Prevalence and associated factors for non-alcoholic fatty liver disease among adults in the South Asian Region: a meta-analysis.

Background: Non-alcoholic fatty liver disease (NAFLD) is the commonest chronic liver disease worldwide. We estimated the prevalence and predefined associated factors for NAFLD among South-Asian adults. Methods: We searched PubMed and included descriptive, epidemiological studies with satisfactory methodology, reporting the prevalence of NAFLD with ultrasound. Two authors screened and extracted data independently. Gender, urban/rural settings, general population and individuals with metabolic diseases (MetD) stratified the analysis. In addition, a random-effects meta-analysis of the prevalence and effect sizes of associations of NAFLD was performed. Findings: Twenty-two publications were included after the quality assurance process. The difference in the NAFLD prevalence between the general population and people with MetD was found to be statistically significant (Q = 15.8, DF = 1, P < 0.001). The pooled overall prevalence of NAFLD in the general population was 26.9% (95% CI: 18.9-35.8%) with high heterogeneity. The prevalence was similar among men and women (Q = 0.06, DF = 1, P = 0.806). The NAFLD prevalence in the rural communities was 22.6% (95% CI: 13.6-33.1%), and the prevalence in urban communities was 32.9% (95% CI: 22.8-43.8%) and the difference was not statistically significant (Q = 1.92, DF = 1, P = 0.166). The pooled overall prevalence of NAFLD in patients with MetD was 54.1% (95% CI: 44.1-63.9%) with high heterogeneity. The pooled overall prevalence of NAFLD in the non-obese population was 11.7% (95% CI: 7.0-17.3%). The pooled prevalence of non-obese NAFLD in the NAFLD population was 43.4% (95% CI: 28.1-59.4%). Meta-analysis of binary variables showed that NAFLD in the South Asian population was associated with diabetes mellitus, hypertension, dyslipidaemia, general obesity, central obesity and metabolic syndrome. Gender was not associated with NAFLD. Interpretation: The overall prevalence of NAFLD among adults in South Asia is high, especially in those with MetD, and a considerable proportion is non-obese. In the South Asian population, NAFLD was associated with diabetes mellitus, hypertension, dyslipidaemia, general obesity, central obesity, and metabolic syndrome. Funding: None.

Climate change maladaptation for health: Agricultural practice against shifting seasonal rainfall affects snakebite risk for farmers in the tropics.

Snakebite affects more than 1.8 million people annually. Factors explaining snakebite variability include farmers' behaviors, snake ecology and climate. One unstudied issue is how farmers' adaptation to novel climates affect their health. Here we examined potential impacts of adaptation on snakebite using individual-based simulations, focusing on strategies meant to counteract major crop yield decline because of changing rainfall in Sri Lanka. For rubber cropping, adaptation led to a 33% increase in snakebite incidence per farmer work hour because of work during risky months, but a 17% decrease in total annual snakebites because of decreased labor in plantations overall. Rice farming adaptation decreased snakebites by 16%, because of shifting labor towards safer months, whereas tea adaptation led to a general increase. These results indicate that adaptation could have both a positive and negative effect, potentially intensified by ENSO. Our research highlights the need for assessing adaptation strategies for potential health maladaptations.

Geographically regulated designs of incidence surveys can match the precision of classical survey designs whilst requiring smaller sample sizes: the case of snakebite envenoming in Sri Lanka.

BACKGROUND: Snakebite envenoming is a neglected tropical disease. Data from the worst affected countries are limited because conducting epidemiological surveys is challenging. We assessed the utility of inhibitory geostatistical design with close pairs (ICP) to estimate snakebite envenoming incidence. METHODS: The National Snakebite Survey (NSS) in Sri Lanka adopted a multistage cluster sampling design, based on population distribution, targeting 1% of the country's population. Using a simulation-based study, we assessed predictive efficiency of ICP against a classical survey design at different fractions of the original sample size of the NSS. We also assessed travel distance, time taken to complete the survey, and sensitivity and specificity for detecting high-risk areas for snake envenoming, when using these methods. RESULTS: A classical survey design with 33% of the original NSS sample size was able to yield a similar predictive efficiency. ICP yielded the same at 25% of the NSS sample size, a 25% reduction in sample size compared with a classical survey design. ICP showed >80% sensitivity and specificity for detecting high-risk areas of envenoming when the sampling fraction was >20%. When ICP was adopted with 25% of the original NSS sample size, travel distance was reduced by >40% and time to conduct the survey was reduced by >75%. CONCLUSIONS: This study showed that snakebite envenoming incidence can be estimated by adopting an ICP design with similar precision at a lower sample size than a classical design. This would substantially save resources and time taken to conduct epidemiological surveys and may be suited for low-resource settings.

Using FIB-4 score as a screening tool in the assessment of significant liver fibrosis (F2) in patients with transfusion-dependent beta thalassaemia: a cross-sectional study.

OBJECTIVE: To evaluate the performance of the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis (F2) compared with transient elastography (TE), among chronic transfusion-dependent beta-thalassaemia (TDT) patients in a resource-poor setting. DESIGN: A cross-sectional study. SETTING: Adolescent and Adult Thalassaemia Care Centre (University Medical Unit), Kiribathgoda, Sri Lanka. PARTICIPANTS: 45 TDT patients who had undergone more than 100 blood transfusions with elevated serum ferritin >2000 ng/mL were selected for the study. Patients who were serologically positive for hepatitis C antibodies were excluded. OUTCOME MEASURES: TE and FIB-4 scores were estimated at the time of recruitment in all participants. Predefined cut-off values for F2, extracted from previous TE and FIB-4 scores studies, were compared. A new cut-off value for the FIB-4 score was estimated using receiver operating characteristics curve analysis to improve the sensitivity for F2 prediction. RESULTS: Of the selected 45 TDT patients, 22 (49%) were males. FIB-4 score showed a significant linear correlation with TE (r=0.52;p<0.0003). The FIB-4 score was improbable to lead to a false classification of TDT patients to have F2 when the FIB-4 cut-off value was 1.3. On the other hand, it had a very low diagnostic yield in missing almost all (except one) of those who had F2. Using a much-lowered cut-off point of 0.32 for FIB-4, we improved the pick-up rate of F2 to 72%. CONCLUSIONS: Regardless of the cut-off point, the FIB-4 score cannot be used as a good screening tool to pick up F2 in patients with TDT, irrespective of their splenectomy status. On the contrary, at a 1.3 cut-off value, though FIB-4 is a very poor detector for F2 fibrosis, it will not erroneously diagnose F2 fibrosis in those who do not have it.

Student usage of open educational resources and social media at a Sri Lanka Medical School.

BACKGROUND: The use of Open Educational Resources (OER) and Social Media (SM) for academic information seeking is common among undergraduates nowadays. There is limited data on OER and SM use for education in Sri Lanka. This study was aimed at evaluating the OER and SM use for education among the medical students at the Faculty of Medicine, University of Kelaniya, Sri Lanka. METHODS: A cross-sectional study was conducted at the Faculty of Medicine, University of Kelaniya. Stratified random sampling was used to select students from the first year to the final year. A self-administrated questionnaire was used to collect data. RESULTS: The study included 257 responses (response rate: 89.5%), of which 185 (72.0%) were females. The OER and SM use for educational purposes at least once a month among students was 96.1% (95%CI: 93.7-98.5%) and 88.3% (95%CI: 84.4-92.3%) respectively. There was no gender difference in OER and SM use. The main reasons for accessing OER were the availability of information at any time (36.1%) and ease of information access (31.5%). Wiki sites (84.4%) and Facebook (79.8%) were the highest accessed OER and SM platforms. The majority of students were in view that the information on wiki sites (51.4%) and results of general non-specific web searches (56.0%) were reliable. Only 33.9% of students searched information from educational and government-related sources and 18.7% had accessed e-journals. Through SM, 79.0% joined educational groups and 77.0% followed the medical-related sites, pages and people. More than one-third of students (35.8%) could not find academic information from SM due to the information overload and 31.1% mentioned that SM distracted their education. CONCLUSION: The majority of the students used OER and SM for education; however, only a minority accessed reliable information. Students accepted information available in wiki sites and general non-specific web searchers without considering the credibility of sources. The majority of the students did not refer to e-journals. Distractions to academic work and the difficulty to access accurate information were major concerns of using SM. This study highlights the importance of improving information literacy among medical students.

Survival and complications in patients with haemoglobin E thalassaemia in Sri Lanka: a prospective, longitudinal cohort study.

BACKGROUND: Worldwide, haemoglobin E ß-thalassaemia is the most common genotype of severe ß-thalassaemia. The paucity of long-term data for this form of thalassaemia makes evidence-based management challenging. We did a long-term observational study to define factors associated with survival and complications in patients with haemoglobin E thalassaemia. METHODS: In this prospective, longitudinal cohort study, we included all patients with haemoglobin E thalassaemia who attended the National Thalassaemia Centre in Kurunegala, Sri Lanka, between Jan 1, 1997, and Dec 31, 2001. Patients were assessed up to three times a year. Approaches to blood transfusions, splenectomy, and chelation therapy shifted during this period. Survival rates between groups were evaluated using Kaplan-Meier survival function estimate curves and Cox proportional hazards models were used to identify risk factors for mortality. FINDINGS: 109 patients (54 [50%] male; 55 [50%] female) were recruited and followed up for a median of 18 years (IQR 14-20). Median age at recruitment was 13 years (range 8-21). 32 (29%) patients died during follow-up. Median survival in all patients was 49 years (95% CI 45-not reached). Median survival was worse among male patients (hazard ratio [HR] 2·51, 95% CI 1·16-5·43), patients with a history of serious infections (adjusted HR 8·49, 2·90-24·84), and those with higher estimated body iron burdens as estimated by serum ferritin concentration (adjusted HR 1·03, 1·01-1·06 per 100 units). Splenectomy, while not associated with statistically significant increases in the risks of death or serious infections, ultimately did not eliminate a requirement for scheduled transfusions in 42 (58%) of 73 patients. Haemoglobin concentration less than or equal to 4·5 g/dL (vs concentration >4·5 g/dL), serum ferritin concentration more than 1300 µg/L (vs concentration ≤1300 µg/L), and liver iron concentration more than 5 mg/g dry weight of liver (vs concentration ≤5 mg/g) were associated with poorer survival. INTERPRETATION: Patients with haemoglobin E thalassaemia often had complications and shortened survival compared with that reported in high-resource countries for thalassaemia major and for thalassaemia intermedia not involving an allele for haemoglobin E. Approaches to management in this disorder remain uncertain and prospective studies should evaluate if altered transfusion regimens, with improved control of body iron, can improve survival. FUNDING: Wellcome Trust, Medical Research Council, US March of Dimes, Anthony Cerami and Ann Dunne Foundation for World Health, and Hemoglobal.

Evaluating spatiotemporal dynamics of snakebite in Sri Lanka: Monthly incidence mapping from a national representative survey sample.

BACKGROUND: Snakebite incidence shows both spatial and temporal variation. However, no study has evaluated spatiotemporal patterns of snakebites across a country or region in detail. We used a nationally representative population sample to evaluate spatiotemporal patterns of snakebite in Sri Lanka. METHODOLOGY: We conducted a community-based cross-sectional survey representing all nine provinces of Sri Lanka. We interviewed 165 665 people (0.8% of the national population), and snakebite events reported by the respondents were recorded. Sri Lanka is an agricultural country; its central, southern and western parts receive rain mainly from Southwest monsoon (May to September) and northern and eastern parts receive rain mainly from Northeast monsoon (November to February). We developed spatiotemporal models using multivariate Poisson process modelling to explain monthly snakebite and envenoming incidences in the country. These models were developed at the provincial level to explain local spatiotemporal patterns. PRINCIPAL FINDINGS: Snakebites and envenomings showed clear spatiotemporal patterns. Snakebite hotspots were found in North-Central, North-West, South-West and Eastern Sri Lanka. They exhibited biannual seasonal patterns except in South-Western inlands, which showed triannual seasonality. Envenoming hotspots were confined to North-Central, East and South-West parts of the country. Hotspots in North-Central regions showed triannual seasonal patterns and South-West regions had annual patterns. Hotspots remained persistent throughout the year in Eastern regions. The overall monthly snakebite and envenoming incidences in Sri Lanka were 39 (95%CI: 38-40) and 19 (95%CI: 13-30) per 100 000, respectively, translating into 110 000 (95%CI: 107 500-112 500) snakebites and 45 000 (95%CI: 32 000-73 000) envenomings in a calendar year. CONCLUSIONS/SIGNIFICANCE: This study provides information on community-based monthly incidence of snakebites and envenomings over the whole country. Thus, it provides useful insights into healthcare decision-making, such as, prioritizing locations to establish specialized centres for snakebite management and allocating resources based on risk assessments which take into account both location and season.

Outcomes of NAFLD and MAFLD: Results from a community-based, prospective cohort study.

BACKGROUND: The term "metabolic (dysfunction)-associated fatty liver disease" (MAFLD) is suggested alternative for "non-alcoholic fatty liver disease" (NAFLD), as it better reflects metabolic dysfunction. No study has compared outcomes of the two diagnostic criteria. METHODS: In an ongoing, community-based, cohort-study in suburban Sri Lanka, participants were randomly selected in 2007. They were reassessed in 2014 to evaluate new-onset metabolic traits (MTs) and cardiovascular-events (CVEs). Baseline characteristics, MTs and CVEs after 7-years were compared in NAFLD and MAFLD and vs. controls. Similarly, we compared these parameters in those excluded by the NAFLD definition but captured by the MAFLD definition and vice versa, and vs. controls. FINDINGS: Of 2985 recruited in 2007, 940 (31.5%) had NAFLD, 990 (33.1%) had MAFLD and 362 (12.1%) were controls. When compared to NAFLD, MAFLD captured an additional 2.9% and lost 1.3% individuals. At baseline, anthropometric and metabolic traits were similar in NAFLD and MAFLD. At follow-up in 7-years, the risk of having new-onset MTs and fatal/non-fatal CVEs were similar in the groups, but were significantly higher compared to controls. Those excluded by the NAFLD definition but captured by the MAFLD definition showed higher baseline MTs compared to those excluded by the MAFLD definition but captured by the NAFLD definition, and had substantially higher risk for having new-onset MTs and CVEs compared to controls. INTERPRETATION: Although NAFLD and MAFLD had similar MTs at baseline, and similar outcomes after 7-years, those who were excluded by the NAFLD definition but captured by the MAFLD definition seem at higher risk of adverse outcomes than those excluded by the MAFLD definition but captured by the NAFLD definition. Although the increase in the index population was small, redefining NAFLD as MAFLD seemed to improve clinical utility.

Integrating human behavior and snake ecology with agent-based models to predict snakebite in high risk landscapes.

Snakebite causes more than 1.8 million envenoming cases annually and is a major cause of death in the tropics especially for poor farmers. While both social and ecological factors influence the chance encounter between snakes and people, the spatio-temporal processes underlying snakebites remain poorly explored. Previous research has focused on statistical correlates between snakebites and ecological, sociological, or environmental factors, but the human and snake behavioral patterns that drive the spatio-temporal process have not yet been integrated into a single model. Here we use a bottom-up simulation approach using agent-based modelling (ABM) parameterized with datasets from Sri Lanka, a snakebite hotspot, to characterise the mechanisms of snakebite and identify risk factors. Spatio-temporal dynamics of snakebite risks are examined through the model incorporating six snake species and three farmer types (rice, tea, and rubber). We find that snakebites are mainly climatically driven, but the risks also depend on farmer types due to working schedules as well as species present in landscapes. Snake species are differentiated by both distribution and by habitat preference, and farmers are differentiated by working patterns that are climatically driven, and the combination of these factors leads to unique encounter rates for different landcover types as well as locations. Validation using epidemiological studies demonstrated that our model can explain observed patterns, including temporal patterns of snakebite incidence, and relative contribution of bites by each snake species. Our predictions can be used to generate hypotheses and inform future studies and decision makers. Additionally, our model is transferable to other locations with high snakebite burden as well.

The clinical utility of accurate NAFLD ultrasound grading: Results from a community-based, prospective cohort study.

OBJECTIVES: Despite its widespread use there is no consensus on ultrasound criteria to diagnose fatty liver. METHOD: In an ongoing, cohort-study, participants were initially screened in 2007 and reassessed in 2014 by interview, anthropometric measurements, liver ultrasonography, and blood tests. We evaluated utility of increased hepatic echogenicity alone (intermediate) compared to using additional criteria which included signal attenuation and/or vascular blunting along with increase of hepatic echogenicity (moderate-severe), to diagnose fatty liver in NAFLD. We made a comparison of the two radiologically defined groups, in order to choose a classification method for NAFLD, which may better predict baseline adverse metabolic traits (MT), and adverse metabolic and cardiovascular events (CVE) after 7-year of follow-up. RESULTS: Of 2985 recruited in 2007, 940 (31.5 %) had moderate-severe NAFLD, 595 (19.9 %) intermediate NAFLD, and 957 (32.1 %) were controls (no fatty liver). 2148 (71.9 %) attended follow-up in 2014; they included 708 who had moderate-severe NAFLD, 446 intermediate NAFLD and 674 controls, at baseline (in 2007). At baseline, adverse anthropometric indices and MTs were significantly higher in both moderate-severe NAFLD and intermediate NAFLD compared to controls, except for low HDL. They were commoner in moderate-severe NAFLD than in intermediate NAFLD. After seven years, the odds of developing new-onset metabolic traits and CVEs were significantly higher compared to controls only in moderate-severe NAFLD. CONCLUSIONS: Only moderate-severe NAFLD predicted risk of incident adverse MTs and CVEs. However, both moderate-severe and intermediate NAFLD were associated with higher prevalence of adverse anthropometric and metabolic traits, thereby identifying individuals who need medical intervention even among those with milder degrees of fatty liver. We therefore recommend using increased hepatic echogenicity, and not only the more stringent criteria (which include signal attenuation and/or vascular blunting), for the diagnosis of fatty liver in individuals with NAFLD.

Patterns and predictors of mortality in a semi-urban population-based cohort in Sri Lanka: findings from the Ragama Health Study.

OBJECTIVE: To describe patterns and predictors of mortality in a semi-urban population in Sri Lanka. DESIGN: A prospective population-based cohort study. SETTING: Ragama Medical Officer of Health area in the Gampaha district, Sri Lanka. PARTICIPANTS: Adults between 35 and 64 years of age were recruited using an age stratified random sampling technique in 2007. MEASURES: At baseline, we recorded socio-demographic, lifestyle, anthropometric, biochemical and clinical data of the participants. Over 10 years, we obtained the cause and date of death from the death registration documents of deceased participants. We determined the survival probability of the cohort over 10 years and estimated Hazard ratios (HRs) for all-cause mortality (ACM), cardiovascular mortality (CVM) and cancer-related mortality (CRM) using Cox's proportional hazards model. We also estimated the survival probabilities for men and women in each 10-year age group and standardised mortality ratio relative to the source population. RESULTS: There were 169 deaths over 10 years with standardised mortality rates of 5.3 and 2.4 per 1000 years of follow-up for men and women, respectively. Independent predictors of: ACM were older age, lower income, smoking and diabetes mellitus while gender, education, occupation, harmful alcohol use, waist circumference and hypertension were not; CVM were older age, lower income, smoking, diabetes and hypertension while gender and harmful alcohol use were not; CRM was older age while gender, smoking and diabetes were not. Those engaged in clerical and technical occupations or unemployed had a lower risk of CRM as compared with those engaged in elementary occupations. CONCLUSIONS: Older age, lower income, smoking, diabetes and hypertension strongly predict mortality in this cohort. Addressing the identified modifiable predictors through behavioural modification will improve longevity in similar populations.

An epidemiological model to aid decision-making for COVID-19 control in Sri Lanka.

BACKGROUND: Sri Lanka diagnosed its first local case of COVID-19 on 11 March 2020. The government acted swiftly to contain transmission, with extensive public health measures. At the end of 30 days, Sri Lanka had 197 cases, 54 recovered and 7 deaths; a staged relaxing of the lockdown is now underway. This paper proposes a theoretical basis for estimating the limits within which transmission should be constrained in order to ensure that the case load remains within the capacity of Sri Lanka's health system. METHODS: We used the Susceptible, Infected, Recovered (SIR) model to explore the number of new infections and estimate ICU bed requirement at different levels of R0 values after lifting lockdown restrictions. We developed a web-based application that enables visualization of cases and ICU bed requirements with time, with adjustable parameters that include: population at risk; number of identified and recovered cases; percentage identified; infectious period; R0 or doubling time; percentage critically ill; available ICU beds; duration of ICU stay; and uncertainty of projection. RESULTS: The three-day moving average of the caseload suggested two waves of transmission from Day 0 to 17 (R0 = 3.32, 95% CI 1.85-5.41) and from Day 18-30 (R = 1.25, 95%CI: 0.93-1.63). We estimate that if there are 156 active cases with 91 recovered at the time of lifting lockdown restrictions, and R increases to 1.5 (doubling time 19 days), under the standard parameters for Sri Lanka, the ICU bed capacity of 300 is likely to be saturated by about 100 days, signaled by 18 new infections (95% CI 15-22) on Day 14 after lifting lockdown restrictions. CONCLUSION: Our model suggests that to ensure that the case load remains within the available capacity of the health system after lifting lockdown restrictions, transmission should not exceed R = 1.5. This model and the web-based application may be useful in other low and middle income countries which have similar constraints on health resources.

Computed tomography-based evaluation of segmental variation of liver density and its implications.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) has become a major health concern. Focal fat deposition frequently seems to involve segment IV b. This indicates a consistent pattern of fat deposition in the liver. The present study evaluates the pattern of fat distribution in the liver using computed tomogram (CT) attenuation index. METHODS: Two radiologists evaluated 517 non-contrast CT scan images of the abdomen and pelvis. Two 40-mm2 regions of interest (ROIs) were selected from each segment. The hepatic segmental densities (HSDs) were obtained by calculating the mean densities of areas of corresponding liver segments. The mean hepatic attenuation (MHA) was quantified by obtaining the mean segmental densities. Densities were compared between the segments and with the MHA. RESULTS: The mean age (SD) of the patients was 55.5 year (15.6), and 276 (53.4%) were males. The overall mean hepatic density was 53.05 (95% CI, 52.95-53.15) Hounsfield units (HU). The lowest mean HSD was observed in segment IV b and the highest mean HSD was observed in segment V. Segments I, IV a and IV b showed significantly lower mean HSDs and segments V, VI and VIII showed significantly higher mean HSDs compared with the overall mean MHA/mean hepatic density (MHD), whereas mean HSDs of segments II, III and VII were not significantly different from the overall mean MHA/MHD. CONCLUSION: Segment IV b seems to be the most vulnerable site for fat deposition; focal lesions here should be carefully evaluated. Segments II, III and VII seem to closely represent MHD.

Usage of cloud storage facilities by medical students in a low-middle income country, Sri Lanka: a cross sectional study.

BACKGROUND: Cloud storage facilities (CSF) has become popular among the internet users. There is limited data on CSF usage among university students in low middle-income countries including Sri Lanka. In this study we present the CSF usage among medical students at the Faculty of Medicine, University of Kelaniya. METHODS: We undertook a cross sectional study at the Faculty of Medicine, University of Kelaniya, Sri Lanka. Stratified random sampling was used to recruit students representing all the batches. A self-administrated questionnaire was given. RESULTS: Of 261 (90.9%) respondents, 181 (69.3%) were females. CSF awareness was 56.5% (95%CI: 50.3-62.6%) and CSF usage was 50.8% (95%CI: 44.4-57.2%). Awareness was higher in males (P = 0.003) and was low in senior students. Of CSF aware students, 85% knew about Google Drive and 70.6% used it. 73.6 and 42.1% knew about Dropbox and OneDrive. 50.0 and 22.0% used them respectively. There was no association between CSF awareness and pre-university entrance or undergraduate examination performance. Inadequate knowledge, time, accessibility, security and privacy concerns limited CSF usage. 69.8% indicated that they would like to undergo training on CSF as an effective tool for education. CONCLUSION: CSF awareness and usage among the students were 56.5 and 50.8%. Google drive is the most popular CSF. Lack of knowledge, accessibility, concerns on security and privacy limited CSF usage among students. Majority were interested to undergo training on CSF and undergraduate Information Communication Technology (ICT) curricula should introduce CSF as effective educational tools.

Non-resolution of non-alcoholic fatty liver disease (NAFLD) among urban, adult Sri Lankans in the general population: A prospective, cohort follow-up study.

BACKGROUND: There are few studies investigating the natural course of non-alcoholic fatty liver disease (NAFLD) in the community. We assessed resolution of NAFLD in a general population cohort of urban Sri Lankans adults. METHODS: Participants were selected by age-stratified random sampling from electoral lists. They were initially screened in 2007 and re-evaluated in 2014. On both occasions structured interview, anthropometric-measurements, liver ultrasonography, and biochemical/serological tests were performed. NAFLD was diagnosed on ultrasound criteria for fatty liver, safe-alcohol consumption (<14-units/week for men, <7-units/week for women) and absence of hepatitis B/C markers. Non-NAFLD was diagnosed on absence of any ultrasound criteria for fatty liver and safe-alcohol consumption. Resolution of NAFLD was defined as absence of ultrasound criteria for fatty liver. Changes in anthropometric indices [Weight, Body-Mass-Index (BMI), waist-circumference (WC), waist-hip ratio (WHR)], clinical [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and biochemical measurements [Triglycerides (TG), High Density Lipoprotein (HDL), Total Cholesterol (TC), HbA1c%] at baseline and follow-up were compared. RESULTS: Of the 2985 original study participants, 2148 (71.9%) attended follow-up after 7 years. This included 705 who had NAFLD in 2007 and 834 who did not have NAFLD in 2007. Out of 705 who had NAFLD in 2007, 11(1.6%) changed their NAFLD status due to excess alcohol consumption. After controlling for baseline values, NAFLD patients showed significant reduction in BMI, weight, WHR, HDL and TC levels and increase in HbA1c levels compared to non-NAFLD people. Despite this, none of them had complete resolution of NAFLD. CONCLUSION: We did not find resolution of NAFLD in this general population cohort. The observed improvements in anthropometric, clinical and biochemical measurements were inadequate for resolution of NAFLD.

Adjusting for spatial variation when assessing individual-level risk: A case-study in the epidemiology of snake-bite in Sri Lanka.

BACKGROUND: Health outcomes and causality are usually assessed with individual level sociodemographic variables. Studies that consider only individual-level variables can suffer from residual confounding. This can result in individual variables that are unrelated to risk behaving as proxies for uncaptured information. There is a scarcity of literature on risk factors for snakebite. In this study, we evaluate the individual-level risk factors of snakebite in Sri Lanka and highlight the impact of spatial confounding on determining the individual-level risk effects. METHODS: Data was obtained from the National Snakebite Survey of Sri Lanka. This was an Island-wide community-based survey. The survey sampled 165,665 individuals from all 25 districts of the country. We used generalized linear models to identify individual-level factors that contribute to an individual's risk of experiencing a snakebite event. We fitted separate models to assess risk factors with and without considering spatial variation in snakebite incidence in the country. RESULTS: Both spatially adjusted and non-adjusted models revealed that middle-aged people, males, field workers and individuals with low level of education have high risk of snakebites. The model without spatial adjustment showed an interaction between ethnicity and income levels. When the model included a spatial adjustment for the overall snakebite incidence, this interaction disappeared and income level appeared as an independent risk factor. Both models showed similar effect sizes for gender and age. HEmployment and education showed lower effect sizes in the spatially adjusted model. CONCLUSIONS: Both individual-level characteristics and local snakebite incidence are important to determine snakebite risk at a given location. Individual level variables could act as proxies for underling residual spatial variation when environmental information is not considered. This can lead to misinterpretation of risk factors and biased estimates of effect sizes. Both individual-level and environmental variables are important in assessing causality in epidemiological studies.

Patient perspectives on hypertension management in health system of Sri Lanka: a qualitative study.

INTRODUCTION: Uncontrolled hypertension is the leading risk factor for mortality globally, including low-income and middle-income countries (LMICs). However, pathways for seeking hypertension care and patients' experience with the utilisation of health services for hypertension in LMICs are not well understood. OBJECTIVES: This study aimed to explore patients' perspectives on different dimensions of accessibility and availability of healthcare for the management of uncontrolled hypertension in Sri Lanka. SETTING: Primary care in rural areas in Sri Lanka. PARTICIPANTS: 20 patients with hypertension were purposively sampled from an ongoing study of Control of Blood Pressure and Risk Attenuation in rural Bangladesh, Pakistan, Sri Lanka. METHOD: We conducted in-depth interviews with patients. Interviews were audio-recorded and transcribed into local language (Sinhala) and translated to English. Thematic analysis was used and patient pathways on their experiences accessing care from government and private clinics are mapped out. RESULTS: Overall, most patients alluded to the fact that their hypertension was diagnosed accidentally in an unrelated visit to a healthcare provider and revealed lack of adherence and consuming alternatives as barriers to control hypertension. Referring to the theme 'Accessibility and availability of hypertension care', patients complained of distance to the hospitals, long waiting time and shortage of medicine supplies at government clinics as the main barriers to accessing health services. They often resorted to private physicians and paid out of pocket when they experienced acute symptoms attributable to hypertension. Considering the theme 'Approachability and ability to perceive', the majority of patients mentioned increasing public awareness, training healthcare professionals for effective communication as areas of improvement. Under the theme 'Appropriateness and ability to engage', few patients were aware of the names or purpose of their medications and reportedly missed doses frequently. Reminders from family members were considered a major facilitator to adherence to antihypertensive medications. Patients welcomed the idea of outreach services for hypertension and health education closer to home in the theme 'Things the patients reported to improve the system'. CONCLUSION: Patients identified several barriers to accessing hypertension care in Sri Lanka. Measures recommended improving hypertension management in Sri Lanka including public education on hypertension, better communication between healthcare professionals and patients, and efforts to improve access and understanding of antihypertensive medications. TRIAL REGISTRATION NUMBER: NCT02657746.

Reassessment of the prevalence of soil-transmitted helminth infections in Sri Lanka to enable a more focused control programme: a cross-sectional national school survey with spatial modelling.

BACKGROUND: In Sri Lanka, deworming programmes for soil-transmitted helminth infections became an integral part of school health in the 1960s, whereas routine antenatal deworming with mebendazole started in the 1980s. A 2003 national soil-transmitted helminth survey done among schoolchildren found an overall prevalence of 6·9%. In our study, we aimed to reassess the national prevalence of soil-transmitted helminth infections to enable implementation of a more focused control programme that targets smaller administrative areas at risk of continued transmission. METHODS: We did a cross-sectional, school-based, national survey using multistage stratified cluster sampling, covering all nine provinces as well as populations at high risk of soil-transmitted helminth infections living in urban slums and in plantation-sector communities. Our study population was children aged 5-7 years attending state schools. Faecal samples were collected and analysed with duplicate modified Kato-Katz smears. We modelled the risk of soil-transmitted helminth infection using generalised linear mixed-effects models, and we developed prevalence maps to enable informed decision making at the smallest health administrative level in the country. FINDINGS: Between Jan 23 and May 9, 2017, we recruited 5946 children from 130 schools; 4276 (71·9%) children provided a faecal sample for examination. National prevalence of soil-transmitted helminth infection was 0·97% (95% CI 0·63-1·48) among primary schoolchildren. Prevalence in the high-risk communities surveyed was higher than national prevalence: 2·73% (0·75-6·87) in urban slum communities and 9·02% (4·29-18·0) in plantation sector communities. Our prevalence maps showed that the lowest-level health administrative regions could be categorised into low risk (prevalence <1%), high risk (prevalence >10%), or intermediate risk (1-10%) areas. INTERPRETATION: Our survey findings indicate that the national prevalence of soil-transmitted helminth infection has continued to decline in Sri Lanka. On the basis of WHO guidelines, we recommend discontinuation of routine deworming in low-risk areas, continuation of annual deworming in high-risk areas, and deworming once every 2 years in intermediate-risk areas, for at least 4 years. FUNDING: Task Force for Global Health and WHO.

Evaluating temporal patterns of snakebite in Sri Lanka: the potential for higher snakebite burdens with climate change.

Background: Snakebite is a neglected tropical disease that has been overlooked by healthcare decision makers in many countries. Previous studies have reported seasonal variation in hospital admission rates due to snakebites in endemic countries including Sri Lanka, but seasonal patterns have not been investigated in detail. Methods: A national community-based survey was conducted during the period of August 2012 to June 2013. The survey used a multistage cluster design, sampled 165 665 individuals living in 44 136 households and recorded all recalled snakebite events that had occurred during the preceding year. Log-linear models were fitted to describe the expected number of snakebites occurring in each month, taking into account seasonal trends and weather conditions, and addressing the effects of variation in survey effort during the study and of recall bias amongst survey respondents. Results: Snakebite events showed a clear seasonal variation. Typically, snakebite incidence is highest during November-December followed by March-May and August, but this can vary between years due to variations in relative humidity, which is also a risk factor. Low relative-humidity levels are associated with high snakebite incidence. If current climate-change projections are correct, this could lead to an increase in the annual snakebite burden of 31.3% (95% confidence interval: 10.7-55.7) during the next 25-50 years. Conclusions: Snakebite in Sri Lanka shows seasonal variation. Additionally, more snakebites can be expected during periods of lower-than-expected humidity. Global climate change is likely to increase the incidence of snakebite in Sri Lanka.

Increase in premature mortality due to non-communicable diseases in Sri Lanka during the first decade of the twenty-first century.

BACKGROUND: Globally, non-communicable diseases (NCD) are the leading cause of death and more than 40% of NCD deaths are premature occurring before the age of 70 years. In 2012, World Health Assembly declared its commitment to reduce premature NCD mortality by 25% from 2010 to 2025. The trend of premature NCD deaths in Sri Lanka has not been assessed and thus this study was done to assess it between 2001 to 2010. METHODS: Deaths due to cardiovascular diseases, cancers, chronic respiratory diseases and diabetes were studied. Premature NCD mortality was assessed using unconditional probability of dying (UPoD) due to NCDs among those aged 30 to 70 years. Number of relevant premature NCD deaths that occurred in each 5-year age interval and the respective mid-year population was used to calculate UPoD. RESULTS: During the period of 2001 to 2010, premature NCD mortality in Sri Lanka increased from 15·8% to 19·1% and males showed higher mortality compared to females throughout the period. Highest mortality was due to cardiovascular diseases followed by cancer and diabetes and all three showed an increasing trend. Chronic respiratory diseases showed an increase until 2004 and dropped thereafter. Among the four NCDs, diabetes revealed the most marked increasing trend in premature mortality during this period. CONCLUSIONS: The data revealed an increasing trend of premature NCD mortality in Sri Lanka between 2001 and 2010 although it has a relatively lower premature NCD mortality rate in the South-East Asian Region. Therefore, reducing premature NCD mortality by 25% from 2010 to 2025 is likely to be a rather challenging task in Sri Lanka and policy level changes need to be taken to achieve this target.