EXECUTIVE SUMMARY:

Interested parties representing a number of national and international institutions met and established a consortium to facilitate the coordination of their activities designed to prevent rickets in the Chakaria area of Bangladesh. An action plan was developed; it involves undertaking two types of studies:
surveys to determine the actual prevalence and geographic distribution of the disease;
an intervention trial to evaluate the efficacies of dietary improved diets in reducing rickets prevalence in young (6 mos.-3 yrs.) children.
The participants committed to work together to find sustainable means of solving this problem and established an organizational framework to facilitate that work.

MEETING ORGANIZATION:

The meeting was organized by Cornell University, SARPV, Dhaka University, UNICEF and CIMMYT . Financial support was provided by the Cornell Food Systems for Improved Health Program and UNICEF-Bangladesh.

PARTICIPANTS2:

Cornell University : Dr. Jerry Combs Dr. John Duxbury Dr. Ross Welch SARPV: Mr. Shahidul Haque Dr. Abdur Rahman Dhaka University: Dr. Nazmul Hassan CIMMYT: Dr. Craig Meisner University of Utah: Dr. Phil Fischer

AEM: Dr. Jean-Paul Cimma Mr. Roland Crémades MCH: Dr. UNICEF: Dr. Johnny Kyaw-Myint ICDDRB: Dr. Nasrul Islam ICMH: Dr. Luthfur Kabir Dr. Khurshid Talukder

MEETING OVERVIEW:

October 6

The participants met at the Dhaka airport, flew to Chittagong and went to the MCH guest house where they had dinner and spent the evening in informal discussions.

October 7

After breakfast, the participants departed by car to Chakaria, arriving at the SARPV office shortly after noon. Mr. Haque and SARPV staff gave the group an orientation to the local situation which included a meetings with the Thana Administrator and the Thana Health Officer, and visits to villages and conversations with parents and grandparents of children affected with rickets. The group reconvened in the evening for dinner and informal discussions at the Chakaria Bus Terminal Hotel.

October 8

The formal Project Planning Meeting was held at the home of a local Chakaria resident; it was chaired by Mr. Haque and Dr. Johnny. Mr. Haque reviewed the recognition by SARPV in 1991 that rickets is prevalent in Chakaria and their subsequent efforts to stimulate interest among national and international institutions in addressing the problem. He outlined how these efforts led to the involvement of AEM which attracted Dr. Cimma who has worked with SARPV for several years, conducting studies of the etiology of the disease and providing orthopedic surgical treatment for some affected children. Mr. Haque also outlined the shorter situation studies that had been conducted by UNICEF (Dr. Johnny), the Institute of Child and Mother Health, Chittagong Medical College, the Institute of Epidemiological Disease Control and Research. Dr. Johnny discussed his experience in visiting Chakaria, where he examined rachitic children, their siblings and neighboring children; by physical examination he found at least 17 affected children for every index case. Each participant was given an opportunity to introduce himself and to review his group's interest in the problem.

Dr. Cimma, whose studies are the most extensive to date, reviewed his findings which point to two factors contributing to rickets in Chakaria:

· insufficient intakes of calcium (less than 150 mg/day);

· exposure to an aggravating factor, e.g., aluminum (which he found in cooked rice) or, perhaps, another antagonist of calcium utilization/bone metabolism.

Dr. Combs then reviewed the goal of the meeting: to develop a plan of action to develop sustainable solutions to the Chakaria rickets problem. To provide context, Dr. Meisner presented an overview of the general agricultural situation of Chakaria. This revealed a picture of an area heavily cropped with rice (three crops) with some shrimp and taro but relatively few other crops. Its acid sulfate soil type is unique in Bangladesh. It also revealed that Chakaria is not among the poorest of agricultural areas of the country.

Three groups outlined their project ideas:

· Dr. Cimma discussed his plans for assessing the prevalence of bone under mineralization using a bone densitometry; this approach would involve the development of normative data using a cohort of children in an area of Bangladesh without prevalent rickets.

· Drs. Kabir and Talukder discussed their plans for a systematic study of rickets prevalence using physical and radiographic examination. They emphasized the need to define better the clinical diagnosis of rickets.

· Dr. Combs discussed the plans developed by the Cornell group and Prof. Hassan for a calcium intervention combined with analyses of the Chakaria food system to the end of developing sustainable ways of increasing the intakes and utilization of calcium by children in the area.

After lunch, Drs. Combs and Meisner facilitated a general discussion of these project ideas.

The group agreed to use three questions as guides in developing an action plan: What is presently known about Chakaria rickets? What must ultimately be known about the problem to solve it in a sustainable way? What should be done now to reduce the problem and/or to develop the information needed ultimately to solve it? The discussion is summarized below according to this format.

What is known?	What information is needed?	What should be done?
Rickets is prevalent in Chakaria.	Actual prevalence data (by geographic area, subject age and stage of disease)	Define the clinical diagnosis of the disease. Determine prevalence of the disease. Determine the geographic distribution of the disease.
Deficient intakes of calcium contribute at least in part to the problem.	Are there aggravating factors (e.g., antagonists of calcium utilization/bone metabolism)?	Determine the etiology of the disease. Determine whether increased dietary calcium can reduce risk to the disease.
Children at risk to rickets are also malnourished with respect to iron, vitamin A, riboflavin, zinc and/or protein and have a significant morbidity burden (malaria, diarrhea, worms, etc.).	Do other aspects of malnutrition affect calcium utilization/bone health?	Ask Thana Health Office to make rickets a reportable disease (separate from "malnutrition").

Consortium Development

This discussion resulted in the decision to form a consortium to provide coordination among the several groups and institutions interested in solving the Chakaria rickets problem. The nature of the consortium, its leadership and a time line of action were developed; a consortium Mission Statement (see Appendix) was developed and signed by each participant representing the following institutions:

SARPV MCH ICDDRB AEM Dhaka University

Chakaria Thana Health Complex UNICEF Cornell University ICMH University of Utah

The members agreed to encourage the participation of other individuals and groups interested in solving the Chakaria rickets problem (e.g., NGO's, agricultural extension, Thana educators, etc.).

It as agreed that SARPV is the logical local coordinator for the consortium activities; this Mr. Haque agreed to serve as the Resident Coordinator for the Consortium. The members agreed to share data, reports and other findings through the Resident Coordinator. Jerry Combs agreed to serve as the Non-Resident Coordinator and will work in that capacity with Dr. Nazmul Hassan to develop support and bring relevant technical expertise useful to solving the problem. Dr. Johnny Kyaw-Myint agreed to serve as the Consortium Facilitator.

Consortium Program

The members agreed that the program of the consortium would consist of three major projects:

• Continued Assistance for Rachitic Children - SARPV (Mr. Haque, Dr. Rahman and colleagues) and the MCH will continue their efforts to assist and care for affected children in Chakaria.
• Rickets Prevalence Survey - Drs. Cimma, Kabir and Talukder will coordinate their efforts to define the actual prevalence of rickets (both the florid disease as well as bone under- mineralization in general) with special attention to age, gender and location of residence (i.e., geographical distribution) of subjects, and to stage/severity of the disease. This effort will necessarily entail the development of a better definition the clinical diagnosis of rickets, particularly one that suitable for field use. They will work closely with Dr. Johnny in this effort.
• Rickets Prevention Trial - Drs. Hassan, Rahman, Combs, Fischer, Duxbury and Welch will conduct an intervention trial to evaluate food-based calcium supplementation as a rickets prevention measure. They will work closely with SARPV in this effort.
  

Plan of Action

The members then agreed on the following activities:

SARPV

• In 1998, SARPV will open in Chakaria a school for some 20 physically disadvantaged children (including rickets cases).
• Dr. Rahman will also continue his medical program in the area.
• The SARPV-Cornell supported video3 will be completed by the end of 1997 and will be available for informational/advocacy purposes by consortium members. Versions with narrations in Bangla, Chittagonian, English and French will be made.

Dhaka University

• Dr. Hassan will work with Cornell University and SARPV to develop a food system-based intervention trial in Chakaria.

ICDDRB

• ICDDRB will extend all cooperation possible; this may include collaborating to provide laboratory analytical expertise for intervention and/or prevalence studies.

MCH

• The MCH will continue to provide ongoing service to the people of Chakaria and any support it can to intervention or prevalence studies. [In subsequent conversations on Oct. 10, Dr. Staab agreed to grant access to the MCH patient records for the purpose of gaining better information about the prevalence and distribution of rickets in their catchment area.]

AEM

• Dr. Cimma will work to obtain an affordable bone densitometer.
• Dr. Cimma will work with Dr. Johnny to implement a survey of bone density in Chakaria and a reference area of Bangladesh.

University of Utah

• Dr. Fischer will cooperate with the Cornell-Dhaka-SARPV group to develop and implement a food system-based intervention trial in Chakaria.
• Dr. Fischer will arrange the analysis of pilot blood samples for parameters of vitamin D and calcium status and bone health. He will also have expert radiographic review of the pilot films that were made during this visit; he will report these finding to Dr. Rahman for guiding his patient care and to the other members of the consortium for their general information.

UNICEF

• Dr. Johnny will attempt to find in 1998 resources for Consortium activities (e.g., the SARPV school and prevalence studies) for which he will need some budget projections from the appropriate leaders.
• Dr. Johnny will include analysis of aluminum (a putative calcium-antagonist) on the Bangladesh National Urine Study.
• Dr. Johnny will advocate on behalf of the Consortium

Cornell University

• Jerry Combs will draft a summary report for this meeting.
• Ross Welch will analyze the pilot food, water and blood samples (taken during this visit) for multi-elements by inductively coupled argon plasma emission spectrometry; Jerry Combs will report those results to the other members of the consortium.
• Jerry Combs will draft a combined report based on the two prevalence and one intervention proposals drafted by consortium members; this will be used as the Program of the Consortium. [This will include an analysis of the MCH patient records.]
• Ross Welch will create a web site to facilitate information exchange among all Consortium members.
• Jerry Combs, John Duxbury and Ross Welch will work with Drs. Fischer and Hassan and Mr. Haque to develop a project proposal to submit to the Thrasher Research Fund for consideration of funding a food system-based intervention project.

October 9

The participants formed two study teams each of which was assisted by SARPV staff to undertake some purposive sampling for pilot studies. The food-nutrition team (Meisner, Hassan, Duxbury, Welch) visited villages to sample foods and water supplies; their samples were prepared for shipment to Cornell University for multi-element analyses. The medical team (Fischer, Rahman, Kyaw-Myint, Combs, Kabir, Talukder) examined 25 children (some 13 who had previously identified as rickets cases and 12 who had been identified as unaffected) who were brought to the SARPV office for that purpose. Blood samples were collected from each child and each was taken for radiography. Blood samples were prepared for shipment to the University of Utah and Cornell University for biochemical and multi-element analyses.

A community informational meeting was held to share the plans of the consortium with local opinion leaders. This was conducted in Bangla with all local people and many of the consortium members having chances to speak and have their words translated. The video made by Dr. Cimma was shown. The meeting revealed that many people in the local area had not been aware of rickets as a prevalent problem in their midst; people seem to have been sensitized by the discussion and particularly by the external attention being given to the problem. Mr. Haque and Dr. Johnny emphasized that the solution of the problem would call for local ownership and the consortium would seek to help the community in any way it could. They each described the consortium plans, but emphasized that the etiology of the disease and, thus, its solution were still uncertain.

October 10

The group met with Dr. Dave Staab at the Memorial Christian Hospital in Chakaria. These discussions revealed that the hospital has records for all patients hospitalized over the last 10 yrs. and for all out-patients treated since the hospital was opened (ca. 30 yrs.). Conversations revealed that the MCH would allow someone to go through those records for information on the frequency, geographic distribution and management of rickets cases if that can be done at no labor cost to the hospital. After touring the facilities, the group returned by car to Chittagong from which it flew back to Dhaka.

Rickets is prevalent in Chakaria and possibly elsewhere in Bangladesh. Its etiology involves dietary deficiency of calcium, perhaps as the major factor, but the disease occurs in a population of children that is not well nourished in general and suffers from a significant morbidity burden.

We believe that the ultimate resolution of this problem will require a better understanding of the disease and the food system where it occurs. To this end we see the need for:

· Determination of the prevalence (by age, gender and disease stage) and geographic distribution of the disease. This will require the establishment of clear diagnostic criteria suitable for field use.

· Elucidation of the etiology of the disease. This will require understanding the relationships of calcium deficiency and potential aggravating factors.

We further believe that there is now sufficient evidence to warrant an intervention trial to determine whether calcium supplementation can prevent the disease in young children in Chakaria. Such an effort should be undertaken according to sound scientific and ethical standards. In addition, simultaneous efforts should be made to render effective intervention outcomes sustainable within the local social, economic and environmental contexts.

Therefore, we pledge ourselves to working together in a coordinated manner to accomplish this work for the children of Chakaria.

[signed by the participants at the Planning Meeting, Chakaria, Oct. 9, 1997]