Availability of cytotoxic medicines in the WHO essential medicine list used in treating childhood malignancies in low-income and lower-middle-income countries: a systematic review protocol.

INTRODUCTION: Cancer is a leading cause of death globally with childhood cancers accounting for around 5% of the total incidence. Almost 90% of childhood cancers are recorded from low-income and lower-middle-income countries (LLMICs), where survival rates are comparatively low. The unavailability of essential medicines for childhood cancers is identified as a reason for this observed health inequity. The objectives of this review are to describe the availability of cytotoxic medicines in the WHO essential medicine list (EML) used in treating children with cancer in LLMICs and to determine the enablers and barriers to accessing WHO essential medicines for childhood cancer. METHODS AND ANALYSIS: A systematic review will be conducted using electronic databases: MEDLINE, EMBASE and CINAHL. Additional articles and grey literature will be searched in Google Scholar and reference list of the selected articles. It will include primary studies, national/regional reports and policy documents. Review questions will be framed into different components according to the ECLIPSe framework. Children less than 19 years of age diagnosed with any malignant disorder in LLMICs will be the client group. Studies that have focused on the availability of EML for adult malignancies and care providers' knowledge of EML for childhood malignancies will not be considered. Only the studies reported in the English language will be included. Mixed methods Appraisal Tool will be used to assess the quality of included studies. Data will be presented as a narrative synthesis. ETHICS AND DISSEMINATION: This research is exempt from ethics approval because the work is carried out on published documents. Findings of this review will be disseminated through a peer-reviewed journal for the authorities in LLMICs to understand the magnitude of the problem and to identify enablers and barriers to take evidence based decisions to improve their health system. PROSPERO REGISTRATION NUMBER: CRD42022334156.

Vitamin D knowledge and sun exposure practices among Sri Lankan healthcare undergraduates.

INTRODUCTION: Although overexposure to ultraviolet radiation may lead to skin cancer, inadequate exposure results in vitamin D deficiency (VDD). We explored vitamin D-related knowledge and sun exposure practices among Sri Lankan healthcare undergraduates. METHODS: The sampling frame consisted of medical and allied health undergraduates in a single centre. A newly developed, pre-piloted, self-administered questionnaire collected data on vitamin D knowledge, sun avoidance behaviour and outdoor time. Univariate and multivariate logistic regression analysis examined the factors related to outdoor time. RESULTS: A total of 482 were included in the analysis. The mean (SD) vitamin D knowledge score (0-100% scale) was 31.3% (18%). Only 17.8% scored ≥50% for knowledge. At least one sun avoidance measure was used by 59.3% of the undergraduates. A lower knowledge score was observed with a higher number of sun-avoidance behaviour (mean difference 0.84, p = 0.03). The majority (66%) spent outdoors <30 minutes per day between 9 am-3 pm. The odds of having low outdoor time were 1.6 higher for the female sex (OR:1.61, 95%CI:1.039, 2.492, p<0.001) and studying in the final year (OR:1.63, 95%CI:1.020, 2.602, p = 0.04). Medical students had a higher likelihood of low outdoor time (OR:0.55, 95%CI: 0.361, 0.835, p = 0.005). CONCLUSIONS: The healthcare undergraduates had low vitamin D knowledge and outdoor time while having increased sun avoidance. Gender, course of study, and academic year appeared to affect outdoor time. Support and guidance should improve knowledge and sun exposure habits that suit academic work and lifestyle in this population. Also, universities can actively promote positive sun exposure by organizing outdoor events.

Child emotional and behavioral difficulties and parent stress during COVID-19 lockdown in Sri Lankan families.

INTRODUCTION: Understanding parents' and children's mental health issues would help design population-specific intervention programs. The present study explored parents' perceived stress and child emotions and behavior during the COVID-19 lockdown among Sri Lankan families. METHODS: A cross-sectional survey was conducted among Sri Lankan parents of children aged 11 to 17 years. Validated instruments (Perceived Stress Scale-PSS and Strengths and Difficulties Questionnaire-SDQ) evaluated parental stress, child emotions, and hyperactivity/inattention. Multiple linear regression assessed the predictors of mental health issues, including the interaction between age and gender. RESULTS: Three hundred fifty-five parents responded to the survey (mothers:76%). One-third of parents experienced difficulties with their children during the pandemic. Emotions and hyperactivity-inattention problems measured via the SDQ scale were high among 38% of children, while the perceived stress was high in 79.2% of parents. Overall, child emotions and hyperactivity-inattention increased with decreasing age, increasing parent stress, having middle-income compared to high-income, and having a family member/close relative tested positive for COVID-19. Hyperactivity-inattention (29.3%) was more than the emotional problems (22%) among children. The emotional problems were reported more with increasing parent stress, while child hyperactivity-inattention alone was reported more with decreasing age, middle-income compared to high-income families, and increasing parent stress. Also, the interaction effect of age and gender indicated that higher age was related to greater parent-reported hyperactivity-inattention problems in males. CONCLUSIONS: The findings highlight how the COVID-19 crisis and social isolation have contributed to increased parental stress and child emotional and hyperactivity-inattention problems. In addition to cautioning the healthcare workers, socio-culturally appropriate preventive and supportive mental health programs may help deal with further waves of COVID-19 or any other adverse circumstances.

Thinness negatively affects lung function among Sri Lankan children.

BACKGROUND: There have been conflicting findings on the effect of body mass index (BMI) on lung functions in children. Therefore, we studied the relationship between spirometry parameters and BMI among healthy Sri Lankan school children aged 5-7 years. METHODS: A cross-sectional study was conducted among 296 school children (5-7-year-old) without apparent lung disease. Recruitment was done with stratified random sampling. Spirometry parameters, FEV1, FVC, PEFR, and FEV1/FVC ratio were determined. The acceptable and reproducible spirometry recordings were included in the analysis. Simple and multivariate linear regression analysis examined possible associations of lung function parameters with BMI, socio-demographic variables and indoor risk factors. Also, the mediator effect of gender on lung function through BMI was explored. RESULTS: The participants' mean age (SD) was 6.4 (0.65) years. One-third were thin/severely thin (37%). A statistically significant difference in FVC (p = 0.001) and FEV1 (p = 0.001) was observed between BMI groups (obesity/overweight, normal, and thinness). Yet, PEFR or FEV1/FVC did not significantly differ among BMI groups (p = 0.23 and p = 0.84). Multivariate regression analysis showed that FEV1 and FVC were significantly associated with BMI, child's age, gender, family income, father's education, having a pet, and exposure to mosquito coil smoke. Interaction between gender and BMI for lung functions was not significant. The thin children had significantly lower FVC (OR: -0.04, 95%CI: -0.077, -0.012, p = 0.008) and FEV1 (OR: -0.04, 95%CI: -0.075, -0.014, p = 0.004) than normal/overweight/obese children. Family income demonstrated the greatest effect on lung functions; FVC and FEV1 were 0.25L and 0.23L smaller in low-income than the high-income families. CONCLUSION: Lower lung function parameters (FVC and FEV1) are associated with thinness than normal/overweight/obese dimensions among children without apparent lung disease. It informs that appropriate nutritional intervention may play a role in improving respiratory health.

Healthcare provider perspectives on delivering next generation rotavirus vaccines in five low-to-middle-income countries.

BACKGROUND: Live oral rotavirus vaccines (LORVs) have significantly reduced rotavirus hospitalizations and deaths worldwide. However, LORVs are less effective in low- and middle-income countries (LMICs). Next-generation rotavirus vaccines (NGRVs) may be more effective but require administration by injection or a neonatal oral dose, adding operational complexity. Healthcare providers (HPs) were interviewed to assess rotavirus vaccine preferences and identify delivery issues as part of an NGRV value proposition. OBJECTIVE: Determine HP vaccine preferences about delivering LORVs compared to injectable (iNGRV) and neonatal oral (oNGRV) NGRVs. METHODS: 64 HPs from Ghana, Kenya, Malawi, Peru, and Senegal were interviewed following a mixed-method guide centered on three vaccine comparisons: LORV vs. iNGRV; LORV vs. oNGRV; oNGRV vs. iNGRV. HPs reviewed attributes for each vaccine in the comparisons, then indicated and explained their preference. Additional questions elicited views about co-administering iNGRV+LORV for greater public health impact, a possible iNGRV-DTP-containing combination vaccine, and delivering neonatal doses. RESULTS: Almost all HPs preferred oral vaccine options over iNGRV, with many emphasizing an aversion to additional injections. Despite this strong preference, HPs described challenges delivering oral doses. Preferences for LORV vs. oNGRV were split, marked by disparate views on rotavirus disease epidemiology and the safety, need, and feasibility of delivering neonatal vaccines. Although overwhelmingly enthusiastic about an iNGRV-DTP-containing combination option, several HPs had concerns. HP views were divided on the feasibility of co-administering iNGRV+LORV, citing challenges around logistics and caregiver sensitization. CONCLUSION: Our findings provide valuable insights on delivering NGRVs in routine immunization. Despite opposition to injectables, openness to co-administering LORV+iNGRV to improve efficacy suggests future HP support of iNGRV if adequately informed of its advantages. Rationales for LORV vs. oNGRV underscore needs for training on rotavirus epidemiology and stronger service integration. Expressed challenges delivering existing LORVs merit further examination and indicate need for improved delivery.

National stakeholder preferences for next-generation rotavirus vaccines: Results from a six-country study.

BACKGROUND: Currently available live, oral rotavirus vaccines (LORVs) have significantly reduced severe rotavirus hospitalizations and deaths worldwide. However, LORVs are not as effective in low- and middle-income countries (LMIC) where rotavirus disease burden is highest. Next-generation rotavirus vaccine (NGRV) candidates in development may have a greater public health impact where they are needed most. The feasibility and acceptability of possible new rotavirus vaccines were explored as part of a larger public health value proposition for injectable NGRVs in LMICs. OBJECTIVE: To assess national stakeholder preferences for currently available LORVs and hypothetical NGRVs and understand rationales and drivers for stated preferences. METHODS: Interviews were conducted with 71 national stakeholders who influence vaccine policy and national programming. Stakeholders from Ghana, Kenya, Malawi, Peru, Senegal, and Sri Lanka were interviewed using a mixed-method guide. Vaccine preferences were elicited on seven vaccine comparisons involving LORVs and hypothetical NGRVs based on information presented comparing the vaccines' attributes. Reasons for vaccine preference were elicited in open-ended questions, and the qualitative data were analyzed on key preference drivers. RESULTS: Nearly half of the national stakeholders interviewed preferred a highly effective standalone, injectable NGRV over current LORVs. When presented as having similar efficacy to the LORV, however, very few stakeholders preferred the injectable NGRV, even at substantially lower cost. Similarly, a highly effective standalone injectable NGRV was generally not favored over an equally effective oral NGRV following a neonatal-infant schedule, despite higher cost of the neonatal option. An NGRV-DTP-containing combination vaccine was strongly preferred over all other options, whether delivered alone with efficacy similar to current LORVs or co-administered alongside an LORV (LORV + NGRV-DTP) to increase efficacy. CONCLUSION: Results from these national stakeholder interviews provide valuable insights to inform ongoing and future NGRV research and development.

Serum Vitamin D Level and Risk of Community-Acquired Pneumonia: A Case-Control Study.

INTRODUCTION: Recent research has shown conflicting evidence on the connection between vitamin D deficiency and community-acquired pneumonia (CAP) in children. Thus, we hypothesized that vitamin D deficiency could be a risk factor for CAP. METHODS: Hospitalized children between 2 and 60 months with physician-diagnosed, radiologically confirmed severe community-acquired pneumonia (CAP) were enrolled as cases. Age-matched controls were enrolled from immunization and weighing clinics. A blood sample was collected to assess serum 25-(OH)D concentration. Unconditional logistic regression was done to examine the independent association of vitamin D level with community-acquired pneumonia. RESULTS: Seventy-four children (females: 68%) were included. Overall, 27% had vitamin D deficiency (<20 ng/mL) and 37.8% had insufficiency (20-29 ng/mL). The vitamin D level ranged from 8.67 to 46.2 ng/mL. There was no statistically significant difference in 25(OH)D levels in controls and cases (p=0.694). In unconditional logistic regression, 25(OH)D concentration was not a determinant of CAP (OR: 0.99, CI: 0.937-1.044, p=0.689). This lack of association remained after adjustment for age, gender, income, crowding, and exposure to passive smoke (OR: 0.99, CI: 0.937-1.065, p=0.973). Household income was significantly associated with CAP (OR: 0.11, 95% CI: 0.021-0.567, p=0.008). CONCLUSION: Two-thirds of the children with CAP had vitamin D deficiency/insufficiency. In comparison with healthy controls, vitamin D level was not a significant determinant of community-acquired pneumonia. It informs that further multisite research is required using more rigorous scientific methods for conclusive evidence on the relationship between vitamin D and CAP.

Vitamin D Deficiency in Dengue Hemorrhagic Fever and Dengue Shock Syndrome among Sri Lankan Children: A Case-Control Study.

INTRODUCTION: Dengue fever is a vector-borne disease associated with a significant public health impact. The clinical picture ranges from undifferentiated fever to more severe forms such as dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Compared to healthy controls, we explored the likelihood of having vitamin D deficiency (VDD) among children with severe dengue infection. METHODS: This case-control study compared hospitalized children (2 months to 12 years) with DHF and DSS with radiologically confirmed plasma leak with age-matched healthy controls. The association of 25-hydroxy vitamin D [25(OH)D] level, age, sex, and socioeconomic status with DHF/DSS was assessed using univariate and multivariate logistic regression. RESULTS: Forty children with DHF/DSS were compared with 52 healthy controls. Mean (SD) age was 8.8 (2.9) years and 7.9 (3.7) years among cases and controls, respectively. Most (n = 28, 70%) had DHF. In multivariate logistic regression, the likelihood of having VDD [25(OH)D < 20 ng/mL] was 3.6 times higher in cases compared to controls (Odds Ratio (OR): 3.65, 95% Confidence Interval (CI): 1.461, 9.102, p=0.006). When serum 25(OH)D was used as a continuous independent variable, the strength of the association between DHF/DSS and serum 25(OH)D was weak but statistically significant; the likelihood of having DHF/DSS is 0.94 times less with 1 ng/mL increase in serum 25(OH)D (OR: 0.940, 95% CI: 0.887, 0.995, p=0.03). CONCLUSION: The present study suggests that the likelihood of having VDD among children with DHF/DSS is higher than that in their healthy counterparts. Thus, further studies are critical in confirming whether vitamin D repletion is beneficial in preventing severe forms of dengue in the quest to reduce the morbidity and mortality associated with dengue infection.

Parathyroid hormone in Sri Lankan pregnant women: Vitamin D and other determinants.

INTRODUCTION: Determinants of parathyroid hormone level during pregnancy have been less frequently studied. We aimed to describe the serum parathyroid hormone (PTH) and its determinants in Sri Lankan pregnant women in a community setting. MATERIALS AND METHODS: In this cross-sectional analysis, 390 pregnant mothers in their third trimester were enrolled from primary care centers of 15 health divisions in the Colombo District in Sri Lanka. Venous blood was analyzed for a total 25-hydroxyvitamin-D [25(OH)D], serum parathyroid hormone (PTH), serum calcium, and alkaline phosphatase. The bone quality was assessed in terms of speed of sound (SOS) using the quantitative ultrasound scan (QUS). Univariate and multivariate regression analysis was used to examine the determinants of PTH concentration in blood. RESULTS: Median serum 25(OH)D was 17.5ng/mL. Most (61.6%) were vitamin D deficient (<20ng/mL). Median PTH was 23.7pg/mL. Only 0.8% had hyperparathyroidism (PTH >65pg/mL). The correlation between 25(OH)D and PTH was weak but significant (r = -0.197; p<0.001). SOS Z-score was below the cut-off (≤-2) in fifty-six women (14.7%), and SOS did not relate significantly to PTH. In regression analysis, serum 25(OH)D, serum calcium, body mass index, educational level, and weeks of pregnancy were significant independent variables when adjusted. The model explained 16% of the variation in the PTH level. CONCLUSIONS: A high prevalence of vitamin D deficiency was observed among Sri Lankan pregnant women in the present study. Serum 25(OH)D, calcium, weeks of pregnancy, and educational level were determinants of serum PTH.

Burden of Respiratory Syncytial Virus Associated Severe Pneumonia in Hospitalized Children.

Respiratory syncytial virus (RSV) is a leading cause of severe respiratory infections. We examined the burden of RSV-associated severe community-acquired pneumonia among hospitalized children and factors that predict RSV etiology. A hospital-based prospective study examined children below five years of age admitted with radiologically confirmed severe or very severe pneumonia in two tertiary care centers in Sri Lanka. Nasopharyngeal secretions (NPS) were tested for 19 viruses by multiplex RT-PCR. Univariate and multivariate analysis was performed to determine whether RSV etiology could be predicted based on clinical, sociodemographic, environmental, radiological, and laboratory parameters. A total of 108 children with severe or very severe were included in the study. At least one virus was found in NPS in 92.5% of children. Forty-six children had RSV (+) pneumonia. Mean RSV proportion was 42.6% (95% CI: 33.1-52.5%, p value = 0.149). RSV as a single virus was found in 41.3% (19/46). The children with RSV (+) pneumonia were younger (p = 0.026) and had lower C-reactive protein (p = 0.003) and household crowding (p = 0.012) than the RSV (-) group, after controlling for confounding covariates. In conclusion, the present study demonstrated that respiratory syncytial virus was the commonest virus associated with CAP in children under five years. Younger age, crowded housing, and lower C-reactive protein levels were predictors of severe RSV-associated pneumonia.

Invasive Candidiasis Associated with Adenovirus Pneumonia.

Invasive Candida infections in immunocompetent children lead to high morbidity and mortality despite available treatment. Candida albicans and Candida parapsilosis are the most common pathogens; however, there are newly emerging pathogenic non-albicans species. Adenovirus accounts for at least 5-10% of respiratory infections in children, and specific serotypes are associated with severe pneumonia. To the best of our knowledge, invasive Candida infection complicating adenovirus-associated pneumonia in immunocompetent children has not been reported previously. Herein, we describe a preschool child with invasive candidiasis associated with adenovirus pneumonia.

Hand hygiene behavior among Sri Lankan medical students during COVID-19 pandemic.

BACKGROUND: Poor compliance with hand hygiene practices among medical students poses a risk for cross-infection. It has become more critical during the COVID-19 pandemic than ever before. This study aimed to determine the knowledge, attitudes, practices of hand hygiene among final-year medical students. It also explored reported hand hygiene behavior before the COVID-19 pandemic and the need for educational strategies to correct the deficiencies. METHODS: A concurrent mixed-method approach was used. In the quantitative strand, a cross-sectional online survey was carried out via a Google form. Mann-Whitney U test and Chi-squared test were used for comparisons. In the qualitative strand, twelve participants were interviewed, based on a semi-structured interview guide and audio recorded. Transcribed data were evaluated with thematic content analysis. RESULTS: A total of 225 final-year medical students were studied in the quantitative strand. Most were females. The mean score for knowledge was 3.35 ± 0.795 out of six. Of them, 31.6 % of participants scored below 3 points (< 50 % of the total). Most (78.9 %) had positive attitudes (score of > 80 %). Only 36.4 % reported "adequate" hand hygiene performance in all eight dimensions of the behavior domain. Noticeably, fewer participants reported to clean their hands after checking blood pressure (55.6 %), and only 66.2 % stated carrying a hand sanitizer in their pocket. Significant correlations were not found between reported behavior and attitudes (p = 0.821) or knowledge (p = 0.794). The qualitative strand with 12 respondents revealed the positive influence of both hierarchical and non-hierarchal role models. Time constraints, skin irritation, and workload pressures were the main barriers. Frequent reminders, supervision, and interactive teaching were suggested as methods to improve hand hygiene compliance. They also stated that increased enthusiasm was noted on hand hygiene during the COVID-19 pandemic compared to the pre-pandemic period. CONCLUSIONS: Most of the participants had positive attitudes towards hand hygiene. Yet, a considerable gap between attitudes and knowledge and reported hand hygiene behavior was evident. Coupling educational programs that use cognitive and behavioral methods, including role modeling, supervision, and frequent reminders, is recommended to bridge the knowledge-attitude-behavior gap.

Vitamin D Deficiency Rickets and COVID-19 Pandemic.

In a breastfed infant, the main source of vitamin D comes from the mother. Thus, maternal vitamin D deficiency is the key reason for vitamin D deficiency (VDD) and rickets during infancy. As they grow older, inadequate sun exposure, diet and lack of supplements also contribute. Individuals with darker skin require at least three to five times longer exposure to the sun than a person with lighter skin to produce adequate endogenous vitamin D. Not many food items naturally contain vitamin D; most of those are less affordable to the poor. We report an 18-month-old child with vitamin D deficiency rickets during strict self-isolation measures during the coronavirus disease 2019 (COVID-19) pandemic. Prolonged periods of confining indoors, low dietary intake of vitamin D, economic distress, maternal deficiency, and nonsupplementation could have contributed to vitamin D deficiency rickets in this child. During an unprecedented pandemic of this nature, simple sun exposure and diet advice may suffice for most. This case report highlights the importance of strengthening individuals and communities with information and formulating strong public health policies to prevent vitamin D deficiency.

Body image dissatisfaction and its determinants in urban Sri Lankan adolescents.

Background: Body image dissatisfaction is a significant public health issue, particularly among adolescents. We investigated the prevalence of body image dissatisfaction in urban Sri Lankan adolescents and its determinants. Methods: A descriptive cross-sectional study examined the body image dissatisfaction among urban adolescents of 15-16 years old in one educational zone in the Colombo district. Perceived current body size and body size ideals were assessed based on the Stunkard Figure Rating Scale (SFRS). Body mass index (BMI) was categorized according to WHO 2007 growth references. Univariate and multivariate analysis was performed to examine the correlates of body image dissatisfaction. Independent variables were BMI, waist to height ratio, gender, socioeconomic status, and ethnicity. Results: Overall, most (73.5%) were not satisfied with their body image. More males (79%) than female (69%) adolescents were dissatisfied. Among the dissatisfied, 66% of males desired larger body size, and 57% of females preferred a thinner size. Overweight/obese adolescents had four times greater body image dissatisfaction, and underweight adolescents had three times greater dissatisfaction when compared to students with normal BMI when adjusted for gender. (OR:4.18, CI:1.209,14.416, p=0.02 and OR:3.2, CI:1.073,9.852, p=0.04). Males had higher odds of dissatisfaction than females (OR: 1.9. CI: 1.020,3.407, p=0.04). Conclusions: Most adolescents were dissatisfied with their body image. Overweight/obesity and underweight were significant determinants of dissatisfaction when adjusted for gender. Also, males had a greater risk of having dissatisfaction than females. It informs that further research is required using more rigorous scientific methods to clarify these findings further.

Maternal Vitamin D Status and Its Effect on Vitamin D Levels in Early Infancy in a Tertiary Care Centre in Sri Lanka.

Epidemiologic studies from South Asian countries have reported vitamin D deficiency among all age groups. However, there is very little information on vitamin D levels, especially in the vulnerable populations (pregnant/breast feeding mother and infants) in Sri Lanka. More data on vitamin D status of such populations will be important for policy decisions to be made at a national level. Similarly, it will be valuable for healthcare programs in other countries (e.g., United States, Australia, Europe, and Canada) as Sri Lankans are a fast-growing migrant population to those countries. The purpose of this study was to investigate maternal vitamin D status and its effects on infants in a state sector tertiary care centre in Sri Lanka. This prospective cohort study was conducted on 140 healthy pregnant mothers in the third trimester (mean gestational age 39±1 weeks). Blood was collected for 25(OH)D and parathyroid hormone (PTH). Sun exposure and feeding patterns of the infants were recorded based on maternal reporting. Mean age of the infants at follow-up visit was 36±7 days. Vitamin D (25 (OH)D) deficiency (<25 nmol/L) was observed in 12% pregnant mothers, 5% lactating mothers, and 63% infants. Insufficiency (<50 nmol/L) was found in an additional 51% and 43% in pregnant and lactating mothers and 25% of infants. Mean 25(OH)D was higher in pregnant (46.4±17.5 nmol/L) and lactating (51.9±17.0 nmol/L) mothers than infants (28.1±13.7 nmol/L). Maternal vitamin D level during pregnancy was a significant risk factor (OR: 6.00, 95%CI: 1.522-23.655) for infant deficiency and insufficiency. Sun exposure of infants showed a significant positive correlation with vitamin D level (OR: 3.23, 95%CI: 1.19-8.68). In conclusion, the presence of Vitamin D deficiency/insufficiency is higher in infants compared to pregnant/lactating mothers. Low maternal 25(OH)D during pregnancy was a risk factor for deficiency in infants. Although majority of lactating mothers had sufficient vitamin D, most of their exclusively breastfed offspring were deficient.

Two Case Reports on Thalamic and Basal Ganglia Involvement in Children with Dengue Fever.

There have been increasing numbers of case reports of dengue infection with unusual manifestations. Such unusual manifestations including acute liver failure and encephalopathy could be manifested even in the absence of significant plasma leakage. Further, severe organ involvement including nervous system involvement indicates severe dengue infection. However, neurological manifestations of dengue fever are rare. This is the first case report of dengue infection with thalamic and basal ganglia involvement in Sri Lanka.