Dhaka Community Hospital Research Articles

Umbilical Cord Blood Metal Mixtures and Birth Size in Bangladeshi Children.

Background:Studies have evaluated environmental exposure to toxic metals such as arsenic (As), cadmium (Cd), manganese (Mn), or lead (Pb) on birth size; however, information on potential effects of exposures to metal mixtures is limited.Objectives:We assessed the association between metal mixtures (As, Cd, Mn, Pb) in umbilical cord blood and neonate size in Bangladeshi children.Methods:In this birth cohort study, pregnant women who were of age with an ultrasound-confirmed singleton pregnancy of gestation were recruited from two Bangladesh clinics between 2008 and 2011. Neonate size metrics were measured at the time of delivery. Metals in cord blood were measured using inductively coupled plasma mass spectrometry. We employed multivariable linear regression and Bayesian kernel machine regression (BKMR) to estimate associations of individual metals and metal mixtures with birth size parameters.Results:Data from 1,088 participants was assessed. We found a significant negative association between metal mixture and birth length and head circumference when all metal concentrations were above the 60th and 55th percentiles, respectively, compared with the median. An interquartile range (IQR) increase in log Cd concentration {log[Cd (in micrograms per deciliter)] } was associated with a 0.13-standard deviation (SD) decrease in mean birth length (95% CI: , ) and a 0.17-SD decrease in mean head circumference (95% CI: , ), based on linear regression models adjusted for covariates and the other metals. An IQR increase in log Mn concentration {log[Mn (in micrograms per deciliter)] } was associated with a 0.07-SD decrease in mean birth weight (95% CI: , 0.002).Discussion:Metal mixtures in cord blood were associated with reduced birth size in Bangladeshi children. Results from linear regression models adjusted and the BKMR mixtures analyses suggest adverse effects of Cd and Mn, as individual metal exposures, on birth size outcomes. https://doi.org/10.1289/EHP7502

One solution to the arsenic problem: a return to surface (improved dug) wells.

Arsenic contamination in drinking-water in Bangladesh is a major catastrophe, the consequences of which exceed most other man-made disasters. The national policy encourages the use of surface water as much as possible without encountering the problems of sanitation that led to the use of groundwater in the first place. This paper describes the success of the Dhaka Community Hospital (DCH) team and the procedure in implementing sanitary, arsenic-free, dugwells. The capital cost for running water is US$ 5-6 per person. Sixty-six sanitary dugwells were installed in phases between 2000 and 2004 in Pabna district of Bangladesh where there was a great need of safe water because, in some villages, 90% of tubewells were highly contaminated with arsenic. In total, 1,549 families now have access to safe arsenic-free dugwell water. Some of them have a water-pipe up to their kitchen. All of these were implemented with active participation of community members. They also pay for water-use and are themselves responsible for the maintenance and water quality. The DCH helped the community with installation and maintenance protocol and also with monitoring water quality. The bacteria levels are low but not always zero, and studies are in progress to reduce bacteria by chlorination.

Maternal Serum Metals Exposure Pattern By Metallomics Profiling and Risk of Preterm Birth in Rural Bangladesh

Background: The prevalence of preterm birth in Bangladesh is estimated to be 19·1%, the highest in the world. Although, prenatal exposure to several metals has been linked with preterm birth, fewer prospective studies have investigated multiple metals simultaneously or potential interaction between metals. Methods: This study included data from 780 mother-offspring pairs recruited in a well-established prospective birth cohort in Bangladesh. Serum concentrations of 19 metals were measured in first and second trimesters using inductively coupled plasma mass spectrometry. Logistic regression and mediation analyses were used to investigate the crucial metals and their exposure windows and interactions, as well as mediating role of the metals. Findings: Maternal exposure to zinc, arsenic, and strontium in the first trimester and exposure to barium in the second trimester were significantly associated with preterm risk. Zinc in the first trimester showed antagonistic effect against arsenic toxicity in the first (ORinteraction= 0·35; 95% CI: 0·12-0·97) and second (ORinteraction= 0·31; 95% CI: 0·11-0·90) trimesters. Furthermore, low marriage age was associated with an exponential increase in the risk of preterm, while 30.16% of its risk effect was mediated through affecting these four metal concentrations. Interpretation: Multiple maternal serum metals are individually and interactively associated with the risk of preterm during pregnancy. The findings suggest that zinc supplementation at early pregnancy might attenuate the risk of preterm attributed to prenatal arsenic exposure. Funding: Funding of China Ministry of Science and Technology and the U.S. National Institutes of Health. Declaration of Interest: The authors declare no conflicts of interest. Ethical Approval: All protocols were reviewed and approved by the Human Research Committees at Harvard T.H. Chan School of Public Health (ES015533 From NIEHS), Nanjing Medical University, and Dhaka Community Hospital Trust.

Prenatal folic acid use associated with decreased risk of myelomeningocele: A case-control study offers further support for folic acid fortification in Bangladesh.

Neural tube defects contribute to severe morbidity and mortality in children and adults; however, they are largely preventable through maternal intake of folic acid before and during early pregnancy. We examined the association between maternal prenatal folic acid supplement intake and risk of myelomeningocele (a severe and common type of neural tube defect) in the offspring. We performed secondary analysis using data from a case-control study conducted at Dhaka Community Hospital, Bangladesh between April and November of 2013. Cases and controls included children with and without myelomeningocele, respectively, and their mothers. Cases were identified from local hospitals and rural health clinics served by Dhaka Community Hospital. Controls were selected from pregnancy registries located in the same region as the cases, and matched (1:1) to cases by age and sex.Myelomeningocele in the offspring was confirmed by a pediatrician with expertise in classifying neural tube defects. Maternal prenatal folic acid supplement intake was the main exposure of interest. We estimated crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) using conditional logistic regression analysis. There were 53 pairs of matched cases and controls in our study. Overall, 51% of case mothers reported using folic acid supplements during pregnancy compared to 72% of control mothers (p = 0.03). Median plasma folate concentrations at the time of study visit were 2.79 ng/mL and 2.86 ng/mL among case and control mothers, respectively (p = 0.85). Maternal prenatal folic acid use significantly decreased the odds of myelomeningocele in the offspring (unadjusted OR = 0.42, 95% CI = 0.18–0.96). The association was slightly attenuated after adjusting for maternal age at the time of pregnancy (adjusted OR = 0.43, 95% CI = 0.18–1.02). Our study confirms the protective association between maternal prenatal folic acid supplement use and myelomeningocele among children born in Bangladesh. Our findings point to an overall low folic acid supplement use and low plasma folate concentrations among women of reproductive age in Bangladesh. Mandatory fortification of staple foods with folic acid can address low folate status among women of child-bearing age, and prevent child morbidity and mortality associated with myelomeningocele in Bangladesh.

Arsenic is associated with reduced effect of folic acid in myelomeningocele prevention: a case control study in Bangladesh.

BackgroundArsenic induces neural tube defects in several animal models, but its potential to cause neural tube defects in humans is unknown. Our objective was to investigate the associations between maternal arsenic exposure, periconceptional folic acid supplementation, and risk of posterior neural tube defect (myelomeningocele) among a highly exposed population in rural Bangladesh.MethodsWe performed a case–control study that recruited physician-confirmed cases from community health clinics served by Dhaka Community Hospital in Bangladesh, as well as local health facilities that treat children with myelomeningocele. Controls were selected from pregnancy registries in the same areas. Maternal arsenic exposure was estimated from drinking water samples taken from wells used during the first trimester of pregnancy. Periconceptional folic acid use was ascertained by self-report, and maternal folate status was further assessed by plasma folate levels measured at the time of the study visit.ResultsFifty-seven cases of myelomeningocele were identified along with 55 controls. A significant interaction was observed between drinking water inorganic arsenic and periconceptional folic acid use. As drinking water inorganic arsenic concentrations increased from 1 to 25 μg/L, the estimated protective effect of folic acid use declined (OR 0.22 to 1.03), and was not protective at higher concentrations of arsenic. No main effect of arsenic exposure on myelomeningocele risk was identified.ConclusionsOur study found a significant interaction between drinking water inorganic arsenic concentration from wells used during the first trimester of pregnancy and reported intake of periconceptional folic acid supplements. Results suggest that environmental arsenic exposure reduces the effectiveness of folic acid supplementation in preventing myelomeningocele.

Groundwater arsenic contamination in Bangladesh—21 Years of research

Department of Public Health Engineering (DPHE), Bangladesh first identified their groundwater arsenic contamination in 1993. But before the international arsenic conference in Dhaka in February 1998, the problem was not widely accepted. Even in the international arsenic conference in West-Bengal, India in February, 1995, representatives of international agencies in Bangladesh and Bangladesh government attended the conference but they denied the groundwater arsenic contamination in Bangladesh. School of Environmental Studies (SOES), Jadavpur University, Kolkata, India first identified arsenic patient in Bangladesh in 1992 and informed WHO, UNICEF of Bangladesh and Govt. of Bangladesh from April 1994 to August 1995. British Geological Survey (BGS) dug hand tube-wells in Bangladesh in 1980s and early 1990s but they did not test the water for arsenic. Again BGS came back to Bangladesh in 1992 to assess the quality of the water of the tube-wells they installed but they still did not test for arsenic when groundwater arsenic contamination and its health effects in West Bengal in Bengal delta was already published in WHO Bulletin in 1988. From December 1996, SOES in collaboration with Dhaka Community Hospital (DCH), Bangladesh started analyzing hand tube-wells for arsenic from all 64 districts in four geomorphologic regions of Bangladesh. So far over 54,000 tube-well water samples had been analyzed by flow injection hydride generation atomic absorption spectrometry (FI-HG-AAS). From SOES water analysis data at present we could assess status of arsenic groundwater contamination in four geo-morphological regions of Bangladesh and location of possible arsenic safe groundwater. SOES and DCH also made some preliminary work with their medical team to identify patients suffering from arsenic related diseases. SOES further analyzed few thousands biological samples (hair, nail, urine and skin scales) and foodstuffs for arsenic to know arsenic body burden and people sub-clinically affected. SOES and DCH made a few follow-up studies in some districts to know their overall situations after 9 to 18 years of their first exposure. The overall conclusion from these follow-up studies is (a) villagers are now more aware about the danger of drinking arsenic contaminated water (b) villagers are currently drinking less arsenic contaminated water (c) many villagers in affected village died of cancer (d) arsenic contaminated water is in use for agricultural irrigation and arsenic exposure from food chain could be future danger. Since at present more information is coming about health effects from low arsenic exposure, Bangladesh Government should immediately focus on their huge surface water management and reduce their permissible limit of arsenic in drinking water.

An interview with Mahmuder Rahman. Bangladesh’s arsenic agony

Professor Mahmuder Rahman obtained his medical degree from Dhaka University in Bangladesh and is a member of the Royal College of Physicians (United Kingdom). He was a full professor and consultant physician at Dhaka National Medical College and Hospital until 2003. Apart from his clinical and academic work, he has contributed extensively to formulating policy for affordable health services, and is actively involved in developing integrated health delivery services such as Dhaka Community Hospital, which is a self-financing hospital dedicated to providing health care for people on low incomes. Rahman was actively involved in developing the "Arsenicosis" National Case Detection and Case Management Protocols. He has published more than 15 papers on Bangladesh's arsenic problem. As a member of Bangladesh's National Expert Committee on Arsenic, he took a leading role in formulating the National Arsenic Mitigation Policy and Action Plan.

The impact of diet and betel nut use on skin lesions associated with drinking-water arsenic in Pabna, Bangladesh.

An established exposure–response relationship exists between water arsenic levels and skin lesions. Results of previous studies with limited historical exposure data, and laboratory animal studies suggest that diet may modify arsenic metabolism and toxicity. In this study, we evaluated the effect of diet on the risk of arsenic-related skin lesions in Pabna, Bangladesh. Six hundred cases and 600 controls loosely matched on age and sex were enrolled at Dhaka Community Hospital, Bangladesh, in 2001–2002. Diet, demographic data, and water samples were collected. Water samples were analyzed for arsenic using inductively coupled plasma mass spectroscopy. Betel nut use was associated with a greater risk of skin lesions in a multivariate model [odds ratio (OR) = 1.67; 95% confidence interval (CI), 1.18–2.36]. Modest decreases in risk of skin lesions were associated with fruit intake 1–3 times/month (OR = 0.68; 95%CI, 0.51–0.89) and canned goods at least 1 time/month (OR = 0.41; 95% CI, 0.20–0.86). Bean intake at least 1 time/day (OR = 1.89; 95% CI, 1.11–3.22) was associated with increased odds of skin lesions. Betel nut use appears to be associated with increased risk of developing skin lesions in Bangladesh. Increased intake of fruit and canned goods may be associated with reduced risk of lesions. Increased intake of beans may be associated with an increased risk of skin lesions. The results of this study do not provide clear support for a protective effect of vegetable and overall protein consumption against the development of skin lesions, but a modest benefit cannot be excluded.

DRINKING WATER EXPOSURE TO ARSENIC, POLYMORPHISMS IN GSTT1, GSTM1 AND GSTP1 AND METHYLATION CAPACITY

ISEE-291 Introduction: Individual differences in the biotransformation of arsenic have has been hypothesized to be a factor in arsenic related disease. Recently there has been a suggestion that the metabolism and methylation of arsenic is a toxification pathway rather than a detoxification pathway. The methylated metabolites of arsenic are thought to be more toxic than originally categorized. Aim: We examined whether polymorphisms in GSTT1, GSTP1 and GSTM1 were associated with primary (MMA monomethylarsonic acid / As III arsenite +As V arsenate) and secondary methylation capacity (DMA dimethylarsinic acid /MMA monomethylarsonic acid). We also examined the association between primary and secondary methylation capacity and development of arsenic related skin lesions and whether this relationship was modified by GSTT1, GSTM1, and GSTP1 polymorphisms. Methods: 592 cases and 597 controls, frequency matched on age and gender, were enrolled at Dhaka Community Hospital, Bangladesh in 2001-2002. Demographic data, toenail and water samples were collected for all subjects. Trained physicians diagnosed skin lesions. Nail and water arsenic levels were determined using ICP-MS EPA Method 200.8. Genotyping was done with multiplex PCR and TaqMan. Statistical analysis was done in SAS version 8.2 and plots in R. Results: While drinking water concentration of arsenic was related to secondary methylation capacity and individual metabolites MMA and DMA, it was not related to primary methylation capacity. Polymorphisms in GSTT1, GSTM1 and GSTP1 did not modify primary or secondary methylation capacity. Betel nut use was significantly associated with secondary methylation capacity. Individual metabolites, DMA and MMA, are associated with arsenic concentration of drinking water; however not associated with the polymorphisms. The odds of developing skin lesions is associated with an increase of secondary methylation capacity, but not primary methylation capacity. Conclusions: GSTT1, GSTM1 and GSTP1 polymorphisms do not impact primary or secondary methylation capacity in the metabolism of arsenic.

First evidence of arsenic phytoremediation

Since the mid-1990s, bioremediation of contaminated soils, groundwater and surface water has been addressed by a new technology – phytoremediation – involving plants and plant–microbe systems. The mechanisms responsible for plant tolerance to a broad spectrum of metals have been studied intensively to determine those characteristics that are essential for application to phytoremediation. However, there is not, as yet, an effective solution for the phytoremediation of arsenic, one of the most noxious metals to humans. Both soil and water arsenic toxicity continues to be reported in many countries. The most dramatic case was reported in Bangladesh, where groundwater concentrations of arsenic reach 2 mg l−1 1 Ullah, S.M. (1998) Arsenic contamination of groundwater and irrigated soils of Bangladesh. Abstract: International Conference on Arsenic Pollution of Groundwater in Bangladesh: Causes, Effects and Remedies, 8–12 February 1998, p. 133, Dhaka Community Hospital, Dhaka, Bangladesh 1Ullah, S.M. (1998) Arsenic contamination of groundwater and irrigated soils of Bangladesh. Abstract: International Conference on Arsenic Pollution of Groundwater in Bangladesh: Causes, Effects and Remedies, 8–12 February 1998, p. 133, Dhaka Community Hospital, Dhaka, Bangladesh; the World Health Organization's provisional guideline value for drinking water is only 0.01 mg l−1 (http://www.who.int/inf-fs/en/fact210.html). It is estimated that the high levels of arsenic in the drinking water will lead to 200 000–270 000 cancer-caused deaths in Bangladesh. Moreover, the use of contaminated irrigation water has led to soil levels of arsenic of ∼80 mg kg−1, which is tenfold higher than levels in soils considered non-contaminated. The consumption of produce from these regions could also be detrimental to living organisms. Agricultural zones facing this type of contamination need to act quickly to achieve safe levels of soil and water arsenic.

Extent and Severity of Groundwater Arsenic Contamination in Bangladesh

In Bangladesh, the majority of the irrigation and drinking water is supplied from underground sources due to the limitation of surface water. In recent years, arsenic contamination has emerged as a fresh blow to the country. This paper gives an overview of the extent and severity of groundwater arsenic contamination in Bangladesh, as well as a review of the latest statistics and findings of numerous investigations about this issue. Recent reports of the British Geological Survey show that the groundwa-ter in all 61 surveyed districts out of 64 is now contaminated with arsenic. On the other hand, a survey report of School of Environmental Studies, Jadavpur University, and Dhaka Community Hospital shows 47 districts are contaminated. The population exposed to the arsenic poisoning through drinking water is more than 25 million. In regard to arsenic pollution, Bangladesh is the most vulnerable country in the world. Unfortunately, until now, the cause of groundwater arsenic contamination has not been detected. Initially, several anthropogenic sources of arsenic were presented. Gradually, all were rejected based on the field observations. Finally, it was recognized that the source of arsenic is in the geological deposits. The two prevailing hypotheses, pyrite oxidation and oxy-hydroxide reduction, describe the cause of contamination. However, neither has been studied thoroughly with accurate field data. Therefore, the verdict is still out whether to support one hypothesis over the other. Thousands of people are suffering from arsenic diseases ranging from melanosis to skin cancer and gangrene, and many have even died. Unfortunately, there is no specific treatment for chronic arsenicosis, other than ceasing further intake of arsenic contaminated water. To overcome this predicament, awareness of the problem and the creation of watershed management are necessary.

Arsenic in groundwater and health problems in Bangladesh

Arsenic is listed as a hazardous material and is a suspect carcinogen, reportedly responsible for lung and skin cancers. It is also a teratogen, which means that it is capable of crossing the placental membrane into the metabolic system of unborn children. The level of arsenic allowed in drinking water has been set at 0.01 mg/l by the World Health Organization (WHO). However, the maximum permissible limit of arsenic in drinking water of Bangladesh is 0.05 mg/l. The actual toxicity of arsenic to the human body varies depending on several factors as general health and diet. It is a cumulative substance, which slowly passes out of the body through urine, hair, fingernails/toenails and skin. In Bangladesh, most of the recognized stages of arsenic poisoning have been identified. The risk of arsenic poisoning in Bangladesh is increasing. The number of patients seriously affected by arsenic in drinking water has now risen to 7000 demanding extensive research in this field. This note addresses tubewell contamination in groundwater and health-related impacts. A previous study made by the author presents the subsurface occurrence of arsenic and the reason of contamination. The latest statistics available on the arsenic contamination in groundwater indicate that 52 districts around 80% of the total area of Bangladesh and estimate that around 40 million people are at risk. Patients with melanosis, leuco-melanosis, keratosis, hyperkeratosis, dorsum, non-petting oedema, gangrene and skin cancer have been identified. Among the affected people, the most common presentations are melanosis (93.5%), keratosis (68.3%), hyperkeratosis (37.6%) and dipigmentation (leuco-melanosis) (39.1%). Cancers were found among 0.8% and actinic keratitis and Bowen's disease are identified among 3.1% cases. According to available data the Dhaka Community Hospital (DCH) identified 1903 patients with arsenical skin manifestations, the National Institute for Preventive and Social Medicine (NIPSOM) listed 800 arsenicosis patients and the Institute for Post-Graduate Medical Research (IPGMR) investigated 250 arsenical skin lessions patients.

Status of arsenic hazards in Bangladesh as of June 1997 : By the news of Dhaka Community Hospital(Think of Arsenic Contamination Problems in Asia)

Status of arsenic hazards in Bangladesh as of June 1997 : By the news of Dhaka Community Hospital(Think of Arsenic Contamination Problems in Asia)