Direct and indirect costs for hospitalized patients with dengue in Southern Sri Lanka.

BACKGROUND: The Southern Province of Sri Lanka is endemic with dengue, with frequent outbreaks and occurrence of severe disease. However, the economic burden of dengue is poorly quantified. Therefore, we conducted a cost analysis to assess the direct and indirect costs associated with hospitalized patients with dengue to households and to the public healthcare system. METHODS: From June 2017-December 2018, we prospectively enrolled children and adults with acute dengue hospitalized at the largest, public tertiary-care (1800 bed) hospital in the Southern Province, Sri Lanka. We administered a structured questionnaire to obtain information regarding direct costs spent by households on medical visits, medications, laboratory testing, and travel for seeking care for the illness. Indirect costs lost by households were estimated by identifying the days of work lost by patients and caregivers and school days lost by children. Direct hospital costs were estimated using gross costing approach and adjusted by multiplying by annual inflation rates in Sri Lankan rupees and converted to US dollars. RESULTS: A total of 1064 patients with laboratory-confirmed dengue were enrolled. The mean age (SD) was 35.9 years (15.6) with male predominance (66.2%). The mean durations of hospitalization for adults and paediatric patients were 3.86 (SD = 1.51) and 4 (SD = 1.32) days, respectively. The per-capita direct cost borne by the healthcare system was 233.76 USD, and was approximately 14 times greater than the per-capita direct cost borne by households (16.29 USD, SD = 14.02). The per-capita average number of loss of working days was 21.51 (SD = 41.71), with mean per-capita loss of income due to loss of work being 303.99 USD (SD = 569.77), accounting for over 70% of average monthly income. On average, 10.88 days (SD = 10.97) of school days were missed due to the dengue episode. School misses were expected to reduce future annual income of affected children by 0.44%. CONCLUSIONS: Dengue requiring hospitalization had a substantial economic burden on the public healthcare system in Sri Lanka and the affected households. These findings emphasize the importance of strengthening dengue control activities and improved use of hospital-based resources for care to reduce the economic impact of dengue in Sri Lanka.

A Comparison of the Prevalence of the Metabolic Syndrome among Sri Lankan Patients with Type 2 Diabetes Mellitus Using WHO, NCEP-ATP III, and IDF Definitions.

BACKGROUND: Presence of metabolic syndrome (MetS) in patients with type 2 diabetes mellitus (type 2 DM) increases the risk of cardiovascular morbidity and mortality. Therefore, recognition of MetS in type 2 DM is important in initiating the appropriate preventive and therapeutic measures. The commonly used definitions have similarities and discrepancies. Aims of this study was to investigate the prevalence of MetS among patients with type 2DM using all three well known (WHO, IDF, and NCEP-ATP III) definitions and to identify the concordance and the difference of these three definitions. METHODS: This cross-sectional study included patients with type 2 DM who were followed up at the regional diabetes centre in Galle, Sri Lanka. A total of 2913 type 2 DM patients were recruited by convenient sampling method, and their clinical and biochemical data were collected. RESULTS: The mean age (SD) of the sample was 49.9 (10.2) years and the mean duration of diabetes was 5.04 (5.71). Prevalence of MetS was highest by WHO (70%) followed by IDF (44%) and NCEP-ATP III (29%) definitions. The prevalence was significantly higher in women according to all three definitions, and the difference was most marked with NCEP-ATP III and IDF definitions. Around 25% were identified as having MetS by all three definitions whereas around 45% were recognized with MetS by two definitions. While concordances between WHO with IDF (0.37, p < 0.001) and NCEP-ATP III (0.24, p < 0.001) criteria were poor, they were average (0.53, p < 0.001) between NCEP-ATP III and IDF criteria. CONCLUSIONS: The prevalence of MetS among patients with type 2 DM can significantly be varied based on the definition used and the three definitions of MetS recognized different set of individuals. The highest prevalence of MetS was observed with WHO (70.6%) whereas lowest was observed with NCEP-ATP III definition.

Cerebral vasculitis and lateral rectus palsy - two rare central nervous system complications of dengue fever: two case reports and review of the literature.

BACKGROUND: Dengue fever is a common mosquito-borne viral illness with a clinical spectrum ranging from a simple febrile illness to potentially life-threatening complications such as dengue hemorrhagic fever and dengue shock syndrome. Dengue infection can affect many organs, including the central nervous system. The neurological manifestations reported in dengue infections are meningitis, encephalitis, stroke, acute disseminated encephalomyelitis, and Guillain-Barré syndrome. CASE PRESENTATION: We report the cases of two interesting patients with confirmed dengue infection who presented with complications of possible central nervous system vasculitis and cranial nerve palsy. The first patient was a 53-year-old previously healthy Singhalese woman who developed acute-onset slurring of speech and ataxia with altered sensorium 1 day after recovery from a critical period of dengue hemorrhagic fever. Subsequent investigations revealed evidence of encephalopathy with brainstem ischemic infarctions. Her clinical picture was compatible with central nervous system vasculitis. She was treated successfully with intravenous steroids and had a full functional recovery. The second patient was a middle-aged Singhalese woman who had otherwise uncomplicated dengue infection. She developed binocular diplopia on day 4 of fever. An ocular examination revealed a convergent squint in the left eye with lateral rectus palsy but no other neurological manifestation. CONCLUSIONS: Central nervous system vasculitis due to dengue infection is a very rare phenomenon, and to the best of our knowledge, only one case of central nervous system vasculitis has been reported to date, in a patient of pediatric age. Cranial nerve palsy related to dengue infection is also rare, and only a few cases of isolated abducens nerve palsy have been reported to date. The two cases described in this report illustrate the rare but important central nervous system manifestations of dengue fever and support the fact that the central nervous system is one of the important systems that can be affected in patients with dengue infection.

Isolated septic arthritis of hip joint: a rare presentation of melioidosis. A case report.

BACKGROUND: Despite, Sri Lanka lies in the melioidosis endemic belt between 5°N and 10°N surrounded by countries known to have endemic melioidosis for many years, comparatively fewer cases of melioidosis infection have been reported in Sri Lanka. Melioidosis has a wide spectrum of clinical presentation, ranging from severe pneumonia to abscess formation in various organs. Isolated septic arthritis, which is a rare but well-recognized manifestation of melioidosis, could be the sole presenting problem in some patients with melioidosis. CASE PRESENTATION: We report a middle aged diabetic female who has been on azathioprine for autoimmune hepatitis, presenting with pain and swelling of left hip joint. Investigations confirmed the clinical suspicion of septic arthritis, but all relevant microbiological investigations failed to isolate a causative organism. Due to the history of diabetes, possible immunosuppression with azathioprine, and failure to recognise the possible causative organism by initial investigations prompted us to investigate for melioidosis. Diagnosis of melioidosis was made by presence high titre of antibodies to melioidin antigen, and rapid response to appropriate treatment. The patient was treated with intravenous imipenem 1000 mg 6 hourly and oral cotrimoxazole (1920 mg 12 hourly) for 4 weeks followed by eradication therapy with cotrimoxazole and doxycycline. CONCLUSION: Given that melioidosis-induced septic arthritis share common features with septic arthritis due to other common pyogenic bacteria, differentiation of these two conditions is extremely difficult. Therefore, melioidosis needs to be considered as a possibility, when a patient with risk factors for melioidosis such as diabetes or immunosuppression presents with isolated septic arthritis. This case report has been presented to raise the awareness of an unusual presentation of melioidosis; isolated septic arthritis.

Potential use of telephone-based survey for non-communicable disease surveillance in Sri Lanka.

BACKGROUND: Telephone survey (TS) has been a popular tool for conducting health surveys, particularly in developed countries. However, the feasibility, and reliability of TS are not adequately explored in Sri Lanka. The main aim of this study is to assess the effectiveness of telephone-based survey in estimating the prevalence of common non-communicable diseases (NCDs) in Sri Lanka. METHODS: We carried out an observational cross-sectional study using telephone interview method in Galle district, Sri Lanka. The study participants were selected randomly from the residents living in the households with fixed land telephone lines. The prevalence of the main NCDs was estimated using descriptive statistics. RESULTS: Overall, 975 telephone numbers belonging to six main areas of Galle district were called, and 48% agreed to participate in the study. Of the non-respondents, 22% actively declined to participate. Data on NCDs were gathered from 1470 individuals. The most common self-reported NCD was hypertension (17.%), followed by diabetes (16.3%) and dyslipidaemia (15.6%). Smoking was exclusively seen in males (7.4%), and regular alcohol use was significantly more common in males (19.2%) than females (0.4%, P < .001). CONCLUSIONS: Our study revealed average response rate for telephone based interview in Sri Lankan setting. Overall prevalence of main NCDs in this study showed a comparable prevalence to studies used face to face interview method. This study supports the potential use of telephone-based survey to assess heath related information in Sri Lanka.

Knowledge, attitude and practice related to diabetes mellitus among the general public in Galle district in Southern Sri Lanka: a pilot study.

BACKGROUND: Type 2 diabetes mellitus (DM) has become a global epidemic with significant disability and premature death. Identification of the level of knowledge, attitude and practice (KAP) related to diabetes among the general public is important in strategies for prevention of diabetes mellitus. METHODS: This study was conducted as a community based cross sectional study in three Medical Officers of Health (MOH) areas in Galle district. Previously healthy literate individuals who have not attended any diabetes education program in the last two years were selected for this study. RESULTS: A total of 277 participants were included in the study. The majority (77%) had either moderate (39%) or above moderate knowledge (38%) on diabetes mellitus. Even though, level of education was significantly and positively associated with knowledge (p = 0.001), the association of gender and age with knowledge was not significant. Unlike knowledge, the attitude towards diabetes was poor in majority (90%) and level of education had no significant effect on attitude. With regards to practices, more than half of study subjects never had their blood sugar checked and, about 65% used to take refined sugar liberally and a large majority (80%) had no regular exercise activity. CONCLUSIONS: Even though the majority (77%) had moderate or above moderate knowledge on diabetes, their attitudes towards diabetes was poor (88%). It appears that the higher knowledge on diabetes did not translate into good practices as over 50% of study subjects did not involve with any preventive measures. Therefore, more emphasis should be given to address the issue of poor attitude and practices towards diabetes mellitus among general public in Sri Lanka.

Use of HbA1c to diagnose type 2 diabetes mellitus among high risk Sri Lankan adults.

AIM: Even though, glycosylated hemoglobin (HbA1c) was found to be effective in predicting diabetes especially in Caucasians there is limited evidence of its diagnostic utility in high risk Sri Lankan adults. This study aimed to determine the optimal HbA1c cut-off points for detecting diabetes in a high risk population in Sri Lanka. MATERIALS AND METHODS: This community based study consisted of 254 previously healthy adults with history of diabetes in one or more first-degree relatives. Fasting plasma glucose (FPG) , glucose tolerance test (GTT) and HbA1c were measured in all and GTT was used as a reference to diagnose diabetes. Receiver operating characteristic curve was created to find the optimum HbA1c cut-off value to predict diabetes. RESULTS: Prevalence of diabetes was 12.2% (n=31) with FPG and 16.1% (n=41) with GTT. Prevalence rose to 27.6% (P<0.01) when HbA1c with cut-off of ≥6.5% was used as the diagnostic test. The ROC curves showed the HbA1c threshold of 6.3% provided the optimum balance between sensitivity (80.5%) and specificity (79%). In compared to GTT, FPG had only a modest sensitivity (65%) in diagnosing diabetes in this high risk population. CONCLUSION: Our study showed that optimum HbA1C cut-off for detecting diabetes was 6.3% and it had better sensitivity, but lower specificity than FPG. This study further showed that the prevalence of diabetes would become double if HbA1c is used over FPG to screen this high risk population.