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.

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.

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.

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.

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.

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.

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.

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.

Correlation between serum heavy metals and the risk of oral squamous cell carcinoma and oral potentially malignant disorders.

Oral squamous cell carcinoma (OSCC) is a serious public health problem in various Asian countries, including Sri Lanka, and a combination of cultural practices, lifestyle factors, and genetic predispositions influences the incidence of these cancers. The examination of the connection between exposure to heavy metals and the probability of developing oral potentially malignant disorders (OPMD) and OSCC has been limited in its scope, and the overall consequences of such exposure remain largely unknown. This study aims to clarify the link between serum levels of heavy metals and the risk of OSCC and OPMD. The concentrations of seven heavy metals-namely, arsenic (As), cadmium (Cd), chromium (Cr), cobalt (Co), copper (Cu), lead (Pb), and zinc (Zn)-were analyzed in serum samples from 60 cases and 15 controls in the Sri Lankan cohort. The Inductively Coupled Plasma-Optical Emission Spectrometry (ICP-OES) was used for the analysis. Subsequently, the data underwent statistical evaluation via the Kruskal-Wallis H test, using the Statistical Package for Social Sciences (SPSS) version 28 software, with a confidence interval set at 95%. A p-value less than 0.05 was considered statistically significant. The cohort consisted of 48 men and 27 women, with 15 patients each diagnosed with OSCC, OSF, OLK, and OLP, and 15 healthy controls. The study used the Kruskal-Wallis Test to compare metal concentrations across groups, finding significant differences for all metals except As and Pb. Significant associations were observed between age, past medical history, drug history, gender, smoking, alcohol consumption, and betel chewing. The Spearman Correlation test showed significant correlations between the concentrations of Cr, Co, Cu, As, and Zn and the presence of cancer/precancer conditions. The study's findings suggest that heavy metal contamination may be linked to the development of OSCC and precancerous conditions. When comparing OSCC and OPMD cases with controls, the serum concentrations of As and Pb did not differ significantly. However, Cd, Cr, Co, Cu, and Zn exhibited significantly higher concentrations among cases compared to controls (p < 0.05). This study observed significant variations in the levels of these five heavy metals among cancerous (OSCC), premalignant (OPMD), and healthy tissues, suggesting a potential role in the progression of malignancies. These findings underscore the importance of environmental pollution in this specific context.

Role of the dengue vaccine TAK-003 in an outbreak response: Modeling the Sri Lanka experience.

BACKGROUND: Outbreaks of dengue can overburden hospital systems, drastically reducing capacity for other care. The 2017 dengue serotype 2 (DENV-2) outbreak in Sri Lanka coincided with vaccination in an ongoing phase 3 efficacy trial of a tetravalent dengue vaccine, TAK-003 (NCT02747927). Here, we present data on the efficacy of TAK-003 following two doses of the vaccine administered 3 months apart in participants aged 4-16 years in Sri Lanka. In addition, we have used the 2017 outbreak dynamics to model the potential impact of TAK-003 on virologically confirmed dengue (VCD) cases and hospitalizations during an outbreak situation. METHODOLOGY/PRINCIPAL FINDINGS: Modeling was performed using an age-structured, host-vector, spatial and stochastic transmission model, assuming 65% vaccine coverage and 30 days until initiation of vaccination. Efficacy of TAK-003 against VCD and hospitalized VCD cases was based on data against DENV-2 from the first year of the phase 3 trial. Vaccine efficacy and safety findings in Sri Lanka were in line with those of the overall trial population. The efficacy estimates in Sri Lanka up to the first 12 months after the second dose of TAK-003 were 94.7% and 95.7% against VCD and hospitalized VCD cases, respectively. Modeling of the trial data over an extended geographic area showed a substantial reduction in cases and a flattening of outbreak curves from TAK-003 use. The baseline vaccination scenario (initiation at 30 days, 65% target coverage, vaccine effective at 14 days, 70% hospitalization rate, VE of 95% for VCD and 97% for hospitalized VCD, and 47% for asymptomatic) resulted in a 69.1% reduction in VCD cases and 72.7% reduction in VCD hospitalizations compared with no vaccination. An extreme high scenario (vaccination initiated at Day 15, 80% coverage rate, baseline VE) resulted in 80.3% and 82.3% reduction in VCD and VCD hospitalizations, respectively. Vaccine performance, speed of vaccination campaign initiation, and vaccine coverage were key drivers in reducing VCD cases and hospitalizations. CONCLUSIONS/SIGNIFICANCE: Overall, the study and modeling results indicate that TAK-003 has the potential of meaningful utility in dengue outbreaks in endemic areas.

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.

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.

Restrictions on Pesticides and Deliberate Self-Poisoning in Sri Lanka.

Importance: Deliberate self-poisoning using pesticides as a means of suicide is an important public health problem in low- and middle-income countries. Three highly toxic pesticides-dimethoate, fenthion, and paraquat-were removed from the market in Sri Lanka between 2008 and 2011. In 2015, less toxic pesticides (chlorpyrifos, glyphosate, carbofuran, and carbaryl) were restricted. Subsequent outcomes have not been well described. Objective: To explore the association of pesticide bans with pesticide self-poisonings and in-hospital deaths. Design, Setting, and Participants: In this cross-sectional study with an interrupted time series design, data were prospectively collected on all patients with deliberate self-poisonings presenting to 10 Sri Lankan hospitals between March 31, 2002, and December 31, 2019, and analyzed by aggregated types of poisoning. The correlates of pesticide bans were estimated within the pesticide group and on self-poisonings within other substance groups. The data analysis was performed between April 1, 2002, and December 31, 2019. Exposures: Implementation of 2 sets of pesticide bans. Main Outcomes and Measures: The main outcomes were changes in hospital presentations and in-hospital deaths related to pesticide self-poisoning as measured using segmented Poisson regression. Results: A total of 79 780 patients (median [IQR] age, 24 [18-34] years; 50.1% male) with self-poisoning from all causes were admitted to the study hospitals, with 29 389 poisonings (36.8%) due to pesticides. A total of 2859 patients died, 2084 (72.9%) of whom had ingested a pesticide. The first restrictions that targeted acutely toxic, highly hazardous pesticides were associated with an abrupt and sustained decline of the proportion of poisonings with pesticides (rate ratio [RR], 0.85; 95% CI, 0.78-0.92) over the study period and increases in poisonings with medications (RR, 1.11; 95% CI, 1.02-1.21) and household and industrial chemicals (RR, 1.20; 95% CI, 1.05-1.36). The overall case fatality of pesticides significantly decreased (RR, 0.33; 95% CI, 0.26-0.42) following the implementation of the 2008 to 2011 restrictions of highly hazardous pesticides. Following the 2015 restrictions of low-toxicity pesticides, hospitalizations were unchanged, and the number of deaths increased (RR, 1.98; 95% CI, 1.39-2.83). Conclusions and Relevance: These findings support the restriction of acutely toxic pesticides in resource-poor countries to help reduce hospitalization for and deaths from deliberate self-poisonings and caution against arbitrary bans of less toxic pesticides while more toxic pesticides remain available.

The impact of the National Programme to Eliminate Lymphatic Filariasis on filariasis morbidity in Sri Lanka: Comparison of current status with retrospective data following the elimination of lymphatic filariasis as a public health problem.

INTRODUCTION: Sri Lanka implemented the National Programme for Elimination of Lymphatic Filariasis (NPELF) in its endemic regions in 2002. Five annual rounds of mass drug administration using the two-drug combination diethylcarbamazine (DEC) and albendazole led to sustained reductions in infection rates below threshold levels. In 2016, WHO validated that Sri Lanka eliminated lymphatic filariasis as a public health problem. OBJECTIVE: To explore the impact of the NPELF on lymphatic filariasis morbidity in Sri Lanka. METHODS: Passive Case Detection (PCD) data maintained in filaria clinic registries from 2006-2022 for lymphoedema and hospital admission data for managing hydroceles/spermatoceles from 2007-2022 were analyzed. The morbidity status in 2022 and trends in overall and district-wise PCD rates were assessed. Poisson log-linear models were used to assess the trends in PCD for endemic regions, including district-wise trends and hospital admissions for the management of hydroceles/spermatoceles. RESULTS: In 2022, there were 566 new lymphoedema case visits. The mean (SD) age was 53.9 (16.0) years. The staging was done for 94% of cases, of which 79% were in the early stages (57.3% and 21.4% in stages two and one, respectively). Western Province had the highest caseload (52%), followed by the Southern (32%) and Northwestern (16%) Provinces, respectively. The reported lymphoedema PCD rate in 2022 was 0.61 per 10,000 endemic population. The overall PCD rate showed a decline of 7.6% (95%CI: 4.9% - 10.3%) per year (P < 0.0001) from 2007 to 2022. A steady decline was observed in Colombo, Gampaha and Kurunegala districts, while Kalutara remained static and other districts showed a decline in recent years. Further, admissions for inpatient management of hydroceles/spermatoceles showed a declining trend after 2015. CONCLUSIONS: The PCD rates of lymphoedema and hydroceles/spermatoceles showed a declining trend in Sri Lanka after the implementation of the NPELF.

LEDoxy-SL: A Placebo-Controlled, Double-Blind, Randomized, 24-Month Trial of Six Weeks of Daily Doxycycline Plus Hygiene-Based Essential Care for Reducing Progression of Filarial Lymphedema in Sri Lanka.

Morbidity management of filarial lymphedema remains a challenge even during the post-lymphatic filariasis elimination era in Sri Lanka despite provision of the predominantly hygiene-based WHO Essential Package of Care. Because prior studies have suggested that 6 weeks of doxycycline may reduce progression of limb lymphedema, we conducted a randomized, placebo-controlled, superiority study to evaluate this possibility in Sri Lanka. Patients aged 14 to 65 years with lymphedema in one or both legs received either 200 mg of doxycycline daily for 6 weeks or matching placebo. The primary efficacy endpoint was improvement or lack of progression in lymphedema stage at 24 months postenrollment. Secondary endpoints included change in lymphedema stage at 12 and 24 months, frequency of acute adenolymphangitis episodes, and perceived disability measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Training and supplies for limb hygiene were provided throughout the study. Two hundred participants (100 in each arm) with lymphedema of Dreyer stages 1 to 3 were enrolled. By the end of the 2-year study, 29% of the doxycycline patients and 34% of those on placebo showed improvement (i.e., a decrease in lymphedema stage), whereas 11% and 15% of the two groups showed worsening of the lymphedema. Adenolymphangitis rates were comparable in the two groups (43 doxycycline and 38 placebo recipients), although attacks lasted slightly longer in placebo patients (6.5 days versus 5.2 days). In both groups, perceived disability improved initially, with partial rebound in the second year. Only 34 adverse events affecting 24 patients (11%) occurred during the 6-week treatment period. Although doxycycline did not significantly impact lymphedema progression in this study, the results clearly indicate that clinical and personal benefits can be obtained from intensive hygiene management alone.

Unraveling Sociocultural Influences on Leptospirosis Incidence and Prevalence: A Qualitative Study in Sri Lanka.

This study aimed to explore sociocultural determinants that might contribute to the increased prevalence and incidence of leptospirosis, and how those determinants can also hinder health promotion interventions, particularly in rural areas of Sri Lanka. Even though several epidemiological studies have been conducted on leptospirosis in the Asia-Pacific region, the sociocultural background of this disease has not received sufficient attention. Therefore, through a qualitative study involving nine public health officials and 25 infected patients in five selected health administrative divisions, we demonstrate that a set of certain sociocultural determinants influence leptospirosis incidence and its prevalence. The thematic analysis generated six themes: a lack of knowledge of the causes and consequences of leptospirosis, false illness interpretations, a lack of readiness for the disease, poor economic conditions, social capital failure, and issues within the health system at the community level. Overall, results suggest that awareness programs aimed at demystifying false interpretations of leptospirosis lie at the center of any health promotion interventions at the community level.

Retinoblastoma patients treated in Sri Lanka from 2014 to 2020: epidemiology, clinical status and correlates of lag time in seeking tertiary care services.

BACKGROUND: Retinoblastoma (RB) is a tumour of children < 5 years with a incidence of 1 in 20,000. Around 20 RB cases are diagnosed yearly in Sri Lanka, a lower middle-income country with high literacy levels and healthcare free at point of delivery. Incidence, local and systemic severity and mortality related to RB are reportedly high in low- and middle- income countries in comparison to higher income countries. Aims of this study were to describe demographic, socioeconomic, and clinical characteristics of Sri Lankan RB patients attending the designated RB unit at the Lady Ridgeway Hospital (LRH), Colombo between January 2014 to December 2020, and determine correlates of lag time (LT) for first tertiary care visit after detecting the first symptom/sign. METHODS: Two descriptive cross-sectional studies (DCSS) were conducted, one on 171 RB patients with demographic and clinical data collected between 2017 and 2020. In 2021, the second DCSS took place where socioeconomic and further demographic data were collected using telephone interviews, recruiting a subgroup of 90 (53%), consenting and contactable RB patient/ parent pairs. Bivariate and multivariable analyses were applied to determine correlates of LT of > 4 weeks for first tertiary care visit. Results were expressed as odds ratios and 95% confidence intervals. RESULTS: LRH survey (N = 171): Median age at diagnosis was 15 months (range 1-94 months; IQR: 8-27); 89 (52%) were females. Groups D and E tumours were 25.7% (n = 44) and 62.6% (n = 107) respectively with 121 (71%) enucleations. The number of deaths were 2 (1.2%). Telephone survey (N = 90): Proportion with LT of > 4 weeks for first tertiary care visit was 58% (n = 52). None of the putative risk factors (ethnicity, parental educational level, socioeconomic status, distance from residence to tertiary care unit and receiving financial assistance) were associated with LT in both analyses. CONCLUSION: Despite a high proportion with groups D and E tumours and enucleations, mortality rate was low, most likely due to availability of designated tertiary care. No correlates for LT of > 4 weeks for tertiary care presentation were identified. Early RB detection needs rigorous implementation of screening strategies and increased awareness among primary care health workers and parents.

Determinants of sleep quality among pregnant women in a selected institution in the Southern province, Sri Lanka.

BACKGROUND: Sleep is a vital requirement during pregnancy for the betterment of the fetus and the mother. Sleep quality could vary due to pregnancy-specific psychological and physiological changes. To introduce a tailored programme to enhance the sleep quality of mothers, it is paramount to assess the sleep quality and determinants of sleep. Therefore, this study aimed to assess the determinants of sleep quality among pregnant women in a selected institution in the Southern province of Sri Lanka. METHODS: Hospital-based cross-sectional study was carried out with 245 antenatal women, selected using a systematic random sampling method. A pretested self-administered questionnaire was used to collect data which contains four parts. Below variables were involved and both continuous and categorical data were collected as required. 'Maternal sleep quality, socio-demographic data and gestational age, maternal depression and anxiety.' Data were analyzed using IBM SPSS version 25.0 for Windows by using descriptive statistics, Pearson's Chi-square test, and independent sample T-test (p < 0.05). Logistic regression analysis was used to find the relationship with sleep quality and other variables. P-value of less than 0.05 was considered statistically significant, at 95% CI. RESULTS: The majority of women (60.8%) had good sleep quality and they didn't have either depressive symptoms (63.4%) or anxiety (64.2%). Aged between 34-41 years and third-trimester women had higher rates of poor sleep quality. Varying quality of sleep was identified among three-trimesters with subjective sleep quality, sleep latency, habitual sleep efficiency, and sleep disturbances. In comparison with the first and second trimester, pregnant women in the third trimester had higher score of global PSQI (5.22 ± 2.35), subjective sleep quality (1.23 ± 0.70), sleep latency (1.25 ± 0.86), habitual sleep efficiency (0.14 ± 0.43), and sleep disturbances (1.39 ± 0.58). There was a significant association between gestational age (P = .006), maternal age (P = .009), antenatal depression (P = .034), and anxiety (P = .013) with sleep quality. However, multinomial logistic regression revealed that only gestational age affected on quality of sleep. The first trimester was a protective factor for good quality sleep (Adjusted OR = 3.156) compared to the other two trimesters. CONCLUSION: This study revealed that the majority of women had good sleep quality but quality of sleep was deprived with gestational age. It is expected that the findings of this research will be helpful for health and social care policymakers when formulating guidelines and interventions regarding improving the quality of sleep among pregnant women in Sri Lanka.