Risk factors for antenatal anxiety: a cross-sectional study in field antenatal clinics in Sri Lanka.

OBJECTIVES: We aimed to determine the prevalence and factors affecting antenatal anxiety (AA) among Sri Lankan women. DESIGN: We conducted a cross-sectional analysis of first trimester data from a population-based cohort of antenatal women. SETTING: Field antenatal clinics of four field health areas in Colombo District, Sri Lanka. PARTICIPANTS: Antenatal women (n=535) in the first trimester of pregnancy and aged ≥18 years were sequentially recruited when they attended antenatal clinics selected using random cluster sampling. Those with hearing difficulty, visual and speaking problems or currently on treatment for mental disorders were excluded. MEASURES: We used an interviewer-administered questionnaire to collect data. The AA was identified using the validated Sinhala version of Perinatal Anxiety Screening Scale (PASS-S). Self-reported demographic and pregnancy-related information were verified against health records. Psychosocial risk factors were self-reported. We investigated the associations between potential risk factors and AA using regression models that included confounders identified through a directed acyclic graph and reported using adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: The prevalence of AA during the first trimester of pregnancy, identified using a PASS threshold of ≥20, was 34.4% (n=184). We found several novel risk factors for AA, namely, physical (OR 2.1; 95% CI 1.4 to 3.2) and mental health problems of self (OR 2.3; 95% CI 1.2 to 4.4), physical (OR 2.1; 95% CI 1.4 to 3.4) and mental health problems of parents/spouse (OR 6.7; 95% CI 2.8 to 16.2), traumatic life situations (OR 2.7; 95% CI 1.5 to 4.8), substance abuse by the spouse (OR 3.5; 95% CI 1.9 to 6.6) and the spouse being away (OR 2.0; 95% CI 1.1 to 3.7). The other risk factors that we identified included domestic violence among family members (OR 6.4; 95% CI 1.3 to 31.0), loss of family support (OR 2.2; 95% CI 1.0 to 5.2), financial hardships (OR 1.7; 95% CI 1.0 to 2.8), accommodation-related issues (OR 2.2; 95% CI 1.0 to 4.9), unplanned pregnancy (OR 3.7; 95% CI 1.9 to 7.3), difficulties due to pregnancy (OR 2.0; 95% CI 1.1 to 3.4), changed or stopped education (OR 2.9; 95% CI 1.7 to 5.1), recent loss of employment (OR 2.9; 95% CI 1.2 to 7.0), recent death of a loved one (OR 3.5; 95% CI 2.0 to 5.9) and sleep problems during pregnancy (OR 1.6; 95% CI 1.1 to 2.3). CONCLUSIONS: The prevalence of antenatal anxiety is high in Sri Lanka and is associated with several risk factors, not previously described, which are potentially modifiable.

Impulse control disorders and other non-motor symptoms in Sri Lankan patients with Parkinson's disease.

The impact of non-motor symptoms is often overlooked in favour of the motor symptoms when managing Parkinson's disease resulting in suboptimal patient outcomes. This study aimed to characterise the non-motor symptoms of Parkinson's disease in a cohort of Sri Lankan patients with a special focus on the impulsive control disorders and other compulsive behaviours (ICDs-CB) that had not been previously studied in this population. All patients with idiopathic Parkinson's disease followed up at the National Hospital of Colombo, Sri Lanka were included. The presence or absence of non-motor symptoms and their perceived impact was recorded with an interviewer administered questionnaire. Symptoms of anxiety and depression were assessed with Hamilton Anxiety and Depression scales. Presence of ICDs-CB was assessed with the questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease. Of 192 patients 97% (186) reported at least 2 non-motor symptoms. About 83% (160/192) screened positive for anxiety, 40% (76/192) for depression, and 17% (32/192) for an ICDs-CB. A lower Barthel index, history of past psychiatric disorders and family history of alcohol abuse were independent predictors of ICDs-DB. Managing both motor and non-motor symptoms are important to preserve the quality of life of patients with Parkinson's disease. They should be screened for symptoms for anxiety and depression regularly during follow up and educated about the possibility of ICDs-CB soon after diagnosis.

Detection of human strongyloidiasis among patients with a high risk of complications attending selected tertiary care hospitals in Colombo, Sri Lanka using molecular and serological diagnostic tools.

BACKGROUND: Strongyloidiasis a neglected tropical disease is known to cause severe disease among immunosuppressed and has not been studied extensively in Sri Lanka. Parasitological diagnostic approaches based on faecal microscopy and culture often fail to detect low-intensity infections. This study investigates the presence of strongyloidiasis among selected immunocompromised individuals using parasitological, molecular and serological techniques. METHODS: Adult patients with immunocompromising conditions admitted to three tertiary care hospitals in Sri Lanka were recruited. A faecal sample and 2 ml of venous blood were collected. The faecal samples were subjected to direct faecal smear and cultures (agar plate, charcoal and Harada-Mori) and polymerase chain reaction (PCR) using species specific primers designed for Strongyloides stercoralis. The presence of Strongyloides IgG antibodies was tested in the collected serum samples using DRG Strongyloides IgG enzyme-linked immunosorbent assay (ELISA) kits. The PCR products of the positive samples were sequenced using Sanger sequencing method. RESULTS: A total of 260 patients were recruited to this study, out of which 160 provided faecal samples and 122 provided blood samples. Out of the 160 faecal samples, none were positive for strongyloidiasis by direct smear, charcoal and Harada-Mori cultures. Only one sample (0.6%) was positive by agar plate culture. Out of the 123 samples subjected to PCR, 14 (11.4%), including the culture positive patient, were positive for S. stercoralis. Sequencing results of the PCR products indicated 100% similarity to S. stercoralis. Out of the 122 serum samples subjected to ELISA, 20 (16.4%), including the culture positive patient, were positive for Strongyloides IgG antibodies. However, sociodemographic, exposure factors, clinical features were not significantly associated with the presence of strongyloidiasis infection. CONCLUSIONS: Strongyloidiasis is present among the immunocompromised population in Sri Lanka, even in the absence of a significant relationship with associated factors. It is advisable to screen such patients with highly sensitive tests such as PCR for early diagnosis and treatment.

Canine vector-borne infections of working dogs of the Sri Lanka Air Force, and free roaming, and privately owned dogs.

Canine vector-borne infections (CVBIs) are a global health problem. The military working dogs of Sri Lanka die at an early age, and CVBIs have been a leading speculated cause. We examined CVBIs in the working dogs of the Sri Lanka air force (SLAF) and free-roaming dogs (FRDs) and privately owned dogs (PODs) country-wide. Giemsa-stained smears were prepared and conventional PCR-positive DNA was subjected to sequencing and phylogeny. Of the 668 dogs sampled, 212 (31.7%) had one or more CVBIs. The prevalence of infections among the FRDs (40.0%) was significantly higher than SLAF working dogs (30.0%; χ2 = 10.5216; p = 0.0012) and PODs (26.2%; χ2 = 5.3414, p = 0.0208) but not between SLAF dogs and PODs (χ2 = 1.7655, p = 0.1838). Many infected dogs were asymptomatic (57.4%), which was higher among the FRDs. Seven infectious agents were identified: Babesia gibsoni, B. canis, Ehrlichia canis, Anaplasma platys, Leishmania sp., Hepatozoon canis, and filaria worms. The most common infection was B. gibsoni (13.8%), followed by E. canis (9.9%). Three tick species: Rhipicephalus linneai, Rhipicephalus haemaphysaloides and Haemophysalis bispinosa were found infesting the dogs. The SLAF dogs were thoroughly quarantined upon arrival, but the infection prevalence was similar to PODs.

Barriers and facilitators for universal gestational diabetes Mellitus screening in a low resource setting: a cross-sectional study in Sri Lanka.

Gestational Diabetes Mellitus (GDM) is associated with adverse maternal and perinatal outcomes and increased risk of developing diabetes in later life. Sri Lanka adopted universal GDM screening at two time points in pregnancy (before 12 weeks and between 24 and 28 weeks) in 2014 and its utilization has not been assessed. This study assessed the utilization of GDM screening services and associated factors among antenatal mothers in Southern Sri Lanka. A cross-sectional study was carried out in a consecutive sample of 420 postpartum mothers who delivered at three major hospitals in Sri Lanka. Data were collected on socio-demographics, pregnancy, availability and utilization of screening services and logistics using an interviewer-administered questionnaire and a data record sheet. Data was analysed using SPSS software. Chi-square test and binary logistic regression was used to assess the association between variables. The coverage of first and second screening tests were 91.4% and 94.5% and timeliness were 72.4% and 59.5%, respectively. The median period of amenorrhoea at the first and second screening were 10.0 (inter-quartile range: 2.5) weeks and 28.0 (inter-quartile range: 1.5) weeks. A higher utilization was associated with higher income (OR = 3.4, 95% CI: 1.1-10.5) and planned pregnancy (OR = 4.9, 95% CI: 2.2-10.7) for the first screening test. Primiparity (OR = 0.3, 95% CI: 0.1-0.9) and proximity of the nearest laboratory (OR = 3.5, 95% CI: 1.0-12.0) were positively associated with the second screening test. The timeliness of both screening tests was associated with planned pregnancy (OR = 2.1, 95% CI: 1.1-4.0 and OR = 2.3, 95% CI: 1.1-4.5) and being non-employed during the pregnancy (OR = 2.5, 95% CI: 1.4-4.3 and OR = 2.3, 95% CI: 1.3-4.1). A high utilization of GDM screening was observed. Timeliness should be ensured through improved availability and accessibility of screening facilities.

Development and validation of a cardiovascular risk prediction model for Sri Lankans using machine learning.

INTRODUCTION AND OBJECTIVES: Sri Lankans do not have a specific cardiovascular (CV) risk prediction model and therefore, World Health Organization(WHO) risk charts developed for the Southeast Asia Region are being used. We aimed to develop a CV risk prediction model specific for Sri Lankans using machine learning (ML) of data of a population-based, randomly selected cohort of Sri Lankans followed up for 10 years and to validate it in an external cohort. MATERIAL AND METHODS: The cohort consisted of 2596 individuals between 40-65 years of age in 2007, who were followed up for 10 years. Of them, 179 developed hard CV diseases (CVD) by 2017. We developed three CV risk prediction models named model 1, 2 and 3 using ML. We compared predictive performances between models and the WHO risk charts using receiver operating characteristic curves (ROC). The most predictive and practical model for use in primary care, model 3 was named "SLCVD score" which used age, sex, smoking status, systolic blood pressure, history of diabetes, and total cholesterol level in the calculation. We developed an online platform to calculate the SLCVD score. Predictions of SLCVD score were validated in an external hospital-based cohort. RESULTS: Model 1, 2, SLCVD score and the WHO risk charts predicted 173, 162, 169 and 10 of 179 observed events and the area under the ROC (AUC) were 0.98, 0.98, 0.98 and 0.52 respectively. During external validation, the SLCVD score and WHO risk charts predicted 56 and 18 respectively of 119 total events and AUCs were 0.64 and 0.54 respectively. CONCLUSIONS: SLCVD score is the first and only CV risk prediction model specific for Sri Lankans. It predicts the 10-year risk of developing a hard CVD in Sri Lankans. SLCVD score was more effective in predicting Sri Lankans at high CV risk than WHO risk charts.

Socio-behavioural associates of Early Childhood Caries among preschool children aged three to four years in Gampaha district, Sri Lanka: a cross sectional study.

BACKGROUND: Early Childhood Caries (ECC) is a highly prevalent disease among preschoolers in Sri Lanka, with stagnated prevalence over the decades. Therefore, it is important to determine the socio-behavioural associations of ECC among preschoolers to reduce the country's ECC burden. METHODS: A cross-sectional study with a multistage cluster sampling technique was used to select 3 to 4 year-old preschoolers/mothers dyads in Gampaha district in 2019. Preschoolers who completed third birthday and had not completed fifth birthday on the day of data collection were selected. The dependent variable was the presence (dmft ≥ 1) or absence (dmft = 0) of ECC. Independent variables were sex, monthly family income, mother's educational and occupational status, child's birth order, family type, frequency of consumption of sweets and sweetened drinks, time of sweet consumption during the last 24 h, toothbrushing frequency, supervision of toothbrushing, dental visit, and maternal dental caries. A pre-tested validated questionnaire was used. Multiple logistic regression analysis was used. RESULTS: Total of 1038 preschoolers were selected. There were 529 females (51.0%) and 509 males (49.0%). The prevalence of ECC was 56.3% (95% CI: 53.1-59.3). Consuming sweets between meals had a higher odds ratio than consuming sweets after main meals (OR = 1.72, 95% CI:1.25-2.35), consumption of sweets every day had a higher odds ratio than consumption of sweets several times a week or less (OR = 2.89, 95% CI: 2.02-4.13), consumption of sweetened drinks every day had a higher odds ratio than consumption of sweetened drinks several times a week or less (OR = 1.73, 95% CI: 1.07-2.79), and the presence of maternal caries had a higher odds ratio than the absence of maternal caries (OR = 1.74, 95% CI: 1.12-2.69). The use of adult fluoridated toothpaste than not using adult fluoridated toothpaste (OR = 0.64, 95% CI:0.48-0.85), tooth brushing twice per day than not brushing twice per day (OR = 0.67, 95% CI:0.51-0.89), and supervised toothbrushing than unsupervised toothbrushing (OR = 0.61, 95% CI: 0.41-0.93) was negatively associated with ECC. CONCLUSIONS: ECC is highly associated with sweet consumption and oral hygiene behaviours among preschoolers in Gampaha District. Interventions should focus on the oral health behaviours of preschoolers to reduce ECC burden.

Undetected falls among older adults attending medical clinics in four tertiary care centres in Sri Lanka; the need of a comprehensive geriatric assessment.

OBJECTIVE: Falls take a high priority among the prevalent medical conditions in old age. Despite this, a history of falls or the risk of future falls is not routinely assessed or properly managed in medical clinics in Sri Lanka. This study was done to evaluate the prevalence and factors associated with falls and recurrent falls among older adults attending medical clinics in four selected tertiary care centres in the country. METHODS: A cross-sectional study was carried out at four centres (Teaching Hospital Karapitiya, Colombo South Teaching Hospital, Colombo North Teaching Hospital and University Hospital-Kotelawala Defence University) with 704 older adults, aged 65 years and above, attending medical clinics for more than six consecutive months. Information related to falls and possible associated factors (socio-demographic, behavioural, environmental and biological) were collected using an interviewer-administered questionnaire. RESULTS: The Mean (SD) age of the participants was 72.5(5.5) years and 58.7% were females. Of the 704 total sample, 220 (31.3%, 95% CI 28-35%) participants experienced at least one fall after the age of 65, and 12.8% (95% CI 10-15%) (n = 90) experienced recurrent falls (two or more falls within the last 12 months). Falls were associated with gender, level of education, marital status, and physical dependence (p < 0.01). For those who had at least one fall, multiple logistic regression (MLR) revealed being single (p = 0.03, OR = 2.12, 95% CI; 1.052-4.304), being widowed/divorced/separated (p = 0.03, OR = 1.47, 95% CI; 1.039-2.093) compared to living with a spouse, presence of moderate (p = 0.007, OR = 1.72, 95% CI; 1.160-2.577) and severe (p = 0.001, OR = 2.98, 95% CI; 1.563-5.688) physical dependency compared to mild physical dependency as risk factors for falls. Having secondary education (p = 0.01, OR = 0.55, 0.350-0.876) was a protective factor for falls. For those with recurrent falls, MLR showed moderate physical dependency (p = 0.001, OR = 2.34, 95% CI; 1.442-3.821) compared to slight physical dependency as a risk factor. CONCLUSIONS: Approximately one-third of the older adults attending medical clinics had experienced at least a single fall, and one-eighth have had recurrent falls, which were mostly unrecorded and not clinically assessed. Physical dependency was the major contributing factor to falls and recurrent falls. Falls assessment should be included in the routine clinical assessment of older adults attending outdoor medical clinics. Health professionals should be educated to detect and assess those at risk of falling and take appropriate measures to prevent or minimize falls.

Estimating dynamics of dengue disease in Colombo district of Sri Lanka with environmental impact by quantifying the per-capita vector density.

Dengue is a vector-borne disease transmitted to humans by vectors of genus Aedes causing a global threat to health, social, and economic sectors in many of the tropical countries including Sri Lanka. In Sri Lanka, the tropical climate, marked by seasonal weather primarily influenced by monsoons, fosters optimal conditions for the virus to spread efficiently. This heightened transmission results in increased per-capita vector density. In this work, we investigate the dynamic influence of environmental conditions on dengue emergence in Colombo district - the geographical region with the highest recorded dengue threat in Sri Lanka. An iterative approach is employed to dynamically estimate dengue cases leveraging the Markov chain Monte Carlo simulations, utilizing the dynamics of four seasons per year influenced by monsoon weather patterns governing in the region. The developed algorithm allows to estimate the risk of dengue outbreaks in 2017 and 2019 with high precision, facilitating accurate forecasts of upcoming disease emergence patterns for better preparedness. The uncertainty quantification not only validated the accuracy of outbreak estimates but also showcased the model's capacity to capture extreme cases and revealed undisclosed external factors such as human mobility and environmental pollution that might affect dengue transmission in the Colombo district of Sri Lanka.

Prevalence, symptomatology and factors associated with asthma in adolescents aged 13-14 years from rural Sri Lanka: an analytical cross-sectional study.

BACKGROUND: Asthma is the most common chronic disease affecting children. However, the epidemiology of asthma in adolescents from rural geographies is lacking. METHODS: An analytical cross-sectional study was conducted in secondary schools located in the municipal council area of the rural district of Anuradhapura, Sri Lanka. Random sampling was used to select 32 grade 8 classes from 6 out of 9 schools. The prevalence and symptomatology of asthma were determined using the validated International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire and asthma symptom control using the asthma control test (ACT) translated into Sinhalese. RESULTS: The study sample consisted of 1029 participants aged 13-14 years, including 528 (51.3%) boys and 501 (48.7%) girls. The prevalence of wheeze ever, current wheeze and wheeze while playing was 32.6% (n=335), 23.7% (n=244) and 25.2% (n=259), respectively. The prevalence of parent-reported physician-diagnosed asthma was 19.0% (n=196; 95% CI 16.7 to 21.6). Severe asthma was reported by 157 (15.3%; 95% CI 13.1 to 17.6) adolescents. The independent factors associated with severe asthma were sleeping on a cloth laid on the floor instead of a bed (p<0.02, adjusted-OR 9.72; 95% CI 1.56 to 60.78), cooking using sawdust (p=0.04, adjusted-OR 8.71; 95% CI 1.10 to 68.69) eczema (p<0.01; adjusted-OR 7.39; 95% CI 3.34 to 16.39) and allergic rhinitis (p<0.01; adjusted-OR 5.50; 95% CI 3.80 to 7.98). While having a cemented floor in the house (p<0.04; adjusted-OR 0.68; 95% CI 0.47 to 0.99) was a protective factor. Poor control of asthma symptoms was detected in 29 (29.9%) adolescents which was associated with comorbid allergic rhinitis (p<0.01; unadjusted-OR 5.40; 95% CI 1.84 to 15.82). CONCLUSION: Almost one in four adolescents had current wheeze, and 15.3% had severe asthma. Severe asthma was independently associated with allergic rhinitis, eczema, cooking using sawdust as fuel and sleeping on a cloth on the floor instead of a bed. Poor symptom control was found in 29.9% of severe asthmatics which was associated with comorbid allergic rhinitis.

Determining dengue infection risk in the Colombo district of Sri Lanka by inferencing the genetic parameters of Aedes mosquitoes.

BACKGROUND: For decades, dengue has posed a significant threat as a viral infectious disease, affecting numerous human lives globally, particularly in tropical regions, yet no cure has been discovered. The genetic trait of vector competence in Aedes mosquitoes, which facilitates dengue transmission, is difficult to measure and highly sensitive to environmental changes. METHODS: In this study we attempt, for the first time in a non-laboratory setting, to quantify the vector competence of Aedes mosquitoes assuming its homogeneity across both species; aegypti and albopictus and across the four Dengue serotypes. Estimating vector competence in relation to varying rainfall patterns was focused in this study to showcase the changes in this vector trait with respect to environmental variables. We quantify it using an existing mathematical model originally developed for malaria in a Bayesian inferencing setup. We conducted this study in the Colombo district of Sri Lanka where the highest number of human populations are threatened with dengue. Colombo district experiences continuous favorable temperature and humidity levels throughout the year creating ideal conditions for Aedes mosquitoes to thrive and transmit the Dengue disease. Therefore we only used the highly variable and seasonal rainfall as the primary environmental variable as it significantly influences the number of breeding sites and thereby impacting the population dynamics of Aedes. RESULTS: Our research successfully deduced vector competence values for the four identified seasons based on Monsoon rainfalls experienced in Colombo within a year. We used dengue data from 2009 - 2022 to infer the estimates. These estimated values have been corroborated through experimental studies documented in the literature, thereby validating the malaria model to estimate vector competence for dengue disease. CONCLUSION: Our research findings conclude that environmental conditions can amplify vector competence within specific seasons, categorized by their environmental attributes. Additionally, the deduced vector competence offers compelling evidence that it impacts disease transmission, irrespective of geographical location, climate, or environmental factors.

Variations in out-of-pocket spending and factors influencing catastrophic health expenditure of households with patients suffering from chronic conditions in four districts in Sri Lanka.

INTRODUCTION: Healthcare financing systems, dependent on out-of-pocket expenditure(OOPE), impose a heavy burden on those who use the services regularly, such as patients suffering from chronic diseases. High OOPE for health services leads to decreased utilization of the services and/or catastrophic health expenditure, which would significantly impede the achievement of Universal Health coverage. OBJECTIVE: We aimed to determine variations in OOPE and factors associated with Catastrophic Health Expenditure (CHE) of households with patients suffering from non-communicable diseases(NCDs) in four districts. METHODS: A survey was conducted among 2344 adult patients having selected NCD/s. Multi-stage stratified cluster sampling selected respondents from 4 districts representing urban, rural, semi-urban, and estate. Data was collected using a validated interviewer-administered questionnaire. Logistic regression identified the predictors of CHE(> 40%). Significance was considered as 0.05. RESULTS: Common NCDs were hypertension(29.1%), diabetes(26.8.0%), hyperlipidaemia(9.8%) and asthma(8.2%). Only 13% reported complications associated with NCDs. Fifty-six percent(N = 1304) were on regular clinic follow-up, and majority utilized western-medical government hospitals(N = 916,70.2%). There were 252 hospital admissions for chronic-disease management in the past 12 months. Majority(86%) were admitted to government sector hospitals. Most patients incurred nearly SLR 3000 per clinic visit and SLR 3300 per hospital admission. CHE was beyond 40% for 13.5% of the hospital admissions and 6.1% of the regular clinic follow-up. Patients admitted to private sector hospitals had 2.61 times higher CHE than those admitted to government sector hospitals. CONCLUSIONS: Patients with NCDs incurred high OOPE and faced CHE during healthcare seeking in Sri Lanka. The prevalence of NCDs and complications were high among the participants. Patients with chronic conditions incur high OOPE for a single clinic visit and a hospital admission. Patients incur high OOPE on direct medical costs, and district-wise variations were observed. The proportion with more than 40% CHE on monthly clinic care was high. Patients being followed up in the government sector are more likely to have CHE when obtaining healthcare and are more likely to face barriers in obtaining needed health services. The services rendered to patients with chronic conditions warrant a more integrative approach to reduce the burden of costs and related complications.

Tubulointerstitial nephropathy is the predominant finding in men in a review of more than 3000 renal biopsies over a 10-year period from Sri Lanka.

BACKGROUND: Chronic kidney disease (CKD) is a significant clinical challenge in Sri Lanka. The present study presents histopathological diagnoses from native renal biopsies in Kandy District, 2011-2020. METHODS: Reports of 5,014 renal biopsies principally performed at Kandy Teaching Hospital over 2011-2020 were reviewed. After exclusions for post-kidney transplant biopsies (1,572) and those without evident pathology (347), 3,095 biopsies were included. The predominant histopathological entities were grouped and categorised according to diagnosis and stratified by age and sex. RESULTS: The main histopathological entities (all biopsies) were tubulointerstitial nephropathy (TIN) 25% (n = 760), glomerulonephritis (GN) 15% (467), lupus nephropathy 14% (429), focal segmental glomerular sclerosis (FSGS) 10% (297), and IgA nephropathy (IgAN) 8% (242). For adult women ≥ 15 years, the main histopathological entities were lupus nephropathy 24% (325), TIN 17% (228), and GN 16% (217). For adult men ≥ 15 years, the main histopathological entities were TIN 34% (449), GN 14% (180), and IgAN 10% (125). The proportion of TIN in the present study was higher than international studies of a similar size. CONCLUSION: This is the largest study of renal biopsies reported from Sri Lanka to date. TIN was the most common diagnosis in adults ≥ 15 years at 25%. Notable sex differences showed TIN was the most common histopathology in men (34%) but not in women (17%). No previously published similar study of this size has found TIN as the predominant diagnosis amongst renal biopsies in men. Further research is required into the possible causes of these observations in Sri Lanka. CLINICAL TRIAL NUMBER: Not applicable.

First report of oriental theileriosis in the Intermediate Zone, Sri Lanka: Is Theileria orientalis type 7 always apathogenic?

PURPOSE: Theileriosis in cattle has a significant economic implication for dairy production globally. Thus, it is crucial to investigate the prevalence of bovine theileriosis, the causative agent and genotypes of Theileria species in dairy cattle in the Kurunegala District in the Intermediate zone, where the third largest population of dairy cattle in Sri Lanka is present and experienced a substantial reduction in the cattle population recently. METHODS: Sixty blood samples and background data were collected from three dairy farms in Galpokuna (n = 20), Koulwewa (n = 20), and Andigama (n = 20) areas. Haematocrit was used to identify anaemia while Giemsa-stained blood smears demonstrated the presence of piroplasms. A Fisher's Exact Test (p < 0.05) compared the prevalence of infection among age groups and farms. PCRs using species-specific primers designed to amplify regions of MPSP and 18 s rRNA genes followed by sequencing of selected amplicons allowed phylogeny of the species detected. RESULTS: All three farms had semi-intensive farming practices keeping animals in a 'closed' setup with limited movement. Theileriosis prevalence in dairy cattle was 55.0 % with no difference among the farms (Koulwewa: 65.0 %, Galpokuna: 50.0 %, Andigama: 50.0 %). One-third of the cattle (33.3 %) were anaemic based on haematocrit results but most showed mild anaemia. Anaemia was significantly higher in calves (45.0 %) than in adults (25.0 %; χ2 = 5.743; p = 0.03) tested positive for theileriosis. None of the animals showed any other signs of theileriosis. PCR revealed the presence of both T. orientalis (pathogenic or benign) and T. annulata (pathogenic). The sequencing data revealed that the T. orientalis genotype present in Kurunegala District is type 7. CONCLUSION: This is the first report on T. orientalis and T. annulata in dairy cattle in the Intermediate zone of Sri Lanka. The type 7 of T. orientalis was more common showing severe anaemia in calves while mild anaemia or no anaemia in adults and sub-adults. In immunologically intact animals, the reported genotype of the parasite can persist asymptomatically for life, occasionally causing a relapse, particularly under stressful conditions like pregnancy, lactation, and rapid changes in environmental conditions. However, the susceptibility of calves for pathogenic and apathogenic genotypes of T. orientalis and the carrier status of asymptomatic animals needs further investigation.

Clinical Practice Guidelines for the Management of Type 2 Diabetes in South Asia: A Systematic Review.

BACKGROUND: Clinical practice guidelines (CPGs) are a helpful tool for the evidence-based management of Type 2 Diabetes Mellitus (T2D). The aim of this systematic review was to synthesize and appraise the scope and quality of South Asian T2D CPGs. METHODS: This PROPSERO registered (CRD42023425150) systematic review adhered to the 2020 PRISMA guidelines. We searched the PubMed, Embase, Cochrane, and Google Scholar databases for relevant guidelines. Data synthesis was performed using a qualitative approach and methodological quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: We identified eleven unique CPGs (three each from Pakistan and Sri Lanka, two from India, and one each from Bangladesh, Nepal, and Bhutan) which were published or updated between 2017 and 2023. The CPGs included recommendations regarding screening, diagnosis, prevention, and management of T2D and its acute and chronic complications, comorbidities, and fasting with T2D. The AGREE II mean domain scores ranged from 37 % to 80 %; three CPGs were 'recommended for clinical use,' seven were 'recommended for use with modifications' and one was deemed unfit for implementation. CONCLUSION: The present review summarized and appraised broadly CPGs from South Asia for T2D and can help direct improvements to future iterations.

Risk Factors for Latent Tuberculosis among Health-care Workers in Sri Lanka.

INTRODUCTION: Management of latent tuberculosis infection (LTBI) was introduced as a national policy in Sri Lanka in 2022, targeting high-risk groups, including health-care workers (HCWs). This study aimed to identify the potential risk factors for LTBI among HCWs in government hospitals. METHODS: A case-control study was conducted. Cases and controls were identified by a screening survey conducted among those tested by the tuberculin skin test (TST). The survey was conducted among HCWs of eight government hospitals in Colombo in 2022. LTBI cases were defined as TST positives (≥10 mm) without a history of pulmonary tuberculosis (TB) and controls were those rated as negative. The cases-to-control ratio was 1:1, with a sample size of 128 cases and 128 controls. Multiple logistic regression analysis was conducted to identify the risk factors. RESULTS: The significant risk factors identified included age ≥40 years (adjusted odds ratio [AOR] - 2.4, 95% confidence interval [CI]: 1.28-4.47) having a service duration of ≥6 years (AOR - 2.92, CI: 1.469-5.82), not maintaining distance (AOR - 2.83, CI: 1.43-5.58) and not wearing face masks when dealing with suspected or diagnosed TB patients (AOR - 3.55, CI: 1.80-7.00), and settings with inadequate TB infection control practices (AOR - 3.47, CI: 1.85-6.47). CONCLUSION: Improving infection control measures, training HCWs on TB prevention, providing adequate personal protective equipment, and initiating screening for LTBI among HCWs are recommended.

Preventing the re-establishment of malaria during the COVID-19 pandemic in Sri Lanka: implications for health security.

BACKGROUND: The COVID-19 pandemic-with its first reported case in Sri Lanka in March 2020-had the potential to impact the risk of re-establishing malaria, a disease which was eliminated from Sri Lanka in 2012. Post-elimination, the country remains highly vulnerable to a return of malaria on account of high vector mosquito densities and the inflow of imported malaria cases. METHODS: Parallels between COVID-19 and malaria after its elimination as health security threats were drawn, and the many ways in which the COVID-19 pandemic impacted the prevention of re-establishment of malaria programmes in the country in 2020 were examined. The implications of this experience for global health security are analysed. RESULTS: In 2020, imported malaria cases were fewer than in the previous 3 years, due to restrictions on international travel. Yet, a high level of malaria case and entomological surveillance was sustained through surveillance strategies modified to focus on quarantine centers, in response to the pandemic. As a result, more imported malaria cases were detected by active case detection than by passive surveillance. Some of the operational shifts adopted by the Anti Malaria Campaign were moving rapidly into functioning as an intersectoral player by reinforcing its collaborations with the Ministries of Aviation and Defense, switching to the use of online communication systems, and integrating and synergizing its field activities with the COVID-19 control programme. CONCLUSIONS: The experience highlights the need for disease control programmes to be agile, flexible and responsive, and underscores the importance of maintaining even a lean focal programme for diseases such as malaria after they have been eliminated. Sustaining public health leadership and robust technological capacities in communication and data management were paramount in preventing the disruption of the malaria prevention programme during the pandemic and sustaining the malaria-free status of the country.

Prevalence and associated factors of anaemia in patients with type 2 diabetes mellitus: a cross-sectional study in a tertiary care medical unit, Sri Lanka.

BACKGROUND: Anaemia is a global public health issue that impacts individuals of all ages in both developed and developing countries. Anaemia is common in patients with diabetes mellitus; however, it is often undiagnosed and untreated. The main aim of this study was to assess the prevalence and associated factors of anaemia in patients with type 2 diabetes mellitus admitting to a medical unit at National Hospital Kandy. METHODS: A descriptive, cross-sectional study was conducted in type 2 diabetes mellitus (T2DM) patients admitted to a medical ward at National Hospital Kandy (NHK). They were assessed with a pre-tested, interviewer-administered, structured questionnaire using consecutive sampling method. The data was entered and analyzed using SPSS 26. RESULTS: Total 252 patients with diabetes were included. The prevalence of anaemia in patients with T2DM was 31.3%. The corresponding values for males and females were 34.2% and 65.8% respectively. Independent predictors for anaemia among diabetic patients were older age, female gender, poor glycemic control, diabetes duration > 5 years, diabetic nephropathy, retinopathy, neuropathy, stage ≥ 3 chronic kidney disease (CKD), ischaemic heart disease (IHD), peripheral vascular disease (PVD), diabetic foot ulcers (DFU) and usage of aspirin. These were significantly associated with the prevalence anemia among patients with type 2 diabetes mellitus. Multivariate logistic regression analysis revealed that female gender, age ≥ 65 years, diabetic duration > 5 years, poor glycaemic control, stage ≥ 3 CKD, diabetic nephropathy and retinopathy were associated with greater odds for the presence of anaemia. CONCLUSION: We found that 31.3% T2DM patients in a medical ward at NHK had previously undiagnosed anaemia. Anaemia screening during diabetes diagnosis, maintaining glycaemic control and raising patient awareness can reduce anaemia prevalence, improve patient quality of life and potentially reduce microvascular complications.

Non-tunneled haemodialysis catheter-related blood stream infections and associated factors among first time haemodialysis patients: a prospective study from a tertiary care hospital in Sri Lanka.

BACKGROUND: A significant number of patients require non-tunneled haemodialysis catheters (NTHCs) in the event of an urgent need for immediate haemodialysis in developing countries. Catheter-related bloodstream infections (CRBSIs) are a major concern in haemodialysis, but there is a lack of local epidemiological data. This study aimed to determine the incidence of CRBSI, causative agents and associated risk factors in a tertiary care hospital in Sri Lanka. METHODS: A prospective study was conducted at the dialysis unit of Colombo South Teaching Hospital, Sri Lanka from December 2019 to August 2020. Adult patients who had haemodialysis for the first time with NTHCs were included. RESULTS: Of 149 dialysis patients (104-jugular vein and 45-femoral vein, mean age 58 ± 13.7 years, mean duration of catheterization 7.9 ± 3.4 days), the incidence of CRBSI was 13.58 per 1000 catheter days. Serum albumin levels, capillary blood sugar levels at admission, haemoglobin levels and duration of catheterization were significantly associated with CRBSI. Prescence of diabetes and patients with ESRD who started routine haemodialysis had a significantly higher risk of CRBSI. Gram-positive bacteria were the most common microorganisms associated with CRBSI (87.5%). CONCLUSIONS: Our results show high rates of infection with temporary vascular catheters in Sri Lanka, mainly due to Gram-positive bacteria. Diabetes mellitus, duration of catheterisation, low serum albumin, haemoglobin level and CBS on admission were identified as significant risk factors for CRBSI. Management strategies tailored to specific centers should be established in the nation to optimise catheter care and to monitor local microbiology for appropriate empirical antimicrobial treatment.

Effects of global change on snakebite envenoming incidence up to 2050: a modelling assessment.

BACKGROUND: Human activities are driving climate, land cover, and population change (global change), and shifting the baseline geographical distribution of snakebite. The interacting effects of global change on snakes and communities at risk of snakebite are poorly understood, limiting capacity to anticipate and manage future changes in snakebite risk. METHODS: In this modelling study, we projected how global change will affect snakebite envenoming incidence in Sri Lanka, as a model system that has a high incidence of snakebite. We used the shared socioeconomic pathway (SSP) scenario analysis framework to integrate forecasts across the domains of: climate change (historical trend from WorldClim plus three underlying regional circulation models [RCMs] in the Coordinated Regional Downscaling Experiment-South Asia repository, with two emissions pathways [representative concentration pathways RCP4.5 and RCP8.5]); land cover change (Dyna-CLUE model); and human population density change (based on Gridded Population of the World data) from Jan 1, 2010 to Dec 31, 2050. Forecasts were integrated under three different development scenarios: a sustainability pathway (SSP1 and no further emissions), a middle-of-the-road pathway (SSP2 and RCP4.5), and a fossil-fuelled pathway (SSP5 and RCP8.5). For SSP2 and SSP5, we nested three different RCMs (CNRM-CM5, GFDL-CCM3, and MPI-ESM-LR; mean averaged to represent consensus) to account for variability in climate predictions. Data were used as inputs to a mechanistic model that predicted snakebite envenoming incidence based on human-snake contact patterns. FINDINGS: From 2010 to 2050, at the national level, envenoming incidence in Sri Lanka was projected to decrease by 12·0-23·0%, depending on the scenario. The rate of decrease in envenoming incidence was higher in SSP5-RCP8.5 than in SSP1 and SSP2-RCP4.5. Change in envenoming incidence was heterogenous across the country. In SSP1, incidence decreased in urban areas expected to have population growth, and with land cover changes towards anthropised classes. In SSP2-RCP4.5 and SSP5-RCP8.5, most areas were projected to have decreases in incidence (SSP5-RCP8.5 showing the largest area with incidence reductions), while areas such as the central highlands and the north of the country showed localised increases. In the model, decreases occurred with human population growth, land use change towards anthropised classes (potentially shifting occupational risk factors), and decreasing abundance of some snake species, potentially due to global warming and reduced climatic and habitat suitability, with displacement of some snake species. INTERPRETATION: Snakebite envenoming incidence was projected to decrease overall in the coming decades in Sri Lanka, but with an apparent emerging conflict with sustainability objectives. Therefore, efforts to mitigate snakebite envenoming incidence will need to consider the potential impacts of sustainability interventions, particularly related to climate and land use change and in areas where increases in incidence are projected. In view of global change, neglected tropical diseases and public health issues related to biodiversity, such as snakebite, should be managed collaboratively by both environment and health stakeholders. FUNDING: UK Medical Research Council.