Development of a risk prediction model to predict the risk of hospitalization due to exacerbated asthma among adult asthma patients in a lower middle-income country.

BACKGROUND: Asthma patients experience higher rates of hospitalizations due to exacerbations leaving a considerable clinical and economic burden on the healthcare system. The use of a simple, risk prediction tool offers a low-cost mechanism to identify these high-risk asthma patients for specialized care. The study aimed to develop and validate a risk prediction model to identify high-risk asthma patients for hospitalization due to exacerbations. METHODS: Hospital-based, case-control study was carried out among 466 asthma patients aged ≥ 20 years recruited from four tertiary care hospitals in a district of Sri Lanka to identify risk factors for asthma-related hospitalizations. Patients (n = 116) hospitalized due to an exacerbation with respiratory rate > 30/min, pulse rate > 120 bpm, O2 saturation (on air) < 90% on admission, selected consecutively from medical wards; controls (n = 350;1:3 ratio) randomly selected from asthma/medical clinics. Data was collected via a pre-tested Interviewer-Administered Questionnaire (IAQ). Logistic Regression (LR) analyses were performed to develop the model with consensus from an expert panel. A second case-control study was carried out to assess the criterion validity of the new model recruiting 158 cases and 101 controls from the same hospitals. Data was collected using an IAQ based on the newly developed risk prediction model. RESULTS: The developed model consisted of ten predictors with an Area Under the Curve (AUC) of 0.83 (95% CI: 0.78 to 0.88, P < 0.001), sensitivity 69.0%, specificity 86.1%, positive predictive value (PPV) 88.6%, negative predictive value (NPV) 63.9%. Positive and negative likelihood ratios were 4.9 and 0.3, respectively. CONCLUSIONS: The newly developed model was proven valid to identify adult asthma patients who are at risk of hospitalization due to exacerbations. It is recommended as a simple, low-cost tool for identifying and prioritizing high-risk asthma patients for specialized care.

Hypertension Pharmacological Treatment in Adults: A World Health Organization Guideline Executive Summary.

Hypertension is a major cause of cardiovascular disease and deaths worldwide especially in low- and middle-income countries. Despite the availability of safe, well-tolerated, and cost-effective blood pressure (BP)-lowering therapies, <14% of adults with hypertension have BP controlled to a systolic/diastolic BP <140/90 mm Hg. We report new hypertension treatment guidelines, developed in accordance with the World Health Organization Handbook for Guideline Development. Overviews of reviews of the evidence were conducted and summary tables were developed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. In these guidelines, the World Health Organization provides the most current and relevant evidence-based guidance for the pharmacological treatment of nonpregnant adults with hypertension. The recommendations pertain to adults with an accurate diagnosis of hypertension who have already received lifestyle modification counseling. The guidelines recommend BP threshold to initiate pharmacological therapy, BP treatment targets, intervals for follow-up visits, and best use of health care workers in the management of hypertension. The guidelines provide guidance for choice of monotherapy or dual therapy, treatment with single pill combination medications, and use of treatment algorithms for hypertension management. Strength of the recommendations was guided by the quality of the underlying evidence; the tradeoffs between desirable and undesirable effects; patient's values, resource considerations and cost-effectiveness; health equity; acceptability, and feasibility consideration of different treatment options. The goal of the guideline is to facilitate standard approaches to pharmacological treatment and management of hypertension which, if widely implemented, will increase the hypertension control rate world-wide.

Improving the Policy Utility of Cause of Death Statistics in Sri Lanka: An Empirical Investigation of Causes of Out-of-Hospital Deaths Using Automated Verbal Autopsy Methods.

Background: Setting public health policies and effectively monitoring the impact of health interventions requires accurate, timely and complete cause of death (CoD) data for populations. In Sri Lanka, almost half of all deaths occur outside hospitals, with questionable diagnostic accuracy, thus limiting their information content for policy. Objectives: To ascertain whether SmartVA is applicable in improving the specificity of cause of death data for out-of-hospital deaths in Sri Lanka, and hence enhance the value of these routinely collected data for informing public policy debates. Methods: SmartVA was applied to 2610 VAs collected between January 2017 and March 2019 in 22 health-unit-areas clustered in six districts. Around 350 community-health-workers and 50 supervisory-staffs were trained. The resulting distribution of Cause-Specific-Mortality-Fractions (CSMFs) was compared to data from the Registrar-General's-Department (RGD) for out-of-hospital deaths for the same areas, and to the Global-Burden-of-Disease (GBD) estimates for Sri Lanka. Results: Using SmartVA, for only 15% of deaths could a specific-cause not be assigned, compared with around 40% of out-of-hospital deaths currently assigned garbage codes with "very high" or "high" severity. Stroke (M: 31.6%, F: 35.4%), Ischaemic Heart Disease (M: 13.5%, F: 13.0%) and Chronic Respiratory Diseases (M: 15.4%, F: 10.8%) were identified as the three leading causes of home deaths, consistent with the ranking of GBD-Study for Sri Lanka for all deaths, but with a notably higher CSMF for stroke. Conclusions: SmartVA showed greater diagnostic specificity, applicability, acceptability in the Sri Lankan context. Policy formulation in Sri Lanka would benefit substantially with national-wide implementation of VAs.

Leveraging mobile phone surveys during the COVID-19 pandemic in Ecuador and Sri Lanka: Methods, timeline and findings.

Effective and rapid decision making during a pandemic requires data not only about infections, but also about human behavior. Mobile phone surveys (MPS) offer the opportunity to collect real-time data on behavior, exposure, knowledge, and perception, as well as care and treatment to inform decision making. The surveys aimed to collect coronavirus disease 2019 (COVID-19) related information in Ecuador and Sri Lanka using mobile phones. In Ecuador, a Knowledge, Attitudes and Practices (KAP) survey was conducted. In Sri Lanka, an evaluation of a novel medicine delivery system was conducted. Using the established mobile network operator channels and technical assistance provided through The Bloomberg Philanthropies Data for Health Initiative (D4H), Ministries of Health fielded a population-based COVID-19-specific MPS using Surveda, the open source data collection tool developed as part of the initiative. A total of 1,185 adults in Ecuador completed the MPS in 14 days. A total of 5,001 adults over the age of 35 in Sri Lanka completed the MPS in 44 days. Both samples were adjusted to the 2019 United Nations Population Estimates to produce population-based estimates by age and sex. The Ecuador COVID-19 MPS found that there was compliance with the mitigation strategies implemented in that country. Overall, 96.5% of Ecuadorians reported wearing a face mask or face covering when leaving home. Overall, 3.8% of Sri Lankans used the service to receive medicines from a government clinic. Among those who used the medicine delivery service in Sri Lanka, 95.8% of those who used a private pharmacy received their medications within one week, and 69.9% of those using a government clinic reported the same. These studies demonstrate that MPS can be conducted quickly and gather essential data. MPS can help monitor the impact of interventions and programs, and rapidly identify what works in mitigating the impact of COVID-19.

Phenotype and metabolic profile of South Asian women with polycystic ovary syndrome (PCOS): results of a large database from a specialist Endocrine Clinic.

BACKGROUND: Compared with other populations, South Asians have a greater propensity to insulin resistance and the metabolic syndrome (MetS). This is the first study to determine the distribution of phenotypes of polycystic ovary syndrome (PCOS) and their relationship to the MetS among indigenous South Asians. METHOD: An evaluation of the phenotype and metabolic characteristics of PCOS was conducted by recruiting consecutive women diagnosed by Rotterdam consensus criteria from an Endocrine clinic in Colombo, Sri Lanka. Prevalence of MetS was determined, in relation to the phenotypic subgroup of PCOS and compared with ethnically matched, BMI- and age-adjusted controls (n =231). RESULTS: Acanthosis nigricans (AN) occurred in 64.6% of women with PCOS (n= 469). MetS occurred in 30.6% of the PCOS group compared with 6.34% of controls (P = 0.0001). Those with PCOS and MetS had significantly higher median BMI, blood pressure (BP), fasting plasma glucose, insulin and triglycerides and lower high-density lipoprotein and sex hormone-binding globulin (SHBG), but similar testosterone concentrations compared with those with PCOS alone. Prevalence of MetS was similar in the four PCOS phenotypes, although oligomenorrhoeic women were more obese compared with the normal cycling hyperandrogenic group. Multivariate logistic regression confirmed age ≥35 years, BMI ≥25 kg/m(2) and AN as significant predictors of MetS in PCOS. Case-control comparisons showed that the presence of PCOS results in higher odds of having the MetS, a high waist circumference, elevated diastolic BP, abnormal fasting lipids and high fasting insulin and plasma testosterone concentrations. CONCLUSIONS: Young indigenous South Asians with PCOS have greater odds of being centrally obese, with a third having the MetS that bears no relationship to the androgenic phenotype. Significant predictors for MetS within the PCOS cohort are advancing age, obesity determined by the Asian cut off (BMI >25 kg/m(2)) and AN, while family history of diabetes, hyperandrogenism and elevated SHBG have no predictive value.

Human rabies focusing on dog ecology-A challenge to public health in Sri Lanka.

Sri Lanka is among the top ten countries in the world that report the highest rate of human rabies deaths (2.8 per 1,000,000 in 2007) and animal bites requiring anti-rabies post-exposure treatment (PET) (755 per 100,000 in 2003). Dogs are the main reservoir and transmitters of rabies in Sri Lanka. Present study evaluates the effectiveness of dog rabies control strategies on reducing incidence of human rabies deaths. Analysis is based on data from last three decades and showed strong correlations between the interventions and human rabies incidence. GIS maps provided a method for illustrating the district distribution of human rabies deaths and dog population density and for recognizing districts at risk. Interrupting the natural transmission cycle of rabies in dogs would be a logical approach in eliminating dog rabies in Sri Lanka. However, interventions implemented so far, such as dog vaccination, elimination of stray dogs (abandoned in 2005), and animal birth control have been inadequate to do so. Better understanding of the ecology of stray and owned dogs (e.g. population density, population structure, confinement status) in the context of the human environment and culture, are needed to strategize the control activities, requiring coordination among regional Public Health and Veterinary services.