Garcia, Cristina

Public Health

PhD

Bangladesh

Bangladesh - Establishing a baseline rate of pneumonia admissions for children prior to pneumococcal conjugate vaccine introduction, Bangladesh

Ongoing longitudinal surveillance for pneumonia has taken place in a heavily populated urban area of Dhaka for over 5 years. All children in a catchment population with respiratory symptoms are referred to a local clinic. Children meeting a case defintion undergo chest x-ray. X-rays are read by radiologists using a standardized reading frame. Pneumococcal conjugate vaccine will be introduced in Bangladesh in 2013. Reductions in radiologic pneumonia are expected. This surveillance will provide a unique opportunity to evaluate the vaccine's impact on pneumonia. However, before this can be done the baseline data pre-vaccine needs to be evaluated in terms of secular trends, which could be influenced by outbreaks of respiratory pathogens or changes in health-seeking. The student will work with the data team at ICDDRB to evaluate the existing database. Rates of pneumonia using various case defintions will be calculated. Temporal trends will be explored. Sub-group analyses will be done. The student will have field exposure at the level of the community and clinic to observe how surveillance is done.

GHEFP Personal Narrative – Dhaka, Bangladesh

I was interested in the Global Health Established Field Placements because while I had been doing work in global health for years, I had yet to work in a developing country. Most of my previous research involved synthesizing existing evidence or focused on policy decisions. The one thing I felt I was missing was the on the ground, in-country experience. Before arriving in Bangladesh, I felt well prepared for my experience. I had knowledge of ICDDR,B and the public health problems in Dhaka and throughout Bangladesh from my studies and previous work, and I had several calls with my in-country mentor on what to expect while living in Dhaka. However, my arrival in Dhaka was a unique one and provided an example of the current challenges affecting the people in Dhaka.

Bangladesh is currently experiencing political unrest, often resulting in frequent hartals or political strikes called by rivaling political parties. These hartals led to shutdowns of the city and attacks on those who defied the shutdown. It just so happened that the day of my arrival a hartal was called. I didn’t have a working phone or internet access during my travel, so I was not sure if my prearrange ride would be there when I landed. Fortunately, my transport was waiting for me at the airport, but for my safety and the safety of the driver, I was picked up by an ICDDR,B ambulance. Dhaka is very much a typical large, densely populated, urban city in a developing country with crowded roads, sidewalks filled with pedestrians and animals, and vendors lining the streets. Because of the hartal, the streets were virtually empty the day I arrived. The fact that I was in Dhaka did not sink in until the next day on the way to work. Traffic was backed up for miles and sidewalks were overflowing as people tried to get to work after the forced shutdown. There were a total of 10 days of hartals during my field experience, resulting in a loss of 2 weeks of work and 20% of my time in country. Fortunately, I was able to continue working from home on those days, but most people in Bangladesh could not work or risked violence if they attempted to work. The economic loss due to these shutdowns perpetuated the cycle of poverty in Dhaka and reduced health service utilization.

Aside from the political instability, Dhaka experiences many of the common public health challenges facing urban cities in developing countries, including pollution, a lack of reliable water and sanitation, poor living conditions, poverty, and insufficient access to health care for the poorest. However, despite these challenges, ICDDR,B has established several successful programs to reduce maternal and child mortality and improve health for the people of Dhaka, most notably their diarrheal disease control efforts. An example of this is the urban field site in Kamalapur. I split most of my time between the main ICDDR,B center in central Dhaka and the Kamalapur urban field site in southeastern Dhaka. The Kamalapur site serves a population of about 200,000 in one of the poorest areas of Dhaka. The site was established in 1998 and provides routine care and surveillance to children and adults through regular in home visits by field assistants and referrals to the clinic. Kamalapur is also the site of several studies on childhood pneumonia, influenza, and several vaccine and drug trials.   

My project was an analysis of the association between influenza infection in children under-five and developing pneumococcal pneumonia within 2 years of the influenza infection. The majority of studies on the synergism between influenza and bacterial infections rely on animal models, and few epidemiologic studies exist. Those that do exist use historical data from influenza epidemics that lack a control population. The surveillance data from Kamalapur provided a unique opportunity to look at this kind of longitudinal analysis not usually found in other urban populations or developing countries. Most of my time was spent in the clinic working on data analysis, but I did get the opportunity to participate in some routine surveillance home visits. I was able meet several families and see how they live. While I was not always in the field during my experience, the importance of the analysis I was working on was always in my mind. The Kamalapur surveillance data can be used to study numerous different research questions, but they lack the time or personnel to do it. Towards the end of my experience, a group from CDC was visiting the field site to learn about the various projects that were ongoing. It gave me the opportunity to present my preliminary work and get feedback on the next steps. This was something I did not expect going into the experience, but it reinforced the importance of the work I was doing. 

An added benefit of working at ICDDR,B was the opportunity to interact with students from other schools and other countries also working at the center. Whether I was with locals or other students, I never felt alone. Living in Dhaka made it easy to travel on the weekends to other parts of Bangladesh or neighboring countries. I had the opportunity to visit the rural ICDDR,B site in Matlab and explore the tea plantations of Sylhet. From the landscape to the standard of living, Dhaka is so different from the rest of Bangladesh, and any students interested in working in Dhaka should take time to travel to surrounding areas.

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