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Keywords:

  • Bangladesh;
  • urban;
  • children;
  • diarrhoea;
  • slum
  • Bangladesh;
  • urbain;
  • enfants;
  • diarrhée;
  • bidonville
  • Bangladesh;
  • urbana;
  • niños;
  • diarrea;
  • tugurios

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Objectives

To determine and compare socio-demographic, nutritional and clinical characteristics of children under five with diarrhoea living in slums with those of children who do not live in slums of Dhaka, Bangladesh.

Methods

From 1993 to 2012, a total of 28 948 under fives children with diarrhoea attended the Dhaka Hospital of icddr,b. Data were extracted from the hospital-based Diarrhoea Disease Surveillance System, which comprised 17 548 under fives children from slum and non-slum areas of the city.

Results

Maternal illiteracy [aOR = 1.57; 95% confidence interval (1.36, 1.81), P-value <0.001], paternal illiteracy [1.37 (1.21, 1.56) <0.001], mother's employment [1.59 (1.37, 1.85) <0.001], consumption of untreated water [2.73 (2.26, 3.30) <0.001], use of non-sanitary toilets [3.48 (3.09, 3.93) <0.001], 1st wealth quintile background [3.32 (2.88, 3.84) <0.001], presence of fever [1.14 (1.00, 1.29) 0.047], some or severe dehydration [1.21 (1.06, 1.40) 0.007], stunting [1.14 (1.01, 1.29) 0.030] and infection with Vibrio cholerae [1.21 (1.01, 1.45) 0.039] were significantly associated with slum-dwelling children after controlling for co-variates. Measles immunisation [0.52 (0.47, 0.59) P < 0.001] and vitamin A supplementation rates [0.36 (0.31, 0.41) P < 0.001] amongst children 12–59 months were lower for slum dwellers than other children in univarate analysis only.

Conclusions

Slum-dwelling children are more malnourished, have lower immunisation rates (measles vaccination and vitamin A supplementation) and higher rates of measles, are more susceptible to diarrhoeal illness due to V. cholerae and suffer from severe dehydration more often than children from non-slum areas. Improved health and nutrition strategies should give priority to children living in urban slums.

Objectifs

Déterminer et comparer les caractéristiques sociodémographiques, nutritionnelles et cliniques des enfants de moins de 5 ans souffrant de diarrhée et vivant dans les bidonvilles avec celles des enfants ne vivant pas dans des bidonvilles à Dhaka, au Bangladesh.

Méthodes

De 1993 à 2012, un total de 28 948 enfants de moins de cinq ans souffrant de diarrhée ont visité l'hôpital de Dhaka de l'icddr,b. Les données ont été extraites du Système de Surveillance des Maladies Diarrhéiques en milieu hospitalier, qui comprenait 17 548 enfants de moins de cinq ans des bidonvilles et autres zones de la ville.

Résultats

L'analphabétisme maternelle [ORa = 1.57; intervalle de confiance à 95% (1.36–1.81), P < 0.001], l'analphabétisme paternelle [1.37 (1.21–1.56) < 0.001], l'emploi de la mère [1.59 (1.37–1.85) < 0.001], la consommation d'eau non traitée [2.73 (2.26–3.30) < 0.001], l'utilisation de toilettes non hygiéniques [3.48 (3.09–3.93) < 0.001], appartenir au 1er quintile de richesse [3.32 (2.88–3.84) < 0.001], la présence de la fièvre [1.14 (1.00–1.29) 0.047], la déshydratation sévère ou quelconque [1.21 (1.06–1.40) 0.007], le retard de croissance [1.14 (1.01–1.29) 0,030] et l'infection à Vibrio cholerae [1.21 (1.01–1.45) 0.039] étaient significativement associés pour les enfants des bidonvilles après ajustement pour les covariables. La vaccination contre la rougeole [0.52 (0.47–0.59) P < 0.001] et la supplémentation en vitamine A [0.36 (0.31–0.41) P < 0.001] chez les enfants de 12 à 59 mois étaient moins élevées chez les habitants des bidonvilles que chez les autres enfants dans l'analyse univariée seule.

Conclusions

Les enfants des bidonvilles sont plus mal nourris, ont des taux inférieurs de vaccination (vaccination contre la rougeole et supplémentation en vitamine A) et des taux plus élevés de rougeole, sont plus sensibles à la maladie diarrhéique due à V. cholerae et souffrent de déshydratation sévère plus souvent que les autres enfants. Des stratégies de santé et de nutrition améliorées devraient donner la priorité aux enfants vivant dans les bidonvilles.

Objetivos

Determinar y comparar las características sociodemográficas, nutricionales y clínicas de niños menores de 5 años con diarrea viviendo en tugurios con las de niños provenientes de otras zonas de Dhaka, Bangladesh.

Métodos

Entre 1993–2012, un total de 28 948 menores de cinco años con diarrea fueron atendidos en el Hospital de Dhaka de icddr,b. Se extrajeron datos del sistema hospitalario de vigilancia de la enfermedad diarreica, con datos de 17 548 menores de cinco años viviendo en tugurios y en otras áreas de la ciudad.

Resultados

El analfabetismo materno [aOR = 1.57; IC 95% (1.36, 1.81), P < 0.001], el analfabetismo paterno [1.37 (1.21, 1.56) < 0.001], el empleo materno [1.59 (1.37, 1.85) < 0.001], el consumo de agua sin tratar [2.73 (2.26, 3.30) < 0.001], el uso de letrinas inadecuadas [3.48 (3.09, 3.93) < 0.001], el 1er quintil de riqueza [3.32 (2.88, 3.84) < 0.001], la presencia de fiebre [1.14 (1.00, 1.29) 0.047], alguna deshidratación o deshidratación severa [1.21 (1.06, 1.40) 0.007], la hipotrofia nutricional [1.14 (1.01, 1.29) 0.030], o la infección con Vibrio cholerae [1.21 (1.01, 1.45) 0.039] estaban significativamente asociadas con los niños viviendo en tugurios después de controlar para covariables. Las tasas de inmunización para sarampión [0.52 (0.47, 0.59) P < 0.001] y la suplementación con vitamina A [0.36 (0.31, 0.41) P < 0.001] de niños con 12-59 meses, era menor entre quienes habitaban en tugurios que entre otros niños, solo en un análisis univariado.

Conclusiones

Los niños viviendo en tugurios están más desnutridos, tienen menores tasas de inmunización (vacuna de sarampión y suplementación con vitamina A) y mayores tasas de sarampión, son más susceptibles a la enfermedad diarreica por V. cholerae y sufren de deshidratación severa más a menudo que los niños de otras zonas de la ciudad. Las estrategias para realizar mejoras sanitarias y nutricionales deberían priorizar a los niños que viven en tugurios.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

People living in slums have little or no access to services such as water sanitation, proper drainage and waste disposal (http://www.eminence-bd.org/index.php?option=com_content&view=article&id=106&Itemid=90). Waterborne diseases such as diarrhoea, especially cholera, dysentery, and typhoid are common problems in the lower socio-economic stratum (Firdaus 2012). Environmental characteristics and behavioural practices have been identified as risk factors for diarrhoea in developing countries (Stanton & Clemens 1987; Ahmed et al. 1994; Shobha et al. 2013; Tumwebaze et al. 2013). In Kampala, Uganda, 60% of the slum dwellers used shared toilets, and half of the respondents (52%) were not satisfied with their facilities primarily due to lack of cleanliness and excess demand (Tumwebaze et al. 2013). In Western India, 44% of urban slum households practice open defecation (Khatun et al. 2012). In Bangladesh, approximately 5.7 million people live in urban slums (Climate Change Drives Rural-Urban Migration to Dhaka's Slums's 2012; Farthing et al. 2013).

Diarrhoeal disease-related mortality amongst under-five children has fallen globally, but morbidity remains unchanged (Korkes et al. 2009). High infant mortality and morbidity rates are well-documented, and aetiologic infections are a common problem amongst slum-dwelling children (Gupta et al. 1991; Ellis et al. 2007; Vaid et al. 2007). Substandard living conditions, such as lack of safe drinking water, poor sanitation, ineffective waste disposal, intrusion by disease vectors (insects and rats) and inappropriate food storage are the main causes of the spread of infectious diseases (Firdaus 2012). Access to improved water and sanitation is an effective preventive measure to reduce the burden of diarrhoeal illnesses (Tumwebaze et al. 2013). Lack of these facilities exposes slum-dwelling children to a highly contaminated environment that renders them vulnerable to repeated infections resulting in growth faltering and poor immune status (Stoll et al. 1985; Climate Change Drives Rural-Urban Migration to Dhaka's Slums's 2012). Hence because of their socio-economic, environmental, health and nutritional conditions slum-dwelling children may differ from other children, particularly those from non-slum areas.

The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has maintained a Diarrhoeal Disease Surveillance System (DDSS) in Dhaka Hospital since 1979. The system systematically enrols patients reporting to the triage area regardless of age, sex, nutritional status and socio-demographic status (WHO 1995). Detailed socio-demographic, epidemiologic and clinical characteristics of patients including housing and water sanitation information are also recorded prospectively. Such information is lacking in the literature for the children presenting from urban slums with diarrhoeal illnesses. The electronic database of DDSS gave the opportunity to analyse these data for slum-dwelling infants and toddlers attending Dhaka Hospital due to diarrhoeal illnesses. We aimed to describe the clinical, epidemiological and aetiological profile of under-fives from slums of urban Bangladesh and compare the results with those of children from non-slum areas of urban Dhaka.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Study location

Dhaka Hospital of icddr,b, was established in 1962 and provides free treatment mostly to the poor urban population of Dhaka, the capital of Bangladesh. Each year, the facility treats approximately 140 000 people; 60% of them are children <5 years old.

Sample selection

Between 1993 and 2012, a total of 28 948 under-fives were included in the DDSS of icddr,b. This analysis is composed of children from slum and non-slum areas. Slum children are the group of interest because they are frequently the most impoverished children. We hypothesised that slum children presenting to the facility with diarrhoeal illnesses differ in various characteristics from children from non-slum areas. Excluding children from residential and rural areas, the analysable sample for our analysis comprised 17 548 under-fives from slum and non-slum areas.

Definitions

Diarrhoea was defined as three or more abnormally loose or watery stools during the previous 24 h (Zverev 2001). Stunting was defined as [height-for-age z-score (HAZ) <−2.00SD], wasting [weight-for-height z-score (WHZ) <−2.00SD], and underweight [weight-for-age z-score (WAZ) <−2.00SD] as per WHO guidelines (Center for Disease Control, Coordinating Center for Infectious Diseases/Division of Bacterial & Mycotic Diseases 2005).

Urban slum was defined as an area of the city where (i) poor individuals live in semi-durable housing, (ii) one room is usually shared by more than three people, (iii) there is limited access to safe water, (iv) public toilets are used by an average of 10 families with 30–35 members each, (v) and inhabitants have some protection against forced eviction. Slum housing is usually constructed by the inhabitants, mostly of bamboo or, in some cases, corrugated tin (http://www.eminence-bd.org/index.php?option=com_content&view=article&id=106&Itemid=90; http://www.cpc.unc.edu/measure/publications/tr-08-68; http://www.unhabitat.org/documents/media_centre/sowcr2006/SOWCR%205.pdf). Common characteristics of slum dwellers are poverty, poor quality housing, overcrowding, lack of access to health care services and unhealthy environment. Figure 1 shows slum and non-slum areas of Dhaka city.

image

Figure 1. Slum and non-slum areas of Dhaka.

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Non-slum area was defined as an area with small, low-cost houses, where dwellers are mostly tenants and 2–3 families with 10–15 members each share a toilet and water supply. Non-slum housing consists mostly of permanent structures of concrete or brick, usually built to a design (http://www.eminence-bd.org/index.php?option=com_content&view=article&id=106&Itemid=90; http://www.cpc.unc.edu/measure/publications/tr-08-68).

Ethics

The DDSS of icddr,b is a routine ongoing activity of the Dhaka Hospital approved by the Research Review Committee and Ethical Review Committee of icddr,b. As DDSS is part of standard medical care, at the time of enrolment, verbal rather than written consent is given by caregivers or guardians on behalf of the patient or by the patient himself. This has also been approved by the Research Review Committee and Ethical Review Committee of icddr,b.

Data analysis

Statistical analyses were performed using Statistical Package for Social Science (SPSS, Chicago, IL version 15.5) and Epi Info (Version 6.0, USD, Stone Mountain, GA). For categorical variables, differences in the proportion were compared by chi-square test and strengths of associations were estimated by calculating the odds ratios (OR) and their 95% confidence intervals (CI). Comparative statistics were done for all explainable socio-demographic characteristics, nutritional, and immunisation status between children of slum dwellers and the non-slum population. It was also equated for clinical characteristics and aetiologies of diarrhoea. Finally, backward step-wise logistic regression analysis was performed to examine the association between independent variables of interest and outcome variable (slum dwellers = 1 and non-slum areas = 0) after adjusting for co-variates with the probability of exclusion at P = 0.10.

We used a wealth index as a measure of socio-economic status (SES) using information on household possessions. Variables included were construction material of the wall, roof and floor of the house and household assets (electricity, radio, television, fan, almirah, luxury cot, ordinary cot, gas for cooking). The categories for construction materials of the walls, roof, and floor of the house comprised ‘brick/cemented’ and ‘not brick/cemented’. For household assets, categories for each item were ‘owned’ or ‘not owned’ by the household. Principal component analysis (factor analysis) facilitated understanding of the wealth index. A weight was attached to each item from the first principal component. Households were classified into five SES quintiles based on the wealth index (http://www.cpc.unc.edu/measure/publications/tr-08-68; http://www.icddrb.org/what-we-do/publications/cat_view/52-publications/10042-icddrb-periodicals/ 10048-health-and-science-bulletin-bangla-and-english/14036-vol-10-no-1-english-2012/14039-inequity-in-utilization-of-maternal-health-services-a-challenge-for-achieving-millennium-development-goal-5-in-bangladesh">http://www.icddrb.org/what-we-do/publications/cat_view/52-publications/10042-icddrb-periodicals/10048-health-and-science-bulletin-bangla-and-english/14036-vol-10-no-1-english-2012/14039-inequity-in-utilization-of-maternal-health-services-a-challenge-for-achieving-millennium-development-goal-5-in-bangladesh">http://www.icddrb.org/what-we-do/publications/cat_view/52-publications/10042-icddrb-periodicals/ 10048-health-and-science-bulletin-bangla-and-english/14036-vol-10-no-1-english-2012/14039-inequity-in-utilization-of-maternal-health-services-a-challenge-for-achieving-millennium-development-goal-5-in-bangladesh).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The median age was 12 months for slum-dwelling children and 10 months for the non-slum children; this difference was statistically significant (P < 0.001). 60% were male in the both areas. Compared with children from non-slum areas, children from slums came from smaller families (≤5) (72% vs. 66%, P < 0.001), had less-educated parents [paternal (68% vs. 24%, P < 0.001); maternal (79% vs. 30%, P < 0.001)], higher rates of maternal employment (25% vs. 11%, P < 0.001), came from the 1st (47% vs. 4%, P < 0.001) and 2nd (35% vs. 12%, P < 0.001 ) wealth quintiles, drank water from tube wells, ponds, rivers and ditches (27% vs. 14%, P < 0.001), drank untreated water (93% vs. 52%, P < 0.001) and were more likely to use non-sanitary toilets (74% vs. 18%, P < 0.001). Slum children more frequently reported with vomiting, fever, some or severe dehydration which required IV rehydration and required longer average hospitalisation (≥24 h). 37% of fathers of slum-dwelling children were rickshaw pullers.

A history of measles within 6 months (7% vs. 6%, P = 0.008) and diarrhoeal deaths after hospitalisation (0.9% vs. 0.4%, P < 0.001) were more often reported for slum-dwelling children. They were on average more underweight (71% vs. 42%, P < 0.001), stunted (61% vs. 36%, P < 0.001) and wasted (47% vs. 25%, P < 0.001) than non-slum children. A higher proportion of children from slum areas under 2 years were breastfed than non-slum children (90% vs. 84%, P < 0.001). Measles immunisation (69% vs. 86%, P < 0.001) and vitamin A supplementation rates (46% vs. 61%, P < 0.001) amongst children 12–59 months old from urban slums were lower than amongst children from non-slum areas. Shigella (7% vs. 6%, P < 0.001), Vibrio cholerae (13% vs. 9%, P < 0.001) and Entamoeba histolytica (0.5% vs. 0.2%, P = 0.016) infections were more common amongst slum-dwelling children, whereas rotavirus infections (29% vs. 35%, P < 0.001) were more commonly reported amongst children from non-slum areas (Table 1).

Table 1. Characteristics of under-five diarrhoeal children from slum and non-slum areas during 1993–2012
IndicatorsSlum; n = 2918 (%)Non-slum; n = 14 630 (%)OR (95% CI) P-value
  1. HPF, High power field.

Male sex1736 (59.5)8780 (60.0)0.98 (0.90, 1.06) 0.614
Small family size (≤5)2090 (71.6)9692 (66.2)1.29 (1.18, 1.40) <0.001
Paternal illiteracy1993 (68.3)3474 (23.8)6.32 (6.34, 7.55) <0.001
Maternal illiteracy2309 (79.1)4315 (29.5)9.06 (8.23, 9.98) <0.001
Mothers with employment715 (24.7)1570 (10.8)2.72 (2.46, 3.01) <0.001
Used non-tap water786 (26.9)1970 (13.5)2.37 (2.15, 2.61) <0.001
Drink untreated water2709 (93.3)7436 (51.7)12.96 (11.14, 15.09) <0.001
Used non-sanitary toilet2144 (73.5)2581 (17.6)12.93 (11.78, 14.20) <0.001
Socio-economic background
1st1382 (47.4)582 (4.0)21.74 (19.44, 24.32) <0.001
2nd1019 (35.0)1801 (12.3)3.65 (3.33, 4.00) <0.001
3rd397 (13.6)2625 (18.0)0.72 (0.64, 0.81) <0.001
4th94 (3.2)4191 (28.7)0.08 (0.07, 0.10) <0.001
5th22 (0.8)5411 (37.0)0.01 (0.01, 0.02) <0.001
Vomiting2319 (79.5)10 935 (74.7)1.31 (1.19, 1.44) <0.001
Fever283 (9.7)1171 (8.0)1.23 (1.07, 1.42) 0.002
Duration of diarrhoea (≥24 h)2181 (74.7)11 000 (75.2)0.98 (0.89, 1.07) 0.628
Duration of hospitalisation (≥24 h)1405 (50.8)5127 (36.1)1.83 (1.68, 1.99) <0.001
Some or severe dehydration1155 (39.6)4330 (29.6)1.56 (1.43, 1.69) <0.001
Use of intravenous (IV) rehydration method543 (18.7)1505 (10.3)2.00 (1.79, 2.23) <0.001
Death25 (0.9)53 (0.4)2.44 (1.47, 4.02) <0.001
History of measles within 6 months207 (7.1)848 (5.8)1.24 (1.06, 1.46) 0.008
Received vitamin A within last 6 months (children aged 12–59 months)685 (45.5)3807 (61.4)0.52 (0.47, 0.59) <0.001
Measles immunisation (children aged 12–59 months)1043 (69.3)5337 (86.4)0.36 (0.31, 0.41) <0.001
Breastfeeding status (children aged 0–23 months)1975/2187 (90.3)10 430/12 387 (84.2)1.75 (1.50, 2.04) <0.001
Stunted1747 (61.2)9286 (35.6)2.86 (2.63, 3.11) <0.001
Underweight2037 (71.1)6011 (41.6)3.45 (3.16, 3.77) <0.001
Wasted1336 (46.9)3609 (25.1)2.64 (2.43, 2.87) <0.001
Rotavirus812 (28.6)5042 (35.1)0.74 (0.68, 0.81) <0.001
Shigella 216 (7.4)810 (5.5)1.36 (1.16, 1.60) <0.001
ETEC220 (11.3)1094 (10.0)1.16 (0.99, 1.35) 0.071
Vibrio cholerae 384 (13.2)1262 (8.6)1.61 (1.42, 1.82) <0.001
Giardia lamblia 20 (0.7)92 (0.7)1.07 (0.64, 1.78) 0.871
Entamoeba histolytica15 (0.5)34 (0.2)2.19 (1.14, 4.16) 0.016
Pus cell (11 to >50/HPF)1098 (41.2)4851 (36.9)1.20 (1.10, 1.30) <0.001
RBC (1 to >50/HPF)508 (19.1)2380 (18.1)1.06 (0.96, 1.19) 0.257
Macrophage (1–10/HPF)363 (13.6)1792 (13.6)1.00 (0.88, 1.13) 0.990

Significant associations were found between living areas (slum = 1, non-slum = 0) and maternal illiteracy [aOR = 1.57; 95% confidence interval (1.36, 1.81), P-value <0.001], paternal illiteracy [1.37 (1.21, 1.56) <0.001], mother's employment status [1.59 (1.37, 1.85) <0.001], consumption of untreated water [2.73 (2.26, 3.30) <0.001], use of non-sanitary toilets [3.48 (3.09, 3.93) <0.001], 1st wealth quintile background [3.32 (2.88, 3.84) < 0.001], presence of fever [1.14 (1.00, 1.29) 0.047] and some or severe dehydration [1.21 (1.06, 1.40) 0.007], stunting [1.14 (1.01, 1.29) 0.030] and infection with Vibrio cholerae [1.21 (1.01, 1.45) 0.039]. The significance of these associations was retained in multivariate analysis after controlling for the potential confounders family size (≤5), use of non-tap water, presence of vomiting, duration of hospitalisation (≥24 h), use of intravenous (IV) rehydration, history of measles within 6 months, fatal outcome, infections with rotavirus, Shigella, and Entamoeba histolytica and Pus cell (11 to >50/high power field) (Table 2).

Table 2. Characteristics of diarrhoeal children from slums and non-slum areas of urban Bangladesh, 1993–2012
IndicatorsAdjusted OR, (95% CI) P-value
  1. OR, Odds ratio; CI, confidence interval. Outcome variables: maternal illiteracy, paternal illiteracy, employment of mothers, no treatment of drinking water, use of non-sanitary toilet, wealth index, presence of fever, some or severe dehydration, history of measles within 6 months, stunting, and infection with Vibrio cholerae.

  2. Main exposure: Living area, slum vs. non-slum area.

  3. Adjusted factors: family size (≤5), use of non-tap water, infections with rotavirus, shigella, and Entamoeba histolytica, pus cell (11 to >50/HPF), presence of vomiting, duration of hospitalisation (≥24 h), use of intravenous (IV) saline as rehydration method, and fatal outcome of child.

Maternal illiteracy (1 = illiterate, 0 = literate)1.57 (1.36, 1.81) <0.001
Paternal illiteracy (1 = illiterate, 0 = literate)1.37 (1.21, 1.56) <0.001
Mothers employment status (1 = yes, 0 = no)1.59 (1.37, 1.85) <0.001
No treatment of drinking water (1 = non treatment, 0 = boiled)2.73 (2.26, 3.30) <0.001
Use of non-sanitary toilet (1 = non-sanitary toilet, 0 = sanitary toilet)3.48 (3.09, 3.93) <0.001
Wealth index (4 = 1st, 3 = 2nd, 2 = 3rd, 1 = 4th, 0 = 5th)
1st3.32 (2.88, 3.84) <0.001
2nd0.33 (0.29, 0.39) <0.001
3rd0.08 (0.06, 0.10) <0.001
4th0.03 (0.02, 0.05) <0.001
5th
Fever (1 = yes, 0 = no)1.14 (1.00, 1.29) 0.047
Dehydration (1 = some or severe, 0 = no sign of dehydration)1.21 (1.06, 1.40) 0.007
Measles (1 = yes, 0 = no)1.23 (0.98, 1.55) 0.074
Stunted (1 = stunted, 0 = normal)1.14 (1.01, 1.29) 0.030
Vibrio cholerae (1 = yes, 0 = no)1.21 (1.01, 1.45) 0.039

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

In developing countries, urbanisation is an accelerating trend. Rural–urban migration leads to the creation of informal settlements which leave vulnerable populations marginalised. These are areas where basic amenities such as drinking water, sanitation, drainage and waste disposal facilities are lacking (Firdaus 2012). Approximately half of slum dwellers belong to poor socio-economic strata, and their children are at higher risk of diarrhoeal disease than children from other housing areas. Our analysis indicates that parental illiteracy is higher amongst slum-dwelling children, with fathers commonly being unskilled, low-wage workers such as rickshaw pullers, industrial workers and day labourers. Mothers are frequently engaged in income-earning activities, which reduce the amount of time dedicated to child care (Unger 2013). This lack of care, compounded by a highly contaminated environment, might be responsible for higher rates of infection amongst slum-dwelling children. Infection due to Vibrio cholerae was more often reported for slum-dwelling children, which could explain the higher proportion amongst them presenting with severe dehydration requiring immediate intravenous rehydration. Higher fatality rates amongst slum children could be explained by the combination of severe disease caused by large inoculum size found in slum environments and malnutrition (Chowdhury et al. 2011; Sayem et al. 2011).

Vitamin A is known to reduce the severity of infections such as measles and diarrhoeal diseases in children (Ghosh & Shah 2004). Lack of immunisation and vitamin A supplementation along with a higher proportion of children with malnutrition might be the factors that are influencing the higher rates of such diseases amongst slum children. In both this study and the literature, it has been observed that fewer slum-dwelling children receive measles immunisation and vitamin A supplementation (Ghosh & Shah 2004).

Children from slums were more underweight, stunted and wasted than non-slum area children. Only stunting remained significant in multivariate model. The malnutrition could be associated with inappropriate infant feeding practices, impaired uptake of nutrients due to infections and parasites, inadequate food and health security, poor environmental conditions and lack of proper child care (Varadharajan et al. 2013). Simultaneous poverty and undernutrition, and poor childhood growth may be due to poor dietary quality, deficiency of micronutrients, and lack of immunisation and vitamin A supplementation (Chopra et al. 2012). Slum dwellers are predominantly migrants from rural areas. Rural to urban migration is frequently associated with low wage, informal employment facilitating conditions of food insecurity (Firdaus 2012; Mahmud et al. 2012).

Changes in the pattern of diarrhoeal disease seen at the hospital over the years (Table 3) are a decrease in the proportion of older children aged 24–59 months, an increase in the proportion of under-fives presenting with some or severe dehydration, and an increase in the proportion of children reporting with rotavirus diarrhoea. No changes were observed for case fatalities, age distribution (0–11 and 12–23 months) and the proportions of children presenting with cholera and shigellosis.

Table 3. Characteristics of under-five children with diarrhoea attending Dhaka Hospital of icddr,b between 1993 and 2012
YearOf theseConfirmed pathogens
Annual total of casesAged 24–59 monthsSome/severe dehydrationDiedVCO1 Shigella Rotavirus
199324995796472197261486
1994241449359022271194637
1995259246570714279192505
19961317238331813083407
19971309242300721971458
19981621341438832194495
19991382186299612058636
200013231683621111585585
2001110213538037470465
20021155165438611782498
20031096163465910278446
20041114212518713962438
20051091196481315957459
20061045164430311845461
20071148199567111032459
2008119815055747846497
20091236212500112542537
2010134518343768943550
2011129715738104635573
2012166417950226341708

Some positive changes have also been documented. A higher proportion of slum dwellers had a smaller family size, demonstrating the achievements of birth control. Mothers in slums may have gathered knowledge from mothers of a better socio-economic background, as many of them work as maid servants in well-off families (Varadharajan et al. 2013). Inclusion of women in the workforce results in smaller families and improves women's self-efficacy and empowerment (Chopra et al. 2012).

This study was conducted in an urban hospital of Bangladesh; respondents were mothers who presented with their children having diarrhoea. They may not be representative of the greater population. Our findings are from a descriptive study and have generated several hypotheses; future studies could examine the time dimension. Our respondents were asked about their address, then whether they were slum dwellers or not. Interviewers were familiar with the locations of slums in Dhaka and queries about slum dwellings were cross-checked.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Slum-dwelling children are more malnourished, have lower immunisation rates (measles vaccination and vitamin A supplementation), higher rates of measles, are often susceptible to diarrhoeal illnesses due to V. cholerae and have higher rates of severe dehydration than children of non-slum areas. Improved health and nutrition strategies should prioritise urban slum-dwelling children. Mass sanitation programmes especially for slum dwellers are highly recommended, as this population can be easily accessed for any intervention.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Hospital surveillance was funded by icddr,b and the Government of the People's Republic of Bangladesh through IHP-HNPRP. icddr,b acknowledges with gratitude the commitment of the Government of the People's Republic of Bangladesh for their research efforts. icddr,b also gratefully acknowledges the following donors who provide unrestricted support to the Centre's research efforts: the Australian Agency for International Development, the Government of the People's Republic of Bangladesh, the Canadian International Development Agency, the Swedish International Development Cooperation Agency, the Swiss Agency for Development and Cooperation and the Department for International Development, UK.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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