Mustafa Mahfuz

Background: Lead is a cumulative environmental toxicant for which no safe level of exposure has been identified, and pregnant women and their fetuses are particularly vulnerable because lead readily crosses the placenta and can be mobilised from maternal bone stores. Bangladesh conducted its first nationally representative blood lead testing among pregnant women through the 2025 Multiple Indicator Cluster Survey (MICS), but a detailed, multi-domain analysis of the determinants of elevated blood lead level (BLL) among this population has not yet been reported. Methods: We conducted a secondary cross-sectional analysis of 1,928 pregnant women aged 15– 49 years with complete data from the women’s dataset of Bangladesh MICS 2025. Elevated BLL was defined as ≥5 μg/dL. Survey-weighted logistic regression was used to estimate unadjusted and adjusted odds ratios (aOR) for co-exposure to arsenic, cadmium and mercury and sociodemographic and socioeconomic covariates. Slope Index of Inequality (SII) as well as Relative Index of Inequality (RII) were used to quantify wealth-related inequality. Population attributable fractions (PAF) were estimated for three counterfactual scenarios, and adaptive least absolute shrinkage and selection operator (LASSO) regression was used as a sensitivity analysis. Results: Elevated BLL was present among 6.2% of participants. In the adjusted model, a 2-fold rise in blood cadmium was associated with higher odds of elevated BLL (aOR: 1.54; 95% CI: 1.21–1.96), whereas a 2-fold rise in blood mercury (aOR: 0.63; 95% CI: 0.48–0.83), rural residence (aOR: 0.55; 95% CI: 0.32–0.94), secondary education (aOR: 0.49; 95% CI: 0.28–0.85) and post-secondary education (aOR: 0.22; 95% CI: 0.11–0.46) were associated with lower odds. Belonging to progressively wealthier quintiles was associated with markedly higher odds, BLL rising to an aOR of 10.32 (95% CI: 4.41–24.15) for the richest versus poorest quintile. The RII was 8.59 (95% CI: 4.24–17.40) and the SII was 0.159 (95% CI: 0.101–0.218), indicating a substantial pro-rich gradient in elevated BLL. Counterfactual scenarios suggested that shifting the population to secondary-level education could reduce the prevalence of elevated BLL by 52.9% (95% CI: 20.6–72.0) and shifting to rural residence by 24.3% (95% CI: 1.4–41.9). Adaptive LASSO variable selection produced estimates consistent in direction and magnitude with the fully adjusted model. Conclusion: In this national sample, approximately one out of every 16 pregnant women had blood lead levels that met or exceeded the action threshold set by the World Health Organization, with this issue being particularly prevalent among wealthier, urban, and less-educated women, and was compounded by co-exposure to cadmium. In Bangladesh, the typical pattern observed for maternal and child health indicators does not align with the inverse relationship found between household wealth and lead exposure. This suggests that the sources of exposure are not merely indicators of material poverty. Antenatal blood lead screening, source investigation, and equity-informed lead-reduction strategies that specifically reach wealthier and urban households are warranted.

Background: Given the well-documented risks of undernutrition, micronutrient deficiencies and adverse health outcomes associated with poor dietary quality, we examined the effect of behaviour change communication (BCC) on dietary diversity (DD) among adolescent girls in a resource-poor urban setting. Methods: We conducted a quasi-experimental study with an embedded qualitative component to contextualise quantitative findings. We enrolled 700 adolescent girls aged 11–17 years (350 intervention and 350 comparison) in Bauniabadh, Mirpur, Dhaka, Bangladesh between April 2022 and November 2023. We also conducted focus group discussions (FGD) with 22 parents from intervention areas. The intervention group received two times-monthly BCC sessions for 6 consecutive months, along with zinc and iron-folic acid supplementation; the comparison group received no intervention. We assessed the primary outcome as change in DD using the Women’s DD Score. Secondary outcomes included household DD, haemoglobin level and nutrition knowledge. We estimated intervention effects using difference-in-difference (DID) analysis implemented in R (V.4.4.2) and analysed qualitative data using thematic content analysis. Results: The mean (SD) age of participants was 13.5 (1.7) years, and approximately half were enrolled in secondary education. The median (IQR) family income was US$212.9 (158.4 to 280.6). Knowledge on health and nutrition improved significantly at endline in the intervention group. DID analysis showed a significant increase in the haemoglobin levels in the intervention group (adjusted coefficient (aCoeff.): 0.60, 95% CI 0.44 to 0.76, p value <0.001). We observed no significant change in DD (AOR: 0.09, 95% CI −0.06 to 0.23, p value=0.263). FGD indicated that rising food prices constrained parental purchasing power. Conclusion: Community-based BCC with supplementation improved knowledge and haemoglobin level but did not improve DD among adolescent girls. Achieving sustainable nutritional gains requires integrated strategies that combine nutrition education with improved household food security, affordability and active parental engagement in similar resource-poor settings. Trial registration number: NCT05311436 .

Background: Undernutrition during pregnancy is a major public health issue and may lead to negative pregnancy outcomes. The body mass index (BMI), considered widely used as the reference method for assessing nutritional status due to its established population-based cut-off points; however, it can be misleading in pregnancy. This study aimed to validate the mid-upper arm circumference (MUAC) as a screening tool for identifying undernourished pregnant women (PW) in an urban slum, compared to BMI. Methods: Data for this analysis were extracted from studies conducted in Bauniabadh, a slum located in Dhaka, Bangladesh. The final sample size was 375 PW aged 15-39 years with a gestational age of <14 weeks. The first recorded weight during enrolment was considered a proxy for pre-pregnancy weight. Participants were classified as undernourished or well-nourished accordingly. The BMI Z-scores for adolescents and the BMI categories for adult women were used to define undernutrition. Receiver operating characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC), sensitivity, specificity, predictive values, and likelihood ratios. BMI-MUAC concordance was analyzed using McNemar’s test to determine optimal MUAC cut-offs. Results: Among the candidate MUAC cut-off values, a threshold of <22.5 cm demonstrated high diagnostic accuracy, with 78.1% sensitivity, 92.9% specificity, an AUC of 85.5%, and a positive likelihood ratio (LR+) of 11.0. The alternative threshold of <23.0 cm showed higher sensitivity (84.4%) and AUC (86.9%) but lower specificity (89.4%) and LR+ (7.9). The difference in AUCs between the two thresholds was not statistically significant (p = 0.400). Using the <22.5 cm cut-off, 19.2% of pregnant women were classified as undernourished compared with 17.1% based on BMI. Concordance between MUAC <22.5 cm and BMI-defined undernutrition was satisfactory (p=0.182). Conclusions: MUAC can be considered a simple and effective screening tool for identifying undernutrition in PW. Given its strong diagnostic accuracy, a threshold of <22.5 cm may be a practical alternative to BMI and considered for integration into nutritional programs for PW in Bangladesh.

Environmental Enteric Dysfunction (EED) is a subacute inflammation of the small intestinal (SI) mucosa associated with undernutrition and perturbation of t

Objective: Distress financing (DF) refers to financial strategies adopted by households to secure funds in response to stressor events, potentially leading them into a persistent cycle of poverty. We aimed to estimate the prevalence of DF for food and identify factors associated with it in an urban Bangladeshi slum. Methods: This cross‐sectional study utilised data from the community survey component of the Nutrition for Children, Adolescent Girls and Pregnant Women in Slums of Dhaka City (Nutri‐CAP) study (NCT05311436), conducted in Bauniabadh slum, Dhaka, Bangladesh. The current analysis included 2826 households. Unadjusted logistic regression analyses and a multiple logistic regression model were used to examine associations with DF. A classification and regression tree was constructed to identify household subgroups with differing prevalence of DF. DF included taking loans, mortgaging or selling assets, begging, receiving salary advances, or seeking assistance from relatives. Results: The prevalence of DF was 23.5%, while 73.3% of households were food secure. Higher monthly income was associated with lower odds of DF (adjusted odds ratio [aOR]: 0.88, 95% CI: 0.82–0.94), as was postprimary education of the female household manager (FHM) (aOR: 0.61, 95% CI: 0.46–0.80). Compared with food‐secure households, the odds of DF were higher among mildly (aOR: 28.31, 95% CI: 16.79–47.72), moderately (aOR: 36.96, 95% CI: 27.81–49.14) and severely food‐insecure households (aOR: 53.57, 95% CI: 35.09–81.78). Households with a monthly income < 12,000 BDT and lower FHM’s education had the highest observed prevalence of DF. Conclusion: The findings highlight important socioeconomic and household characteristics associated with DF and may inform the development of targeted policy interventions, particularly for low‐income households and those where the FHM has limited education. Potential measures include conditional cash transfers, education‐based subsidies, livelihood programmes, subsidised food provision and improved housing conditions in slum areas. Trial Registration: ClinicalTrials.gov Identifier: NCT05311436

Background: Subclinical or asymptomatic cryptosporidiosis can contribute to malnutrition in children, especially in environments where the infection is persistent or occurs repeatedly. Despite the absence of symptoms, these infections are associated with impaired growth and nutritional deficiencies, potentially increasing the risk of stunting, wasting, and underweight. This study examined the association between asymptomatic Cryptosporidium infection and nutritional status in children under 2 years old. Methods: This is a secondary analysis of data from the MAL-ED study which is a longitudinal birth cohort study conducted in eight countries: Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and Tanzania, a multi-country investigation of enteric infections and malnutrition. We excluded Pakistan due to the lack of available anthropometric data. Nutritional indicators were assessed using the World Health Organization growth chart,[18] including stunting (length-for-age <-2 standard deviations [SD]), underweight (weight-for-age <-2 SD), and wasting (weight-for-length <-2 SD). Poisson regression estimated Cryptosporidium incidence rates, while GEE (generalized estimation equation) with a binomial family and logit link assessed associations with nutritional indicators, calculating odds ratios. Result: Findings indicate an incidence rate of 7.89 per 100 child-months for asymptomatic Cryptosporidium infections, which are significantly associated with stunting (aOR: 1.32; 95% CI: 1.24–1.41), wasting (aOR: 1.47; 95% CI: 1.08–1.49), and underweight (aOR: 1.47; 95% CI: 1.08–1.49). Incidence was highest in Tanzania (14.35) and Peru (12.55), indicating a hidden burden, while Brazil (1.34) had the lowest. Stunting was strongly associated with infection in India, Peru, and Tanzania, underweight in Bangladesh and Tanzania, and wasting was notably high in Peru. Conclusions: This study highlights the significant burden of asymptomatic Cryptosporidium infections and their potential impact on child growth and nutrition. The strong associations with stunting, wasting, and underweight suggest that even in the absence of symptoms, these infections may contribute to long-term developmental challenges. Furthermore, the differential effects on nutritional outcomes across countries emphasize the importance of targeted strategies to mitigate the hidden consequences of Cryptosporidium infections and improve child health globally.

Objective: Intestinal Alkaline Phosphatase (IAP), expressed by enterocytes, maintains gut homeostasis by promoting commensal microbiota growth and limiting inflammation. Vitamin D strengthens intestinal barrier, and its deficiency is linked to various diseases. This study explores the relationship among IAP, vitamin D, and enteric pathogens in children. Methods: In the MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development) study, 265 newborns were enrolled between February 2010 to February 2012, from Dhaka, Bangladesh. 15-month time point data was collected and analyses, where intestinal pathogens were identified by TaqMan Array Card assay, stool IAP and serum vitamin D level were determined by colorimetric assay and chemiluminescence immunoassay respectively. Multivariable linear regression was performed to determine the association between IAP, vitamin D and gut pathogens. A p-value of Campylobacter-pan Genome (p=0.047), Campylobacter jejuni (p=0.020) and Enterocytozoon bieneusi (p=0.023). Multivariable linear regression analysis revealed a significant and inverse association with the Adenovirus-pan genome (β= -2.00; 95% CI= -3.94, -0.07) and E. bieneusi (β= -3.03; 95% CI= -5.94, -0.11). Conclusion: IAP was inversely and significantly associated with Adenovirus-pan genome and E. bieneusi, a less-explored enteric pathogen, while its relationship with vitamin D was positive but not statistically significant. These findings suggest that IAP may play a protective role against specific enteric pathogens. What is already known on this topic: Intestinal Alkaline Phosphatase (IAP) plays a crucial role in maintenance of gut homeostasis by promoting beneficial microbiota and reducing intestinal inflammation. Vitamin D strengthens the intestinal barrier, and deficiency has been linked to increased risk of infections and various chronic diseases. While both IAP and vitamin D are important in gut health, evidence linking them with specific enteric pathogens in human, especially in children remains limited. What this study adds: This study demonstrates that IAP is inversely and significantly associated with Adenovirus-pan genome and Enterocytozoon bieneusi , a less-explored pathogen in children. It shows that although not statistically significant, IAP levels were positively related to vitamin D These findings provide novel evidence that IAP may play a protective role against specific viral and protozoan enteric infections. How this study might affect research, practice or policy: The results highlight IAP as a potential biomarker of intestinal defense and a candidate for future therapeutic or preventive interventions targeting childhood enteric infections. Insights into IAP–pathogen relationships could guide in the development of microbiome-based or nutritional strategies to reduce diarrheal disease burden, and support the inclusion of IAP as potential intervention in child health and nutrition research in low-resource settings.

Post-COVID syndrome, or long COVID, refers to the long-term health consequences of COVID-19 that can persist for months or even years after recovering from the acute infection [1,2]. Despite a significant decline in COVID-19 cases and the disease no longer being a global health emergency, new cases are still being reported. Between 4–31 March 2024, […]

Malnutrition in the early days of life is a global public health concern that affects children’s growth. It results from a variety of factors, including pathogenic infections. Enterocytozoon bieneusi is a microsporidian parasite that can cause diarrhea and malnutrition in children. The study aimed to assess the impact of E. bieneusi on child growth. The MAL-ED study, a multicountry birth cohort research project, investigated the relationship between enteric infections and malnutrition in participating children from eight countries. A customized real-time polymerase chain reaction-based TaqMan array card was used in this study to identify enteropathogens from stool samples, where E. bieneusi was one of the target pathogens. The impacts of E. bieneusi infection on growth measures were assessed. Mixed-effect linear models were used to investigate the relationship between E. bieneusi and growth outcomes, including length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) Z scores. At the endpoint (last month of measurement), the infected group had significantly lower scores than the noninfected group for all outcomes. The adjusted difference-in-difference (D-in-D) values were −0.53 (95% CI: −0.67 to −0.38) for LAZ, −0.38 (95% CI: −0.52 to −0.23) for WAZ, and −0.22 (95% CI: −0.38 to −0.06) for WLZ. Enterocytozoon bieneusi infection has been identified as a factor associated with reduced linear growth, weight gain, and weight gain relative to linear growth in children, underscoring the importance of treating this infection.

Water, sanitation, and hygiene (WASH) is an imperative issue for infection prevention, and disease control. To understand the existing resources, and WASH situation, a participatory appraisal was conducted at Bauniabadh slum, Mirpur, Dhaka, Bangladesh from February-March 2022, and June-July 2023. Social mapping, transect walk, and informal discussion were conducted to identify available resources in the community for maintaining WASH, and also understand the challenges related to these; explore the surrounding cleanliness, waste disposal, and drainage system. Most of the households (HHs) fetched water from the nearest supply stations. Few families did not treat drinking water for purification; the gas flow was not sufficient to boil drinking water most of the time. A number of HHs did not clean their water reservoirs regularly, resulting in odor in supplied water. Regular garbage removal system was absent. WASH being a communal issue in slum setting, community engagement for WASH management is strongly recommended.