bangladesh include the following: inadequate supplies of ppe for hospital staff, absence of isolation wards, absence of handwashing facilities in hospital wards and physicians' rooms, and inadequate training and monitoring for infection control ( ) . because saliva is the most likely vehicle for transmission of niv among care providers, implementation of standard and contact precautions ( ) that have been culturally and economically customized to fit this setting could reduce niv transmission. as a first step, we recommend that handwashing stations be established and consistently supplied with soap and water in every ward of the hospital for health care workers and patient attendants. second, because laboratory diagnosis for niv infection is not available during the initial evaluation of patients with meningoencephalitis syndrome, during niv season all hospitals in niv infection-prone areas should admit patients with meningoencephalitis syndrome into an isolation room or ward and routinely provide gloves and masks for health care workers when they are caring for meningoencephalitis patients. patient attendants could reduce their exposure to patient saliva and respiratory secretions by frequent handwashing and by avoiding sharing food and beds with patients. transmission of human infection with nipah virus foodborne transmission of nipah virus date palm sap linked to nipah virus outbreak in bangladesh molecular biology of hendra and nipah viruses the presence of nipah virus in respiratory secretions and urine of patients during an outbreak of nipah virus encephalitis in malaysia genetic characterization of nipah virus person-to-person transmission of nipah virus in a bangladeshi community nipah virus outbreak with person-to-person transmission in a district of bangladesh cluster of nipah virus infection nipah virus encephalitis reemergence risk of nosocomial transmission of nipah virus in a bangladesh hospital clinical presentation of nipah virus infection in bangladesh laboratory diagnosis of nipah and hendra virus infections characterization of nipah virus from outbreaks in bangladesh risk factors for nipah virus encephalitis in bangladesh date palm sap collection: exploring opportunities to prevent nipah transmission recurrent zoonotic transmission of nipah virus into humans a study quantifying the hand-to-face contact rate and its potential application to predicting respiratory tract infection the terminally ill muslim: death and dying from the muslim perspective superspreading sars events the effect of superspreading on epidemic outbreak size distributions nipah virus-associated encephalitis outbreak, siliguri, india health economics unit, ministry of health and family welfare policy making in bangladesh: a study of the health policy process guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. atlanta: centers for disease control and prevention we thank the family members of study participants for their constant support and the volunteers from the outbreak village for their participation in the investigation. we are grateful as well to md yusuf ali, barun k. biswas, and muzahidul islam for their extensive cooperation in the surveillance and investigation. in addition, we acknowledge dorothy southern's helpful review of this manuscript.the study was funded by cdc, atlanta, ga, usa, cooperative agreement no. u ci - , the us national institutes of health (nih), grant no. - - - (bangladesh-nih/emerging infectious disease), and national science foundation/nih ecology and evolution of infectious diseases grant no. r -tw from the fogarty international center. icddr,b also acknowledges with gratitude the commitment of cdc, nih, and the government of bangladesh to its research efforts.dr sazzad is a physician working with the centre for communicable diseases at icddr,b. his research area of interest is emerging and reemerging disease epidemiology, including prevention and control in low-income countries. key: cord- -hf tav authors: abir, tanvir; kalimullah, nazmul ahsan; osuagwu, uchechukwu levi; yazdani, dewan muhammad nur -a.; mamun, abdullah al; husain, taha; basak, palash; permarupan, p. yukthamarani; agho, kingsley e. title: factors associated with the perception of risk and knowledge of contracting the sars-cov- among adults in bangladesh: analysis of online surveys date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: hf tav this study investigated the perception and awareness of risk among adult participants in bangladesh about coronavirus disease (covid- ). during the lockdown era in bangladesh at two different time points, from − march (early lockdown) and − may (late lockdown), two self-administered online surveys were conducted on respondents ( and participants, respectively) via social media. to examine risk perception and knowledge-related factors towards covid- , univariate and multiple linear regression models were employed. scores of mean knowledge ( . vs. . , p = . ) and perception of risk ( . vs. . , p < . ) differed significantly between early and late lockdown. there was a significant decrease in perceived risk scores for contracting sars-cov- [β = − . , %ci: − . , − . ], while knowledge about sars-cov- decreased insignificantly [β = − . , %ci: − . , . ] in late lockdown compared with early lockdown period. self-quarantine was a common factor linked to increased perceived risks and knowledge of sars-cov- during the lockdown period. any effort to increase public awareness and comprehension of sars-cov- in bangladesh will then offer preference to males, who did not practice self-quarantine and are less worried about the propagation of this kind of virus. this may contribute to a big economic tragedy in a country such as bangladesh, which is still attributed to everyday wages, as seen in other heavily affected regions of the world. since the sheer illness of the whole country is sufficient to destroy the health care system, this current study is to examine changes of individual perception of risk for contracting sars-cov- , and the awareness level in bangladesh during the early and late lockdowns implemented by the government of bangladesh. the findings of this study will provide an understanding of people's knowledge level, perception of risk and awareness which can be used to implement emergency policies to counter the spread of sars-cov- . from to march , the first cross-sectional survey entitled "early lockdown" was performed, referring to the week of the lockdown period in bangladesh and the second cross-sectional survey entitled "late lockdown" was carried out from to may . even though a national community-based sampling survey throughout that time was not conceivable, the data were collected electronically using a google form. a standardized synchronized questionnaire was uploaded on social networking sites, such as facebook and whatsapp, which are widely used by investigators and local people throughout the country. emails with the survey link were sent in the second step via contact lists of the researchers to broaden the scope of the survey. participants in the survey received no incentives. the first survey (early lockdown) assumed a % proportion with % confidence. because the main objective of this research was on sars-cov- and there are no previous studies from bangladesh that examined factors associated with this, an online sample size calculator [ ] was used and we took a sample size of approximately , including a % non-response rate. the second survey (late lockdown) assumed a proportion of % (very worried about sars-cov- ) reported in the first study (early lockdown) with % confidence [ ] . the calculation of the total sample size for the second survey was , including a % non-response rate. the participants responding to a "yes" or "no" question obtained voluntary on-line consent to express their willingness to attend the study via google forms. this study was approved by the ethics committee (approval number: brur/dwrti/a.n. ) of the dr wazed research and training institute, begum rokeya university, rangpur. rangpur- , bangladesh. table presents the questionnaire used in this study. the questionnaire was divided into three sections, including demographics, knowledge, and perception. the demographic variables included age, gender, marital status, education, employment, and religion. there were items on the questionnaire that assessed the respondent's knowledge of covid- , most of which required a "yes" or "no" response. each question used a binary scale. the scores for each item ranged from (no) to (yes). the knowledge score ranged from - points. these items have been validated elsewhere to have an acceptable internal consistency [ ] . the survey tool for the covid- knowledge questionnaire was developed based on the guidelines from the world health organization [ , ] for clinical and community management of covid- . those that have contact with someone who has covid- infection should be isolated in the right place immediately. the observation period is usually days k children and young adults should not take steps to prevent the covid- virus from infection. k covid- individuals with no symptoms of fever cannot spread the virus to anyone k individuals should stop being crowded to prevent covid- infection. please rate your chances of personal risk of infection with covid- for each of the following? risk of becoming infected. risk of becoming severely infected p risk of dying from the infection p how much worried are you because of covid- ? are you currently or have you been in (domestic/home) quarantine because of covid- ? how do you feel about the quarantine? i am worried/anxious/alarmed and frightened by the quarantine. i consider the quarantine as necessary and reasonable. i am nervous about the quarantine. i am bored by the quarantine. i am frustrated by the quarantine. i am angry because of quarantine. revised and adopted from world health organization, : available at https://www.who.int/bulletin/online_first/ - .pdf). we asked the respondents about risk perception towards covid- (p −p ). each question used a likert scale with five levels. the scores for each item ranged from (lowest) to (highest). the risk perception score ranged from to points. the cronbach's alpha coefficients of the perception items were . and demonstrated that the internal consistency of perception items was satisfactory. respondents were also asked, "how they felt about the quarantine" (p −p ). each question used a likert scale with five levels. the scores for each item ranged from (lowest) to (highest) and the cronbach's alpha coefficient of the "how they felt about the quarantine items" was . , indicating acceptable internal consistency. the explanatory (independent) variable included basic characteristics and explanatory factors including gender, age in categories, level of education, marital, employment, and religious status. the question of worrying about quarantine score ranged from to points. the worried about quarantine score was divided into three categories. the bottom . % of the score was arbitrarily referred to as "low quarantine practice", the next . % as "moderate quarantine practice", and the top . % as "high quarantine practice". furthermore, "high quarantine practice", which was derived by combining the moderate quarantine practice ( . %) with the high quarantine practice ( . %) and low quarantine practice, was "low quarantine practice scores" . %. data analysis was performed using stata version . (stata corp. college station united states of america). categorical variables were presented as frequency and percentage. this study used a t-test to compare the differences between means for early and late lockdowns for knowledge and risk perception items. in the univariate linear regression analysis, all confounding variables with a p-value < . were retained and used to build a multivariable linear regression model and to determine factors associated with the knowledge and perception score towards covid- . additionally, we performed a similar stage modelling to that employed by dibley et al. [ ] , and a two-staged modelling technique was employed in the multivariable modelling. in the first stage, the demography factors were entered into the baseline multivariable model. a manual process of backward elimination was performed, and variables with p < . were retained in the first model (model ). in the second and final stage of modelling, perceived risk of covid- factors was added into significant variables in model , and variables with p-values < . were retained in the final model. for all regression analyses performed, we checked the homogeneity of variance and multicollinearity using variance inflation factors (vif). the descriptive statistics of the explanatory and dependent variables are shown in table . this summary of responses was obtained from those who participated in the survey during the early lockdown ( - march ) and late lockdown ( ) ( ) ( ) ( ) ( ) ( ) may ) periods. total responses were a combination of both. most of the respondents ( . %, n = ) were - years old with equal representation of males and females. most respondents ( . %, n= ) were married, and almost all ( . %, n = ) completed tertiary education or its equivalent. of the respondents, . % (n = ) were muslims, about two-thirds of them ( . %, n = ) voluntarily quarantined themselves during the study period while about a quarter of them ( . %, n= ) did not quarantine. regarding their concern for the spread of the sars-cov- virus, the majority ( . %, n = ) stated that they were very worried. figure a,b show the mean and % confidence intervals of perceives risk and knowledge towards covid- , respectively. data of early and late lockdown periods are presented here, correspondingly. figure a indicates statistical differences between early and late lockdowns (p < . ), with early lockdown reporting the highest mean values. additionally, as indicated in figure b , knowledge towards covid- for early lockdown significantly reported the highest mean value compared with late lockdown (p = . ). the horizontal values in figure a ,b are the minimums and maximums of perceived risk and knowledge scores. the unadjusted and adjusted coefficients for factors associated with the perceived risk of contracting sars-cov- are presented in table . compared with the early lockdown period, the results indicated that perceived risk scores for contracting covid- in late lockdown period reduced significantly (adjusted coefficients (β) − . , % ci:− . , − . ). other factors associated with perceived risk scores for contracting covid- are females, practised high quarantine, very worried about covid- , and quarantined at the request of public health order during the lockdown period. age stratification was significant in the univariate analysis and the final model, we removed religion and replaced it with age stratification, and the result showed that age stratification was not statistically significant (wald χ = . , p = . ) and similarly, when gender was replaced with age stratification, age stratification was not significant (wald χ = . , p = . ). the factors associated with perceived risk scores for contracting covid- in early lockdown and late lockdown period are presented in tables a and a . towards covid- , respectively. data of early and late lockdown periods are presented here, correspondingly. figure a indicates statistical differences between early and late lockdowns (p < . ), with early lockdown reporting the highest mean values. additionally, as indicated in figure b , knowledge towards covid- for early lockdown significantly reported the highest mean value compared with late lockdown (p = . ). the horizontal values in figure a ,b are the minimums and maximums of perceived risk and knowledge scores. table showed the unadjusted and adjusted coefficients with % confidence intervals (cis) of the knowledge level of covid- . after the adjustment of potential confounding factors, knowledge about covid- has decreased but it was not statistically significant [β = − . , % ci: − . , . ] in late lockdown period compared to early lockdown period. additionally, comparatively less knowledge of covid- was pertinent among those who performed low quarantine and those who had less education (completed secondary or primary education only). increased knowledge of covid- was pertinent among the participants who practised high quarantine, held a bachelor and above degree, and the non-muslim participants. age stratification and employment status were significant in the univariate analysis and our final model, we removed religion and replaced it with age stratification, and age stratification was not statistically significant (wald χ = . , p = . ) and when education was replaced with age stratification, age stratification was not significant (wald χ = . , p = . ), but when education was replaced by employment status, employment status was associated with increased knowledge of covid- [β = . , % ci: . , . , p = . for those employed]. factors associated with the knowledge level of covid- for each lockdown periods are reported in tables a and a . this current study reported a higher mean of perception of risk and low knowledge of contracting the sars-cov- among adults in bangladesh. the study also revealed factors associated with the perception of risk and knowledge of contracting the sars-cov- in bangladesh and found that females and those with a bachelor's degree reported decreased perceived risk and knowledge of contracting sars-cov- than males, and master's/higher degree holders, respectively, practised high quarantine, were very worried, and quarantined at the request of public health order during covid- , and reported higher perceptive risk of contracting covid- , while non-muslims (christian/hindu) practised high quarantine and quarantined at the request of public health order during covid- , and reported increased knowledge scores of contracting the infection. the higher mean score of risk perceptions stated in this analysis could be because the bangladesh government has taken exceptional measures to track the rapid spread of the current global covid- disease outbreak [ ] . when the number of individuals infected and the fatalities from this epidemic escalate, residents will stick to preventive measures because they are influenced by their knowledge, perceptions and practices towards this disease outbreak [ ] . in this study, we analyzed the opinions of bangladeshi people about vulnerability and awareness towards covid- during the drastic rise period of the disease outbreak. researchers identified that many were extremely concerned about the transmission of the infectious disease in this predominantly well-educated young muslim population and more than one-third considered themselves to be at low risk of contracting the infection. such a high perception of low risk, coupled with the fairly average covid- knowledge scores, is extremely important because clear knowledge predicts a positive attitude and appropriate attitude against covid- [ ] . in this study, males who were worried about contracting sars-cov- were more likely to perceive themselves as being at high risk of contracting the infection, as well as those who did not quarantine themselves or only did so at the request of the public health officers. these findings were similar to those reported in the studies conducted in india, china, and jordan. adults with a higher level of knowledge about covid- and who were in quarantine were more concerned about the infection and became frustrated as they did not know how long the impact of the pandemic would last [ ] . moreover, in india, it was found that a higher level of knowledge on covid- was associated with the high-risk perception of contracting the infection during the consistent lockdown period [ ] . in jordan [ ] , it was found that, with adequate knowledge, people can perceive the importance of lockdown and the risk of contracting the infection caused by sars-cov- . experience from previous similar virus attacks (sars-cov- ) in china highlighted the fact that, during such a crisis, people's knowledge, attitudes, and perceptions about the situation affects their response to the crisis. to effectively manage a health emergency, citizens need to be conscious of the problem, to be alert, and acknowledge their responsibilities to preserve their steadiness, because circumstances culminating in fear in the public can escalate the situation into misery [ ] . a similar survey conducted to test the knowledge, attitudes, and perceptions of people in the hubei province, china, about the covid- outbreak found that higher knowledge, attitude and perception scores among residents was related to the ages and socioeconomic statuses of the respondents [ ] . it was surprising to find an average score of knowledge against covid- among bangladesh residents, considering that this epidemiological survey was performed at the very early stage of the pandemic in bangladesh. we believe this to be partially attributed to the survey being skewed by people with a bachelor's degree or higher, the largest percentage of respondents being %. the magnitude of this pandemic and the unprecedented media attention of this public health disaster will have an important effect on people's awareness about this epidemic. television channels, bangladesh health ministry official websites, and all corporation websites had details about this infectious disease during this time. adults with higher levels of education are more likely to seek information which enhances a sense of personal control through mastering content and acquiring stronger skills [ ] . similar to previous findings [ , [ ] [ ] [ ] which suggested that men and young adults are more inclined to engage in risk-taking behaviours, the present study found a significant association between male gender and perceived high-risk of covid- among respondents after adjusting for other cofounders. adults who were employed at the time of this study were . times more likely to show adequate knowledge scores compared to those who were unemployed, but this association was significant only when it interacted with other demographic variables in the model. the slightly higher chances of sufficient information among citizens who did not quarantine themselves, relative to those who did so willingly, could be due to the less severe situation of the covid- outbreak in bangladesh and the prevalence of younger adults in this sample, resulting in respondents feeling that they had a lower probability of contamination with the sars-cov- virus. it is worth noting that, in this analysis, higher covid- awareness scores are strongly correlated with not becoming a practising muslim. it is understood that the negative mentality shown by certain religious manipulators is one of the toughest obstacles in attempts to tackle the dissemination of covid- awareness. while the government has called for the public to keep social distances to stop the gathering of crowds (physical distance), certain so-called religious leaders might also be preparing to host meetings involving hundreds. resistance from religious communities to physical isolating appeals has been observed across several predominantly muslim countries, such as indonesia, and the trend exacerbates local government attempts to negotiate with covid- propagation. research in turkey [ ] echoed the significance of religious figures throughout this disease outbreak in positively motivating populations. although some practitioners preferred to seek counsel from their municipal officials, others adopted their religious leader's instructions when it came to debatable questions, such as covid- , suggesting that religious leaders have strong influence on the respondent's attitude towards covid- mitigation practices during the pandemic. the finding of this study indicates the value of strengthening public health knowledge for bangladeshi citizens towards covid- . this, in effect, would change behaviours and activities towards covid- . research findings of the demographic variables correlated with knowledge towards sars-cov- are broadly compatible with previous research on sars-cov- in [ , ] , further indicating that the intervention in health education towards covid- in bangladesh would become more successful if it had been primarily structured for mass people and those with low educational thresholds. since sars-cov- is a new type of coronavirus, and no pharmacologic therapies at this time are available, increased public awareness and caution seem to be the best approaches to preventing community spread. the travel bans and lockdowns placed in many countries, including bangladesh, may have worked, but they also raised the level of panic among residents. this was evident in this study, where approximately % of the respondents were very worried, and others were somewhat worried about the situation. in this situation, lai and others showed that educating the public is a very helpful and effective resource [ ] . for countries with fragile health care systems who have dense populations, such as the sub-saharan african countries, lack of awareness about the virus and corrupt policies can combine to create a disaster that is impossible to contain [ ] . in the case of covid- , issues with the current response, lack of transparency, travel restriction delay, quarantine delay, public misinformation, and emergency announcement delay contributed to the outbreak. the findings of this study show that many of the respondents in bangladesh were very worried about the spread of covid- coupled with their significant inadequacies in the knowledge of the disease. this suggests the need for more awareness to increase public knowledge and reduce the worries of the bangladeshi people regarding the sars-cov- virus. in addition to adhering to the government recommendations of routine hand washing and home quarantine, older males of the muslim faith could be targeted to further improve the knowledge and avoid further transmission of this novel coronavirus, even as the lockdown continues. the current study provided the first evidence of the knowledge and perception of people using an appropriately sampled population during a critical period-the early stage of the covid- outbreak. however, the online nature of data collection meant that respondents who had an internet connection were more likely to participate, which may lead to bias, including selection bias because of the over-representation of well-educated people in bangladesh compared to the background population [ ] and, as such, the findings may not represent the opinion of the less educated population. hence, findings from this study cannot be generalizable to the entire bangladeshi population and lack causal inference because it was an online cross-sectional design. despite this limitation, this was the only feasible way of data collection at the time of this study. additionally, since the virus is novel and already widespread, there is little possibility to undertake extensive social studies in bangladesh. another limitation of this study was the cross-sectional study design, making it impossible to determine causation. further studies across randomly selected populations across the country are needed to confirm these findings. such studies should also assess the social aspects of the condition. despite these limitations, the present study provides relevant information to fill research gaps in the fight for covid- . the datasets analyzed during this study are available from the authors on reasonable request. deadliest enemy: our war against killer germs inhibition of sars-cov- (previously sars-cov- ) infection by a highly potent pan-coronavirus fusion inhibitor targeting its spike protein that harbors a high capacity to mediate membrane fusion world health organization declares global emergency: a review of the novel coronavirus (covid- ) modelling transmission and control of the covid- pandemic in australia who|world health organization. maintaining essential health services and systems covid- infection and rheumatoid arthritis: faraway, so close! autoimmunity rev associations between immune-suppressive and stimulating drugs and novel covid- -a systematic review of current evidence covid- infection: origin, transmission, characteristics of human coronaviruses characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention the response of milan's emergency medical system to the covid- outbreak in italy evaluation and treatment coronavirus (covid- ) power and social distance the sars, mers and novel coronavirus (covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? covid- -knowledge, attitude and practice among medical and non-medical university students in jordan stopping future covid- like pandemics from the source-a socio-economic perspective survey of knowledge of villagers in prevention and control of sars in hainan province q&a on coronaviruses (covid- ). available online imf. how does coronavirus affect the economy?|world economic forum. . available online quarantine role in the control of corona virus in the world and its impact on the world economy blockchain without waste: proof-of-stake an online statistical calculator. sample size calculator for estimating a single proportion knowledge, attitudes, and practices towards covid- among chinese residents during the rapid rise period of the covid- outbreak: a quick online cross-sectional survey world health organization. covid- update iron and folic acid supplements in pregnancy improve child survival in indonesia the financial express who releases guidelines to help countries maintain essential health services during the covid- pandemic comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the covid- epidemic in southwestern china study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid- pandemic examining associations between health information seeking behavior and adult education status in the us: an analysis of the piaac data sex differences in everyday risk-taking behavior in humans sex differences in risk taking behavior among dutch cyclists age patterns in risk taking across the world politics and the covid- pandemic: the turkish response severe acute respiratory syndrome coronavirus (sars-cov- ) and corona virus disease- (covid- ): the epidemic and the challenges key: cord- - rshrecb authors: hossain, m. a.; hossain, k. m. a.; walton, l. m.; uddin, z.; haque, m. o.; kabir, m. f.; arafat, s. m. y.; sakel, m.; faruqui, r.; jahid, i. k.; hossain, z. title: knowledge, attitudes, and fear of covid- during the rapid rise period in bangladesh date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: rshrecb objectives: to determine the level of knowledge, attitude, and practice (kap) related to covid- preventive health habits and perception of fear towards covid- in subjects living in bangladesh. design: prospective, cross-sectional survey of (n= ) male and female subjects, - years of age, living in bangladesh. methods: ethical approval and trial registration were obtained prior to the commencement of the study. subjects who volunteered to participate and signed the informed consent were enrolled in the study and completed the fear of covid- scale (fcs). results: twenty-eight percent ( . %) of subjects reported one or more covid- symptoms and . % of subjects reported one or more comorbidities. knowledge scores were slightly higher in males ( . , sd . ) than females ( . , sd . ). knowledge was significantly correlated with age (p<. ), an education level (p<. ), attitude (p<. ), and urban location (p<. ). knowledge scores showed an inverse correlation with fear scores (p<. ). eighty-three percent ( . %) of subjects with covid- symptoms reported wearing a mask in public and . % of subjects reported staying away from crowded places. subjects with one or more symptoms reported higher fear compared to subjects without ( . , sd . ; . , sd . ). conclusions: overall, bangladeshis reported a high prevalence of self-isolation, positive preventive health behaviors related to covid- , and moderate to high fear levels. higher knowledge and practice were found in males, higher education levels, older age, and urban location. fear of covid- was more prevalent in female and elderly subjects. positive attitude was reported for the majority of subjects, reflecting the belief that covid- was controllable and containable. the trial registration obtained prospectively from a primary trial registry of who (ctri/ / / ). the data are available regarding this study and can be viewed upon request acknowledgement authors acknowledges shafin rubayet and ahnaf al mukit, research assistants for their contribution in data collection and input, also students of bangladesh health professions institute helped in collecting data. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . bangladesh is among the top countries in terms of confirmed cases of covid with a positive case rate of . % - . % since the first of june (mustazir & alif, ) . however, questions remain regarding the actual number of cases and concerns regarding the scarcity of testing facilities (the daily star, ) . there are also concerns about bangladesh's ability to mount an effective response to the covid- pandemic (the economist, a). this newspaper also states ( ,b), bangladesh is a developing economy, and is largely dependent on remittances, readymade garments, and small trades. the country is in the mid-phase of a few financial megaprojects. natural calamities and covid- pose challenges for the bangladeshi government and its residents at home and abroad (hasina & verkooijen, ) . due to the economic concerns, bangladesh did not impose a countrywide lockdown. instead the authority sub-sectioned the country into red, yellow, and green based on the level of community contamination ("covid tracker. bangladesh computer council (bcc)", ). additionally, the government website of corona briefing ( ) measures are being taken to improve the situation raising individual awareness by improving individual's knowledge, attitude, and practices which has helped alleviate unnecessary fears and social stigmas. battling with the covid- pandemic is a lengthy process and requires the combined effort of individuals and the government; adequate testing, isolation, and supportive treatment provision are the best ways to overcome the pandemic (adhikari et al., ) . there is ongoing research to find the vaccine, but measures to raise the general population's knowledge and implementing recommended health practices are some of the best policies to combat covid (watkins, ). the world health organization ( ) stated that only % of cases were projected to have severe symptoms and one-third of the severe cases needing critical care; the main priority of the world health organization (who) is to mobilize the resources to improve community healthcare practices. there is an emphasis on improving community's receptiveness to staying home. moreover, who raised concerns regarding mental health needs (world health organization: regional office for the western pacific, ). mental health needs, related to covid- , are emerging regardless of age, occupation, and education and are related to isolation, financial uncertainty, quarantine effect, excessive online operation, gaming, physical inactivity, insomnia, anxiety, depression, and fear of covid (ornell, schuch, sordi . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . & kessler, ). the study also suggests excessive fear and anxiety led individuals in china to have more physical and psychological signs even with mild to no symptoms reported. bangladesh reported a few cases of suicide due to extreme fear of covid , with some cases showing a negative report after the real time polymerase chain reaction (rtpcr) test, postmortem (mamun & griffiths, ) . bangladesh responded relatively early on march , with no cases for nearly a week. subsequent arrival of travelers from italy who defied quarantine regulations could be the source of the virus (anwar, nasrullah & hosen, ). in addition, religious gatherings and the lack of travel restrictions are considered the primary reason for the sharp upward projection (chowdhury, ) in covid cases. a population-based study was required to determine general knowledge about the disease and what practices were being taken by bangladeshi individuals to combat covid. fear is thought to be one of the main contributors towards mass anxiety and depression (ornell, schuch, sordi & kessler, ) it has been shown to predict a poor response to overall health, insomnia, and suppression of immunity. other influencing factors for anxiety and depression include: occupation, knowledge, attitudes, and practice of health related habits, and other environmental indicators. the study objectives were to determine the level of knowledge, attitude, and practice related to covid- preventive health habits and underlying fear towards covid in the bangladeshi population and how they are affected by socio-demographics factors. this study was a prospective cross-sectional survey conducted online through a structured questionnaire. both male and female bangladeshi subjects, ages to years that were able to respond to the questionnaire were eligible for the study. subjects with a challenged cognitive ability or an inability to communicate were excluded from the survey. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint questionnaire a structured questionnaire was designed to fulfill the objectives of the study. knowledge, attitude, and practice were measured using a survey questions used in a study during the rapid raise period in china (zhong et al., ) . to determine fear, the "fear of covid scale" (fcs) has been employed, which is reported to be valid and reliable to measure fear attributed to the coronavirus disease (ahorsu et al., ) . the questionnaire was complied with forward and backward translation into bangla and a pilot study was completed before commencement of the research. ethical permission obtained, participation was voluntary, consent has been taken and confidentiality of the information is assured. the trial registration obtained prospectively from a primary trial registry of who. from march to april , the questionnaire was disseminated online and through email and social media targeting students, professionals and public groups of facebook and appealed to fill themselves, their family members and neighbors. a video tutorial supplied in addition to ensure appropriate response; in case of family members who are illiterate, another member assisted in responding the questionnaire. the survey was requested to be sent back after completion. questionnaires were sent, and questionnaires were returned answered. participation was voluntary, and a written consent form was supplied with the questionnaire. the data auditor found responses were eligible to be included in the study and analyzed. descriptive statistics were employed for correct answers to knowledge and diverse attitude and practices were presented. knowledge, fear scores, attitude and practice variables of respondents were presented and compared with independent sample t-test, one-way analysis of variance (anova) or chi-square test depending on the nature of the data. multivariate linear regression analysis, using demographic variables as predictor variables and knowledge and fear scores as outcome variables were analyzed for significant associations. binary logistic regression analysis was used to identify factors related to attitude and practice. data . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . analysis completed using the statistical package of social sciences (spss) version . . the alpha level of significance was set at <. . among respondents, ( . %) were male and ( . %) were female. the mean population age was . ± . years. participant's ages ranged from years to years and the majority of the respondents were ages - years ( . %). respondents were categorized as adolescent ( - years), young ( - years), young adult ( - years), and elderly (above years). there was a larger response in higher secondary education ( . %) and graduates ( . ). . % of respondents were either undergoing primary education or reported low levels of literacy. respondents were from all divisions of bangladesh, the highest response was from dhaka ( %), and lowest form sylhet ( . %). majority of the respondents were non-public servant ( %), % were healthcare professionals, . % worked or did business in a crowded place, . % were students and . % of the respondents reported that a relative, colleagues or a neighbor had been diagnosed with covid . other socio-demographic profiles are described in table . multiple response analyses found . % of the respondents (n= ) reported one or more symptom related to covid in the last days, but none reported completing a covid- test during the response. the most prevalent symptoms were dry cough . % (n= ), cough with sputum ( . %), sore throat ( %), fever of more than f ( . %), anosmia or taste loss ( . %), shortness of breath ( . %), cases of diagnosed pneumonia and cases hospitalized for pneumonia were also reported. multiple response analysis also found respondents ( . %) reported one or more comorbidities, including: diabetes ( . %), chronic obstructive pulmonary disease (copd) ( . %) and heart disease or hyptertension ( . %). nine subjects reported a chronic neurological disability, including stroke; subjects reported chronic kidney disease (ckd) and . % reported chronic smoking habits. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint knowledge knowledge regarding covid was similar in both males ( . ± . ) and females ( . ± . ). there was a significant relationship found between knowledge scores and age (p=<. ), education level (p=<. ), and geographical distribution (p=<. ). no significant difference in knowledge score was found between public servants ( . ± . ) and others ( . ± . ); between healthcare professionals ( . ± . ) and others ( . ± . ); working in a crowd ( . ± . ) or working alone ( . ± . ); or in people who reported covid- positive relatives, friends or colleagues ( . ± . ) compared to those with non-covid- associate others ( . ± . ). significant differences were found between subjects with symptoms of covid- ( . ± . ) and subjects without covid- symptoms ( . ± . ) with statistical significance (p=<. ). also, a significant difference (p=<. ) was found in knowledge score between subjects with comorbidities ( . ± . ) and subjects without comorbidities ( . ± . ). the detailed associations are available in table . multiple linear regression analysis, showed a significant correlation between knowledge scores and age (r=. ; p<. ). linear associations were found between knowledge and education levels, with lowest knowledge scores found in primary education compared to all other education groups (r=. ; p<. ). dhaka "urban dwellers" reported significantly higher knowledge of covid- symptoms and precautions, compared to subjects from rural areas of bangladesh (p<. ). knowledge and education levels were directly associated, with bachelor of science (bsc) degree holders reporting higher knowledge of covid- symptoms and precautions than any other education group (p=<. ). public servants reported higher knowledge than other non-public servants groups (p=<. ), and students reported higher knowledge of covid- symptoms and precautions compared with other non-student groups (p=<. ). subjects without symptoms showed a significant inverse relationship with knowledge compared to those with symptoms (p=<. ). (table ) . attitude was measured in respect to "belief" on whether bangladesh can overcome the challenge of covid or "positive synergy" towards disease control. females reported higher belief that covid- can be controlled (p=<. ). similarly graduates, or more qualified respondents were confident that covid- can be controlled (p=<. ) and also agreed that bangladesh was capable of overcoming the challenge (p=<. ). the majority of . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint subjects who identified as public servants in bangladesh also reported belief that the disease was controllable (p=<. ); however, they did not believe covid- would be overcome, easily (p=<. ). the subjects with a higher knowledge score of covid- and higher score in the covid- fear scale also showed higher scores in "belief" that the virus was controllable (p=<. ) and that eradication of the virus nationwide would be achieved (p=<. ). subjects with covid- symptoms and comorbidities reported higher prevalence of "belief" that the virus was both controllable and containable (p=<. ). practice was measured by report of subject's attendance at crowded areas and report of wearing a mask. the majority of female subjects in the study followed the practice of staying home ( . %) and ( . %) wearing a mask to prevent spread of covid- (p=<. ). similarly, graduates and above qualified personnel reported ( . %) staying home and avoiding crowded spaces (p=<. ). the majority of the population from dhaka followed the health advisory by staying home ( . %) and reported wearing a mask ( . %) (p<. ). no significant relationship was found between knowledge score and practice, but a highly significant relationship was found between the fear score and with maintaining health advisory, and between the fear score and report of mask wearing (p<. ). the majority of subjects with covid symptoms reported wearing a mask (p<. ) but also reported going to a crowded place. the majority of subjects, with comorbidities, also reported staying at home, but did not report wearing a mask (p<. ). (table ) fear fear scores were strongly associated with gender, education and geography (p=<. ), with females reporting a higher score ( . ± . )and respondents' aged - years, - years and - years reporting a higher score of fear of contracting . ± . ; . ± . ) . dhaka urban dwellers also reported a higher status of fear than rural dwellers ( . ± . ). the demographic relationship of fear scores are listed in table and figure . multiple linear regression found females have fear score differences than male (p=<. , r=. ). other regression are described in table . an indirect, strong, but significant relationship (p=<. ) was found between fear scores and practice of recommended health advisory habits of subjects (see table ). there were significant differences (p=<. ) in fear scores between subjects with a symptom and those without a . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint symptom ( . ± . ; . ± . ) ( table ) . inverse relationships were found among persons having positive covid- symptoms and fear score (p=<. , r=. ). the study intended to explore the knowledge, attitude, and practice of recommended health advice for prevention of covid- and to explore the impact of fear towards contracting indian, chinese, and egyptian studies had similar responses of age group and education, while the usa study reported a mean age higher than our study. our study found a satisfactory level of knowledge by gender, geography, occupation, and education (table ) and relatively higher fear score compared to similar studies across the world. one study, in china, showed similar scores of fear by age, with respect to knowledge, and occupation zhong et al., ), while another study completed in india (roy et al., ), reported % of people in need of mental healthcare-for covid- related fear, anxiety, and depression. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint twenty-nine percent ( . %) of the respondents (n= ) reported one or more than one symptom related to covid in the last days including cough . % (n= ), cough with sputum ( . %), sore throat, ( %), fever ( . %), anosmia or taste loss ( . %), and shortness of breath ( . %). the symptoms were related to covid , as per cdc ("coronavirus disease (covid- ) -symptoms", ). who south east asia region ( ) reported the test positivity in bangladesh to be %, with positive tests being reported only for a person with one or more covid- related symptoms. eleven percent ( %) of subjects reported co-morbidities, including subjects with disabilities. in addition, . % of the respondents were over years of age. the who south east asia region ( ) country profile and institute for epidemiology, disease control and research iedcr covid update ( ) states that the number of deaths are higher in elderly persons, males, and those with pre-existing co-morbidities for bangladesh. overall, we found a low number of elderly with symptoms, low reported levels of comorbidities, but a slightly higher rate of infection by males compared to females. knowledge regarding covid- , by subjects, was similar and satisfactory when comparing age, gender, and occupation. there were a few variations in the perspectives of occupation. young adults, graduates, urban dwellers had more knowledge than the older adults, with lower education, living in rural areas. several similar articles in preprint (haque et al., ; karim et al., ; ferdous et al., ) found more than half of the respondents reported "good knowledge" of covid- , with age and education showing a significant linear association with knowledge. this study is similar to one study in china that found a significant relationships between knowledge and age and knowledge and educational level, with males reporting higher levels of knowledge than females regarding covid- symptoms, precautions and health advisory practices (zhong et al., ) . however, in our study, subjects living in bangladesh reported similar knowledge for both males and females regarding covid- symptoms, precautions and advisory health practices. overall, a high prevalence of "positive attitudes" from the subjects towards the belief of disease control was reported. female subjects and subjects with higher education were more likely to believe that covid- can be controlled, but they doubt the ability of bangladesh to contain it. subjects with "good knowledge" or "high score of fear", both were more likely to believe that covid- can be controlled and that a collective effort can contain the spread of the disease. similar studies in bangladesh, india and china all found similar results regarding the relationship between knowledge and fear of covid- (haque et al., ; . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . . . . doi: medrxiv preprint ferdous et al., roy et al., ; zhong et al., ) regarding "practice", our study reported similarities to previous studies across the world (roy et al., ; zhong et al., ; abdelhafiz et al., ; clements, ) . our study found ( . %) of women reported "staying home" and . % reported wearing masks in public places. the majority of the population outside of dhaka, in the more rural regions, reported advisory staying home ( . %) and wearing a mask ( . %). however, no statistical relationship was found between knowledge scores and practices. this is similar to results reported in studies in both india and china. our study did find, however, subjects with a high score of fear, and were also more likely to follow good preventive practice as recommended by the health advisory. the fear score was significantly associated with female gender, higher education, and urban dwellers. the senior citizens aged - years, - years, and - years reported the highest score of fear compared to all categories. one study suggests that fear comes from longer duration of isolation, movement restriction, and being reactive to news and rumors from social media (banerjee, ). women, senior citizens, and young adults had limited movement, were isolated to quarantine and were attached to media. studies report fear and stress can lead to insomnia and psychological illness (zhong et al., ) . however, though important as an indicator, this was not evaluated in this study, and may be considered a limitation of the study. our study faced many challenges regarding the structured questionnaires, reporting and resources. limitations response rates, correlation with fear and psychological issues, and completion of the questionnaire for covid- positive. we recommend future studies to include information on limitation of movement, isolation and insomnia as it relates to psychological illness, as well as information regarding neurological signs and symptoms of patients and relationship to cognition and fear. in a resource-challenged country, like bangladesh, individual knowledge, positive attitude, and practice of suggested precautionary and preventive health advisories are crucial to control vicious community transmission of covid . the study found knowledge levels were adequate in majority of population and were directly and significantly related to higher education levels, younger age, and female gender. there were positive attitude among respondents regarding control the disease and overcome challenges of covid- in bangladesh. majority of the population had a high score of fear and significant higher scores . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . found in women and elderly. surprisingly, the person having a higher score had a good practice of staying home and wearing masks. future studies on explanatory issues related to activity, function, social issues and quality of life might add more insight studying biopsychological impact of covid- in the most densely populated country in the world. this is a self-funded study of the authors. the authors declare that there are no conflicts of interest regarding the publication of this article. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . https://www.dhakatribune.com/bangladesh/ / / /covid- -record- -deaths-and- -fresh-cases-in-a-day. • mustazir, h., & alif, a. ( ) . covid- : bangladesh records highest deaths in a day, cases cross , mark. dhaka tribune. retrieved from https://www.dhakatribune.com/health/coronavirus/ / / /covid- -bangladeshrecords-highest- -deaths-in-a-day-cases-cross- - -mark. • ornell, f., schuch, j., sordi, a., & kessler, f. ( ) . - -who-bangladesh-situation-reports/who-ban-covid- sitrep- - .pdf?sfvrsn=c b efc _ . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . • world health organization. ( ). covid- strategy update - april . retrieved from https://www.who.int/publications/i/item/covid- -strategy-update--- april- • world health organization. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . knowledge and behaviors toward covid- among us residents during the early days of the pandemic: cross-sectional online questionnaire coronavirus disease (covid- ) information bangladesh | corona.gov.bd. retrieved retrieved bangladesh computer council (bcc) knowledge, attitude, and practice regarding covid- outbreak in bangladeshi people: an online-based cross-sectional study knowledge, attitude and practices (kap) towards covid- and assessment of risks of infection by sars-cov- among the bangladeshi population: an online cross sectional survey fighting cyclones and coronavirus: how we evacuated millions during a pandemic. the guardian knowledge and attitude towards covid- in bangladesh: population-level estimation and a comparison of data obtained by phone and online survey methods . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . key: cord- -le eifv authors: rahman, mohammad mahmudur; ahmed, asif; hossain, khondoker moazzem; haque, tasnima; hossain, md. anwar title: impact of control strategies on covid- pandemic and the sir model based forecasting in bangladesh. date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: le eifv covid- is transmitting worldwide drastically and infected nearly two and half million of people sofar. till date cases of covid- is confirmed in bangladesh till th april though the stage- / transmission is not validated yet. to project the final infection numbers in bangladesh we used the sir mathematical model. we also tried to demonstrate the impact of control strategies like social distancing on the covid- transmission. due to large population and socio-economic characteristics, we assumed % social distancing and lockdown can be possible. assuming that, the predicated final size of infections will be on the th day from the first infections. to estimate the impact of social distancing we assumed eight different scenarios, the predicted results confirmed the positive impact of this type of control strategies suggesting that by strict social distancing and lockdown, covid- infection can be under control and then the infection cases will steadily decrease down to zero. coronavirus disease (covid- ) is exhibiting an unparalleled challenge before the mankind. till date ( th april ) there are about . million confirmed cases of covid- and about k reported deaths globally [ ] . nearly % of the world populations are currently under lockdown by govt. or community to reduce the transmission of this extreme contagious disease. covid- is the viral infectious disease caused by the sars-cov- , for which there is no treatment and vaccine yet. covid- is transmitted by respiratory droplets and fomites with incubation period from to days [ ] .institute of epidemiology, disease control and research (iedcr), bangladesh first reported a covid- case in bangladesh on march , [ ] . since then, there has been a steady increase in the number of infections with cases on april , among which there are , active cases, recovered cases and deaths. in response, bangladesh has employed international travel bans and a gradual lockdown. however, countries like bangladesh are at a greater risk because of large population density, inadequate infrastructure and healthcare systems to provide required support. initially, it was thought that hot and humid weather [ , ] , a large proportion of the young population, and probable immunity caused by bcg vaccinations [ ] , may help to keep infection number low.. however, larger portion of these outcomes are preliminary and correlation-based, thus additional confirmation is necessary for hard conclusion [ ] . we hereby present mathematical and epidemiological models for the covid- transmission in bangladesh. the trends of the maximum of pandemics follow the rapid exponential growth during the preliminary stage and ultimately fallen down [ ] . the mathematical epidemic models are therefore based on an exponential fit for short term and long term predictions. the susceptible-infectious-recovered (sir) compartment epidemiological model [ ] is used by considering susceptibles, infectious, and recovered or deceased status of individuals during pandemics. this sir model has revealed a significant prognostic aptitude for the increase of covid- transmission in bangladesh on a day-to-day basis. we have also calculated the probable effects of social distancing and frequent hand wash with soaps or sanitizer on the increase of infections. bangladesh announced a countrywide lockdown excepts the emergency services till april. there are no exact data how many people maintaining social distances in bangladesh, although our previous study (elsewhere submitted) [ ] showed that . % did not maintained social distances, however, the study was conducted through online cross-sectional methods thus a big portion of the population was not included due to unavailability of internet. the study also estimated that no one is free of risk of infection suggesting a longer period of lockdown is required for controlling the covid- pandemic. in the present study, we also estimated the possible infections in case of %, %, %, %, % and % populations are in lockdown. however, socioeconomic conditions in a country of more than million populations with high density cause considerable challenges in implementing strict social distancing. considering this dense population of bangladesh and to know the effects of tiny percentages of differences of social distance, we assumed two scenarios. we estimated the prediction of highest infection cases where % and . % people maintained strict social distancing. as the sir epidemiological model is entirely dependent on data, it is very important to mention on the character of this data. different diagnostic strategies are taken in different countries for the confirmation of covid- cases. in bangladesh, in the beginning testing has mostly been limited to persons travelling from infected countries and their direct contacts. very recently, countrywide testing is started with the suspected persons as well as selected pneumonia patients and symptomatic healthcare workers. as of april , bangladesh has tested , samples ( /million) [ ] . a number of recent studies [ ] have shown that the effectiveness of coronavirus infection may vary due to the warmer weather. in addition, differential immunity of bangladeshi people due to bcg vaccine [ ] is already completely assumed in the data as basic reproduction number. present sir model forecast the transmissions as a result of stage- (persons with a travel history to infected areas/countries) and stage- (person-to-person contact). however, if the confirmed cases of infections start to surpass the predicted infection thoroughly, then the outbreak will enter a new stage, and no mathematical model explained above will be applicable. nevertheless, as of april th , there is no strong evidence for community transmission. high population density as well as socio-demographic characters puts bangladesh on a high risk for stage three and four community transmission. even though, the social distancing and scrupulous contact tracing actions are taken by bangladesh authority, may limiting these virus transmissions to small groups, relocation of laborers, workers and small income groups could deteriorate the situation. consequently, these factors need to be measured during constructing conclusions based on the current study. the missing expat populations with infections possibly will also influence the predictions but this could be a debatable issue as discussed below. however, if a considerable number of infections were missed, a point would have already become visible in the curve by the end of the april. the most important and common questions regarding covid- is its final infection numbers and death tolls. to get the answer, a range of mathematical epidemic models have been utilized, such as stochastic [ ] , analytical [ ] , and phenomenological [ ] . in this study, we attempt to estimate the final epidemic size of covid- using the classic compartmental susceptible-infected-recovered (sir) model [ ] . with this model, we obtain a series of daily predictions with different circumstances. to predict the maximum infections number we used sir epidemic model [ ] .the sir epidemic model is a method of modeling infectious diseases by categorizing the population based on their disease condition. this classifies susceptible, infected and recovered. the susceptible population means they are not affected, however, are at risk for infection. infected persons already infected by the causative agents and are able to infect the susceptible persons. recovered means infected persons who have either recovered from the disease or achieved stable immunity, or are otherwise detached from the population that are not able to infect susceptible population (death, quarantine etc.). the sir model presents the increase of decrease information of an outbreak based on some initial data i.e. total given population (n), the infection rate of the infectious disease (β), the recovery rate of the disease (Ɣ), initial susceptible population (s ), initial infected population (i ) and the initial recovered population (r ). this model assumes blocked populations where no one is dies or born, so the population remains constant and every person is either part of s, i, or r. the general form of the model is here, β is infection rate per day, n is the total given population, and Ɣ is the recovery rate per day. (thus, Ɣ is the mean infection time). again + + = , and s +i +r =n indicate that the population is closed and change in numbers with respect to time is . we considered some initial conditions as well to use this model such as the initial susceptible numbers, infected numbers, and recovered populations. that means: ➢ s > (population who are susceptible), ➢ i > (at least one infected that can infect susceptible persons), and ➢ r ≥ (there may be some people already recovered or died population at the start of the model, or there may be no one). and again, both s +i +r=n and st+it+rt=n for any t. since rt can be found exclusively based on st and it, considering these variables, we can write after integration we got as st decreases with t increases (susceptible persons are infected but not ever added back into the susceptible numbers) and = Ɣ× , is the maximum value of it and if > Ɣ× then it will raise to that all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . highest before declining to zero. however, in case of ≤ Ɣ× then it will decline to zero and there will be no epidemic. so that, we can certainly say that it must approach to zero as t→∞, and while we observe from the model is strictly positive and based only on it. therefore, if it was not zero, rt would increase freely, which is not possible because the population is blocked. the dynamics of the sir mathematical model depend on the ratio where, r is the effective rate. r is = Ɣ , referred to as the basic reproduction ratio or basic reproduction number. as β is the infection rate per day, and Ɣ is the average infectious time (or average time an individual stays infected). generally, if r > then infected persons are transmitting diseases into susceptible people quicker than recovery rate, so the disease grow to be an epidemic. if r < , an epidemic does not take place. in a compartmental model, sir, populations are moving from one compartment to another. this model can often be molded using recursive interaction of the form, thus we can write: considering these parameter, the number of population at any time who are susceptible, infected or recovered may be calculated with the following equations. these equations estimate the number of person in each state today (n), based on the number yesterday (n- ) and the rates of infections and recovery and Ɣ respectively.the n denotes the number in one time period and n- stands for the number in the prior period. so with a time period of one day, the equation eight (e ) can be explained as the number of susceptible individual today (sn) equals the number of yesterday (sn- ), minus the fraction of people who turn into infected today (yesterday's number of susceptible individual (sn- ) divided by the original susceptible number (s), multiplies their rate of infection and number of individuals were infected (in- ) yesterday. in the equation number nine (e ), the numbers of infected person today (in) equals to the numbers who were infected yesterday (in- ), in addition, the numbers of susceptible individual who became infected today, and subtract the numbers of recovered today who were infected yesterday. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . in equation number ten (e ), the numbers of recovered people today (rn) equals to the previous numbers who had recovered and the numbers who were infected yesterday and recovered today. we obtained covid- infection data o bangladesh from icedr [ ] and calculated the rate of infections per day and the rate of recovery (recovered and dead) per day based on the number of infection, the number of recovery and death as of date th march. then we calculated the basic reproduction ratio/number and the highest infected population. to do this we used the total population [ ] of bangladesh where we assumed there is no interventions at all and later with the population who did not practices properly towards covid- . afterward with the equations (e , e and e ) we calculated the date of reach of the highest number of infection. we also predict infection numbers by assuming %, %, %, %, %, % and . % of the bangladeshi population maintained strict social distances. we have created the scatter plot to compare our model of infection prediction with actual infection of bangladesh, as well as we have made prediction of infection numbers on end of april, may, june, july and august . all the analyses were done in microsoft excel and spss using the equations (e , e , and e ) described above. graphs were prepared in graphpad prism . according to iedcr, on march , three individuals were confirmed with covid- . since then infection cases are gradually increasing and till date april it reaches ( figure ). in the beginning diagnostic tests were conducted by iedcr only, however, from last week several diagnostic facilities were opened country wide thus the infection cases are increased. although there are few evidences of community transformation, most infections are transmitted from infected persons to relatives and to health workers who treated them. the results for the sir mathematical models are discussed. we consider that the sir model will give good forecast for the stage- and stage- infections as we assumed there is no stage- transmission yet. in addition, we guesstimate all cases to be symptomatic since estimation of asymptomatic cases in numbers all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint is difficult. this possibly misjudges the real numbers of cases. figure is showing the predicted cases and confirmed cases till april suggesting that confirmed infection cases are following the sir model prediction trends (r = . , p< . ). combined prediction results according to the sir model have been showed in figure . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . due to high population density, it is difficult to control infections as well as prediction of infections. socio-economic conditions makes complicated to maintain social distances. though, the sir model analysis is not considering all of these factors, we used this classic model to predict the outbreak in bangladesh. figure shows all the prediction curves of susceptible, infected and recovery (sir) cases. the prediction was conducted based on the total population and considered there is no intervention implied. as government imposed lockdown from march , we again estimated the sir with these new all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . situations. however, due to dense population, socio-economic conditions, religious orthodoxy and no scientific data till date, it is not clear how many people are maintaining sustainable social distancing in bangladesh. bearing in mind these factors, we considered eight possible scenarios such as if there is no interventions, %, %, %, %, %, % and . % people maintain strict social distancing resulting %, %, %, %, %, % % and . % people of bangladesh susceptible for covid- . the sir model prediction results considering the above mentioned scenarios have been demonstrated in table . the figure shows the combined curve of susceptible, infected and recovery confirming our model worked flawlessly. in the model analysis, the infection rates per day (β) was . and recover rates (Ɣ) per day was . on march th , and the basic reproduction number (r) . confirms the pandemic conditions. if there is no intervention then the infection cases among bangladesh population will reach around . million in days ( th of june) from the first infection (table ) . then the infection cases will steadily decrease down to zero. on th day ( th of september) from the first infection there will no new infection according to sir prediction model. the sir model base prediction of infection curve was compared with the confirmed cases ( figure ). the comparison suggested that the confirmed cases are following the predictions till april . we also predicted the infection case numbers on the end of april. the prediction estimated that infections will reach , by the date where the whole populations were in susceptible. figure shows the prediction of infections along with the confirmed cases by the end of april. the sir model prediction. the consequences of social isolation on covid- pandemic have been observed by several investigators using diverse mathematical models [ , ] . it is well-known that the effects of social distancing become evident solitary after some days from the lockdown. since the sign of the covid- characteristically take - days to appear after sars-cov- infection. bangladesh announced lockdown pretty early ( days first case and the number of cases were ) compare to china (on cases) and all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . india (on cases) [ ] . however, a mismanagement of the announcement and the transport bar nearly millions of people moved to countrywide from the capital dhaka whom most of were low income people. we assumed that these people did not carry viruses from the capital to other regions as then the infection cases were very low. in addition, most of expats who returned to bangladesh from infected regions did not follow home quarantines and be scattered in different part of the country. some of them might carry viruses which are turning out to be true now. as a result, the exact scenarios of maintaining social distances in bangladesh are indistinguishable. therefore, we assumed the eight possible scenarios, mentioned above where %, %, %, %, %, % % and . % people of bangladesh are susceptible in our current sir model based study. as the infection rates per day, recover rates per day and the basic reproduction number remain unchanged, we wanted to know is there any effect of social distancing on covid- transmission with the above mentioned scenario. the prediction results are illustrated in figure and tabulated in the third column in table confirmed that by social distancing, covid- infection cases can be controlled and reduced as well as the ending of the outbreak will be rapid. in table we have summarized the predicted infection cases on the end of april, may, june, july and august. comparing with total population with all possible scenarios suggested that covid- transmission cannot be stopped now; however, it could be decreased at tolerable level by strict social distancing. factually, the later four scenarios are not possible for high population density countries like bangladesh. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . infection. according to the prediction the peak infection cases will appear in may and afterwards it will go down to zero and by august, bangladesh will be free from covid- infection. * denotes the confirmed cases reported by iedcr [ ] . in the sir model, the number of susceptible individual today equals to the persons who were susceptible yesterday minus the numbers who become infected today. as long as the disease is spreading the outstanding susceptible number declines each day. in addition, the persons who turn into infected today equals to the yesterday's number of susceptible multiplied by the rates of infection per day, but it might look unusual that we also multiply that result by how many were infected the previous day. this is because the rate of infection per day is for every infected individual. if persons are infected the chance of any person else becoming contaminated is times higher than individual is infected. so any estimation of the rate of transmission of the disease needs information of the infection rate per day and the numbers of primarily infected and originally susceptible persons. at the beginning of an epidemic the number of persons becoming infected each day is perhaps bigger than the number recovering, so the number of infected will maintain growing until more person recover than be infected. the numbers of susceptible individual always reduces, but the number of infected and recovered at first goes up and then turn down. the model used in this study is data-driven, so they are as dependable as the data are. compare to other model based studies [ ] on different locations, at the beginning; the infection patterns of bangladesh are in exponential growth stage. according to the available data, we be able to predict that the highest size of the covid- outbreak using the sir model will be nearly , , if there is no intervention. with such a large population and for socio-economic conditions, it is not possible to maintain even % lockdown or social distances in bangladesh. we assumed, by law and enforcements and self awareness % lockdown and social distances can be maintained. in accordance the final size of covid- will be cases which is obtained from the sir model analysis. early strict lockdown and social distancing is the key factors of prevented covid- transmissions. studies showed that several other countries such as uk, germany, italy and usa where this stringent action was employed only after covid- entered community transmission stage (stage- ), and the outbreak became uncontainable. additionally, different nations have different strategies as well as acquiescence levels due to several all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint realistic considerations in enforcing the lockdown. this may have an effect on the final size of outcome. for example, the infection rates in italy and usa are still not become stable after more than days of lockdown. they have witnessed the uppermost percentage of death as well. conversely, south korea, japan, singapore etc. has shown significant decline by imposing lockdown [ ] . as estimated in a recent study [ ] , a reduction of infections in australia can be evident only if the social distancing levels go beyond %. assuming the same pattern as australia in bangladesh as well (even though the lockdown in australia was more strict with stringent police control over person movement activities), we can assume that till april ( days from lockdown) very tiny effect of social estrangement will be observed. by this date, bangladesh may have reported cases as many as if % of bangladesh population are susceptible that are shown in table . this number could rise significantly if community transmission (stage- ) turns out and transmissions due to the movement of industries workers and laborers. in addition, on may , bangladesh should observe the peak of transmission predicted , if no further strict lockdown imposed. to reach on the numbers of infection, on th of may, bangladesh should expect around patients on a single day. a latest study by mandal et al.[ ] has revealed that social distancing can decrease cases by up to % confirms the effect of social distancing, the similar prediction were made by our model (table , and table ). exponential increase is thought throughout to consider for the worsen-case scenario. a reduction of - % can bring the condition to more convenient. in addition, if bangladesh pursues the case isolation approach strictly, it is anticipated that the infection curve will begin flattening out soon. naturally, the degree of accuracy of these estimates remains to be seen. in conclusion, qualitatively, both models show that the epidemic is moderating, but recent data show a linear upward trend. the next few days will, therefore, indicate in which direction the epidemic is heading. this investigative estimate shows that the transmission rate of covid- in bangladesh will be as high as . million and for the socio-economic conditions and some other practical considerations it is not possible to impose most strict lockdown. however, still now, the transmission rate per day and basic reproduction number for bangladesh are nearly the level of global ( . to . ) range [ ] . due to the questionable small amount of testing [ ] compare to other countries referencing a low transmission rate per day and therefore the lesser basic reproduction number than world. the mathematical epidemiological model sir is used to forecast the short-term and long-term outcomes. the sir model assumes all the infection cases to be symptomatic, which is a limitation and could be underestimate the actual cases because of an unsure number of asymptomatic cases. with this constraint, the sir model satisfactorily predicts the cases till today (april ). the prediction indicates that bangladesh will enter equilibrium by the end of the first week of june with estimated total number of cases to be approximately , if no further stringent measures taken by the government of bangladesh. it is projected that the effect of social distancing will be visible shortly by the end of april. however, bangladesh is on the door to go into community transmission due to reported infringement of quarantine standard by people as well as other sociodemographic characteristics. the predictions completed using the epidemiological model in this study will be unacceptable if the transmission goes into stage- massively. in conclusion, the model is as good as the original data. on account of real time changes in data every day, the forecasting will therefore changes. for this reason, the outcomes from this study are supposed to be used only for qualitative understanding and rational estimation of the nature of pandemic, but are not meaningful for any judgment making or strategy/policy change. this study is conducted with available data and concluded with predictions using sir epidemiologic model. however, the sir model predictions will invalid if the transmission enters into stage- . thus, no policy making decision should be made based on this predictions except imposing of strict lockdown. covid- coronavirus pandemic a review of coronavirus disease- (covid- ) covid- status bangladesh effects of temperature variation and humidity on the mortality of covid- in wuhan. medrxiv spread of sars-cov- coronavirus likely to be constrained by climate. medrxiv the mystery behind childhood sparing by covid- the role of absolute humidity on transmission rates of the covid- outbreak estimating initial epidemic growth rates . . si, sis, and sir epidemic models knowledge, attitude and practices (kap) towards covid- and assessment of risks of infection by sars-cov- among the bangladeshi population: an online cross sectional survey will coronavirus pandemic diminish by summer? available at ssrn a note on the derivation of epidemic final sizes early estimates of epidemic final sizes using phenomenological models for forecasting the ebola challenge countries in the world by population modellingtransmission and control of the covid- pandemic in australia predictions for covid- outbreak in india using epidemiological models prudent public health intervention strategies to control the coron-avirus disease transmission in india: a mathematical modelbased approach. the indian journal of medicalresearch authors thank and acknowledge to all health care workers including doctors, nurses, assistants and the law and enforcement authority for their diehard efforts to manage the covid- pandemic conditions in bangladesh. mmr, th and aa conceived the study with input from kmh. mmr, th and aa studied the equations and prepared study design. mmr led the project regarding, data collections, analysis to writing with the help of th and aa. mmr led the solving the equations and analyzing the data with the help from th and aa. mmr, aa and th produced the first draft of the manuscript; kmh did put efforts regarding writings and corrections of the manuscripts. kmh and mah added additional points in discussions. mmr, aa, kmh, th, and mah finalized the manuscripts after necessary corrections and obtaining suggestions from all authors. mmr, and kmh jointly supervised all the works from the beginning to the end. all authors did read and agreed unanimously to submit the manuscripts. this study has not yet received any funds from any institute, organizations or government. all authors declare that there is no conflict of interests among them. key: cord- - zrtjuwf authors: biswas, raaj kishore; afiaz, awan; huq, samin title: underreporting covid- : the curious case of the indian subcontinent date: - - journal: epidemiol infect doi: . /s sha: doc_id: cord_uid: zrtjuwf covid- has spread across the globe with higher burden placed in europe and north america. however, the rate of transmission has recently picked up in low- and middle-income countries, particularly in the indian subcontinent. there is a severe underreporting bias in the existing data available from these countries mostly due to the limitation of resources and accessibility. most studies comparing cross-country cases or fatalities could fail to account for this systematic bias and reach erroneous conclusions. this paper provides several recommendations on how to effectively tackle these issues regarding data quality, test coverage and case counts. since the inception of the covid- pandemic, both the media and research focus were on china, europe and the usa primarily due to the large cluster of cases in these regions during the early days. however, despite low fatality rates and total cases, the focus then shifted to the low-and middle-income countries (lmics) soon after the outbreak had hit the indian subcontinent (isc) and their covid- response dynamics. in the meantime, academic studies started making inferences on the covid- response effectiveness through comparing the disease prevalence and fatality rates between higher and lower income nations in order to investigate the curious case of low covid- infection rates among the lmics. conducting research on lmics with limited data could often lead to erroneous findings and biased interpretations, which is becoming a concern with the avalanche of studies published daily. the reasons behind inadequate data in lmics or even low fatality/detection rates could be qualitatively discussed. while these would not impede academicians in conducting research, caution should be exercised during interpretation and in proposals of 'evidencebased' policies and the development of operational plans focusing on mitigation and response in respective contexts. for a greater focus and authors' area of expertise, this paper is limited to the countries in the isc, which is a sample representation of lmics; however, country-wise discussion of lmics based on the respective socioeconomic context is required for a reasonable generalisation. india, pakistan and bangladesh are among the worst countries affected by the covid- pandemic in terms of total number of cases; however, they are ranked , and , respectively, in tests per million population, as of june [ ] . it is worth noting that countries such as bangladesh reached the threshold of tests per day on may, an astonishing days after the detection of the first confirmed case which was still a mere fraction of the number of tests conducted by countries such as the usa, uk and italy. this lack of testing capabilities during the early days accompanied by the limited protective gears for health personnel and low implementation capacity related to the response of such pandemics could have concealed the true rate of infection and disease spread in the lmics of the isc. due to limited testing facilities and availability of trained personnel, long delays in both sample collection and dissemination of test results are observed in these countries [ , ] . furthermore, these inadequate facilities could compromise sample handling and storage as they require strict low temperature preservation for an optimum result [ ] , which is a challenge for lmics including the isc. evidently, the official press releases in bangladesh reflected that all collected samples were not tested daily with long backlogs leading to curbing sample collection [ ] and resulting in public distress as many non-covid medical facilities require certification of a negative test result before admitting new patients. another issue for maintaining a rigorous score of transmission rates is to adequately define both cases and deaths from covid- , which varies across borders resulting in inconsistencies among reports [ ] . for example, countries such as china and bangladesh, have changed the definition of confirmed cases or recoveries during the on-going pandemic [ , ] . moreover, leadership and political goodwill during such crisis play a crucial role in data collection, testing quality and country-wide coverage [ ] . testing coverage in the indian subcontinent has yet to reach the peripheral areas. the government testing facilities are mostly free but are consequently overwhelmed with backlogs, whereas the costs of private tests are well out of the reach of most people [ ] . particularly with countrywide lockdowns and reduced patient transport facilities, it is hard to acquire free-public amenities as an observed % increase in extreme poverty in bangladesh and % of people (around million) working in the informal economy in india are at the risk of deeper poverty due to the lack of work during lockdowns [ , ] . in such scenarios, people living in urban slums or rural areas are likely to prioritise wage-earning activities meeting the heightened unmet basic needs in the midst of low economic flow considering the risks of covid- infection instead of a -day post-test quarantine. furthermore, given that the testing centres are mostly located in metropolitan areas, the coverage is often centralised to a few locations. for example, as of june , . % of all tests in bangladesh were conducted in dhaka district compared to . % in jessore district [ ] , and . % tests in pakistan were conducted in sindh compared to . % in gilgit-baltistan [ ]. this decidedly undermines the coverage across these countries and limits the cases to few privileged cohorts challenging identification of the disease at the community level and underrepresenting cluster transmission for an extended period of time. the lack of testing facilities in peripheral areas requires samples to be transported over long distances in a limited timeframe, which could jeopardise the reliability of samples and test results. the presence of centralised laboratories in few locations contributes to inadequate risk assessments across the country and impacts subsequent decision making. the bbc has put forward an interesting idea of calculating the underreported deaths of covid- using fatality data from previous years [ ] . while this could be a way forward, the burden of diseases varies yearly. one particular example could be the expected decrease in road fatalities in and an increase in suicide rate due to the adverse effects on mental health from stress during lockdown. similarly, as covid- is not identical with regard to seasonal outbreaks such as measles or dengue in bangladesh or wild polio in pakistan, we cannot predict covid- fatality rate from the mortality of the previous seasonal outbreaks, which is likely to lead to a dubious understanding of covid- numbers in these countries. instead the total increase in death count after adjusting for typical seasonal diseases observed in the previous years could provide a better crude estimate of the impact of covid- . another avenue of estimating some of the deaths by covid-like symptoms is data from graveyards and crematoriums. in west bengal, india, the number of bodies cremated is nearly seven times more than the typical rate, whereas in dhaka and narayanganj districts of bangladesh have seen twice or three times more burials in may compared to march or april [ , ] . disease misclassifications based on the differentiation in information regarding covid- mortality apart from its comorbidities across multiple sources can adversely impact comparative analyses. this can also undermine subsequent resource mobilisation and evidence-based decision making in generating appropriate covid- management and response worldwide. moreover, the deceased with covid-like symptoms are often untested in these countries, which although is understandable considering the resource limitations, but again considerably undermines the overall death tally. another method of scrutinising the underreporting of cases is to assess the data of frontline workers since they are more likely to be tested alongside the politicians. as of june , . %, . % and . % of covid- fatalities in bangladesh, afghanistan and pakistan were health workers respectively, whereas they were . %, . % and . % in the usa, uk and italy, respectively. these indicate that the health workers lacked adequate protective gear and knowledge about infection prevention and control measures in the isc during the preparation phase as well as the fact that they were likely to be over-represented in the tests conducted, leading to an overall underreporting. as of june , a total of members of the bangladesh parliament out of had tested positive with two fatalities and over staff of the parliament secretariat, which resulted in a truncated budget discussion in the parliament [ ] . moreover, . % of the covid- infected belongs to the bangladesh police with fatalities so far [ ] . their testing is expectedly prioritised and the rapid increase in these numbers indicates that community transmission has been severely underreported in the isc. in the isc, people over generally do not go out of home much, and often their external visits are limited to their familial circle [ ] . furthermore, a considerable number of women are homemakers [ ] . thus, a large portion of the society is used to staying at home, where able males mostly go out for work. while these scenarios are gradually changing, it could partially explain the slower transmission in isc compared to the developed nations where all household members are more likely to go out increasing the speed of infection. social dogma regarding the covid- is also playing a role in these nations. people in pakistan and india are typically religious. there exist concerns among them that some of the funeral rituals, such as bathing the deceased, cannot be performed if they died of covid- which has created public resentment towards testing [ ] . furthermore, neighbourhood protests were observed in bangladesh where locals denied the covid- deceased to be buried in their local graveyards [ ] . thus, comparison of case prevalence and fatalities across countries need to consider the cross-cultural and demographic factors. there exists a major cause for concern regarding the data quality in the isc. the subsequent use of these data in their raw form could lead to biased findings [ ] . davies et al. rightly found that younger age could be a protective factor in lmics [ ] ; however, it is still too early to extrapolate any generalised conclusions. non-random sampling has been conducted in the isc, and their limited capacity forces them to test mostly the symptomatic individuals and foreign returnees from the high risked countries in the early days. thus, statistical or epidemiological modelling might be statistically unprincipled with marginalised results when not taking into account the weaknesses of the data generating mechanism [ ] . some findings are developing on a regular basis. for example, in the early days of the pandemic, a hypothesis was shown to be 'statistically significant' that temperature is associated with the infection rate [ ] without adequate information on true r value and its impact over covid- transmission, which gave a misleading hope to politicians who used it to assure the general mass in bangladesh leading to a sense of nationwide complacency [ ] . another assumption was that they are genetically immune to the coronavirus, or bcg vaccine might work as a protective factor [ ] ; however, the large death tolls of bangladeshi expatriates in saudi arabia, singapore and new york have evidently debunked it [ ] . this false optimism has led to relaxation of social distancing policies in public transport and consideration of opening schools across the country [ , ] . while it is inevitable that modelling with data from lmics on covid- would continue, a few cautions should be exercised: • an appropriate definition of 'death from covid- ' is essential before collapsing deaths from the covid-like symptoms with the covid- fatalities. for example, bangladesh changed the definition of covid- recovery a month after the detection of the first case [ ] . • for validating the covid- fatality scores of a region, specific mortality causes of comorbid conditions such as respiratory and cardiovascular complication or communicable diseases representing similar manifestation of symptoms linked to covid- could be coded to calibrate from the total deaths during the pandemic period. however, this also needs to consider the seasonal outbreaks of diseases in specific regions. • comparison among seemingly random countries based on convenience or data availability might lead to a systematic bias. a comparative assessment on countries with similar testing coverages, analogous socioeconomic context, close geographical borders (e.g. eu or isc), cultural resemblances and contextspecific priorities with homogeneous health systems might be more insightful. • contrasting country-wise performances and covid- infection timeline, where the covid- prevalence curve has started to flatten with countries that are yet to reach its peak (figs and ) , are unreasonable as true propensity of the pandemic is yet to be observed in lmics such as isc. • instead of modelling covid- incidence rates across borders, cultures and demographics, this could be limited to regions with homogeneous attributes. comparison between neighbourhoods in the same locality might be better suited for hypothesis testing on mortality and disease prevalence, with the utmost care in avoiding narratives that might mislead the public opinion. • validating the covid- official data with random sampling, hospital data, disease burden trends and local news outlets could account for some of the underreporting biases. with thousands of phd dissertations and research articles developing the evidence-base are expected on covid- in years to come, it is imperative that the data validity is constantly epidemiology and infection questioned, and cross-border comparisons are routinely scrutinised given the definition of fatalities from covid-like symptoms and quality of non-random data vary worldwide. coronavirus cases lower dir residents complain of delay in virus test results as tests pile up, infections spread, patients suffer dhaka tribune. covid- : bangladesh lags behind in sample testing despite being among worst affected; dhaka tribune case-fatality rate and characteristics of patients dying in relation to covid- in italy a review of coronavirus disease- (covid- ) the daily star. explaining the jump in number of covid- recovered patients in bangladesh a systematic assessment on covid- preparedness and transition strategy in bangladesh the caravan. india's private covid- tests cost highest in south asia rapid-perception-survey-on-covid -awareness-and-economic-impact.pdf . international labor organization ( ) covid- and the world of work distribution of reported covid- fatalities in three higher income countries (uk, italy and germany) and three countries of isc (bangladesh, india and pakistan) for the first days coronavirus info bangladesh: press release coronavirus: what is the true death toll of the pandemic? the telegraph. asia's hidden deaths: coronavirus fatalities are being covered up and undercounted dhaka tribune. burials in dhaka rose by a third in may budget session to be cut short as mps united news of bangladesh grandparents in bangladesh, india, and pakistan gender, 'race' and patriarchy: a study of south asian women dhaka tribune. panic continues to obstruct burials of coronavirus patients covid- in bangladesh: data deficiency to delayed decision age-dependent effects in the transmission and control of covid- epidemics covid- : a massive stress test with many unexpected opportunities (for data science). harvard data science review high temperature and high humidity reduce the transmission of covid- new age. warm weather may buy bangladesh some time to fight coronavirus could tb vaccine protect medics from covid- ? the daily star. expatriate bangladeshis died of covid- , symptoms in saudi arabia road transport association leaders want to operate vehicles at full capacity bangladesh plans to reopen schools combining online acknowledgements. the authors acknowledge european centre for disease prevention and control, who regularly published worldwide covid- data. we convey thanks to the media for the situational analysis. we extend our appreciation to the three anonymous reviewers who have significantly improved the focus and clarity of the paper. key: cord- -a l e z authors: selim, s. a.; aziz, k. m. s.; sarker, a. j.; rahman, h. title: rotavirus infection in calves in bangladesh date: journal: vet res commun doi: . /bf sha: doc_id: cord_uid: a l e z faecal samples from calves under year of age ( diarrhoeal and normal) were collected from three dairy farms and one village in selected areas of bangladesh. the samples were tested by an enzyme-linked immunosorbent assay (elisa) to detect the presence of rotavirus antigen. of dairy calves tested, ( . %) were positive, of which ( . %) were from diarrhoeic calves and ( . %) from non-diarrhoeic calves. rotavirus infection varied from farm to farm ( . – . %) and there was no positive response from any of the village calves. rotavirus was most commonly found in calves of week of age or less (up to . % in one group) but was not found in any calves later than months of age. more than % of rotavirus-positive samples from diarrhoeic calves exhibited a titre of or more (geometric mean ± . ), whereas non-diarrhoeal calves had titres less than or equal to (geometric mean= ± . ), suggesting that rotavirus infection in calves in bangladesh was mostly associated with diarrhoea. rotavirus infection in calves is very common, with a worldwide distribution (mcnulty, ; kurstak et al., ) . the role of the virus in causing diarrhoea, especially in young subjects, is well established (mebus et al., % ; woode and crouch, ; castrucci et al., ) . although rotavirus infection in diarrhoeic calves usually involves multiple enteropathogens including escherichiu cob, corona virus, and/or cryptosporidia (morin et al, ) , single infections are not uncommon (tzipori, ) . in calves, the infection is mostly associated with diarrhoea, sometimes as the primary agent, in naturally infected and experimentaily produced cases (mebus et al., % ; woode and crouch, ) and the infection varies widely depending on various factors (mcnulty, ; tzipori, ) . calf diarrhoea (gastroenteritis syndrome) remains the most often reported clinical problem in calf management and in rural conventional cattle rearing systems in bangladesh (debnath et al., ) . this study was undertaken to determine the prevalence of rotavirus infection in selected dairy farms and in conventionally reared village calves in bangladesh, and to study the prevalence of rotavirus in diarrhoeic and age matched non-diarrhoeic calves. farms a and b are close to each other, km apart, in dhaka district. farm c and the selected village are km away in mymensingh district. the populations of calves under year of age on the farms were , and respectively at the beginning of the study. the equivalent calf population in the village could not be ascertained but was estimated to be around so. calves on farms a and b were holstein crossed (fl) with either sindi, sahiwal (tropical breeds) or local improved nondescript zebu. farm c calves were cross breeds between sindi and sahiwal, while most calves of the village were improved zebu crossed with sindi or sahiwal. all the calves were grouped as diarrhoeic (d), having clinical diarrhoea with liquid or semi-liquid faeces, or non-diarrhoeic (n), without any abnormal fluidity of the faeces, regardless of any previous history of illness. all the calves were further categorized into four groups on the basis of age: group i, calves from birth up to week of age; group ii, from over week to month old calves; group iii, calves aged over month to months; and group iv, calves from over months to year old. calves were reared in individual metal calf pens until they were month of age. they were then moved to pens containing lo- calves where they were housed up to year of age. on farm c, the newborn calves were reared in groups of or and transferred to a common calf shed at months of age where they remained up to year of age with occasional moving to similar sheds. each farm calf was bottle-fed colostrum and natural milk from their dams soon after birth, usually within hours. sick calves were usually transferred to a separate calf shed in all the dairies. the village calves were reared in the conventional way for backyard rearing systems in bangladesh. most farmers in the village had - cattle, the cows being used for dual purposes, i.e. draught power and milk. their calves receive milk naturally by sucking from their respective dams. these calves usually received sufficient colostrum and milk, and occasionally roamed freely in the small grazing fields. sampling procedures and processing of samples faecal samples were collected from calves during weekly visits to each location. the diarrhoeic samples were collected first, followed by the collection of up to an equal number of normal faeces from age-matched non-diarrhoeic calves. a total of samples, diarrhoeic and non-diarrhoeic, were collected over a lo-month period (table i) . faecal samples (ca. g) were collected directly from the rectum, kept in a sterile screw-capped, labelled container, and transported to the laboratory as soon as possible in a thermostable box. each sample was diluted : in phosphate-buffered saline (pbs, ph . ), mixed, and centrifuged at oog for min ( °c). the supernatants were separated, labelled and kept at - °c until the samples were used for elisa. a commercially available kit (dakopatts a/s, code k , denmark) was used to analyse the samples for the presence of rotavirus in the faecal materials. the test was done as described elsewhere (ellens and de leeuw, ; ellens, ) and following instructions provided in the kit. each sample was tested in duplicate. the readings were taken spectrophotometrically at nm wavelength using automated equipment. positive results were assessed by comparing the light absorbance of the test samples with that of the known standard positive and negative controls. if a test sample had an absorbance value of times that of corresponding negative control, it was taken as positive. the p/n ratio was . titration of the positive samples was done with a twofold serial dilution of each sample using duplicate rows of elisa plates and adopting the above elisa methods. a : dilution of a positive sample was used as the initial dilution, being considered to have a titre of . titre was defined as the reciprocal of the highest dilution of a sample at which it was still positive by the above elisa interpretation. the distribution of samples positive for rotavirus as between locations and ages of calves is shown in tables i and ii respectively. a higher prevalence was observed in young diarrhoeic calves than in the older groups, whereas in non-diarrhoeic samples the prevalence was higher in older calves (table ii and figure ). no rotavirus was detected in calves over months of age. the titres in diarrhoeic calves with positive samples ranged from to (median ). the highest and the lowest titres were and respectively (median ) in samples from non-diarrhoeic calves. figure shows the distribution of the titres of the positive samples from both diarrhoeic and non-diarrhocic calves. age groups shown as i, ii and iii represent calves of not more than week, from over week to month, and from over month to months of age respectively little was known about the status and viral aetiology of calf diarrhoea in bangladesh under field conditions, although rotavirus-associated human infantile diarrhoea is prevalent (sack et al., ; huq et al., ) . a . % infection of diarrhoeic calves as detected in the present study appears low in comparison with fmdings elsewhere (de leeuw et az., ; moerman et az., , bellinzoni et uz., . rotavirus infection may vary widely from place to place or even from farm to farm (tzipori, ) . our findings, however, show similarity with limited observations (debnath et al., ) in the area of dhaka in diarrhoeic calves up to month old. the variation in the rate of infection on different farms (p=o.o ) needs more investigation before reaching any firm conclusions. hygiene measurement is one of the important factors, along with other interacting variables (tzipori, ) . farm b, which had the lowest prevalence ( . %) of the virus differed significantly (p=o.o ) from farm a and was noted to have a better cleaning and disinfecting procedure than the other two farms. a higher infection rate (table ii) in the first week of life suggests widespread rotavirus in this group of younger calves. other studies (acres and babiuk, ; de leeuw et al., ) showed similar results. in farm c, infection in the non-diarrhoeic calves was relatively high (table i) . subclinical infection is not uncommon on premises where clinical infection occurs in calves (de leeuw et al., , snodgrass and sherwood, ) . the overall infection rate in non-diarrhoeic calves in this study corresponds with some other reports (bellinzoni et al., ) . as numerous factors (tzipori, ) interplay in precipitating clinical diarrhoea, it is difficult to make absolute conclusions based on the limited information we have. however, rotavirus infection has been shown to be more important than other agents in diarrhoea in young calves of around week of age ( - days) (de leeuw et al., ) . although our findings did not reveal a significant difference in rotavirus infection between diarrhoeic and non-diarrhoeic calves, rotavirus was mostly associated (p =o.l) with young diarrhoeic calves. the age-related (r=o. ) prevalence in diarrhoeic calves (figure ) tends to agree with the report by tzipori ( ) . the absence of detectable rotavirus antigen in non-diarrhoeic calves up to week old and the high prevalence rate in diarrhoeic calves in the same age group (table ii) emphasizes the association between rotavirus and diarrhoea in such calves. the higher viral antigen titres (figure ) in samples from diarrhoeic calves, for which the geometric mean (gm) of titre was . as against those from non-diarrhoeic calves (gm = . ) confirms an association of the virus with diarrhoea in these young dairy calves. the small numbers of conventionally reared village calves makes it difficult to draw firm conclusions from the absence of rotavirus in these animals. the study, however, suggests that the rotavirus infection in young calves also exists in different locations of the country outside the dhaka region and is the first report of the existence of the virus in high concentration in association with diarrhoea in young dairy calves in that country. studies on rotaviral antibody in bovine serum and lacteal secretions calf diarrhea (scours): reproduced with a virus from a field outbreak prevalence and significance of viral enteritis in dutch dairy caives neonatal calf diarrhea: pathology and microbiology of spontaneous cases in dairy herds and incidence of enteropathogens implicated as etiologic agents sero-epidemiology of rotavirus infection in rural bangladesh aetiology of diarrhoea in young calves the aetiology and diagnosis of calf diarrhea. veterinary record, lot? naturally occurring and experimentally induced rotaviral infections of domestic and laboratory animals the study was sponsored by the icddr,b, mohakhali, dhaka , bangladesh (project no. - (p)). national science and technology division (bangladesh) supported the work by offering a ncst fellowship to the senior author. suggestions by drs ca. mebus, p.w. de leeuw and s. tzipori at the start of the study are acknowledged. journal of the american veterinary medical association, , - bellinzoni, rc., mattion, n.n., la torre, j.l. and scodeller, ea., key: cord- -wxliz authors: mottaleb, khondoker abdul; mainuddin, mohammed; sonobe, tetsushi title: covid- induced economic loss and ensuring food security for vulnerable groups: policy implications from bangladesh date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: wxliz at present nearly half of the world’s population is under some form of government restriction to curb the spread of covid- , an extremely contagious disease. in bangladesh, in the wake of five deaths and infections from covid- , between march and may , , the government imposed a nationwide lockdown. while this lockdown restricted the spread of covid- , in the absence of effective support, it can generate severe food and nutrition insecurity for daily wage-based workers. of the million employed labor force in bangladesh, nearly % of them are paid on a daily basis. this study examines the food security and welfare impacts of the covid- induced lockdown on daily wage workers both in the farm and nonfarm sectors in bangladesh. using information from more than , respondents complied with the – household income and expenditure survey (hies) in bangladesh, this study estimates daily wage rates as bangladesh taka (bdt) . in the farm sector and bdt . in the nonfarm sector. using the estimated daily wage earnings, this study estimates that a one-day complete lockdown generates a us$ . million equivalent economic loss only considering the wage loss of the daily wage workers. after estimating the daily per capita food expenditure separately for farm and nonfarm households, this study estimates a minimum compensation package for the daily wage-based farm and nonfarm households around the us $ per day per household to ensure minimum food security for the daily wage-based worker households. by september , , nearly million people in countries and territories have been sickened by the severe acute respiratory syndrome coronavirus- (sars-cov- ) or covid- [ ] . by that time, the covid- induced death toll had reached more than thousand globally [ ] . the virus was first detected on december st in wuhan province, china, and on january , , china confirmed the first covid- induced death followed by the first death in the united states on january , [ ] . on january , , the world health organization (who) declared covid- a global public health emergency of international concern [ ] . covid- is an extremely contagious disease, spreading rapidly through human to human contact [ ] [ ] [ ] . until the time of writing this article, there is no effective medicine to cure or vaccine to protect from this virus. to curb the spread of this disease, national governments have imposed varying levels of movement restrictions. for example, by april , , national governments of countries and territories in asia, in europe, in the americas and the caribbean, and in africa imposed varying levels of movement restrictions [ ] . studies and opinions warned that the covid- lockdown and restricted labor movement could generate havoc across the world [ , ] , and could cause severe global food shortages by disrupting the supply chain [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . particularly, the one-size-fits-all approach of lockdown can aggravate the plight of daily wage workers in low-income countries. considering this, one suggestion is to expand social safety net programs in developing countries [ ] . however, to our knowledge, there is no solid study based on microdata that examines the economic loss due to the covid- induced lockdown and the minimum compensation required to ensure the basic nutrition of the poor households. the present study uses information from , economically active workers in bangladesh, collected by the bangladesh bureau of statistics (bbs), to quantify the economic loss due to the covid- lockdown based on the lost wage earnings of the daily wage workers in the farm and nonfarm sectors of bangladesh. then, applying simple econometric estimation processes, this study estimates the minimum compensation packages for the daily wage-based farm and nonfarm households of bangladesh that ensure their minimum food security during the lockdown. the rest of the study is organized as follows. the next section describes the current poverty situation and the covid- induced restricted movement and lockdown in the world and bangladesh. section explains materials and methods, and section presents major findings. section provides conclusions and policy implications. to control the spread of covid- , at least countries and territories in the world imposed varying levels of movement restrictions [ ] . in asia, countries implemented localized lockdowns, countries implemented national lockdowns, and the rests implemented localized or suggested national recommendations, such as maintaining social distance [ ] . these covid- induced lockdowns and movement restrictions can exacerbate the already worsening global poverty situation. despite the extraordinary success in alleviating abject hunger and extreme poverty since the s [ ] , the share of hungry people in the globe has been increasing in recent years [ , ] . in , more than % of the total population of the world was extremely poor, living on less than us$ . /day [ ] . in , globally, the extremely poor reduced to . % ( , million), which further reduced to . % ( , million) in [ ] . however, since , the absolute number of hungry people has started to increase. in , out of a global population of . billion, million ( . %) were hungry, which increased to million ( . %) in [ ] . it is projected that covid- will further exacerbate the poverty and abject hunger in the world in a number of ways. it is argued that the overburden on the health sector causes the reallocation of resources to the health sector to save lives, which may reduce resource allocation to the agriculture and industrial sectors, thereby hampering the food production and input supply chains [ ] . more importantly, covid- induced lockdowns and movement restrictions have already increased unemployment and under-employment, which has severely reduced the purchasing power of consumers [ ] . the international labor organization (ilo) estimates that the participation of the global working force in the first quarter of declined by . % which is equivalent to million full-time jobs [ ] . in a recent report, asian development bank (adb) projected that the covid- induced global loss will range between $ . to $ . trillion compared to a no-covid- baseline, which is equivalent to . % to . % of the global gdp [ ] . the international monetary fund (imf), warned that due to the covid- induced lockdown and resource reallocation to the health sector to save lives, the global gdp could be reduced by . % in compared to the previous year [ ] . the economic commission for latin america and the caribbean (eclac) and ilo [ ] projected that due to the covid- pandemic, the economy of the latin american and caribbean region will shrink by . % and the unemployment rate will increase from . % to . %, equivalent to more than . million new unemployed persons. furthermore, the poverty rate in the region will increase by . % and the extreme poverty rate will increase by . % [ ] . studies also warned about a possible severe food crisis, particularly in countries currently experiencing economic shocks, weather extremes, or conflicts [ , ] . it is observed that during epidemics like hiv/aids and ebola, food prices in affected countries increased significantly, with severe impacts on food security, especially for vulnerable populations including women, children, and marginal people [ ] . for example, in sierra leone, the triennium average ending in for rice (paddy) and cassava prices were us $ . /ton and us$ . /ton, respectively [ ] . however, when the ebola epidemic hit the country in , the price of rice (paddy) rose to us$ . /ton (+ %) and the cassava price to us$ . /ton (+ %) [ ] . increased food prices can disproportionately affect vulnerable groups, such as marginal households and women [ , ] . in bangladesh, for example, the food price hikes of - pushed an additional million people below the poverty line [ ] . given the covid- induced chaos, if major food and cereal exporting countries restrict their exports, a severe crisis may be generated in the food and cereal import-dependent countries [ , ] . in , droughts in australia and argentina and rising oil prices prompted a number of major cereal exporting countries such as india to ban cereal and food exports, aggravating the food price crisis [ ] . it is reported that kazakhstan has already banned wheat flour exports and restricted exports of buckwheat, vegetables, onions, carrots, and potatoes; while vietnam has temporarily stopped rice exports [ ] . in fact, in its latest report, the united nations warned that world trade could shrink by %, the global economic output could be slashed by us$ . trillion over the next two years, and the economic growth of developed countries could reduce to - %. consequently, the global economy is projected to shrink by . % and some . million people are projected to fall below the poverty line due to covid- [ ] . unu-wider warned that in the most extreme case, covid- induced responses could reduce % of the income or consumption expenditure at the global level, and poverty levels could increase by an additional - million people compared to levels [ ] . covid- could create a severe setback to attaining the zero hunger goal of the united nations by [ ] . in , a total of million people in the world were severely food insecure [ ] . food insecurity triggered by conflicts affected million people in countries; economic shockrelated food insecurity affected million people in eight countries, and weather extremes caused food insecurity for million people in countries [ ] . the world food program (wfp) cautioned that in the absence of swift and effective actions, the number of severely food insecure people could reach million in [ ] . in addition, at present, nearly billion people in the world are moderate to severely food insecure [ ] . these food vulnerable people are mostly concentrated in africa, west asia, and latin america [ ] . although has been affecting high-and low-income countries, the aftermath of covid- could have severe negative impacts on low-income developing countries. in bangladesh, on march , , in the wake of three deaths and infections of covid- [ ] , the bangladesh government imposed a nationwide holiday and lockdown initially from march to april , [ ] , and later extending the general holiday to april , and then to april , [ ] . finally, the government extended the general holiday and airport and road lockdown until may , [ ] . until april , , out of districts of bangladesh, districts were completely under lockdown and were under partial lockdown [ ] (fig ) . as of september , , bangladesh had a total of , confirmed covid- cases, with , recovered and , deaths [ ] . since , bangladesh has continued to achieve stunning economic progress. after independence in , the per capita gdp of bangladesh was $ . , which had increased to $ . in , and $ in [ ] . due to the enormous population pressure, the average farm size in bangladesh is as small as . ha [ ] . despite the fact, bangladesh became the fourth-largest paddy-rice-producing country ( . mmt) in the world after china ( mmt), india ( mmt), and indonesia ( . mmt) [ ] . today, bangladesh is self-sufficient in rice, the major staple of the country. the - triennium average daily per capita dietary energy intake was kcal, which has increased to kcal/daily in - [ ] . in , bangladesh ranked rd out of countries on the global food security index [ ] , whereas it ranked nd out of countries in [ ] . the covid- induced turmoil, however, could substantially undermine the economic achievement of bangladesh by affecting trade and the garment industry of bangladesh. bangladesh is the second largest garment exporting country in the world after china, where, in more than , garment factories, more than . million workers are employed, the majority of whom are female [ ] . more than % of the total export earnings of the country solely come from the garment industry [ ] . this industry is thus dependent on foreign export demand, especially from developed economies and also on imported materials from abroad and particularly from china. in , the total merchandise trade value (export + import) of commodities and goods (excluding services) of bangladesh was us $ . billion, of which total trade value with china was $ . billion [ ] , which was nearly % of the total commodity trade value of bangladesh. in march , organization for economic co-operation and development (oecd) projected that in global gdp will drop by . % compared to , and china's gdp growth rate would be below % [ ] . thus, negative impacts of covid- in china and in other high-income economies could be transmitted to bangladesh through the commodity trade channel. alarmingly, it is already reported that the unemployment rates in china and the united states have increased to unprecedentedly high levels [ ] . in bangladesh, reportedly, until august , export order worth of us $ . billion has been cancelled, which affected the employment of . million garment workers [ ] . the nationwide lockdown and movement restriction can also severely undermine the economic achievement of bangladesh by directly curbing the wage earning opportunity of the economically employed labor force. in - , the economically active employed labor force ( years and above) of the country was . million, of which . % were informal workers ( table ). the share of informal workers is the highest in the farm sector, in which out of total . million employed workers, . % of them are informally employed [ ] . the international labor organization (ilo) stressed that the income opportunity of the informal workers and casual labor in both farm and nonfarm sectors are mostly affected by the covid- induced contraction of employment and the restricted movement measures [ ] . the severe labor shortages problem in harvesting boro rice (dry-season irrigate rice crop) in has not only spoiled farmers' harvest, but also curbed income opportunity of the casual labor, who in , . % of the total population of . million, were classified as poor, which reduced to . % in [ ] . however, in , out of million people, . % were classified as poor [ ] . in , children under years of age, every children in , were stunned, and % were wasted [ ] . a recent report warns that if lockdown continues for a long time, the current poverty rate and undernutrition could deteriorate significantly [ ] . for example, it is stressed that in bangladesh, at least million extra people have fallen below the poverty line due to covid- [ ] . a recent survey asserts that % of the sampled respondents reported not having enough food, while % reported of not having enough money to purchase food [ ] . what is missing in the existing literature is an estimate of the magnitude of the economic loss associated directly with the lockdown measure taken by the government to curb the spread of the coronavirus, as opposed to the estimate of overall negative impacts. using bangladesh as a case, this study quantifies the daily economic loss due to wage earning forgone of daily wagebased workers both in farm and nonfarm sectors. as to food security, it has already been suggested to expand the public support system [ ] . the present study, in addition, suggests that the minimum compensation package should be provided to ensure the minimum food security of the daily wage-based workers. this study relies on bangladesh's - household income and expenditure survey (hies) data collected by the bangladesh bureau of statistics (bbs). since , bbs has conducted rounds of surveys, with the hies - survey being the th series. the monetary poverty of the country is measured mainly based on the hies, which is a nationally representative comprehensive survey [ ] . to enhance data precision by improving the data collection process, the world bank provides technical support. bbs uses a two-stage stratified random sampling process. in the first stage, primary sampling units (psus), consisting of specific geographic areas, are selected. in the second stage, from each psu, households are randomly selected for a detailed interview. the - dataset comprises , psus covering all districts of bangladesh and , households. the - hies survey is a multipurpose survey, with nine sections detailing information on household level demographics, food consumption, farm and nonfarm economic activities, and labor allocation. this study uses data on labor allocation, daily wage earnings, and food consumption. as each household was comprised of . persons on average, information on age, education, marital status, rural-urban affiliation, and job status in the sampled seven days were given for all , members of the sampled , households. in this study, however, we have only considered the economically employed respondents, who were more than or less than years old. thus, this study uses the sub-sample consisting of , individuals, of which , ( . %) were from rural areas, , ( . %) from urban areas, , ( . %) female and , ( . %) male. to calculate the economic loss associated with the covid- induced lockdown, we estimate the daily wage earnings (w is ) of a respondent i, working in sector s (= farm and nonfarm separately. the wage function is specified as follows: where lnw is is the natural log of daily wage earned by a sampled respondent i in sector s (= farm f or nonfarm nf), and cereal price is the price of cereals per kg in bangladesh taka (bdt/ kg). this variable is included in the regression to control for a possible association between cereal price and wage payment of the daily wage workers. the ilc is is a vector of variables, which includes respondent-level characteristics, such as: • years of schooling, • female dummy (fm) (female = , otherwise); • marital status (married = , otherwise); • age in years; the vector of variables rlc is includes a rural dummy that assumes a value of , if a respondent is from a rural area, and otherwise, and dummies for districts of bangladesh. in addition, in estimating daily wage income, we include inverse mill's ratio calculated after estimating eq ( )-the occupation choice model, to take into account a possible self-selection bias in selecting wage receiving methods of the respondents as will be explained below. by multiplying the estimated per head average daily wage earnings (in bdt) in the farm sector w f and that in the nonfarm sector w nf by the absolute number of daily waged workers in those in bangladesh, the expected loss of daily wage earnings due to the covid- induced lockdown is calculated as follows: to estimate the minimum compensation package for the daily wage-based workers to ensure the minimum food security, we specify and estimate a function that explains household level daily food expenditure for the household of daily wage worker i (that is, survey respondent i) in sector s, as follows: where lnedfx is the natural log of the household level daily total expenditure on all food (in terms of bdt); wage earnings, lndweh is is the natural log of the total daily wage earning of the household of respondent i calculated as: the definitions of the vectors of variables ilc is and rlc is are the same as explained in eq ( ). the vector of variable hlc is includes: • household level income from rent of land and other properties, insurance income, profit and dividend income, lottery and prize money, charity, gift, royalty and assistance both in cash and kind, remittance income, gratuity and retirement benefits, interest received and other income in cash or kind. to make it daily, we divided by ; • household level receipt from social safety nets, including any positive income from any social safety net programs by any member of the household. to make it daily, we divided it by ; and • land owned (acres). in estimating eq ( ), we have estimated, firstly without including division dummies; secondly including seven division dummies for eight divisions, and finally including district dummies for districts to capture the regional heterogeneity on the daily household level food expenditure. as both the dependent variable (lnedfx is ), and the estimated household level total daily wage earnings ðlndweh is Þ are in log form, the coefficient g ŝ in eq ( ) is simply the elasticity. it provides the share of total wage earnings are spent on household level daily food expenditure of a sampled day-labor household in farm and nonfarm sectors. assuming, zero income of the daily wage-based households in a very strict lockdown situation, the minimum daily support can be calculated as: where edfx is is the estimated daily household level total food expenditure in sector s. in reality, however even under a stringent lockdown measure, daily wage earners may desperately search for any miscellaneous work, and thus can earn some positive income (> ). the earnings of a daily wage worker during lockdown time, however, can be lower by a fraction by θ than the normal time, where < θ < . it means, in the lockdown time, the total wage earnings of a daily wage-based household will be ydweh is , which is lower than the normal time household level daily total earnings dweh is in eq ( ), where θ = . consequently, the logarithm of the household level daily total food expenditure with this lost income (ydweh is ) would be smaller than that without income loss by: by rearranging eq ( ), we obtain where (ydwehÞ is is the lockdown induced reduced daily total wage earnings of a daily wagebased household, θ is the lockdown induced wage earning fraction ( < θ < ), and g ŝ is the estimated coefficient of wage earning in explaining the daily household level total food expenditure lnedfx is specified in eq ( ) a reasonable amount of minimum daily food expenditure support would be the average of the difference between food expenditures with and without income loss due to lockdown measures. using the estimated coefficient of the daily wage earning g ŝ from eq ( ) and assuming different rates of income share, modifying eq ( ) we recalculate the minimum required daily support to be provided to each household in sector s as follows: where ms s is the minimum required daily support to a household, edfxðdwehÞ s is the estimated household level daily food expenditure that is obtained by estimating eq ( ), and θ is the estimated coefficient. eq ( ) indicates that the calculated daily minimum support is now contingent upon the fraction of daily wage earning θ, the value of g ŝ and the household level daily total food expenditure in the normal time. under the assumption that a daily wage-based household earns only % of their wage income (θ = . ) in the covid- induced lockdown time compared to the daily wage earning in the normal time, then the household level daily total food expenditure will become fraction . ^(g ŝ ) of the initial per capita food expenditure, which is the estimated value of the dependent variable of eq ( ). in that case, the minimum support will be - . ^(g ŝ ) estimated value of the hosehold level daily food expenditure in suggesting daily minimum support to ensure minimum food security of the daily wagebased households, we assume a range of income loss. in estimating the wage function (eq ( )), we have incorporated the inverse mill's ratio for controlling the possible self-selection bias due to occupation choice (daily wage-based workers in the farm, or nonfarm sectors. the multinomial logistic regression estimation procedure was employed to characterize the daily wage-based workers in the farm and nonfarm sectors (i), setting the non-daily wage workers as the base (= ) and assigning a value of for daily wagebased farm workers (n f ), and a value of for daily wage nonfarm workers (n nf ) as follows: pðdaily; farmÞ pðnon dailyÞ pðdaily; nonfarmÞ pðnon dailyÞ where hlc is , ilc is , and rlc is are the same as in eq ( ), and homestead is is the size of the homestead land owned (acres). some basic background information of the sampled respondents is presented in table . the sampled respondents are divided into three groups based on the wage payment methods: daily wage workers in farm and nonfarm sectors and other workers. out of , sampled respondents, , ( . %) were paid other than daily basis mode, , ( . %) worked in the farm sector and were paid daily, and , ( . %) worked in the nonfarm sector and were paid daily. on average, a sampled respondent was more than years old, with nearly five years of schooling, more than % were married, and more than % were from rural areas ( table ). in addition, a sampled household comprised of . family members, with . earners ( table ) . female workers were less likely to be paid on the daily basis. in general, the daily wage workers were mostly engaged in the open field related physical works. in bangladesh, it is not socially acceptable that females and males perform physical work together in an open field. a closer scrutiny of table reveals that, on average, the daily wage-based workers in the farm sector are statistically significantly older ( . years) with significantly fewer years of schooling ( . years) and was more likely to be from rural areas compared to others. in addition, the number of family members and earners were lower for households of daily wage workers in both farm and nonfarm sectors compared to the other group. thus, daily wagebased workers in general, are relatively more resource poor compared to other workers. more than one-fifth of the sampled respondents were from dhaka division, followed by chattogram ( . %) and khulna divisions ( . %) ( table ) . dhaka and chattogram are the largest garment industry clusters in bangladesh [ ] , where more than . million workers are employed, the majority of which are female [ ] . thus, as there are more nonfarm work opportunities in dhaka and chattogram than other divisions of bangladesh, the largest share of sampled respondents was drawn from these two divisions. nearly % of the daily wage-based farmworkers were from rangpur division ( table ) . of the total population of bangladesh, . % live below the national poverty line [ ] . rangpur division has the highest incidence of income poverty ( . %) [ ] , which is reflected in the concentration of daily waged-based farmworkers. as per table , more than % of respondents did not have their own homestead land, and more than % were landless. on average, the daily wage earning in the farm sector was bdt , and bdt in the nonfarm sector ( table ). the yearly average income from land rent, rent of other properties, insurance, profits and dividends, lottery and prize money, charity, gifts, royalties and other assistance both in cash and kind, remittances, gratuities and retirement benefits, interest received and other income in cash or kind, was bdt , . however, this income was significantly lower for daily wage workers in the farm sector (bdt , . ) and the nonfarm sector (bdt , . ). more than % of respondents reported inclusion in the social safety net programs, with the yearly average receipt from them being nearly bdt , . it shows that daily wage workers were more likely to be included in a social safety net program than others ( table ). the average daily household level total food expenditure was bdt . , of which the expenditure only on cereals accounted for % (bdt . ). the daily per household level consumption of cereals was . kg (table ) . this indicates the importance of cereals as a cheap source of dietary energy for the poor in developing countries. importantly, as expected, the daily household level total food expenditure was significantly lower for daily wage farmworkers, which confirms that the daily wage-based workers are more distressed than others. tables - present estimated functions specified in eqs ( ) and ( ). table presents the estimated functions explaining the (ln) daily earning per earner for farm and nonfarm workers. the estimates were obtained by means of the generalized linear model (glm) estimator. there is a positive relationship between years of schooling and the daily wage earnings in the nonfarm sector, however, such relation is insignificant in the case of the farm sector (table ) . on average, the female daily wage workers were paid less than their male counterparts in both farm and nonfarm sectors ( table ). the coefficients on the district dummies can be seen in s table. the estimated daily wage earnings for farm workers is bdt . , and bdt . for nonfarm workers (table ). in - , there were . million workers in the farm sector and . million in the nonfarm sector (table ) . there is no straightforward information on the share of workers who were paid on daily basis. in - , however, . % workers in the rural area, and . % workers in the urban area were paid on daily basis [ ] . as most of the workers in the rural area of bangladesh are mainly engaged in farming, we assume that out of . million workers in the farm sector, . % of them, or . million were paid on daily basis. similarly, as in the urban area, most of the workers are mostly engaged in the nonfarm sector, we assume that out of . million workers in the nonfarm sector, . % of them, or . million, were paid on daily basis. following eq ( ), multiplying the estimated daily wage earnings for farmworkers as bdt . /day and for the nonfarm worker as bdt . /day, under the assumption of a complete lockdown with no-one allowed to work, the economic loss in one day is estimated at bdt . million or approximately us$ . million. assuming % of the daily wage workers are not allowed to work and the rest are, the economic loss/day will be bdt . million or us$ . million. table presents the estimated functions applying the ordinary least square (ols) estimation approach, explaining the (ln) daily household level total food expenditure of the sampled farm and nonfarm daily wage-based households. we have presented the results of three different models. in model ( ), we did not include the division or district dummies, whereas in model ( ) we included seven division dummies for eight divisions; and in model ( ) we included district dummies for districts. in the estimated functions, we have included the natural log (ln) of the estimated daily total wage earnings of a sampled household in explaining the daily household level total food expenditure of the sampled daily wage-based farm and nonfarm households ( table ). the estimated (ln) daily household level total wage earnings are highly statistically significant and positive in explaining the (ln) daily household level total expenditure on food (table ) . it shows that a % increase in total household level daily wage earnings leads to an increase in the daily districts effects are controlled by including district dummies for districts (s table) inverse household level food expenditure by . % (model ) at the minimum to . % at the maximum for the daily wage-based farm households in the farm sector, and a % increase in wage earnings leads to an increase in the daily per capita food expenditure by . % (model ) to table) districts effects are controlled by including district dummies for districts (s table) . % (model ) at the maximum for the daily wage-based nonfarm households ( table ). the income from other sources, years of schooling and age also positively and significantly affect the daily per capita food expenditure of the sampled farm and nonfarm workers. this shows that, on average, both farm and nonfarm daily wage-based households in khulna, mymensingh, rangpur and rajshahi divisions spend statistically significantly less on food per capita compared to the households in barishal division, which is the base division. the coefficients on the district dummies can be seen in s table. in table , in the case of the sampled daily wage-based household in the farm sector, the estimated coefficient of the daily total wage earnings in the household level daily total food expenditure ðg f Þ are . , . and . , respectively (models - ) . the estimated daily household level food expenditures ðedfx f Þ are bdt . , bdt . and bdt . , respectively (models - ) . similarly, the estimated share of the daily total wage earnings in the household level daily total food expenditure ðg f Þ are . , . and . , respectively (models - ), and the estimated daily household level food expenditures ðedfx nf Þ are bdt . , bdt . , and bdt . respectively (models - ). assuming %, % and % of the daily earnings of the daily wage-based households in the farm and nonfarm sectors (θ = . , . and . ) compared to the normal time daily wage earnings, the estimated daily minimum supports are presented in table . in estimating the daily minimum support, we have set γ f = . and edfx f ¼ bdt . for the daily wage-based farm household, and γ nf = . and edfx nf ¼ bdt . , for the daily wage-based nonfarm households. our estimation shows that the estimated daily minimum support is ranged from bdt . - depending on the share of the daily wage earnings (θ) for the daily wage-based farm households, and it ranged between bdt - in the case of the daily wage-based household in the nonfarm sector under the assumptions of %, % and % income loss (θ = . , . and . ) due to covid- induced lockdown time ( table ). the estimation suggests a common minimum support at us $ per daily wage-based household in bangladesh to ensure minimum food security during covid- induced lockdown time. however, our estimation process is flexible which contingent upon the share of income loss due to the severity of the lockdown. this flexibility in estimating the daily minimum support will allow policymakers to set the daily minimum support based on the severity of a lockdown situation in a specific region. table presents the estimated functions that characterize the sampled daily wage workers (eq ), applying the multinomial logit estimation procedure setting the workers who receive their remuneration, not on a daily basis as the base (= ). compared to the base workers, respondents with higher income, with more family members and more years of school and female respondents were less likely to be daily wage-based workers (table ). in contrast, married and rural respondents; and relatively older respondents, were more likely to be daily table . calculation of minimum daily support using the estimated daily household level food expenditure and the estimated coefficient ðg Þ reported in table wage-based workers both in farm and nonfarm sectors. female respondents were in general less likely to be daily wage-based workers, and specifically, female respondents in age groups - , - , and - years old were less likely to work as daily wage-based workers in both farm and nonfarm sectors. in characterizing the daily wage-based workers, the district level effects are also included by including dummies for districts setting bagerhat district as the base (= ). the coefficients of the district dummies can be seen in s table. after estimating the functions that characterize the sampled daily wage-based workers reported in table , the generalized inverse mill's ratios are calculated separately for daily wage-based workers in farm and nonfarm sectors following vella's [ ] procedure, and plugged in into eq ( ) in estimating daily wage earnings (table ). it is noted that the methodology of this study is simple and relatively easily replicable for other countries. for example, in india, . % of employed workers are casual labor, of which % are engaged in agriculture [ ] . the daily average wage earnings per day by a casual labor ranged between india rupee (rs.) - [ ]. a recent report stressed that in india, in april , million people became jobless, and the unemployment rate had increased from . % in march to . % in april , due to covid- induced turmoil [ ] . by examining the share of expenditure of the daily income on food, it is possible to suggest a minimum support package to ensure the food security of casual labor-based households in india during the covid- induced lockdown period. using information of more than , respondents from the hies - dataset, this study, firstly quantified the economic loss due to the covid- induced lockdown and suggested the minimum support package to ensure food security of the daily wage-based workers in bangladesh. nearly half of the world's population is now under some form of restrictions imposed by national governments to curb the spread of covid- . while this lockdown may restrict the spread of covid- , in the absence of effective support, it may also generate severe food and nutrition insecurity for daily wage-based workers, particularly in the developing countries [ , ] . the ilo warned that due to covid- induced movement restrictions and lockdown, the participation of the global working force in the first quarter of has declined by . % which is equivalent to million full-time jobs [ ] . in bangladesh, out of a . million employed labor force, . million ( . %) are directly engaged in the farm sector, of which . % are paid on daily basis, and . million are engaged in the nonfarm sector, of which . % are paid on daily basis. this study stressed that, compared to others, the daily wage-based workers in both farm and nonfarm sectors are comparatively more resource poor in terms of land ownership and education. based on the estimated daily wage earnings, this study found that under the assumption of complete lockdown, the daily economic loss due to prohibiting daily wage-based workers to work would be us$ . million. this study also demonstrated that the average wage elasticity in explaining the daily food expenditure at the household level ranged from . to . , and the daily household food expenditure ranged from bdt . - . for the daily wage-based farm households. for the daily wage-based nonfarm households, the average wage elasticity in explaining the daily food expenditure at the household level ranged from . to . , and the daily household food expenditure ranged from bdt - . assuming %, % and % of the daily earnings of the daily wage-based households in the farm and nonfarm sectors (θ = . , . and . ) compared to the normal time income, we have estimated that on average it is necessary to provide daily bdt - or around us $ per daily wage-based households during the covid- induced lockdown time. it is important to mention here is that, the suggested minimum support us$ /day/household is calculated based on considering only food expenditure. the suggested minimum support package is thus only suitable for the short-term. in the case of a long-term lockdown situation, it is necessary to include the costs of health, education, clothing and housing. recently, the government of bangladesh announced the provision of approximately us$ /month to two million to households [ ] . in addition, kg cereals and food will be provided to million households in bangladesh [ ] . while the amount of support is in line with our findings, in the case of a lengthy lockdown period, it is necessary to consider other household costs, such as clothing, medicine and education in the support package. moreover, as the labor market of bangladesh is comprised of . million active workers, the coverage of the safety net should be expanded in the case of a lengthier lockdown. as food and nutrition insecurity can have long-run impacts on human capital formation, the government must expand the emergency safety network program to include almost all marginal households or consider loosening restrictions in the agriculture sector. without effective support programs, an implementation of a strict lockdown for a long time may be very difficult, if the poor households are forced to come out to search for works, money and food. in such case, to support smallholder agriculture, wage workers and agricultural value chains, the government should consider issuing movement passes to persons and carriers of agricultural input and output in the case of a very strict lockdown scenario. finally, it is also imperative to take necessary steps against government failure in the form of leakage in distributing compensation packages. otherwise, the benefits of government effort may not reach to the vulnerable groups. supporting information s table. district dummies included in explaining daily wage earnings (reported in table ) of the daily wage workers in the farm and nonfarm sectors (bagerhat district is the base = ). (docx) s table. district dummies included in explaining the daily household level total food expenditure (reported in table ). base district: bagerhat = . 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needs analysis. dhaka; the daily prothom alo. the holiday has increased to covid- in bangladesh: districts under partial or complete lockdown. covid- in bangladesh world development indicators conversion of agricultural land to non-agricultural uses in bangladesh: extent and determinants data: production. in: online database on crop production,yield and harvested area online database on food balance sheets strengthening food systems and the environment through innovation and investment, the economist and intelligence unit the challenge of hunger global hunger index: facts, determinants, and trends. food policy bangladesh garment industry rebounds un comtrade database the world economy at risk. oecd interim econ assess united nations dev program china impact of covid- on bangladesh rmg industry dhaka: ministry of health and family welfare, government of bangladesh the political economy of the stimulus package for covid- induced economic crisis in bangladesh opinion on fighting on covid- induced increasing poverty. the daily ittefaq bbs. preliminary report on households income and expenditure survey an inquiry into the rapid growth of the garment industry in bangladesh estimating models with sample selection bias: a survey job losses may have narrowed the daily prothom alo. governmet will provide monthly bdt to hosueholds of bangladesh. stuff report households will get kg food support per month. the daily prothom alo key: cord- -fb vv my authors: islam, m. z.; riaz, b. k.; islam, a. n. m. s.; khanam, f.; akhter, j.; choudhury, r.; farhana, n.; jahan, n. a.; uddin, m. j.; efa, s. s. title: risk factors associated with morbidity and mortality outcomes of covid- patients on the th day of the disease course: a retrospective cohort study in bangladesh date: - - journal: epidemiology and infection doi: . /s sha: doc_id: cord_uid: fb vv my diverse risk factors intercede the outcomes of coronavirus disease (covid- ). we conducted this retrospective cohort study with a cohort of covid- patients diagnosed in may to identify the risk factors associated with morbidity and mortality outcomes. data were collected by telephone-interview and reviewing records using a questionnaire and checklist. the study identified morbidity and mortality risk factors on the th day of the disease course. the majority of the patients were male ( . %) and belonged to the age group – years ( . %). urban patients were higher in proportion than rural ( . % vs. . %). major comorbidities included . % diabetes mellitus (dm), . % hypertension (htn), . % chronic obstructive pulmonary disease (copd), and . % coronary heart disease (chd). the morbidity rate (not-cured) was . %, and the mortality rate (non-survivor) was . %. morbidity risk factors included elderly (aor = . , % ci = . – . ), having comorbidity (aor = . , % ci = . – . ), and smokeless tobacco use (aor = . , % ci = . – . ). the morbidity risk was higher with copd (rr = . ), chronic kidney disease (ckd) (rr = . ) and chronic liver disease (cld) (rr = . ). mortality risk factors included elderly (aor = . , % ci = . – . ), having comorbidity (aor = . , % ci = . – . ) and slt use (aor = . , % ci = . – . ). the mortality risk was higher with copd (rr = . ), dm (rr = . ), chd (rr = . ), htn (rr = . ), ckd (rr = . ), cld (rr = . ) and malignant diseases (rr = . ). we must espouse programme interventions considering the morbidity and mortality risk factors to condense the aggressive outcomes of covid- . a newly emergent coronavirus (severe acute respiratory syndrome coronavirus − sars-cov- ) causes coronavirus disease (covid- ) was first documented in wuhan city, hubei province, china in december as an outbreak of pneumonia of unknown cause [ ] . based on phylogeny, taxonomy and established practice, on february , the world health organization (who) named the disease as covid- [ ] . who declared covid- as a global emergency on january [ ] and as pandemic on march [ ] . globally countries (on august ) are confronting the grave consequences of the ongoing covid- pandemic [ ] . the situation is sprouting rapidly with increasing case counts and deaths worldwide [ ] . in this course, bangladesh is also confronting the tolls of morbidity and mortality posed by this highly infectious disease with community transmission across the country. in our setting, a patient with acute respiratory illness (ari) and residence of bangladesh or travel to a country reporting community transmission of covid- disease during the days before symptom onset, or a patient/health care worker with any ari and having been in contact with a confirmed or probable covid- case in the last days before symptom onset, or a patient with ari and in the absence of an alternative diagnosis that fully explains the clinical presentation' is considered as a suspect case. moreover, a suspect case for whom testing for the covid- virus is inconclusive (inconclusive being the result of the test reported by the laboratory), or a suspected case for whom testing could not be performed for any reason is considered as probable case and a person with laboratory confirmation of covid- infection, irrespective of clinical sign and symptom is known as a confirmed case. according to the guideline, all suspected cases have undergone rt-pcr test for covid- infection [ ] . the clinical spectrum of covid- appears to be in a wide range, encompassing asymptomatic infection, mild ( %) or moderate ( %) disease, severe disease ( %) that requires oxygen support and only % critical disease [ ] . the incubation period of covid- infection is around . days and the period from the onset of symptoms to death ranges from to days with a median of days [ ] . a study conducted in wuhan of china found that increased age and various comorbidities like hypertension (htn) and diabetes mellitus (dm) were associated with the severity of covid- . but the study did not identify the tobacco use and chronic obstructive pulmonary disease (copd) as the risk factors for covid- [ ] . another study in china found that nearly half of the patients had comorbidity where htn was the most common followed by dm and coronary heart disease (chd). the study also established the association between increased age and death of the covid- patients [ ] . another study showed that severe patients were older and had comorbidities including htn ( . %), dm ( . %) and cardiovascular diseases. the median age was years in severe cases and . years in non-severe cases [ ] . the presence of any comorbidity was more common among the severe patients than those having a mild or moderate disease ( . % vs. . %) with a similar exposure history between the two groups of disease severity [ ] . widespread shreds of evidence have emphasised the harmful impact of tobacco use possibly related to adverse outcomes of covid- . one of the leading studies conducted in the wuhan city of china found higher percentages of current and former tobacco users among the patients that needed icu support, mechanical ventilation or who had died, and a higher prevalence of smoking among the severe cases [ ] . a study conducted on outcomes of the covid- patients found that non-survivors were more often older and men, and they had a higher prevalence of dm, hyperlipidemia and chds. the history of current tobacco uses and having copd was more among the non-survivors [ ] . however, the pandemic is still under progression, diverse risk factors influence the outcomes of covid- , but relevant data and studies are very scarce in bangladesh. therefore, it is irrefutably obligatory to determine the risk factors to avert the aggressive consequences of covid- patients. based on these realities, in this particular study, we aimed to identify the risk factors associated with morbidity and mortality outcomes of covid- patients. this observational retrospective cohort study was conducted at the national institute of preventive and social medicine (nipsom), dhaka, bangladesh during the period from march to june . the study enrolled a cohort of laboratory-confirmed covid- (sars-cov- ) patients diagnosed at the central laboratory of nipsom, dhaka. the nipsom is the apex public health institute holding the central laboratory designated for covid- diagnosis, approved by the ministry of health and family welfare of the government of bangladesh. the study included all the hospitalised, non-hospitalised and outdoor patients irrespective of sign/symptom, who were referred to the central laboratory of nipsom and diagnosed as covid- by real-time reverse transcriptase-polymerase chain reaction (rt-pcr) assay. the participant who had no contact telephone/cell phone number; who did not respond to a phone call on three separate occasions within days of diagnosis; who were unwilling; and who had incomplete interview were excluded from the study. the cohort comprised all the laboratory-confirmed covid- patients who were diagnosed at the central laboratory of nipsom during the period from to may by rt-pcr assay of nasopharyngeal (np)/oropharyngeal (op)/nasal swab. the exposures were the risk factors associated with the morbidity and mortality outcomes of covid- patients. it included baseline characteristics, comorbidities like chronic obstructive pulmonary disease, dm, chds, htn, clds, ckd, malignant disease, pregnancy and tobacco consumption. the study identified both morbidity (cured/not-cured) and mortality (survivor/non-survivor) outcomes of the covid- and compared between exposed and non-exposed groups on the th day of the disease course. all the patients underwent the rt-pcr test to evaluate the morbidity status. a patient showing a negative result of the rt-pcr test within days of the disease course was considered as cured. we obtained the rt-pcr test results of the patients from the records preserved by the central laboratory of nipsom. initially, we selected all the laboratory-confirmed covid- patients diagnosed in may as the study cohort. finally, covid- patients were enrolled as the study samples considering the selection criteria and single-centred cluster sampling technique. all the covid- patients formed the sampling frame, and each patient was a sampling unit. data were collected by telephone interview and medical records review using a semi-structured questionnaire and checklist. each telephone interview session was recorded by a digital recorder to ensure the validity of data. the data collection instruments were pretested on covid- patients diagnosed in april , and accordingly, necessary corrections were performed for finalisation. participation of covid- patients was voluntary and informed oral consent was obtained from each participant before data collection. in the case of non-survivor, data were collected from the eligible family member of the respective non-survivor. measures were taken to ensure data quality; inconsistency and irrelevance of data were checked and corrected. data were analysed using spss statistics (version . , ibm statistical product and service solutions, armonk, ny, usa). the normality of the variables was tested with the shapiro−wilk test/kolmogorov−smirnov tests of normality. continuous data were written in the form of mean and standard deviation. categorical data were reported as counts and percentages. descriptive statistics estimated mean, standard deviation and frequency while inferential statistics included chi-square test, logistic regression, relative risk (rr) and attributable risk (ar). a p-value < . was considered significant. all the statistical tests were twosided and were performed at a significance level of α = . . exposures were measured by assessing exposure on the risk factors including baseline characteristics, comorbidity, tobacco consumption, of the covid- patients retrospectively. outcomes were measured by assessing the morbidity outcome in terms of cured or not-cured and the mortality outcome in terms of survivor or non-survivor. the study was conducted by maintaining all kinds of ethical issues in different stages of the study. ethical clearance was obtained from the institutional ethics committee (iec) of nipsom, dhaka, bangladesh (ref. no. nipsom/irb/iec/ / ). informed oral consent was obtained from the participants by informing the purpose and procedure, expected duration, nature and anticipated physical and psychological risks and benefits of participating. the confidentiality of data and privacy of the participants was strictly maintained. the participants were offered the right to withdraw their consent at any stage of the study. data were stored in computers at the central office, nipsom under the direct supervision of the principal investigator. data were used anonymously for this study only. out of covid- patients, ( . %) were enrolled followed by . % had a wrong contact number, . % did not attend phone calls, . % were unwilling to participate and . % had an incomplete interview (fig. ) . among covid- patients, the majority ( . %) were males ( . %). the majority ( . %) of the patients were in the age group - years, . % belonged to the age group - years and their median (iqr) age was . ( - ) years. of all, . % were married, . % completed their graduation, the majority ( . %) were service holders and . % were health workers. more than two-thirds ( . %) was from urban settings, and around three-fourth ( . %) was from a nuclear family. the majority ( . %) had monthly family income between tk. and , and their average monthly family income was tk. (± . ) ( table ) . more than one third ( . %) patients had at least one comorbidity. major comorbidities included dm ( . %), htn ( . %), copd ( . %), chd ( . %), cld ( . %), ckd ( . %) and malignant diseases ( . %) (fig. ) . morbidity outcomes included . % cured and . % not-cured. on the contrary, mortality outcomes included . % survivors and . % non-survivors (fig. ). regarding risk factors associated with morbidity, the elderly ( . % vs. . %) were significantly (ρ < . ) higher among the not-cured than the cured patients. having comorbidity ( . % vs. . %), current slt use ( . % vs. . %), ckd ( . % vs. . %) and cld ( . % vs. . %) were also significantly (ρ < . ) higher among the not-cured than the cured patients. copd ( . % vs. . %), ckd ( . % vs. . %) and cld ( . % vs. . %) were also significantly higher among the not-cured than the cured patients (ρ < . ). regarding risk factors associated with mortality, the elderly ( . % vs. . %), having comorbidity ( . % vs. . %) and current slt use ( . % vs. . %) were significantly higher among the non-survivors than the survivors (ρ < . table ) . the risk of 'not-cured' outcome was higher among the elderly table ) . we conducted this single centred retrospective cohort study to identify the risk factors associated with morbidity and mortality outcomes of covid- patients on the th day of the disease course. we followed the case definitions of covid- mentioned in the national guideline of bangladesh and included the covid- cases confirmed by the rt-pcr test [ ] . major risk factors identified include elderly, comorbidity and tobacco consumption. the study results propose decisive preventive, promotive and curative interventions to combat the worst outcomes of covid- . the current study is the pioneering initiative for the first time carried out in bangladesh on the risk factors associated with outcomes of covid- patients. this observational retrospective cohort design was scientifically apposite and feasible for identifying multiple risk factors at a single attempt. we included covid- patients who were confirmed by the nipsom laboratory in may , and in this same study period, the total cases were in bangladesh [ ] . the sample size was large enough to draw a valid inference on the risk factors linked with the outcomes of covid- patients considering both morbidity and mortality consequences. the morbidity and mortality rates of the disease identified by the study are notable and preserve crucial policy importance. the study results might not reflect the scenario of the whole country as it was a single centred cohort study and included the patients from some specific urban and rural areas. we targeted all the patients confirmed by the central laboratory of nipsom in may , irrespective of their sign and severity of symptoms. therefore, discussion on the various degrees of symptoms of sars-cov- infection could not be extensive. despite a few limitations of recall bias that emerged through a telephone-interview and wrong telephone number, the study findings conserve irrefutable policy implications for prevention and control of the morbidity and mortality outcomes of covid- . although males ( . %) have a reasonably higher risk of being affected by covid- than their counterpart females ( . %), but the study did not find any significant difference in outcomes by gender of the patients. other studies [ , , [ ] [ ] [ ] also revealed similar findings where males were being affected more than females. the majority ( . %) of the patients were in the age group - years, and . % belonged to the age group of - years. according to the demographic profile of bangladesh, the majority ( . %) of the population belong to the age group of - years, and . % belong to the age group > years [ ] . though the majority of patients belonged to the middle age group, the adverse outcomes were more prevalent in elderly patients (⩾ years). the prevalence ( . %) of covid- was found higher in the urban than in rural areas. the unplanned urbanisation, higher population density and industrialisation in the urban communities increase disease transmission. moreover, more aware urban people undergo laboratory tests for covid- more than the rural people. by occupation, lion shareholders were service holders ( . %) and health workforce ( . %). the service holders like bankers, security forces, police and community forces provide various emergency services that are high-risk groups for covid- infection. the health care providers like doctors, nurses and support staff are more vulnerable to covid- as they have to provide healthcare in direct contact with the patients. besides, less quality and inadequate quantity of personal protective equipment (ppe) also aggravate their vulnerability to the disease. of all, . % patients had diverse comorbidities including dm ( . %), htn ( . %), copd ( . %) and chd ( . %). another study conducted in wuhan, china [ ] also identified dm, htn, copd and chd as major comorbidities with covid- patients. in this study, the percentage of not-cured 'zarda', 'khoinee', 'gul', 'sadapata', 'nossi' and so forth, which are local smokeless tobacco products [ ] . smokeless tobacco induces pathophysiological changes in the upper respiratory tract, which makes the virus more progressive and aggressive to aggravate acute respiratory distress syndrome and morbidity. further intensive research and analysis could be conducted to establish the scientific arguments on this association in the indian sub-continent including bangladesh. mortality outcome was significantly associated with the elderly (aor = . , rr = . ) and having comorbidity (aor = . , rr = . ). another retrospective study conducted in wuhan, china [ ] also revealed that the higher median age ( . years) of the non-survivors than the survivors ( . years). though the majority of the patients of our study were in the middle age group, the mortality rate was higher among the elderly. it is the fact that compromised body immunity of the elderly patients having comorbidity could not win the fight with covid- rather confront the worst outcome. the study also found comorbidity more in the non-survivors ( %) than the survivors ( %). mortality outcome was also significantly associated with current slt use (rr = . countries [ , , ] . it is evident that the comorbidity deteriorates the defensive mechanism of the patients and worsen the mortality outcome of covid- patients. the identified risk factors associated with the outcomes of covid- patients conserve crucial policy implications for the prevention and control of the morbidity and mortality burden of the disease. the study results could contribute to strengthen and reorganise the health care delivery system of the country for providing need-oriented and prioritised services to covid- patients emphasising the disease course and risk factors associated with morbidity and mortality. the study findings could also contribute to devising effective strategies for the provision of comprehensive health care to covid- patients with comorbidity. policymakers, health care managers and relevant stakeholders may use the study findings to revise the national treatment guidelines considering the risk factors, adverse outcomes and disease course of covid- . clinical management of covid- : interim guidance coronavirus disease (covid- ): a perspective from china risk factors of the severity of covid- : a metaanalysis the covid- pandemic: important considerations for contact lens practitioners reported cases and deaths by country, territory or conveyance national guidelines on clinical management of coronavirus disease the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak clinical characteristics of patients infected with sars-cov- in wuhan, china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study clinical characteristics of coronavirus disease in china covid- and smoking: a systematic review of the evidence (editorial) world health organization (who) cardiovascular disease, drug therapy, and mortality in covid- clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region bangladesh demographic profile (bdp) . the world fact book real estimates of mortality following covid- infection risk factors for sars-cov- among patients in the oxford royal college of general practitioners research and surveillance centre primary care network: a cross-sectional study ministry of health and family welfare, the government of bangladesh. national steps survey for non-communicable diseases risk factors in bangladesh acknowledgements. this research study is attributed to the department of community medicine, national institute of preventive and social medicine (nipsom), mohakhali, dhaka , bangladesh.the authors are indebted to all the staff of the central laboratory of nipsom for their technical assistance in data generation. we are also obliged to all the covid- patients and their families for their participation in the study.financial support. this research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.conflicts of interest. the authors have none to declare.data availability statement. the data for the study is available by contacting the corresponding author upon request. key: cord- -gjo e authors: hoque, e.; islam, m. s.; amin, m. r.; das, s. k.; mitra, d. k. title: adjusted dynamics of covid- pandemic due to herd immunity in bangladesh date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: gjo e amid growing debate between scientists and policymakers on the trade-off between public safety and reviving economy during the covid- pandemic, the government of bangladesh decided to relax the countrywide lockdown restrictions from the beginning of june . instead, the ministry of public affairs officials have declared some parts of the capital city and a few other districts as red zones or high-risk areas based on the number of people infected in the late june . nonetheless, the covid- infection rate had been increasing in almost every other part of the country. ironically, rather than ensuring rapid tests and isolation of covid- patients, from the beginning of july , the directorate general of health services restrained the maximum number of tests per laboratory. thus, the health experts have raised the question of whether the government is heading toward achieving herd immunity instead of containing the covid- pandemic. in this article, the dynamics of the pandemic due to sars-cov- in bangladesh are analyzed with the sird model. we demonstrate that the herd immunity threshold can be reduced to % than that of % by considering age group cluster analysis resulting in a total of . million susceptible populations. with the data of covid- cases till july , , the time-varying reproduction numbers are used to explain the nature of the pandemic. based on the estimations of active, severe, and critical cases, we discuss a set of policy recommendations to improve the current pandemic control methods in bangladesh. since the hospitals are usually centralized in dhaka, the capital of bangladesh, the outcry for hospital beds for the covid- patients could be visible via countless news stories. positive test rate (in %) fig. bangladesh has the lowest number of tests per million people in the world. still, a significant reduction in the rt-pcr based lab tests has been observed from july , , in bangladesh (blue triangle). this results in an increase in the test positivity rate approaching to % (red dot) within the following two weeks. who recommends that the test positivity rate should be less than % [ ] . the total covid- positive patients in bangladesh has been reported to be a total of , , with a total case fatality of , persons throughout the country on july , . regardless of lifting the lockdown, the dghs restricted the number of lab tests which is quite contrary to the test and isolation policy. the result is clearly visible in figure . as the number of lab tests has been decreasing, the number of daily positive cases started dropping as well. on the other hand, we observe that the test positivity rate is on the rise. in addition to this, there has been news in the daily newspapers that people are waiting for covid- tests in a long line and many of them are returning without the tests due to the limited number of test kits to handle a large number patients [ ] . moreover, having a limited number of hospital beds together with unavailability of oxygen supply, many patients stopped seeking medical help. as a result, while in the middle of june, national dailies reported that patients are dying without any medical help on the road while moving from one hospital to another for an empty bed [ ] , recently a lot of covid- patients stopped going to the hospital to seek medical help resulting in empty beds [ ] . therefore, based on the current situation, one can ask if bangladesh is moving toward herd immunity and if so then what could be its consequence on the public health. it is indispensable to have a careful balance between various key epidemiological factors in order to estimate the spread of covid- in bangladesh. this is the reason why mathematical estimation can play a very important role to understand the future we may expect based on the latest policies implemented in the country. in the following sections of this article, we present the dynamics of the covid- pandemic in bangladesh with the sird model and estimate the . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint number of susceptible populations as well as case fatalities rate to achieve the herd immunity in bangladesh. the time-varying reproduction number rt, has been compared with the average mobility [ ] , the growth of confirmed cases and the doubling time to analyze the effect of the implemented lockdown (l to l ) in bangladesh. the lockdown situations are described as l , march when the lockdown is implemented for all over the country [ ] ; l , april when ready made garment factories reopened [ ] ; l , may when shopping malls were reopened before eid-ul-fitre [ ] ; and l , may when everything but educational institutes were reopened [ ] . the confirmed cases and the number of deaths on those days are also shown (labeled as c and d). bangladesh has implemented various types of control measures to contain the pandemic, such as total/partial lockdown, declaring an area as a quarantined/red zone, suspending the long and short distance transportation in the different parts of the country, including wearing masks and maintaining social distance in the public transportation. each of these control measures were imposed on various dates and were lifted off for various reasons. to describe the effect of the implemented pandemic control methods in bangladesh, the time-varying reproduction number, r t is used since it provides the real-time estimation of the pandemic dynamics. in the case of controlling the pandemic of a region, the r t provides valuable information about the dynamics and instantaneous effect of the control mechanism [ ] . we analyze the dynamics of sars-cov- cases in bangladesh using r t with respect to four of the major events, i.e., starting of lockdown, mass movement, ease of lockdown (limited shopping mall, public transportation etc.), and lifting of the lockdown for restarting local economy. the pandemic control method and the changes in sars-cov- cases are shown in figure . bangladesh implemented very early lockdown on march , to control the sars-cov- pandemic [ ] , and that was lifted on may , with , confirmed cases and deaths [ ] . in this report, we choose confirmed is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint cases as the baseline of r t computation that had climbed to . and then fell below . with high confidence on april , . due to the garment factories reopening on april , , a mass population moved to the capital of bangladesh (l ) [ ] . despite of this movement, the value of r t remained around . . during l , all the shopping mall, business office, public transportation were reopened and surprisingly there was not any noticeable variation in r t [ ] . we further observe that r t had dropped below . on may and then it jumped to . on may (l ), the day when bangladesh reopened its economics by unlocking everything except the educational institutes [ ] . since the lifting of the lockdown (l ), we observe that public mobility is on the rise, represented as a drop in the negative google mobility score in the figure . that directly contradicts the drop in the value r t , drop in the daily growth rate and increase in the doubling time ( figure ). in addition to these countering observations, in the figure , we present that the test positivity rate is on the rise. thus, it clearly present that the most successful intervention of test and isolation for controlling the covid- pandemic has not been carefully maintained by the dghs in bangladesh. this is why, a discussion is surfacing among the public health professionals as though bangladesh government is expecting to achieve herd immunity [ ] . in this article, the dynamic behavior of the class of infected people is described using three different reproduction numbers, such as the basic (r ), effective (r e ), and time-varying (r t ) reproduction number. to estimate the number of people to be infected in case of the herd immunity, we consider the total number of current population to be . million by [ ] . according to the sir model, r is used to describe the transmissibility of a disease in a region if the population is randomly mixed. it will have only one value with a marginal error for an epidemic. but with the implementation of the various epidemic control methods in bangladesh, the "randomly mixed" condition for virus transmission within the population has been violated. currently, a few different r estimations have been reported ranging between . to . [ , , ] for the country. but due to the intervention mechanism, the original method to compute susceptible population from the r cannot be followed. so we rather estimate the susceptible population for the herd immunity based on the current transimissiblity of covid- within the individual age group. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint bangladesh has already implemented various types of control measures to contain the pandemic. each of these control measures was imposed on various dates and was lifted off for various reasons. these random events made it very challenging to estimate the susceptible population for herd immunity in bangladesh. hence, we consider the initial susceptible population following the age group distribution of the population depending on the confirmed positive cases to make our final assessment for herd immunity. in the table , we present the age distribution of the population in bangladesh (collected from socioeconomic data and application center, or sedac) along with the confirmed positive cases and deaths for each of those age groups (collected from institute of epidemiology, disease control and research, or iedcr). in bangladesh, the gender ratio for the confirmed cases has been reported as m ale : f emale = : by the iedcr [ ] . using these distributions of population and the confirmed sars-cov- cases, the susceptible population for herd immunity is estimated. as . % of the total confirmed positive cases has been reported within the age group of - , we estimate the total susceptible population with respect to this age group. we consider the population of bangladesh is p , distributed in the age group as, where p i is the population at i-th age group which is redistributed in male (m ) and female (f ). let us assume that q% of the male at age group j will be infected i.e., the susceptible population at j, s j = m j × q%. in our case, we consider the age group j to be − . from the age distribution of the sars-cov- , we can find the distributed number of all confirmed cases c as, where c i is the confirmed cases at i-th age group, where the ratio of male (cm ) and female (cf ) is m : f . thus, since, the age group j ( - in table ) is the mostly affected group in bangladesh due to their activities and movement for earning livelihood, we consider that this scenario of higher transmissibility of covid- in the same age group will persist. we assume that rest of the population that will be affected in herd immunity can be estimated in proportion to the people affected in the age group j. so to find the susceptible population with respect to the age group j, we compute the proportion, x = s j /cm j . this leads us to approximate the number of susceptible population as, . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint the table shows the approximated susceptible population of bangladesh for various rate of infection with respect to the age group - . therefore, if % of the total working population in bangladesh get affected by covid- to achieve herd immunity, we estimate that a total number of positive cases would be approximately . million. similarly, if % of the population at the age group of - get affected, we would observe a total million positive cases in bangladesh. if we consider that % of the population at the age group of - , only . % of the population ( . of . million) of bangladesh required to be infected by sars-cov- to be in a state of herd immunity (figure ) . the above computation indicates that the herd immunity threshold can be reduced from % to % by categorizing the population into age groups. there is another major reason why we may observe such a low threshold in case of herd immunity. due to the closure of all educational institutions from the very early stage of this pandemic in bangladesh, the population in the age group - will not be the primary agent for spreading the virus. around % of the total population belong to this age group, hence reducing the herd immunity threshold. to estimate the dynamics of the covid- cases, such as confirmed, recoverd, and death cases, in case of herd immunity, we have used the unscented kalman filter the age group based population distribution, along with gender, in bangladesh has been used to estimate the initial susceptible population for sird model. to achieve the herd immunity of the people of bangladesh, . m of infected population has been considered at the age group of - years. this has been extrapolated in other age group with a distribution of confirmed case of bangladesh [ ] . the estimated distribution of initial susceptible population, along with gender, is also shown. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . (ukf). we are explaining the reason why ukf is very important to derive the dynamics. the differential equations in the sird model computes the values for an instantaneous event. whereas, the covid- cases that we observe each day is not instantaneous rather a discrete event on a wider time range. the events of a person actually being affected, detected, and reported of covid- happen in different times, and thus loose the required instantaneous effect in the differential equation based sird model. hence, we use the prediction based ukf model to derive the dynamics. the jacobian matrix for designing the ukf algorithm is presented in the supplementary section (equation ). the uncertainty associated with the inference is estimated using the merwe sigma points that deal with the hidden states of the considered system in an optimal and consistent way for a set of noisy and/or incomplete observation. the dynamics of the estimated active cases for both the scenarios considering . million and . million initial susceptible population is shown in figure . it had been reported that the country has the hospital facility of , sars-cov- patients [ ] . in a guideline, provided by the health ministry of bangladesh [ ] , around % of the active cases may need hospitalization [ ] . thus it is estimated that the hospital facilities should have been filled with the sars-cov- patients by the end of june . but we observe contrary scenario as there remain vacancies in hospital beds [ ] . we project that bangladesh might see a death cases of . to . million people (figure ) of whom . % ( . to . million) will be at the age above years. by the end of october , the number of deaths is estimated to be , if there is no implementation of effective pandemic control methods. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . the cfr becomes much lower (about half) if it is computed against the active cases (green dash-dotted). the cross represents the cfr corresponds to the data available. we also present the cfr for different age groups considering only the confirmed cases. the cfr at the age below years, is found very low (< . ) whereas it will pass over . for the age above years. in the case of age group - years, the cfr is estimated to be . . in epidemiology, the case fatality rate (cfr) is used to measure the severity of disease during an outbreak. in general, severity of disease had been defined as the percentage of affected people died in an outbreak. however, this computation has several limitations for realizing the current situation in covid- pandemic. the current definition tends to underestimate the severity as it consider the rate of deceased people among the total affected people, which consider recovered, death or active cases alike. also, this estimation does not consider the time lag between the identification of a positive case and it's outcome (recovery and death). this issue has been discussed in detail in the literature [ , , ] . so, we argue that the computation should consider the ratio between deceased, and cases with outcome instead, defined as cfr adj [ ] . we predict that at the end of pandemic, the cfr adj in bangladesh will be . (black line in figure ). however, we are also interested in the conventional method of calculating the cfr where the ratio is considered between the deaths and confirmed cases [ , ] as we lack sufficient data to compute the cfr adj for different age group. we show that the cfr has been underestimated (green line in figure ) at the early stage of the pandemic in the traditional method which is well known in the literature [ , , ] . but as both the cfr and cfr adj converges at the end of the pandemic(black and green line in figure ), we choose to use the conventional method to estimate the cfr for different age groups using the available data of bangladesh ( table ) . the predicted cfr has a significant variation between the age below and above + ( figure ). this difference illustrates the people of age + as the most is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint vulnerable group in this pandemic. we further estimate the cfr for the age group of +, which is above . . for the age between - , the cfr is estimated to be . while for the other age groups, the cfr is found to be less than . . based on our estimated population for the herd immunity, we compute the basic reproduction number to be r = . ± . . therefore, to break the covid- transmission chain and stop the disease from spreading, bangladesh requires around % of its population to be infected to attain the herd immunity according to the existing method [ ] . but our adjustment shows that if approximately % of the working age group - get affected by covid- in case of herd immunity then we can expect a total % people will be affected in the whole country (presented in table ). as we study the policy to contain the covid- crisis in other countries, we find that taiwan was able to manage the outbreak without imposing any lockdown [ ] , whereas sweden refused to implement the lockdown claiming it as unnecessary for the nation. nevertheless, several studies demonstrate the major role of lockdown to attenuate the contagion, though the negative impact of lockdown on national economies was not mentioned in those reports [ , ] . therefore, it is still a debate regarding health versus the economy for many countries, especially for a lower-middle-income country like bangladesh. in the current state of affairs, herd immunity seems to be inevitable for covid- pandemic in bangladesh. however it might come at the expense of deaths among the vulnerable population. in this work, we analyzed this crucial trade-off in a systematic approach and synthesized a set of observations. . rapid antibody/antigen testing policy: in order to attenuate the community transmission in bangladesh, large scale testing strategy should be taken into account by government policy makers. since, bangladesh has limited capacity for rt-pcr based covid- testing, we propose low-cost rapid antibody/antigen test as soon as possible. it takes about - minutes for antibody test and around minutes for antigen test [ ] . the test results can also be made available to the corresponding health professional instantly. whereas, rt-pcr based test requires - hours to be completed in the lab. in reality, it takes a few days to be made available to the corresponding health professional due to the limited lab capacity and increased number of patients. so, we suggest that each person with covid- symptoms should go through an antibody/antigen test, and in case of negative results, the person should participate in an rt-pcr based test for confirmation. in addition, if we can administer the rapid antibody/antigen test in the highly affected areas for everyone to get an estimation of what percentage of the population already got affected by covid- . this estimation will greatly help to decide on systematic implementation of pandemic control methods. . improving health services and awareness: the total number of hospital beds dedicated for the treatment of covid- patients is about ∼ , [ ] . according to the current estimation in the figure , hospitals in bangladesh should have been filled up by the end of june . but in reality most of the . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint hospitals remain vacant [ ] . one of the major reasons of this situation is the lack of proper health treatment for covid- patients. there were numerous news of mistreatment of hospital patients followed by deaths, because of which people are now treating themselves at home. another issue is the social stigma currently inflicted by the covid- crisis. as covid- patients are considered to be cursed, their entire families are being socially rejected throughout the country. as a result, covid- patients like to keep themselves silent rather than seeking treatment. hence, we need to communicate the cause of covid- and health literacy to improve the situation. in this way, the health system of bangladesh can regain its trust to contain the crisis together with the people. . collecting pertinent covid- cases data: as bangladesh is going through health crisis due to covid- for the first time, we need to understand what policies can be useful for a recovery from this deadly pandemic. countries that already became successful to contain the pandemic showed that data driven approach can be very helpful in this regard. thus, we want to focus on collecting the covid- patient data for every single patient from all over the country. we suggest that each covid- test and patient data should be collected, reported on time and analyzed centrally. this will help us to predict the onset of pandemic in any area within the country as well as to design the appropriate health intervention for different location based on the need. proper data collection will also help us to make a reliable forecast about the progression of the pandemic in the country and thus, in designing proper control methods. . policy regarding the covid- vaccine allocation in bangladesh: the covid- pandemic has given a harsh note about the dire consequences of serious diseases without vaccines. it is quite obvious that vaccines played a significant role to reduce many deaths and disability caused by preventable disease in many countries. therefore, bio-pharmaceutical industries are trying around the clock to develop an effective, safe vaccines and the whole world is pinning its hope on covid- vaccine to stop the current outbreak. unfortunately, this is not the end of puzzle as there will be new challenges once the vaccine is available in the country. for instance, there needs to be a fair and equitable process to determine the vaccine allocation in a densely populated country like bangladesh. moreover, the policy makers need to decide who would get the privilege to be vaccinated first in a community. one may think whether the elders (age group +) should be higher up in the priority list or whether the kids should get the vaccine before the rest of the population. since we show that age group - is the most exposed group for covid- due to their social responsibilities in bangladesh, the policy makers might consider them on the top of the list to save the socioeconomic structure of the country. while designing the study and performing the experiment, we faced several challenges, such as, the limitation of enough covid- tests restricted our understanding of actual scenario in the country, not having the information of covid- test reports in a timely manner from every rt-pcr lab facilities for which making a reliable forecast became very difficult, and unavailability of the dataset in a standard format from the dghs and iedcr made our data analysis task very difficult. to explain the difficulties, we include a few examples in this manuscript. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . for instance, if a person from a family becomes covid- positive, there is a high probability that the whole family might turn out to be positive. but, due to the limited number of test capacity, the infected number reported only for a single member from that family. moreover, it has not been possible to track each deceased person who died with covid- symptoms. again, as the covid- death reports does not mention the comorbidities, it is impossible to understand the actual cause of each fatality. in addition to these, the government considered a person as recovered if that person resulted in two consecutive negative covid- tests. but due to negligence, a considerable amount of the covid- patients did not take the second tests. this resulted inaccurate number of recovered cases, which the government later adjusted (figure and ) . therefore, it has been very difficult to adjust the sird model parameters to represent the pandemic in bangladesh accurately. however, we are optimistic that our data-driven mathematical modeling can be used for the policy recommendations and controlling the disease transmission for the current and future outbreaks in bangladesh. evaluation of any pandemic trend is of great importance for a nation and for its policy makers as it can guide the community towards the use of basic resources in an efficient way to mitigate the outbreak. in this manuscript, we examine the covid- progression in bangladesh by using mathematical modeling and investigate whether the current pandemic trend is destined for the herd immunity. we estimate that . to million which is about % to % of the total population need to be infected by covid- to achieve herd immunity in bangladesh. in a nutshell, our mathematical approach project that herd immunity can be accomplished with less number of infected people than previously estimated [ ] . we further analyzed the efficacy of past lockdown in bangladesh and found out a similar trend in covid- growth rate despite lifting the countrywide lockdown in the begining of june, . the instantaneous observation of the pandemic in bangladesh, with time-varying reproduction number (r t ), is found to be independent of the implemented various control methods. thus, continued decrease of r t does not articulate the actual scenario of the pandemic in bangladesh. the contraction is clearly visible in the figure , where we see that test positivity rate is increasing over time as opposed to the decrease of r t as presented in figure . moreover, we also present that the mobility of people in bangladesh is increasing over time as opposed to the decreasing r t and increasing doubling time (figure ). so it is clearly visible that the testing capacity in bangladesh needs to be ramped up. also, covid- test reporting system needs to be updated in a daily basis with higher precision. we conclude that, it is debatable as though the country-wide lockdown and current zoning methods have been able to control the surge of coronavirus infection in bangladesh. it has been very difficult to interpret the current situation based on the covid- test data as we find that total test count has fallen down despite the fact that test positivity rate is increasing. according to our sird estimation, we notice that the current number of confirmed case should be increasing as both the mobility and test positivity rate are increasing. thus, bangladesh is digressing from the path of containing the pandemic and if such a situation . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint continues then herd immunity would be inevitable. in conclusion, using the data driven approach and sird modeling, we found that approximately . million people ( % of the total population) need to be infected in order to achieve herd immunity in bangladesh. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint persistent vegetative state after brain damage: a syndrome in search of a name outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle statement-on-the-second-meeting-of-the-international-health-regulations-( )-emergency-committee-regarding-the-outbreak world health organization et al. novel coronavirus ( -ncov): situation report transmission of -ncov infection from an asymptomatic contact in germany a contribution to the mathematical theory of epidemics contributions to the mathematical theory of epidemics. ii.-the problem of endemicity challenges, opportunities and theoretical epidemiology epidemic modelling: an introduction estimating and simulating a sird model of covid- for many countries, states, and cities data-based analysis, modelling and forecasting of the covid- outbreak a conceptual model for the outbreak of coronavirus disease (covid- ) in wuhan, china with individual reaction and governmental action can the covid- epidemic be managed on the basis of daily data modelling the covid- epidemic and implementation of population-wide interventions in italy covid- update who. coronavirus disease (covid- ): situation report - covid- testing shortages, long wait times for results trigger concerns bangladesh coronavirus patients shun government hospitals google covid- community mobility reports bangladesh in virtual lockdown as coronavirus fight flares hundreds of clothing factory workers dash for dhaka again in dark hours amid lockdown shopping malls to reopen on may ahead of eid bangladesh set to step into coronavirus new normal with a lot at stake improved inference of time-varying reproduction numbers during infectious disease outbreaks a call to ramp up testing and develop a collective response an early estimation of the number of affected people in south asia due to the covid- pandemic using susceptible, infected and recover model effect of lockdown and isolation to suppress the covid- in bangladesh: an epidemic compartments model impact of control strategies on covid- pandemic and the sir model based forecasting in bangladesh national guidelines on clinical management of coronavirus disease (covid- ) short-term outcomes of covid- and risk factors for progression real estimates of mortality following covid- infection the many estimates of the covid- case fatality rate estimating case fatality rates of covid- covid- ) mortality rate basic epidemiology. world health organization estimating clinical severity of covid- from the transmission dynamics in wuhan, china herd immunity": a rough guide from light touch to total lockdown: how asia is fighting coronavirus impact of lockdown on covid- incidence and mortality in china: an interrupted time series study the positive impact of lockdown in wuhan on containing the covid- outbreak in china the indian express. covid- testing wrap: what are the tests and testing procedures being carried out in india, some key states herd immunity-estimating the level required to halt the covid- epidemics in affected countries we acknowledge the contribution of www.pipilika.com software development team for collecting the daily data of total covid- tests, total positive cases, and total deaths in bangladesh. adjusted dynamics of covid- pandemic due to herd immunity in bangladesh the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. mh, mi, ma, sd made substantial contributions to the conception or design of the work. mh and mi completed the relevant studies and created plots related to the sird estimation using kalman filter, while ma wrote the methods for r t estimation, doubling time and growth rate computation. sd contributes to estimate the susceptible population, while dm critically revised the manuscript. all the authors met regularly to discuss the outcome of each experiment. the data were acquired from the iedcr website and each of the results were cross validated by at least two of the three authors. all authors are responsible for acquiring, analysing, and interpreting the data for this article. mh and mi prepared the final draft. ma critically revised the article for important intellectual content. all the authors approved the version to be published. the authors declare that the research work received not external funding and was completed solely based on research interest. key: cord- -ikomc t authors: van doremalen, neeltje; lambe, teresa; sebastian, sarah; bushmaker, trenton; fischer, robert; feldmann, friederike; haddock, elaine; letko, michael; avanzato, victoria a.; rissanen, ilona; lacasse, rachel; scott, dana; bowden, thomas a.; gilbert, sarah; munster, vincent title: a single-dose chadox -vectored vaccine provides complete protection against nipah bangladesh and malaysia in syrian golden hamsters date: - - journal: plos negl trop dis doi: . /journal.pntd. sha: doc_id: cord_uid: ikomc t nipah virus (niv) is a highly pathogenic re-emerging virus that causes outbreaks in south east asia. currently, no approved and licensed vaccine or antivirals exist. here, we investigated the efficacy of chadox niv(b), a simian adenovirus-based vaccine encoding niv glycoprotein (g) bangladesh, in syrian hamsters. prime-only as well as prime-boost vaccination resulted in uniform protection against a lethal challenge with niv bangladesh: all animals survived challenge and we were unable to find infectious virus either in oral swabs, lung or brain tissue. furthermore, no pathological lung damage was observed. a single-dose of chadox niv(b) also prevented disease and lethality from heterologous challenge with niv malaysia. while we were unable to detect infectious virus in swabs or tissue of animals challenged with the heterologous strain, a very limited amount of viral rna could be found in lung tissue by in situ hybridization. a single dose of chadox niv(b) also provided partial protection against hendra virus and passive transfer of antibodies elicited by chadox niv(b) vaccination partially protected syrian hamsters against niv bangladesh. from these data, we conclude that chadox niv(b) is a suitable candidate for further niv vaccine pre-clinical development. introduction chadox -vectored vaccines fulfil all these requirements, making this a promising platform. the chadox vector is a replication-deficient simian adenovirus vector which has been used to produce several vaccines which are now in clinical development. a common feature of these vaccines is their low reactogenicity, strong immunogenicity, and the absence of vector replication after immunization, an important safety feature. in pre-clinical studies a single dose of chadox vectored vaccines has been shown to be protective against infection with rift valley fever virus, middle east respiratory syndrome coronavirus, mycobacterium tuberculosis and zika virus [ ] [ ] [ ] [ ] . large scale manufacturing has been performed for replicationdeficient adenoviral vectored vaccines for ebola, with one vaccine now licensed and another in advanced clinical development [ , ] . further, a simple thermostabilization process allows for vaccine storage at ambient temperatures [ ] , removing the need for a cold chain for storage and shipping. we now report on pre-clinical immunogenicity and efficacy testing of chad-ox niv b . animal experiment approval was received from the institutional animal care and use committee (iacuc) at rocky mountain laboratories. experiments were performed in an association for assessment and accreditation of laboratory animal care-approved facility by certified staff, following the guidelines and basic principles in the nih guide for the care and use of laboratory animals, the animal welfare act, united states department of agriculture and the united states public health service policy on humane care and use of laboratory animals (protocol # - e and - e). the institutional biosafety committee (ibc) approved work with infectious niv and hendra virus (hev) strains under bsl conditions and sample inactivation was performed according to ibc-approved standard operating procedures for removal of specimens from high containment. henipavirus isolates were obtained from the special pathogens branch of the centers for disease control and prevention, atlanta, ga or public health agency, winnipeg, canada. niv bangladesh (genbank no. ay ), niv malaysia (genbank no. af ), and hev (genbank no. af ) have been passaged three, four, and three times in veroe cells respectively. all virus propagation in this manuscript was performed in veroe cells in dulbecco's modified eagle's medium (dmem, sigma) supplemented with % fetal bovine serum (gibco), mm l-glutamine (gibco), u/ml penicillin (gibco), and μg/ml streptomycin (gibco) ( % dmem). veroe cells were maintained in dmem supplemented with % fetal bovine serum, mm l glutamine, u/ml penicillin and μg/ml streptomycin. the glycoprotein (g) gene from nipah virus (bangladesh outbreak - , genbank accession number: jn . ) was codon optimized for humans and synthesized by geneart (thermo fisher scientific). the synthesized g gene was cloned into a transgene expression plasmid comprising a modified human cytomegalovirus immediate early promoter (cmv promoter) with tetracycline operator (teto) sites and the polyadenylation signal from bovine growth hormone (bgh). the resulting expression cassette was inserted into the e locus of a genomic clone of chadox using site-specific recombination [ ] . the virus was rescued and propagated in t-rex- cells (invitrogen). purification was by cscl gradient ultracentrifugation, and the virus was titered as previously described [ ] . doses for vaccination were based on infectious units (iu). female golden syrian hamsters ( - weeks old) were purchased from envigo. animals were vaccinated i.m. with μl of iu of vaccine or injected i.m. with μl of saline, in each thigh ( μl total volume). for the homologous challenge vaccine experiment, animals were vaccinated at d- and/or d- . for the heterologous challenge experiment, animals were vaccinated at d- . three days prior to vaccination and virus challenge animals were bled via orbital sinus puncture. all animals were challenged with ld of virus in μl dmem via i.p. inoculation: niv bangladesh = . x tcid ; niv malaysia = . x tcid ; hev = . x tcid . we chose the i.p. route as a uniformly lethal challenge route and to be able to compare with previously conducted vaccine experiments [ ] . for each study group, hamsters were utilized. of these, four animals were euthanized (hev) or (niv) days post inoculation and the remaining six animals were followed for days post challenge. weight was recorded daily up to days post infection, and oropharyngeal swabs were taken daily up to days post inoculation in ml of dmem. animals were euthanized when > % of weight loss was recorded, or severe disease signs (e.g. difficulty breathing or paralysis) were observed. upon euthanasia, blood and tissues were collected and subsequently analyzed for virology and histology as approved by iacuc. female golden syrian hamsters ( - weeks old) were purchased from envigo. fifteen animals were vaccinated with either chadox niv b or chadox gfp as described above at and days before serum collection. serum was collected via cardiac puncture, pooled per vaccine group and iggs were purified using the mabtrap kit (sigma) according to manufacturer's instructions from ml of serum. purified iggs were filtered through an . μm filter and diluted to . ml in sterile pbs. ten hamsters were immunized via i.p. injection using μl per hamster. all animals were challenged as described above one day post treatment. for each study group, hamsters were utilized. of these, four animals were euthanized days post challenge and the remaining six animals were followed for days post challenge. weight was recorded daily up to days post challenge, and oropharyngeal swabs were taken daily up to days post inoculation in ml of dmem. animals were euthanized when > % of weight loss was recorded, or severe disease signs (e.g. difficulty breathing or paralysis) were observed. upon euthanasia, blood and tissues were collected and subsequently analyzed for virology and histology as approved by iacuc. virus titrations were performed by end-point titration in veroe cells, which were inoculated with tenfold serial dilutions of virus swab media or tissue homogenates. after hr incubation at ˚c and % co , tissue homogenate dilutions were removed, washed twice with pbs and replaced with μl % dmem. cytopathic effect was scored at dpi and the tcid was calculated from replicates by the spearman-karber method [ ] . added to veroe cells and incubated at ˚c and % co . at dpi, cytopathic effect was scored. the virus neutralization titer was expressed as the reciprocal value of the highest dilution of the serum which still inhibited virus replication. niv-g malaysia (residues e -t , gene accession number nc_ ) was cloned into the phlsec mammalian expression vector [ ] and niv-f malaysia (residues g -d , gene accession number ay . ) was cloned into the phlsec vector containing a c-terminal gcnt trimerization motif [ ] . the constructs were transiently expressed in human embryonic kidney (hek) t cells in roller bottles, as described previously [ ] . supernatant was harvested hours after transfection and diafiltrated using the akta flux system (ge healthcare) against either pbs, ph . (niv-g) or buffer containing mm tris and mm nacl, ph . (niv-f). the proteins were further purified by ni-nta immobilized metal-affinity chromatography using his-trap hp columns (ge healthcare) followed by size exclusion chromatography. niv-g was purified using a superdex / increase gl column (ge healthcare) equilibrated in pbs ph . and niv-f was purified using a superose increase / gl column (ge healthcare) equilibrated in mm tris and mm nacl ph . . maxisorp plates (nunc) were coated overnight at ˚c with μg of g or f protein per plate in carb/bicarb binding buffer ( . g khco and . g na co in l distilled water). after blocking with % milk in pbs with . % tween (pbst), serum ( x serial diluted starting at x dilution) in % milk in pbst was incubated at rt for hr. antibodies were detected using affinity-purified antibody peroxidase-labeled goat-anti-hamster igg (fisher, - - ) in % milk in pbst and tmb -component peroxidase substrate (seracare) and read at nm. all wells were washed x with pbst in between steps. prior to using f and g proteins based on niv malaysia, we established that cross-reactivity with niv bangladesh antibodies was sufficient for usage in elisa by testing sera known to be positive for niv bangladesh antibodies. necropsies and tissue sampling were performed according to ibc-approved protocols. harvested tissues were fixed for a minimum of days in % neutral-buffered formalin and subsequently embedded in paraffin. hematoxylin and eosin (h&e) staining and in situ hybridization (ish) were performed on tissue sections and cell blocks. detection of niv and hev viral rna was performed using the rnascope ffpe assay (advanced cell diagnostics inc., newark, usa) as previously described [ ] and in accordance with the manufacturer's instructions. briefly, tissue sections were deparaffinized and pretreated with heat and protease before hybridization with target-specific probes for niv or hev. ubiquitin c and the bacterial gene, dapb, were used as positive and negative controls, respectively. whole-tissue sections for selected cases were stained for niv and hev viral rna, ubc and dapb by the rnascope vs ffpe assay (rnascopevs, newark, usa) using the ventana discovery xt slide autostaining system (ventana medical systems inc., tucson, usa). a board-certified veterinary anatomic pathologist evaluated all tissue slides. statistical analysis was performed by the log-rank (mantel-cox) test to compare survival curves, and by welch-corrected one-tailed unpaired student's t-test to compare infectious virus titers in tissue. sem was calculated for all samples. p-values < . were significant. to determine efficacy of the chadox niv b vaccine, we vaccinated groups of hamsters with either a single dose at d- or a prime-boost regime at d- and d- . as control groups, we either injected hamsters with chadox gfp at d- and d- or saline at d- ( fig a) . virus neutralizing antibodies could be detected after a single dose of chadox niv b and increased upon a secondary dose (average vn titer ± sem = . ± . after single dose, ± after boost). in contrast, no neutralizing antibodies could be detected in serum obtained from the control groups ( fig b) . all hamsters were challenged with a lethal dose of niv bangladesh ( ld ) via intraperitoneal inoculation on d ( fig a) . all vaccinated animals survived challenge and did not show signs of disease, such as weight loss, at any stage throughout the experiment. this was in contrast to the control groups in which all animals succumbed to disease between d and d and exhibited weight loss (fig c and d) , as well as respiratory and/or neurological signs, including labored breathing and paralyzed hind legs. statistical analysis demonstrated that survival in the vaccinated groups was significant compared to both control groups (p < . ). oropharyngeal swabs were taken daily and assessed for infectious virus by limiting dilution titrations. none of the vaccinated animals shed virus at any timepoint. in contrast, control animals from both groups were found to shed virus at d and d (fig e) . four animals of each group were euthanized at d and lung and brain tissue were harvested. infectious virus could only be detected in lung tissue of animals from both control groups (average titer ± sem = . x ± . x tcid /g of tissue) and was not detected in any tissue of the vaccinated animals ( fig f) . we did not observe any differences between the two control groups. lung and brain tissue harvested at d were then evaluated for pathological changes. none of the vaccinated animals displayed pulmonary pathology and no viral rna was detected in lung tissue by ish. control animals developed pulmonary lesions that were indistinguishable between the two groups. these hamsters developed bronchointerstitial pneumonia that was characterized by multifocal inflammatory nodules that were centered on terminal bronchioles and extend into adjacent alveoli. the nodules were composed of large numbers of foamy macrophages and fewer neutrophils and lymphocytes admixed with small amounts of necrotic debris. in most cases hemorrhage, fibrin and edema admixed with inflammatory cells was observed. edema and fibrin often were extended into surrounding alveoli. alveoli that were adjacent to areas of inflammation were thickened by fibrin, edema and small numbers of macrophages and neutrophils as previously observed in niv infected hamsters [ ] . there was abundant viral rna demonstrated by ish in areas of inflammation (brown staining). the viral rna was predominantly found in type i pneumocytes but was also multifocally present in vascular and bronchiolar smooth muscle and endothelial cells (fig ) . to determine efficacy of chadox niv b against niv malaysia and hev, groups of hamsters were vaccinated with a single dose of chadox niv b or a single dose of chadox gfp at d- ( fig a) . as before, virus neutralizing antibodies could be detected after vaccination with chadox niv b but not upon injection with chadox gfp (average vn titer ± sem = . ± . ) ( fig b) . subsequently, hamsters were challenged with either niv malaysia or hev ( ld ) via intraperitoneal inoculation on d (fig a) . all vaccinated animals challenged with niv malaysia survived with no signs of disease such as weight loss at any stage throughout the experiment. in contrast, animals challenged with niv malaysia that received chadox fgp all succumbed to infection between d and d . these animals experienced weight loss and respiratory and neurological signs (fig c and d) . statistical analysis demonstrated that survival in the vaccinated group was significantly different from the control group (p = . ). oropharyngeal swabs were taken daily and assessed for infectious virus. none of the vaccinated animals challenged with niv malaysia shed virus at any timepoint. in contrast, control animals challenged with niv malaysia were found to shed virus at d and d (fig e) . four animals from both groups were euthanized at d and lung and brain tissue were harvested. infectious virus could only be detected in lung and brain tissue of animals from the control group (average virus titer lung ± sem = . x ± . x tcid /g, brain ± sem = . x ± . x tcid /g) and was not detected in any tissue of the vaccinated animals ( fig f) . four out of six vaccinated animals challenged with hev succumbed to disease between d and d . the two survivors showed minimal weight loss (< %) and no signs of disease. animals that received chadox fgp all succumbed to hev infection between d and d . these animals showed weight loss as well as respiratory and neurological signs (fig c and d) . logrank (mantel-cox) test demonstrated that survival in the vaccinated group was significant (p = . ) compared to the control group. oropharyngeal swabs were taken daily and assessed for infectious virus. none of the vaccinated animals challenged with hev shed virus at any timepoint. in contrast, control animals challenged with hev were found to shed virus at d , d and d (fig e) . four animals from both groups were euthanized at d and lung and brain tissue were harvested. infectious virus was detected in three out of four lungs of the vaccinated animals and all lungs of the control animals (average virus titer ± sem = . x ± . x and . x ± . x tcid /g tissue for vaccinated and control animals, respectively). no statistical difference in infectious virus titer was found between the two groups using an unpaired onetailed student's t-test (p = . ). infectious virus was only detected in brain tissue of animals from the control group (average titer ± sem = . x ± . x tcid /g) and not in vaccinated animals (fig f) . harvested lung tissue was then evaluated for pathological changes. all four groups of hamsters developed pulmonary lesions. all animals challenged with hev and control animals challenged with niv malaysia developed bronchointerstitial pneumonia which was indistinguishable from the lesions described for the control animals in the homologous challenge study. vaccinated hamsters challenged with niv malaysia developed mild to moderate bronchointerstitial pneumonia and did not display any evidence of pulmonary edema, fibrin or hemorrhage. ish demonstrated viral rna predominantly in type i pneumocytes and rarely in vascular and bronchiolar smooth muscle and endothelial cells in animals challenged with hev and control animals challenged with niv malaysia. in vaccinated animals challenged with niv malaysia, however; there was very little rna present and only in type i pneumocytes in areas of inflammation (fig ) . finally, we wanted to assess the protective effect of antibodies elicited after chadox niv b vaccination. two groups of hamsters were either vaccinated with chadox niv b or injected with chadox fgp at d- and d- . all animals were bled at d and we collected and ml respectively. igg was purified from ml pooled serum. ten animals per group were then injected peritoneally with purified igg. animals were challenged with a lethal dose of niv bangladesh ( ld ) one day post passive transfer ( fig a) . we were unable to detect neutralizing antibodies in serum obtained at d from four hamsters from each group. however, serum from animals treated with niv antibodies was positive by elisa against niv g protein, albeit with a lower reciprocal titer than antibodies in serum obtained from single-dose vaccinated animals (fig b) . one out of six animals treated with niv antibodies succumbed to disease on d . no weight loss was observed, however the animal showed severe neurological signs. none of the other niv antibody-treated animals experienced weight loss or signs of disease. four out of six animals treated with gfp antibodies succumbed to disease between d and d . these animals showed weight loss and respiratory or neurological signs. the two surviving animals did not show any signs of disease throughout the experiment. one of these animals did not seroconvert as measured by elisa against niv f and g protein, and it was suspected this animal was not infected. therefore, this animal was excluded from the survival curve. the log-rank (mantel-cox) test demonstrated that survival in the treated group was significant (p = . ) compared to the control group (fig c and d) . oropharyngeal swabs were taken daily and assessed for infectious virus. shedding was minimal and found in one animal treated with niv antibodies on d , and five animals treated with gfp antibodies between d and d (fig e) . four animals from both groups were euthanized at d and lung and brain tissue were harvested. infectious virus could only be detected in lung tissue of animals treated with gfp antibodies and was not detected in any tissue of the animals treated with niv antibodies (fig f) . lung tissue harvested at d was then evaluated for pathological changes. both groups of hamsters developed pulmonary lesions similar to those described in the homologous challenge study, however; the niv antibody-treated hamsters developed mild to moderate pulmonary lesions whereas the control animals developed severe lesions. additionally, none of the niv antibody-treated hamsters displayed any pulmonary fibrin, edema or hemorrhage. ish demonstrated viral rna in type i pneumocytes in areas of inflammation. abundance of viral rna was notably less in animals treated with niv antibodies (fig ) . niv is a re-emerging infectious disease which causes outbreaks with a high case-fatality rate. no licensed vaccine against niv currently exists, and it is therefore key that a safe and effective vaccine be developed. several vaccine candidates have been explored in different animal models. these can be categorized as subunit vaccines or live-vectored vaccines that target the niv outer membrane proteins g and/or f. protection against disease and lethality has been shown in hamsters [ , ] , pigs [ , ] , african green monkeys [ ] [ ] [ ] , cats [ ] , and ferrets [ , ] . efficacy is thought to be mediated by neutralizing antibodies, as passive transfer of chadox nivb efficacy in the syrian golden hamster antibodies in naive animals also results in protection against disease [ , ] . these approaches are promising, but no vaccine candidates have so far been moved into clinical trials. in the studies presented here, we tested the efficacy of a vaccine based on niv bangladesh g protein in a replication-deficient simian adenovirus vector in syrian hamsters. a primeonly as well as a prime-boost regime protected syrian hamsters against challenge with a lethal dose of niv bangladesh and niv malaysia, and partially protected against hev challenge. furthermore, antibodies elicited by vaccination alone provided partial protection against a niv bangladesh challenge. two genetic lineages of niv have been described; niv malaysia and niv bangladesh [ ] [ ] [ ] . although niv malaysia has not caused an outbreak in humans since , the virus was isolated from pteropus vampyrus, pteropus hypomelanus and pteropus lylei in malaysia and cambodia [ ] [ ] [ ] and another spillover event could occur. having one vaccine that protects against both lineages of niv virus would be the easiest and cheapest countermeasure. a singledose vaccination with chadox niv b , which is based on niv bangladesh, fully protected syrian hamsters against lethal disease caused by niv malaysia. the g proteins of the niv strains used in this study are . % pairwise identical on the amino acid level, with amino acid differences scattered throughout the protein. although we did not see sterile protection against niv malaysia, none of the vaccinated animals showed signs of disease and all were protected against lethal disease. these results suggest that chadox niv b could protect against both lineages of niv. like niv, hev is a species in the henipavirus genus and thus we investigated cross-protection of chadox niv b against a lethal challenge with hev in syrian hamsters. the g protein of the hev strain used in this study was . % identical to the chadox niv b g protein; amino acids differ between the two proteins. chadox niv b only protected partially against hev challenge; four out of six animals did not survive challenge. we observed a non-significant decrease in infectious hev titer in lung and brain tissue of vaccinated animals compared to control animals. it is possible that disease progression in vaccinated animals is delayed compared to control animals. this is supported by the delay in time to death; whereas the average time to death is days in control animals, it is days in vaccinated animals. cross-protection of niv or hev vaccines has been studied by other groups as well. an adeno-associated virus vaccine expressing niv g protein offered % protection against a lethal challenge with hev in hamsters [ ] . in contrast, vaccines based on hev provide full protection against niv in the ferret and nhp model [ , , ] . likewise, high levels of crossprotective antibodies were found in sera from hev-infected individuals, whereas cross-protective antibodies were limited in niv-infected individuals [ ] . this might be caused by induction of a more robust and cross-reactive immune response by native hev protein compared to niv protein, as suggested by bossart et al. [ ] . human cases of hev are associated with direct contact with infected horses, the intermediate animal host of hev, and direct contact with bats or their products has not yet been associated with hev infection in humans [ ] . it is therefore likely that prevention of hev in horses will completely prevent human cases. currently, a hev vaccine (equivac) is available for horses and fully protects against hev [ ] . furthermore, the total number of human cases that contracted hev is relatively low at [ ] . thus, the requirement of a human vaccine for hev is therefore less urgent than that of a niv vaccine. previous work has shown that the humoral immune response to niv vaccination is sufficient to protect syrian hamsters against a lethal challenge with niv [ , ] . likewise, administration of a human neutralizing monoclonal antibody (m . ) provided full protection against both hev and niv in multiple animal models [ , ] . administration of purified igg obtained from chadox niv b vaccinated hamsters provided partial protection against niv challenge. furthermore, infectious virus could only be detected in the lungs of control animals and not in the lungs of vaccinated animals, and thus as in previous studies, chadox niv belicited antibodies are able to provide protection against a lethal challenge with niv. although we were able to detect niv g protein-specific antibodies in serum obtained from niv antibody-treated animals, the reciprocal titer was much lower than that detected in serum from syrian hamsters after a single dose of chadox niv b . it is possible that administering a higher dose of igg would have led to uniform protection. two animals treated with igg purified from animals which received injections with chad-ox fgp survived a lethal challenge with niv bangladesh. occasional survival has been observed in the syrian hamster model [ ] . the increased survival rate might however also reflect a non-specific effect of treatment with igg, which has been reported previously [ ] . as the survival rate was significantly different between the niv igg-treated group and the control igg-treated group, the passive transfer experiment shows that antibodies elicited by chad-ox -niv b are sufficient for protection against a lethal challenge with niv. animals in the passive transfer experiment were observed for days, to ensure that the two animals that survived would not succumb to disease after days. the syrian hamster is a suitable initial small animal model to investigate the efficacy of niv vaccines, followed by the african green monkey [ ] . the immune system of african green monkeys is more like humans than that of hamsters and is therefore seen as a more relevant animal model to test niv vaccines. based on the results presented in the current manuscript, future studies are planned to test chadox niv b in african green monkeys, supported by the coalition for epidemic preparedness innovations (cepi). we show that chadox niv b provides complete protection against lethal disease in syrian hamsters challenged with niv bangladesh. furthermore, chadox niv b vaccination results in complete survival but with limited evidence of viral replication after niv malaysia challenge, and partial protection against hev. passive transfer of antibodies elicited by chadox niv b vaccination provide partial protection against lethal challenge with niv bangladesh. nipah virus: a recently emergent deadly paramyxovirus pteropid bats are confirmed as the reservoir hosts of henipaviruses: a comprehensive experimental study of virus transmission pathogenic differences between nipah virus bangladesh and malaysia strains in primates: implications for antibody therapy nipah virus outbreaks in the who south-east asia region person-to-person transmission of nipah virus in a bangladeshi community nipah virus transmission from bats to humans associated with drinking traditional liquor made from date palm sap, bangladesh date palm sap linked to nipah 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challenge single-dose live-attenuated vesicular stomatitis virus-based vaccine protects african green monkeys from nipah virus disease recombinant measles virus vaccine expressing the nipah virus glycoprotein protects against lethal nipah virus challenge a recombinant subunit vaccine formulation protects against lethal nipah virus challenge in cats single injection recombinant vesicular stomatitis virus vaccines protect ferrets against lethal nipah virus disease vaccination of ferrets with a recombinant g glycoprotein subunit vaccine provides protection against nipah virus disease for over months nipah virus: vaccination and passive protection studies in a hamster model characterization of nipah virus from naturally infected pteropus vampyrus bats isolation of nipah virus from malaysian island flying-foxes nipah virus in lyle's flying foxes, cambodia protection against henipavirus infection by use of recombinant adeno-associated virus-vector vaccines feline model of acute nipah virus infection and protection with a soluble glycoprotein-based subunit vaccine neutralization assays for differential henipavirus serology using bio-plex protein array systems changing resource landscapes and spillover of henipaviruses hendra virus vaccine, a one health approach to protecting horse, human, and environmental health a neutralizing human monoclonal antibody protects against lethal disease in a new ferret model of acute nipah virus infection a neutralizing human monoclonal antibody protects african green monkeys from hendra virus challenge a protective monoclonal antibody targets a site of vulnerability on the surface of rift valley fever virus development of an acute and highly pathogenic nonhuman primate model of nipah virus infection we would like to thank the animal care takers for their excellent care of the animals, and anita mora for assistance with figures. benjamin carrasco provided outstanding assistance with the preparation for animal experiments. greg saturday, kimberly meade-white and kathleen cordova were instrumental in assistance during the animal studies. we thank benhur lee for kindly providing the c-dna for niv-f. key: cord- - oy zuy authors: rashid, sabina faiz; theobald, sally; ozano, kim title: towards a socially just model: balancing hunger and response to the covid- pandemic in bangladesh date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: oy zuy nan ► responsive and timely research is needed to better understand the challenges faced by poor and vulnerable populations to inform immediate interventions and policies to address this unprecedented covid- modern-day pandemic. ► there is a need to research changes through time to understand and address the continuous and longterm economic, mental and emotional impact of lockdown on the most marginalised. ► many of the bangladeshi population are vulnerable, yet the covid- response focuses on individual behaviour with limited attention to the social, economic and contextual factors that prevent the most marginalised from following national recommendations. ► in the context of structural constraints, continuation of the lockdown has to be accompanied by strong political resolve to ensure that people do not go without basic meals and have basic health information and support. ► the experiences of people living and working in slums in bangladesh needs to be captured and translated to context specific strategies for lockdown, as current measures risk starvation for many. ► in the context of covid- , the lockdown model is being imported from a different context (western or developed economies) with stronger economic bases and better social safety nets for those in need, but is there a better way forward for low resource contexts? ► economic mortalities may overtake health mortalities for the poorest who survive on daily wage labour. rapid responsive research in bangladesh is revealing the realities of lockdown for the poor and vulnerable in bangladesh, the james p. grant school of public health is undertaking responsive research to try and understand the needs of the population during covid- . the multidisciplinary research includes case studies in urban slums to capture the lived experiences and the impact of shutdown of the people living and working in dhaka during covid- . in addition, a rapid large scale urban/rural survey is being conducted via phone interviews, with follow-ups, aimed to assess the possible effects of the pandemic on several domains of a household or family such as consumption, income, health, coping strategies, psychological well-being and gender. the survey takes a dynamic approach: questions are modified based on current understandings and relevant emerging issues related to the crisis. with a focus on marginality, interviews have taken place with the transgender group of people commonly known as 'hijra' in south asian countries and with street workers including adolescence and young adults. reading these data alongside media reports and articles on the coronavirus pandemic, one is overcome with a range of emotions: depression, paralysis, anger, denial and helplessness; emotions that are reflective of being privileged and of having the luxury to dwell on them. for the vast numbers of the poor, microbusiness owners, labourers, transport workers, informal sector employees and many other groups who depend on daily wages/ earnings and have no social safety net, there is now only the pain of hunger, not figuratively, but literally. with the shutdown now extended to a month, these groups are under real threat of starvation. there are international conventions and declarations on the right to food, on the right to be free from hunger. yet the world suffers from an estimated million people dying of hunger and hunger related diseases annually, more than aids, malaria and tuberculosis combined. it is the world's biggest health problem, and with entire countries and economies now under lockdown, it risks getting much worse for those who live in difficult environments. although bangladesh has achieved a lot over recent decades, with improved availability of food due to increased production, million people-one quarter bmj global health of the population-remain food insecure, and million suffer from acute hunger. these figures will worsen after the impact of covid- . for many, every day is a battle: covid- is one addition to a long list of challenges for survival the poor and the vulnerable with their erratic and meagre earnings somehow manage to keep fighting and living and demonstrating impressive resilience, being confronted with illnesses and deaths is an everyday reality for many. while there is fear of the coronavirus, there is also the acceptance that it is yet another addition to an already long list of health challenges that they face. furthermore, with access to their sparse resources being severely constrained or denied as a result of the shutdown, for many, the immediate threat to consumption for survival, and not necessarily the pandemic, is becoming a greater concern. brac's (ngo) conducted a rapid perception survey on covid- conducted between march and april for instance found that % and % of urban and rural respondents, respectively, had no food stored at home, while % and %, respectively, had only - days food reserve. figure shows 'looting goods from a truck carrying relief' (source: photo tbs (the business standard), april ). the focus on individual behaviour prevents the poorest from following national recommendations health bodies and various governments have been promoting different measures to contain the pandemic that focus on individual behaviour with little attention to the social, economic and contextual factors. public health preventions tend to be based on the biomedical virus and individual determinants of health, whereas for millions, the stark living conditions, social and contextual inequalities and realities of how and where they live prevent them from following such recommended guidelines. there needs to be a recognition of the complexity of factors that underlie and impact on marginalised populations lives. practising social distancing, washing of hands with soap and staying at home are all very well for the privileged who can afford to do so; however, for the poor with - or more members crammed in one room within slums, sharing irregular water supply, communal latrines and cooking spaces, in some of the dirtiest and densest places on earth, such messaging needs urgent adaptation to reflect the realities of context and support is critical. the poor and vulnerable already live on the edge. the added stress of the pandemic combined with prolonged shutdowns will amplify further their despair and hopelessness. while health is a very real concern, for bangladesh to sustain the shutdown requires all of us to focus all of the country's resources on ensuring that no one goes without food. we have to believe the rest will follow, once this is ensured. if not, as nobel laureates esther duflo and abhijit banerjee highlighted with respect to the situation in india, the poor and the vulnerable will be left with no choice but to break the shutdown for their livelihood. the last interview of an adolescent street peddler stated, 'how much longer? we heard four more days. we have no food, no money'. these narratives are typical for most of the poor families we interviewed, in similar distress and concerns were echoed, much more in the urban surveys compared with the rural surveys (for now) and case studies in dhaka city urban settlements with mainly the informal workers, who are dependent on daily wages to survive. try imagining, if you can, the gut-wrenching panic and anxiety, when many of them learn it will be an additional days or more. rumours that the shutdown may continue until end of april or even may is going to lead to unimaginable consequences on the poorest and for the country as a whole. we need a socially just model to tackle this pandemic, and this requires us to acknowledge the fault lines that exist in our underlying assumptions as well as the very real inequities that exist between the poorest and others. political commitment for economic support for the poor needs urgent and effective implementation bangladesh, like many other countries, has rolled out an economic stimulus package to address the severe economic and business fallout from the pandemic. the government is also in the process of unveiling support for the poor. this scheme will also include support for farmers who are critical for ensuring the food supply chain for all of us-the rich, the middle class and the poor. while this package should really have been the first step taken by the state, it now needs to be implemented efficiently, systematically and equitably. there are numerous articles and reports detailing the mismanagement, favoured groups in communities and a complete lack of coordination between different bodies involved in distributing the initial state funded food and/or cash aid programmes. [ ] [ ] [ ] this has to stop. while there is no easy solution or strategy, for bangladesh and its high proportion of vulnerable populations, continuation of the shutdown has to be accompanied with strong political resolve to ensure that people do not go without food bmj global health and have basic health information and support, given the grounded realities of their lives. otherwise, it will be the final nail in the coffin for the poor and maybe even beyond. the trauma and enormity of what will unfold if this is not done properly cannot be emphasised enough. the shutdown or lockdown model has been imported from western or developed economies with stronger economic bases and better social safety nets for those in need. but is it the only way forward? china, hong kong, singapore, countries that were successful in containing the first wave, are now facing a resurgence largely due to infections coming from outside travellers, and some countries have begun reinstating containment measures again. how long can a shutdown be sustained in a largely different context? while this is an entirely unknown territory, iran's president for instance declared that 'low-risk' economic activities will resume from april in spite of the virus not being contained. the iranian government is thus balancing the risks of the pandemic versus further wrecking a sanctions battered economy. sadly, countries with large pools of poor populations may soon be forced to confront similar trade-offs, with all its moral and ethical implications, if there is no solution soon in sight. the political and social actions taken now at the global, national, subnational and local levels to understand and meet the needs of the urban poor are essential to addressing the current pandemic and also in preventing a post-covid- rise in people experiencing extreme poverty and death from the wider social determinants of health. if action is taken now, there is a chance to learn and build cities that are more resilient and responsive to future crises. having a responsive research agenda is the first step to informing, developing and delivering policies and strategies that are informed by data, within lower middle income countries (lmics) and in all countries and contexts where inequities exist. however, these must be developed in partnership with civil society organisations, community leaders/gatekeepers and residents who know what is needed to make a difference, now and in the future. there is also a need to engage in cross-country discussions to share learnings from previous emergency responses in urban settings and support sharing and solidarity around current promising strategies across and between different contexts. contributors sfr produced the first draft of the commentary. ko and st inputted and revised. all authors have approved and signed off the final version the commentary. funding some time for writing was funded through the ukri gcrf accountability for informal urban equity hub (also known as arise), which is a ukri collective fund award, rc grant reference: es/s x/ . the arise hub-accountability and responsiveness in informal settlements for equity-is a research consortium, aiming to enhance accountability and improve the health and well-being of marginalised populations living in informal urban settlements in kenya, sierra leone, bangladesh. the commentary expands on a piece that was published in the newspaper (daily star) in bangladesh. united nations, human rights, fao. the right to adequate food. fact sheet no. the world counts world food programme brac survey finds pc of low income people do not have food at home during shutdown nobel laureates esther duflo & abhijit banerjee bat for bolder social transfers to fight covid- govt to take action again against irregularities in relief distribution unacceptable irregularities in relief operation bangladesh's covid- stimulus: leaving the most vulnerable behind pm: dealers expelled, accused of relief mismanagement corruption mars bangladesh's covid- relief efforts countries in asia are facing new waves of coronavirus infections after lockdowns lift. the same could happen in the rest of the world iran's rouhani says low-risk economic activities to resume from april amid coronavirus competing interests none declared. patient consent for publication not required.provenance and peer review not commissioned; internally peer reviewed. key: cord- -tl bj authors: rayhan arusha, anowara; kishore biswas, raaj title: prevalence of stress, anxiety and depression due to examination in bangladeshi youths: a pilot study date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: tl bj an estimated % people suffer from mental health disorders worldwide. almost million suffer from anxiety and depression in bangladesh. there are several factors that can cause stress among youths, both academic and non-academic, ranging from socioeconomic, environmental, cultural and psychological attributes. however, these are not widely researched in bangladesh. this study identified the factors that affect the mental health of students due to examinations in bangladesh, particularly the socio-demographic, lifestyle and psychological factors. an online cross-sectional survey was conducted on may with a sample size of tertiary level students in dhaka. a modified dass- was used to measure stress, anxiety and depression scores related to examination. binary logistic model showed that those who lived with family, spent time with parents, had regular sufficient (self-assessed) sleeps and consumed balanced (self-assessed) diets had significantly lower stress, anxiety, and depression. balanced lifestyle with greater social bonding might help to better equip youths to reduce stress, anxiety, and depression during examination, which could be an avenue for future intervention studies. one in four people suffer from mental or neurological disorders worldwide (world health organisation, ) , including million who suffer from depression (world health organization, a) . a person with depression often functions poorly at work, school or in family environment, which, at its worst, can lead to suicide. due to depression, suicide is the second leading cause of death for - year-olds (world health organization, a). the global prevalence of moderate to extreme levels of depression is . %, anxiety %, and stress . % (bayram and bilgel ; beiter et al. ; kulsoom and afsar ) . although not widely discussed, mental health issues are increasingly becoming a threat to low-and middle-income countries such as bangladesh. almost million people in bangladesh experience depressive and anxiety disorders respectively (world health organization, b ). an estimate of , committed suicide in , and suicide attempts were considered by % of boys and % of girls by youths aged - years (world health organization, b) . in bangladesh, the levels of depression, anxiety, and stress has been reported to be as high as . %, . %, and . %, respectively (hossain et al., ; alim et al., ; saeed et al., ; mamun and griffiths, ; mamun et al., ) . there are myriads of factors that can cause stress among students, both academic and non-academic, ranging from socioeconomic, environmental, cultural to psychological attributes (brand and schoonheim-klein, ). stress levels vary across students depending on symptoms of anxiety, especially during examination periods. a prevalence rate of - % of university students experience "functionally impairing levels of test anxiety" (chapell et al., ; neuderth, jabs and schmidtke, ) . students with test anxiety are more likely to delay and drop-out in university, which could lead to suicidal behaviors and high economic costs (schaefer et al. ) . it can be bidirectional as majority of students with stress display poor self-confidence and often poor academic performance (sohail, ; baste and gadkari, ) . several contributing factors of stress, anxiety, and depression among students were identified in literature including sex, strained relationships, family and peer pressure, high parental expectation, lack of financial support and hardships, sleep deprivation, future worries, loneliness, longer screen time, toxic psychological environment, academic pressure, workload, size of the academic curriculum, and heavy test schedules (brenneisen mayer et al., ; abdel wahed and hassan, ; saeed et al., ; silva and figueiredo-braga, ; ul haq et al., ; mamun and griffiths, ) . some of the major academic stressors for students include examinations, time demands, competition and class environment while the most common personal stressors have been intimate relationships, finance and parental conflicts (murphy and archer, ) . the stress of examinations and mental health of students are correlated. according to bayram and bilgel ( ) , exam stress and anxiety has negative impacts on students' academic achievement, physical health & development and standard of life. causes of exam anxiety can be associated with social stigma, where students from a rural background could feel incompetent compared to those who grew up in the metropolitan, coupled with the fear of not having competitive skills in english, the general medium for higher education in bangladesh, can demotivate them prior to and during exams which could lead to anxiety, stress, and frustration. higher education in recent times involves considerable financial burden (callender & kemp, ) . roberts et al.'s ( ) cross-sectional survey indicate that financial difficulties often lead to mental disorders such as depression for students. roberts et al.'s ( ) cross-sectional survey indicate that financial difficulties make students particularly vulnerable to depression. of all the adverse experiences assessed, financial hardship was the only one to show an independent relationship with depression when pre-entry anxiety and depression were controlled which indicates that the direction of causality is more likely to be from financial problems to depression than vice versa (andrews and wilding, ) . moreover, excessive parental control is assumed to inhibit the development of children's autonomy, which leads to perceptions of the environment as "uncontrollable and a limited sense of personal competence or mastery" (chorpita, albano and barlow, ; hudson and rapee, ; dadds, ; barlow, ; chorpita, brown and barlow, ) . in turn, these factors are postulated to contribute to the triggering anxiety in children. there is a knowledge gap concerning mental health problems in bangladesh. in , four suicides and one suicide rescued among students attracted media and public attention nationwide, which suggested a need to examine the existing mental health issues among students in bangladesh (shamsuddin et al., ; arafat and al mamun, ) . to contribute to that gap, the present study investigated the prevalence of depression, anxiety, and stress among bangladeshi students and their associated risk factors with respect to socio-demographics and lifestyle measures. the objective of the study was to identify factors that affect the mental health of students due to examinations, particularly the socio-demographic and psychological factors using a survey conducted in dhaka, bangladesh in . there are several theories that discuss risk factors associated with individual mental health. these include the social ecologic theory, the social cognitive theory, as well as the social stress model, among others (van praag et al., ; yen, michael and perdue, ). the present study was framed by the social ecologic theory and the social cognitive theory. the social ecologic theory suggests that individual and environment factors are interrelated and that good health can be achieved with behavioral, economic, and social factors promoting it (krieger, ; cohen, scribner and farley, ) . thus, the social ecologic theory suggested that a person living in a neighborhood with low socioeconomic status (ses) and low social support is expected to have worse health outcomes than someone from a better environment. the theory posits that environmental factors, socio-demographic factors in the current study context, influence the mental health of students. the most common socio-demographic factors discussed in the literature are the student's age, sex, place of residence, education, parents' education, family income, personal income, relationship status, frequency of contact with family and extra-curricular activities. social cognitive theory links these socio-demographic factors with the thought processes of students that contribute to their emotional, behavioral and psychological development such as seeking help, reading books, engaging in volunteering activities, getting sufficient sleep, maintaining a balanced diet, getting regular exercise and practicing relaxation techniques.. the theory also suggests that good health is linked to individuals having beliefs that they can achieve healthy outcomes, having goals to achieve these outcomes as well as having expectations of these outcomes. (bandura, ; fisher et al., ) . [ figure . theoretical hypothesis for the study based on social ecologic and social cognitive theories.] an online survey was conducted among undergraduate and postgraduate students from tertiary institutions of dhaka, bangladesh. due to the covid- pandemic in bangladesh, the authors had to settle for online option and could only collect quantitative data. a total of youths aged between to years participated in the survey using google online survey platform after receiving ethical clearance from university of dhaka, bangladesh. the data was collected during may . the survey questionnaire included sociodemographic information as well as dass scale which measured examination stress, anxiety and depression, and possible coping mechanisms. demographic information included sex, residence before joining university, current living status, relationship status, and contact with parents. the depression, anxiety and stress scale - items (dass- ) is a set of scales designed to measure the psychological states of depression, anxiety and stress. there are items in each of the three dass- scales, divided into subscales with similar content. the depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia and inertia (lovibond and lovibond, ) . the anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect during examination. it examines the difficulty to relax, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient (lovibond and lovibond, ) . scores for the three emotional states of mind are calculated by summing the scores for the relevant items. the stress/anxiety coping mechanism included questions regarding whether the participant ever sought help for depression/anxiety/stress, reading habits, engagement in volunteering activities, whether the participant made any effort to replace negative thoughts with positive ones, and self-assessment on quality of sleep and eating habits. bivariate distribution of the relevant variables across dass stress, dass anxiety and dass depression were quantified. the primary associations were evaluated using t-tests or analysis of variance (anova). to assess the relationships between the dass scores and socio-demographic variables, linear regression model was fitted. these models included only the variables that were found significant in the primary bivariate associations. p-value < . was considered as threshold for the level of significance. all statistical analysis was conducted with r (version . . ). the online survey resulted to responses. in the sample were studying in undergraduate degrees, in master's degrees and one in high school and aged between and years. the validity of the three dass scores were assessed using cronbach's alpha. the alpha values for stress, anxiety and depression were . ( % ci: . ~ . ), . ( % ci: . ~ . ) and . ( % ci: . ~ . ) respectively. these show that the scores were reliable. and balanced diet were fitted to linear regression model. the linear regression models observed a significant association of contact with parents with stress and depression (table ) . those who kept contact with parents only once or twice a month were more likely to have higher examination stress and depression respectively compared to those who contacted daily with their parents. similarly, sleeping pattern was significantly (p < . ) associated with stress and depression during examinations. those who had sufficient sleep were less likely to have higher stress or depression compared to those who self-reported of insufficient sleep. only diet was associated with anxiety (table ) . those who had balanced diet were likely to have lower anxiety during examination period compared to those with unbalanced diet. also, anxiety was marginally associated (p < . ) with living status, that is those living without family were more likely to experience anxiety than those living with it. for all the linear regression model, generalized varianceinflation factors (gvif) were computed and all scores were under , which means there were no multicollinearity in the models (fox and monette, ) the results showed that living with family, time spent with parents, sleeping patterns and diets were significantly associated with mental health factors. given the current study evaluated students who only had mild or moderate stress, anxiety or depression, it could be argued that a balanced lifestyle with sound social communication would help students deal with stress, anxiety and depression related to examination. talking with parents daily seemed to be a stress relieving mechanism among youths, as results indicate. students who talked to their parents daily over phone had the lower stress and depression scores resulting from examinations compared to those who talked - times a month. a pilot study of children with separation anxiety disorder (choate et al., ) found that a parent-child intervention designed to improve the attachment bond resulted in children no longer fitting criteria for separation anxiety disorder in most cases. that would work for examination stress as well, given, a student who shares the concerns are more likely to receive support and encouraging behaviors from their parents. social bonding has proved to be a good depression coping mechanism (karriker-jaffe, foshee and ennett, ). thus, improving the parent-youth attachment, particularly for academic examination related mental health issues, could be an avenue to alleviate excess anxiety and depression. students who generally had sufficient sleep regularly had lower examination related stress and depression compared to those who never had sufficient sleep. recent epidemiological studies suggest that insomnia is not just a typical symptom of depression, rather it could be an independent risk factor for depression in the long run (hohagen et al., ) . although this study did not evaluate a bidirectional relationship, depression is considered to be one of the most frequent and prominent causes of insomnia (hohagen et al., ) . however, academic performance might not necessarily be hindered due to insomnia (taylor, d.j., bramoweth, a.d., grieser, e.a., tatum, j.i. and roane, ) but lack of adequate sleep was found to be associated with a range of impairments in terms of academic functioning (hysing, m., pallesen, s., stormark, k.m., lundervold, a.j. and sivertsen, ) . a disruptive sleeping pattern or lack of it during examination period would suggest higher likelihood of stress, which would result in a deterioration in academic performance. many young adults face traumatic experiences and mental illnesses during university period. higher consumption of food due to anxiety is common. more often, anxiety leads to unbalanced diet and overconsumption of processed food, which hampers the bodily functions (kemp, bui, and grier ; weng et al. ) . in one study, m. hossain, naher, and shahabuddin , found that participants who had healthy food habit had the lowest scores of anxiety, stress and depression respectively whereas students who did not have healthy food habit had the highest scores. food habit is also affiliated with students who live without family, more often they rely on campus canteens or substandard dormitory cafes. this could lead to less than adequate nutrient intake, particularly when studies have repeatedly questioned nutrition in food sources in bangladesh (hossain, naher and shahabuddin, ; khan et al., ) . all these are compounded by factors such as financial condition, sufficient resources and facilities which play a major role here. higher levels of examination anxiety were observed for students who lived without their family compared to those who lived with their family. results indicated that youths with higher anxiety level perceived their mothers and fathers as being more socially isolating, more concerned about others' opinions, more ashamed of the students' shyness and poor performance, and less socially active than youths with low anxiety level (caster et al., ) . staying with family reduces their stress, anxiety and depression, particularly during examination, as they could share some responsibilities with their families and focus more on academic workload. this, in turn, relieves some anxiety and improves their mental health. there were a few limitations to this study. first, there was no active identification of severely stressed individuals to be included in the survey, which might have observed stronger effect sizes in the models. second, this study was limited to only quantitative data, which means future studies could consider in-depth interviews to explore more focused examination related stress factors. also, as the sample size was small, the beta scores in the regression model might not be adjusted to reflect population estimates. thirdly, as the data was cross-sectional, there is hardly a scope to assess a causal link. based on the study findings, some intervention studies can explore the causal link between healthy lifestyle and mental health related factors during examination in bangladesh. moreover, future studies can consider calculating quality-adjusted life year (qaly) & disability-adjusted life year (daly) and assess their impacts. fourthly, the financial barrier between public universities and private institutions in bangladesh could act as a stressor, which was not collected in the current survey. finally, the sample was limited to only youths pursuing higher education in dhaka, bangladesh. for more generalized conclusion, wide scale surveys with funding would be necessary. examinations have a negative effect on the mental health of students in terms of stress, anxiety, and depression. this study explored some demographic factors associated with mental health for bangladeshi tertiary level students. balanced lifestyle with greater social bonding might help better equip fighting stress, anxiety, and depression during examination. future research could examine the relationship between academic results and its association with stresses and psychological disorders. amidst the high density of infections and non-communicable diseases, mental health is still not highly reorganized in bangladesh. implementation of stress management workshops, improvisation of academic environment, use of problem-focused and emotion focused strategies at the policy level should be targeted. moreover, students need assistance and co-curricular programming to help them develop "stress-related coping strategies" attuned to performance and the outcomes borne regarding the effects of stress, in particular regarding eustress, where a positive impact has been cited with respect to the effects of stress on financial aid, institutional commitment, academic performance, and intent to persist. prevalence and associated factors of 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students: relationship with mental health, quality of life, and substance use difficulties psychometric study of depression, anxiety and stress among university students is there any relationship between dietary patterns and depression and anxiety in chinese adolescents? mental disorders affect one in four people, world health organization world health organization ( a) depression, world health organization world health organization ( b) mental health: current mental health situation in bangladesh neighborhood environment in studies of health of older adults. a systematic review key: cord- - qq pp authors: chowdhury, sukanta; azziz-baumgartner, eduardo; kile, james c.; hoque, md. a.; rahman, mohammed z.; hossain, md. e.; ghosh, probir k.; ahmed, syed s.u.; kennedy, erin d.; sturm-ramirez, katharine; gurley, emily s. title: association of biosecurity and hygiene practices with environmental contamination with influenza a viruses in live bird markets, bangladesh date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: qq pp in bangladesh, live bird market environments are frequently contaminated with avian influenza viruses. shop-level biosecurity practices might increase risk for environmental contamination. we sought to determine which shop-level biosecurity practices were associated with environmental contamination. we surveyed poultry shops to describe biosecurity practices and collect environmental samples. samples from ( %) shops were positive for influenza a viral rna, ( %) for h , and ( %) for h . shops that slaughtered poultry, kept poultry overnight, remained open without rest days, had uneven muddy floors, held poultry on the floor, and housed sick and healthy poultry together were more frequently positive for influenza a viruses. reported monthly cleaning seemed protective, but disinfection practices were not otherwise associated with influenza a virus detection. slaughtering, keeping poultry overnight, weekly rest days, infrastructure, and disinfection practices could be targets for interventions to reduce environmental contamination. h ighly pathogenic avian influenza a(h n ) virus causes outbreaks in poultry and sporadic infections in humans globally ( , ) . h n virus is endemic to poultry in several countries in southeast asia, including bangladesh, and causes major economic loss, as well as human illness and death ( , ( ) ( ) ( ) . during - , bangladesh reported > highly pathogenic avian influenza outbreaks in poultry, % of which were reported from commercial poultry farms ( ). since , eight human h n cases, including death, have been reported in bangladesh; of these cases were in live bird market (lbm) workers presumably exposed to infected poultry in the lbm ( ) . vietnam, thailand, indonesia, hong kong, china, and cambodia have also reported human cases of h n infection with a history of poultry exposure in lbms, suggesting that lbms can facilitate spread of h n infection among poultry and from poultry to humans ( , ) . bangladesh has a large number of lbms in urban areas in which multiple poultry species from backyard and commercial farms are housed together for sale; several studies detected highly pathogenic and low pathogenicity avian influenza viruses (aivs) in lbm poultry and the environment ( ) ( ) ( ) ( ) ( ) ( ) . an lbm-based surveillance detected aivs in waterfowl ( %) and environmental samples from poultry markets ( %). during - , many subtypes, including h n , h n , h n , and h n , were identified in waterfowl and environmental samples ( ) . in study, ( %) of lbm workers from lbms across bangladesh had antibodies against h n virus ( ) . such findings suggest that environmental contamination with aivs occurs in bangladesh and that poultry workers are at risk for contracting aivs from infected poultry in lbms and their contaminated environment. affected countries have introduced interventions to reduce the spread of aivs in lbms, including bird markets, bangladesh temporary or permanent lbm closure, banning overnight poultry storage, and mandatory rest day(s), as well as daily cleaning of surfaces to reduce environmental contamination ( ) ( ) ( ) ( ) ( ) ( ) ( ) . temporary, weekly -day closures at live poultry markets in guangzhou, china, was implemented for effective disinfection in response to the h n outbreaks during - ( ). however, market-level interventions have not been effective in reducing environmental contamination in bangladesh. the infrastructure and daily activities of individual poultry shops within markets are heterogeneous ( ) . because individual poultry shops have their own infrastructure and biosecurity controls, shop-level analyses might be useful in developing and designing effective interventions. our study aimed to assess the shop-level prevalence of influenza a virus contamination among lbm shops across bangladesh and to identify biosecurity and hygiene practices that are associated with risk for and protection from influenza a virus contamination. bangladesh has metropolitan areas where large numbers of lbms are located. we conducted a crosssectional study in all areas (figure ). we determined that we needed poultry shops to detect > % prevalence of aiv with % confidence and . % precision. initially, the field team visited each metropolitan area to identify all lbms and count the number of individually owned poultry shops in each market. after visiting all the cities, we prepared a list of lbms with > poultry shops for each ( , , , , , ( ) ( ) ( ) ( ) ( ) . in a questionnaire (appendix , https://wwwnc.cdc.gov/eid/article/ / / - -app .pdf), we defined cleaning as "cleaning of poultry holding areas with water and/or broom," and we defined disinfection as "cleaning of poultry holding areas with a disinfectant." we asked owners whether they cleaned poultry holding areas daily, weekly, monthly, or did not clean within the past month. we asked whether they disinfected poultry holding areas weekly, monthly, or did not disinfect within the last month. the field team also collected some marketlevel information by interviewing members of the market committee. from each selected shop, we collected - swab specimens of poultry droppings, cages, feed, drinking water, slaughtering surfaces and utensils, slaughtering by-products, offal, shop floors, or waste bins. we pooled the - samples from each shop and tested them as a single sample. some shops had no slaughtering facilities within their premises. from these shops, we collected swab specimens from other sources, including poultry droppings, cages, feed, and drinking water. we collected pooled sample from each of selected shops during march because highly pathogenic avian influenza (h n ) activity typically peaks during january-march ( ) . we used a real-time reverse transcription pcr detection kit for typing and subtyping influenza viruses and fluorescent taqman probes at the icddr,b ( ). primers and probes specific for the matrix gene were used to detect influenza a viruses. to identify h , h , and h subtypes in influenza a virus-positive samples, we used h , h , and h hemagglutinin gene-specific primers and probes ( ). on the basis of laboratory testing results, we identified all influenza a/h -positive shops and an equal number of influenza a virus-negative shops by using a random number generator and a list of influenza a virusnegative shops. field staff observed each selected shop for a -hour period during april . staff observed cleaning and disinfection activities of selected poultry shops during surprise visits at times when cleaning activities were scheduled. field staffs were blinded to the laboratory test results of selected shops. we summarized characteristics of poultry shops, including infrastructure and biosecurity and hygiene measures, by using descriptive analyses. we estimated the presence of environmental contamination with influenza a viruses in shops and % cis. initially, we constructed a conceptual framework to identify causal association and confounders as described ( ) (figure ). we then performed univariate analyses to estimate odds ratios (ors). exposure variables associated with outcomes with p < . in univariate analysis and confounder variables from the conceptual framework were selected for multivariate analyses. we used backward stepwise selection of variables with a significance level of . to construct models. we then used mixed-effect logistic regression multivariate models, accounting for clustering by metropolitan area and market, to estimate adjusted ors (aors). we assessed collinearity by calculating the variance inflation factor for independent variables used in the regression models ( ) . weekly cleaning was highly correlated with daily cleaning practices; therefore, we removed weekly cleaning from the model during multivariate analyses. we calculated model χ and r (the coefficient of determination) to measure goodness-of-fit for multivariate regression model. we performed all statistical analyses by using stata version software (statacorp llc, https://www.stata.com). field staff obtained written consent from shop owners or poultry workers for data and sample collection from their shops. the icddr,b research review committee and ethical review committee reviewed and approved the study protocol (protocol no. pr- ). we identified lbms that had ≥ poultry shops. among these lbms, we selected shops in lbms for sample and data collection ( table ). the average number of poultry shops in each market was (sd . , range - ). most ( %) poultry shops were retail and sold live poultry directly to consumers. the average size of each poultry shop was m , and the average duration of trade per day was hours. chickens were the predominant poultry species sold at lbms, and % of shops had a > poultry species the day of our visit (table ) . a total of % of shops sold waterfowl only, and % sold chickens and ducks. poultry shopkeepers housed poultry in different types of settings, including wire cages, bamboo cages, and on the floor. most ( %) poultry shops had uneven floor surfaces, partially made with tiles/concrete and mud. poultry shop owners collected poultry from different sources, including wholesale markets, intermediaries, and directly from poultry farms. most ( %) poultry shops slaughtered poultry on premises. cleaning and disinfecting practices varied among poultry shops: shops ( %) reported cleaning poultry holding areas daily, ( %) reported using a disinfectant once a week, ( %) reported frequently working throughout the week (i.e., not following the recommended weekly day of rest), and shops ( %) reported keeping unsold poultry after the end of each business day. environmental specimens from ( %, % ci %- %) shops were positive for influenza a viral rna; ( %, % ci %- %) were positive for the h subtype and ( %, % ci %- %) were positive for the h subtype (table ). an additional ( %, % ci %- %) influenza a-positive shops had samples that were not subtypeable with h , h , and h primers. samples from ( %) shops were confirmed for both h and h subtypes. no samples were positive for h ( % ci %- . %). shops in all cities had at > sample positive for influenza a viral rna, and cities ( %) had shops positive for the h subtype. among the lbms, > shop from markets ( %) was positive for influenza a viral rna, and > shop from markets ( %) was positive for influenza a/h rna. environmental samples from lbms ( from chittagong, from dhaka, from khulna, and from comilla) were negative for influenza a viral rna. we conducted observations in influenza a/h virus-positive and influenza a virus-negative shops. we did not find any major differences in cleaning and disinfection practices between influenza a/h virus-positive and influenza a virusnegative shops. surveyors observed cleanings in % of influenza a/h virus-positive shops and % of influenza a virus-negative shops. among these shops, only % of influenza a/h viruspositive shops performed disinfection by using washing powder or another recognized disinfectant, whereas % of influenza a virus-negative shops performed disinfection during our period of observation. we showed by using univariate analyses that poultry shops that kept poultry on the floor (or . , % c: - . ; p = . ), slaughtered poultry within the shop (or . , % ci . - . ; p = . ), had unsold poultry after the end of the business day (or . , % ci . - . ; p< . ), did not rest day a week (or . , % ci . - . ; p = . ), kept sick and healthy appearing poultry together (or . , % ci - . ; p = . ), and had uneven floor surfaces (partly made with tiles/concrete and mud) (or . , % ci . - . ; p< . ) were more likely to be positive for influenza a viral rna in environmental samples compared with shops that did not have these characteristics (table ). poultry shops that reportedly cleaned poultry holding areas either daily (or . , % ci . - . ; p< . ), weekly (or . , % ci . - . ; p< . ), or monthly (or . , % ci . - . ; p< . ), and had weekly disinfection (or . , % ci . - . ; p = . ) seemed less likely to be positive for influenza a viral rna compared with shops that did not. in the final multivariate analysis model, we showed that poultry shops that slaughtered poultry within the shop (aor . , % ci . - . ; p = . ), had unsold poultry after the end of the business day (aor . , % ci . - . ; p< . ), did not rest day a week (aor . , % ci . - . ; p< . ), had uneven floor surfaces (partly made with tiles/concrete and mud) (aor . , % ci . - . ; p< . ), held poultry on the floor (aor . , % ci . - . ; p = . ), and kept sick and healthy appearing poultry together (aor . , % ci . - . ; p = . ) were significantly more likely to be positive for influenza a viruses compared with shops that did not report these characteristics (table ) . reported monthly cleaning was protective (aor . , % ci . - . ; p< . ), but disinfecting practices of poultry holding areas was still not significantly associated with influenza a virus detection in the multivariate model (p = . ). the final model selected seemed to fit data well (χ . , df , p< . , and r . ). no market-level factors, including central cleaning and disinfection practices, were significantly associated with influenza a virus detection in the multivariate model (appendix ). evaluation of existing biosecurity and hygiene practices is necessary to develop and design interventions to reduce the spread of aivs in lbms. our study provides a detailed depiction of the daily operation of poultry shops and current biosecurity and hygiene practices in selected lbms of bangladesh. we identified certain biosecurity and hygiene practices associated with environmental contamination with aivs: slaughtering poultry within shops, having unsold poultry after the end of the business day, skipping rest days, uneven floor surfaces, holding poultry on the floor, and keeping sick and healthy appearing poultry together. our study determined that most shops did not implement biosecurity practices, which have reduced aiv in other countries. for example, biosecurity and hygiene practices, including weekly rest days, depopulation, and cleaning with disinfectant, reduced the risk for aiv detection in poultry and environmental specimens in china ( ) . the prevalence of h n virus in environmental specimens from lbms in china decreased after the closure of live poultry markets ( ) . daily waste removal was found to be protective in indonesia ( ) . in the united states, environmental contamination decreased after implementing routine cleaning and disinfection ( , ) . although monthly cleaning was found to be protective in reducing environmental contamination with aivs in this study, most shops in bangladesh do not disinfect, and their current biosecurity practices do not seem to prevent environmental contamination. moreover, most of the studied shops had rough dirt and mud floors that are less suitable for proper cleaning and disinfection, indicating poor market infrastructure. globally, countries reporting human cases of aiv also have lbms contaminated with aivs. aiv contamination of lbm environments increases the risk for infection and amplification of the virus in virusfree birds. in addition, if the aiv is zoonotic, as are h n , h n , and h n viruses, increased viremia in birds increases the risk for human exposure and infection. for example, in vietnam, aivs were detected in . % of poultry specimens collected from lbms; in egypt, h n virus was detected in poultry in . % of lbms; in china, h n virus was detected in % of environmental specimens from lbms; in indonesia, aivs were detected in % of environmental specimens from lbms; in thailand, h n virus was detected in . % of market poultry; and in bangladesh, aivs were detected in % of poultry specimens ( , , ( ) ( ) ( ) . in our study, > % of the lbms were positive for influenza a viruses, and % were specifically positive for aiv h rna. detection of aiv rna in environmental samples indicates that market poultry were infected with aivs near the time of sample collection and might excrete, secrete, or contaminate surfaces and humans through their carcasses, feathers, and offal. our study findings also confirmed the presence of subtypes (h and h ) of aiv, which might lead to genetic reassortment and evolution of new aiv strains in poultry of public health concern ( ). epidemiologic studies have described the effectiveness of weekly or monthly rest days in reducing environmental contamination of lbms with aiv ( , ) . the number of human cases of infection with h n virus has been observed to be reduced after permanent or temporary closure of lbms and the culling of poultry ( , , , ) . the government of bangladesh imposed an order in to practice weekly rest days for cleaning and disinfecting lbms within dhaka ( ) . nevertheless, study found % of poultry shop owners did not practice weekly rest days, which might increase the risk for environmental contamination. a weekly rest day should be enforced by the government to decrease the risk for aiv circulation in lbms. unsold poultry can play a major role in maintaining virus circulation in markets ( ) . unsold infected poultry can infect incoming poultry, promoting further transmission of influenza viruses in susceptible birds. banning overnight poultry storage in china reduced h n virus isolation in chickens ( %) ( ) . in our study, most ( %) poultry shops reported that they stored poultry overnight in their shops to sell the next day. a previous study from bangladesh also found that % of poultry shops kept poultry in their stalls for > day ( ) . slaughtering by-products, such as blood and offal, of aiv-infected poultry provide the most likely opportunity for environmental contamination and subsequent human exposure to high loads of virus. in indonesia, slaughtering poultry within market premises was a risk factor for environmental contamination ( , ) . h n virus was detected in swab samples collected from surfaces of chopping boards in china ( ) . persons from china and bangladesh prefer to purchase live chickens that are slaughtered in the market at the time of purchase ( , ) . a study suggested introducing central slaughtering of all live poultry in the lbm to control the risk posed of aivs ( ) . in bangladesh, most poultry shops, including those in this study, sold and slaughtered poultry within their shop ( ) . this practice might increase the risk for aiv contamination and perpetuate the exposure of poultry to aiv in lbms. although our study did not assess aiv transmission within lbms, we cannot rule out the risk for aiv transmission to humans through slaughtering of infected poultry. we recommend introducing centralized slaughter facilities in lbms to decrease the spread of aiv. lbms in bangladesh are larger (ranging from to poultry shops) than those in hong kong, where the number of poultry shops in each lbm was - ( ) . maintaining effective biosecurity and hygiene measures might be more difficult in larger lbms that had poor infrastructure. the infrastructures of lbms in city areas were quite similar. however, the prevalence of h and h subtypes varied between cities and might naturally differ in virus ecology by farm or geographic site. the infrastructure of our studied poultry shops within lbms was often rudimentary: most were fully enclosed by walls, but most had rough muddy floors, unsystematic poultry holding areas, poor waste disposal systems, and unconfined slaughtering facilities. urban markets have more poultry shops than rural markets. urban lbms usually are open every day, whereas rural lbms are open once or twice per week. bangladesh should consider investing in poultry shop infrastructure improvements and biosecurity practices, particularly in city areas, to better control environmental contamination with aivs. in china, poultry trading networks linked with lbms were strongly associated with a higher prevalence of h n virus among poultry and risk for h n transmission to humans ( ) . movement of infected poultry between markets has a major role in the spread of aivs from market to another ( , ) . poultry market supply chains in urban areas of bangladesh are complex, collecting poultry from different sources, including directly from farms, intermediaries, or wholesale markets. these complex networks might promote a high number of contacts between infected and susceptible marketed birds and, therefore, increase aiv transmission potential within the trade networks. this cross-sectional study design might have limited interpretation of some of the results. although aiv circulation and amplification at lbms are continuous processes influenced by time-dependent parameters, such as time to last cleaning before sampling and time to last poultry introduction/mixing before sampling, we only examined environmental contamination for aivs at point in time and did not explore time from last cleaning or disinfection. no additional laboratory tests were performed to characterize viral load and viability of aivs detected because of limited funding. therefore, it is unclear if the aivs detected during the study were infectious to humans. the information we collected from poultry shop owners and workers about biosecurity might have been affected by social desirability bias, which might have underestimated the prevalence of practices that place shop at risk for contamination with aivs. in conclusion, our study identified risky practices, hygiene, and infrastructure in bangladesh lbms associated with an increased likelihood of shop contamination with aivs. improvement of these biosecurity practices, such as removing poultry at the end of the day, observing weekly rest days, introducing centralized slaughter facilities, and regular cleaning and disinfection, might help to prevent aiv contamination. lbm infrastructure, including floors, poultry holding areas, waste disposal systems, and slaughtering 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n ) in poultry and humans and seasonal influenza activity worldwide centers for disease control and prevention. laboratory support for influenza surveillance (clsis). atlanta: the centers causal diagrams for epidemiologic research collinearity: a review of methods to deal with it and a simulation study evaluating their performance surveillance of avian h n virus in various environments of zhejiang province, china before and after live poultry markets were closed in - prevalence and distribution of avian influenza a(h n ) virus clade variants in live bird markets of vietnam circulation of avian influenza h n in live bird markets in egypt biosecurity in the epidemiology of influenza a (h n ): a cross-sectional observational study in four eastern china provinces biosecurity and circulation of influenza a (h n ) virus in live bird markets in bangladesh knowledge, attitudes and practices on biosecurity of workers in live bird markets at mymensingh, bangladesh effect of closure of live poultry markets on poultry-to-person transmission of avian influenza a h n virus: an ecological study poultry movement networks in cambodia: implications for surveillance and control of highly pathogenic avian influenza (hpai/h n ) address for correspondence: sukanta chowdhury, programme for emerging infections, international centre for diarrheal diseases research, mohakhali , bangladesh; email: sukanta@icddrb.org or sukanta.icddrb@yahoo.com ® emerging viruses to revisit the case manifestations and public health response for outbreak of meningococcal w disease • transmission of chikungunya virus in an urban slum, brazil • public health role of academic medical center in community outbreak of hepatitis a resistant mycoplasma pneumoniae infections in pediatric community-acquired pneumonia • efficient surveillance of plasmodium knowlesi genetic subpopulations lyssavirus exposure among humans in area that celebrates bat festival • rickettsioses as major etiologies of unrecognized acute febrile illness risk for coccidioidomycosis among hispanic farm workers • paradoxal trends in azole-resistant aspergillus fumigatus in a national multicenter surveillance program, the netherlands and cost of hospitalization for respiratory syncytial virus in young children we thank susan c. trock and nord zeidner for providing scientific input during protocol development, gladys leterme for proofreading and editing the manuscript, and field staff for their efforts during sample and data • human adenovirus type distribution, regional persistence, and genetic variability july