The human Toll-like receptor 2 (TLR2) response during pathogenic Leptospira infection.

Background: Human innate immune responses are triggered through the interaction of human pattern recognition receptors and pathogen-associated molecular patterns. The role of toll-like receptor2 (TLR2) in mice innate immune response to leptospirosis is well established, while human studies are limited. The present study aimed to determine the TLR2 response among confirmed cases of leptospirosis. Methodology/Principle findings: The study has two components. Clinically suspected patients of leptospirosis were confirmed using a previously validated qPCR assay. Total RNA was extracted from patients' RNA-stabilized whole blood samples. Human TLR2 gene expression (RT-qPCR) analysis was carried out using an exon-exon spanning primer pair, using CFX Maestro™ software. The first set of patient samples was used to calculate the Relative Normalized Expression (ΔΔCq value) of the TLR2 gene in comparison to a healthy control sample and normalized by the reference gene GAPDH (Glyceraldehyde-3-phosphate dehydrogenase). Secondly, recruited patient samples were subjected to TLR2 gene expression analysis and compared to healthy controls and normalized by the reference genes Beta-2-microglobulin(B2M), Hypoxanthine phosphoribosyltransferase 1 (HPRT 1).In the initial cohort of 64 confirmed leptospirosis cases, 18 were selected for human TLR2 gene expression analysis based on criteria of leptospiremia and RNA yield. Within this group, one individual exhibited a down-regulation of TLR2 gene (Expression/ΔΔCq=0.01352), whereas the remaining subjects presented no significant change in gene expression. In a subsequent cohort of 23 confirmed cases, 13 were chosen for similar analysis. Among these, three patients demonstrated down-regulation of TLR2 gene expression, with Expression/ΔΔCq values of 0.86574, 0.47200, and 0.28579, respectively. No TLR2 gene expression was noted in the other patients within this second group. Conclusions: Our investigation into the acute phase of leptospirosis using human clinical samples has revealed a downregulation of TLR2 gene expression. This observation contrasts to the upregulation commonly reported in the majority of in-vitro and in-vivo studies of Leptospira infection. These preliminary findings prompt a need for further research to explore the mechanisms underlying TLR2's role in the pathogenesis of leptospirosis, which may differ in clinical settings compared to laboratory models.

Challenges of Continuation of Exclusive Breast Feeding up to 6 Months in a Setting with High Exclusive Breast Feeding Rates Reported. Experience from Eastern Province of Sri Lanka.

BACKGROUND: According to the World Breastfeeding Trends Initiative, Sri Lanka ranked as number one and only country to achieve green status. Exclusive breastfeeding (EBF) for six months is current practice with a rate of 75.5% among 0-5 months. AIM: Identify factors contributing early cessation of breastfeeding in a single centre of Eastern province Sri Lanka. METHODS: A descriptive cross-sectional study conducted in Sammanthurai Medical officer of Health area. Consecutive mother-infant days with the infant ageing < 6 months were included from 25 public health midwife areas using an interviewer administered questionnaire. Missing values imputed using 'missForest' algorithm. RESULTS: The mean age of the sample was 28.4(SD ± 5.6). Of the 257 mothers recruited, 15(5.8%) were teenagers and 42(16.3%) > 35 years. 251(97.6%) had children 1-5 and 86(33.5%) were first born. 140 (54.5%) had tertiary education, 28 (10.9%).31(12.1%) were employed. EBF rates 0-6 months was 79.8% (n = 205). 239(93.0%) started breastfeeding within an hour. EBF was not associated with maternal age, birth order or income. 18 employed mothers and 186 unemployed mothers continued EBF. Regarding the factors associated with EBF, having a tertiary education (p < .001), being employed (p = .004) and having less than 3 children (p = .03) were associated with non-exclusive breastfeeding. Tertiary education was the significant predictor of non-exclusive breastfeeding in this population with an odds ratio of 4.50 (95% CI 1.331-15.215). CONCLUSION: Employment identified as a risk factor for early cessation of EBF needs well planned further research to overcome this practical issue. Also might need revision of workplace policies, establishment of lactation areas in office premises to overcome some of these issues.

Protocol for systematic review and meta-analysis: magnitude, reasons, associated factors, and implications of the out-of-pocket expenditure during pregnancy.

OBJECTIVES: Health-related out-of-pocket expenditure (OOPE) impedes utilization for maternal health care. We aim to systematically review the magnitude, reasons, associated factors, and implications of OOPE during pregnancy. STUDY DESIGN: The study design is a protocol for systematic review and meta-analysis. METHODS: A comprehensive literature search will be conducted with the electronic databases of PubMed, Web of Science, Scopus, Cochrane, Trip, Social care online, IDEAS, EconPapers, ERIC, and EconStor. A manual search will be carried out for the reference lists of eligible studies and reviews. The search strategy will include combining two key blocks of terms, namely: 'pregnancy' and 'OOPE,' using database-specific subject headings and text words. Two independent reviewers will screen and assess data quality and extract data for synthesis. Any disagreements during any stage will be determined by consensus with the involvement of a third reviewer. The 'Mixed methods appraisal tool' will be adapted for the quality appraisal of the eligible studies. A narrative synthesis will be provided for the reasons, associated factors, and implications of OOPE, and a meta-analysis will be conducted for the magnitude of OOPE. Furthermore, a subgroup analysis will be done with countries with different income levels and health care policies. TRIAL REGISTRATION: PROSPERO 2020 CRD42020168566.

Knowledge, Attitudes, and Practices of Responsive Feeding in Rural Sri Lanka (A Qualitative Study)

Introduction: Responsive Feeding has been proven to be an effective feeding method for children who are at early stages of development. The concept is not popular at the primary health care level and it is reported as a missing link in the current nutrition program in Sri Lanka. Objective: To explore responsive feeding practices among caregivers who have an infant aged between 6 to 12 months and residing in rural Anuradhapura. Methods: A qualitative approach was adopted. The study was carried out in Padaviya Medical Officer of Health area. Study participants were 18 mothers and all ten Public Health Midwives. Diary studies, interviews and focus group discussion were conducted to collect data. The framework approach was used to analyze the data. Results: Pleasant and healthy feeding environment is non-existent. Identification of hunger and satiety cues was poor and hunger sensitive schedule to feed the child was absent. Feeding situations commenced in an emotionally supportive manner, but were not optimally utilized to promote psycho-social stimulation. During the feeding caregivers neglect emotional support and ultimately moves to forceful feeding. Conclusions: The knowledge, attitude and practices are poor on responsive feeding among caregivers and health workers. This may contribute to poor growth and development in children. Action is needed to implement RF practices in the community.

Early renal damage among children living in the region of highest burden of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka.

BACKGROUND: Chronic kidney disease of unknown origin (CKDu) in Sri Lanka is grouped with several other epidemics of similar nature across the world as Chronic Interstitial Nephritis in Agricultural Communities (CINAC). In CKDu endemic countries, the focus has mainly been on adults. We hypothesized that studying distribution and factors associated with elevated urine albumin to creatinine ratio (UACR), an early marker of kidney injury, among children living in a CKDu endemic area may provide important clues about the onset and progression of the disease. METHODS: This cross sectional study was performed in rural primary schools in North Central Province of Sri Lnaka, a CKDu high endemic region. Total of 2880 students aging 5 to 11 years from 67 schools were enrolled for urinalysis in a random spot urine sample. Bedside Schwartz formula was used to measure estimated glomerular filtration rate (eGFR) on all children with UACR > 30 mg/g in Polonnaruwa district and a group of age matched controls. A standard multiple linear regression using log transformed UACR as the dependent variable was performed. Mean eGFR were compared between UACR elevated group and controls using independent sample t test. RESULTS: Median UACR was 10.3 mg/g. Sex, ethnicity, history of having a chronic disease and age uniquely contributed to the multiple regression model which only explained 2.8% of the variance in the log of the UACR (p < 0.001). Only 15 (0.5%) had UACR> 300 mg/g while 8.2% (n = 236) had UACR between 30 to 300 mg/g and 89.8% (n = 203) of them did not have a chronic disease (Chi square 2.21, p = 0.091). Mean eGFR was significantly lower in the group with elevated UACR (88.9 mg/dl/1.73 m2, 95% CI for mean 86.4- 91.3) compared to group with normal UACR (93.7 mg/dl/1.73 m2,95% CI 91.1- 96.3) (t 2.7, p 0.007). Three out of the four students with eGFR less than 60 mg/dl/1.73 m2 had moderately elevated UACR. CONCLUSION: This study provides evidence to suggest that children in CKDu endemic regions are having an early renal damage. This observation needs to be investigated further in order to understand the worldwide epidemic of CKDu.

Body image construct of Sri Lankan adolescents

Introduction: "Body image" is more than the visual perception of size and it is probably multidimensional. It is known to influence eating behaviors and self-esteem of adolescents. Although widely studied in developed countries, it has been studied little in Sri Lanka. Objectives: This study was designed to translate and culturally adapt a tool to assess dimensions of body image in Sri Lankan adolescents. Methods: The study was carried out in the Anuradhapura District on school going children in grades nine to eleven. A multidimensional body image questionnaire was translated to Sinhalese language using the nominal group consensus method. The translated version was administered to 278 (114 boys) students after content validation and pre-testing. To assess test-retest reliability, the same questionnaire was administered to the same sample after two weeks. Psychometric properties were assessed using exploratory factor analysis. Results: Three-factor model emerged when dimensions in body image were analysed. Both boys and girls had almost identical factor structure. The three dimensions identified were "affective body image", "body perception" and "orientation on body size". All factors had good internal consistency with Cronbach's alpha > 0.76 and explained more than 56% of the total variance in both sexes. Conclusions: The translated body image questionnaire was a valid and reliable tool which can be used in Sri Lankan adolescents. Both genders had a similar, multidimensional body image construct.

Nutritional status among primary school children in rural Sri Lanka; a public health challenge for a country with high child health standards.

BACKGROUND: Nutritional status of pre adolescent children is not widely studied in Sri Lanka. The purpose of this study was to determine the nutritional status among pre-adolescent school children in a rural province of Sri Lanka. METHODS: A school based cross sectional study was carried out in North Central Province in 100 rural schools, selected using multi stage cluster sampling with probability proportionate to size. Children in grade one to five were enrolled with a maximum cluster size of fifty. Anthropometric measurements were done by trained data collectors and venesection was done at site by trained nurses. WHO AnthoPlus was used to calculate the BMI, height for age and weight for age Z scores. Survey design adjusted prevalence estimates with linearized standard errors were generated using svy function of STATA. Mean haemoglobin concentration (Hb) was calculated using methaeamoglobin method. Screening for iron deficiency and thalassemia trait was done using peripheral blood films. RESULTS: Height and weight measurements were done for 4469 of children and the Hb data was available for 4398 children. Based on the survey design adjusted estimates, prevalence of severe thinness, thinness, overweight and obesity in this population was 8.60% (SE 0.94), 2.91%(SE 0.74), 2.95%(0.26) and 2.43%(SE 0.92) respectively. Similarly, survey design adjusted prevalence of underweight and stunting were, 25.93% (95% CI 24.07-27.89%) and 43.92%(95% CI 40.55-47.56%). Adjusted mean estimates for hemoglobin was 12.20 (95% CI 12.16-12.24) g/dL. Prevalence of anemia was 17.3% (n = 749). Prevalence of mild and moderate anemia was 9.4 and 7.6% respectively. CONCLUSION: This study confirms that malnutrition is still a major problem in North Central Province, Sri Lanka.

Severe leptospirosis and pancreatitis; A case series from a leptospirosis outbreak in Anuradhapura district, Sri Lanka.

BACKGROUND: Acute pancreatitis is identified as an atypical and rare presentation of leptospirosis. In this report, we discuss a case series of severe leptospirosis with pancreatitis as a main complication during an unusual outbreak of leptospirosis in Anuradhapura district, Sri Lanka. CASE PRESENTATION: We retrospectively reviewed clinical presentation, investigations, treatment and outcome of six confirmed cases of severe leptospirosis admitted to intensive care unit (ICU) of Teaching Hospital, Anuradhapura, within a three months period from November 2014 to January 2015. All six patients were previously healthy paddy farmers presented with fever, myalgia and arthralgia. Four patients had abdominal pain, nausea and vomiting on admission. Hypotension, Neutrophilic leukocytosis and thrombocytopaenia was detected in all patients in the initial stage. Four patients had serum amylase more than 900 (range 941-2420). All patients had acute kidney injury and hepatitis. Significantly elevated amylase and low serum calcium were present in 4 cases. Five patients recovered without any evidence of residual organ damage, but one succumbed to the illness. CONCLUSION: This case series emphasizes the importance of identification of acute pancreatitis as a common complication of Leptospirosis, in order to reduce mortality and morbidity.

From organophosphate poisoning to diabetes mellitus: The incretin effect.

Organophosphate (OP) poisoning induced disruption of glucose homeostasis is well established. OP poisoning leads to accumulation of acetylcholine (ACh) due to the inhibition of acetylcholinesterases (AChE). On the other hand the incidence of type 2 diabetes mellitus (T2DM) is shown to rise along with the use of pesticides in Southeast Asia. Attenuation of the 'incretin effect' is seen in T2DM. This effect is regulated by a complex loop of mechanism involving ACh driven muscarinic receptors. We hypothesize that OP poisoning leads to disruption of glucose homeostasis by attenuation of the incretin effect. Inhibition of the Glucagon Like Peptide-1 (GLP-1) secretion is our main focus of interest. Positive finding of the hypothesis will open possibility of using incretin based treatment modalities to treat or prevent acute OP induced disruption of glucose homeostasis.

Cutaneous leishmaniasis in Mullaitivu, Sri Lanka: a missing endemic district in the leishmaniasis surveillance system.

The purpose of this study was to describe the emergence of cutaneous leishmaniasis in a district of Sri Lanka, documented at the national level as having zero incidence. We analyzed data from the Sri Lanka Army (SLA) to describe reported cases of cutaneous leishmaniasis for all armed forces personnel located in all 24 districts of Sri Lanka. These data are not included in the National Surveillance System. From January 2011 through February 2013, 314 armed forces personnel were confirmed as having leishmaniasis. Of these, 223 (81.4%) were working within the district of Mullaitivu at the time of investigation and another 21 (6.5%) reported that the lesion first appeared when they were working in Mullaitivu. The reported cumulative annual incidence of leishmaniasis among the army population was 7.5 per 10000, while in the general area of Mullaitivu the incidence was 234 per 10000. Leishmaniasis is emerging in epidemic proportions in Mullaitivu and is still not detected through the public health surveillance system. Urgent attention directed at disease surveillance and control activities is needed to control this emerging public health threat.

Outbreak of leptospirosis after white-water rafting: sign of a shift from rural to recreational leptospirosis in Sri Lanka?

This paper reports the first recreation-related leptospirosis outbreak in Sri Lanka in 20 office workers who were involved in white-water rafting during a staff outing. Two weeks after the rafting event on 7 September 2012, six participants developed fever, of which four had classical clinical features of leptospirosis. Four weeks after the exposure, an outbreak investigation was conducted for 19 of the 20 participants. Of the six fever patients, four were confirmed as having acute leptospirosis using either single sample MAT titre ≥ 1/400 (n = 2) or positive IgM ELISA (n = 2). An afebrile patient with headache and myalgia also had a MAT titre ≥ 1/400. Seventeen of the 19 participants investigated showed anti-leptospiral antibodies. None of the participants had a history of leptospirosis or recent outdoor exposures other than the rafting event. This outbreak provides evidence of the changing epidemiology of leptospirosis and suggests a wider range of risk exposures including those related to recreational activities of more affluent urban populations in addition to the well recognized occupational hazards of rural farming.

Factor structure and normative data of the Sinhalese version of self reported Strength and Difficulties Questionnaire (SDQ) for adolescents.

OBJECTIVES: To describe the normative data, factor structure and the internal consistency of the Sinhalese, self reported version of SDQ for adolescents. METHODS: The present study was carried out in eight provinces in Sri Lanka. A sample of school going adolescents aged 12-16 years were selected from Sinhalese medium schools using a multi stage cluster sampling technique with probability proportionate to size. The component structure of the SDQ was examined using principal component analysis. Normative banding and the cut off values were determined, based on the distribution of raw data in this non-clinical sample. RESULTS: The study sample consisted of 535 (45.3%) boys and 645 (54.5%) girls. Mean total difficulty score for girls (10.66±5.440) was significantly (p=0.014) higher than that for boys (9.93±4.671). Mean scores for emotional (2.97±2.009), conduct (2.11±1.755) and peer (2.24±1.760) subscales were also significantly higher among girls than that of boys (2.7±1.915, 1.78±1.406 and 2.04±1.383 respectively). In the factor analysis, only factor that was loaded with all five items in the original subscale was "emotional" and the loading values were more than .445 for all five items. None of the other extracted factors contained more than 3 items from one subscale. Internal consistency (Cronbach's alpha) for total difficulties was satisfactory in the total sample as well as in boys and girls separately (>.71). However, in all five subscales, Chrobach's alpha was less than six, showing a low homogeneity. CONCLUSIONS: Factor structure and internal consistency of the current Sinhalese version of the self reported SDQ is not satisfactory. Revalidation of this version of SDQ is recommended to capture the intended objectives of the SDQ.

Anaemia in pregnancy in the district of Anuradhapura, Sri Lanka--need for updating prevalence data and screening strategies.

OBJECTIVES: To determine the prevalence of anaemia during pregnancy in Anuradhapura district and evaluate present screening methods for anaemia. METHODS: Modified WHO 30 cluster sampling method with increased precision was used to estimate the prevalence of anaemia in the Anuradhapura district, Sri Lanka. Serum haemoglobin was measured using methemoglobin method. Clinical examination was carried out to evaluate the conjunctival method in anaemia screening. Values recorded from haemoglobin colour scale method used in the field antenatal clinics were collected. RESULTS: A total of 990 pregnant women participated in the study. In the first, second and third trimesters, prevalence of anaemia was 7.6%, 19.7% and 19.3% respectively. Gestational age adjusted anaemia prevalence among pregnant women in this study population was 14.1% (95% CI 12.0-16.4%). Mean and median haemoglobin concentration of the study sample was 11.8g/dL (SD 1.02g/dl and IQR 11.2-12.5g/dl). Among anaemic pregnant women, average values for Mean Corpuscular Volume (MCV), Mean Corpuscular Haemoglobin (MCH), and Mean Corpuscular Haemoglobin Concentration (MCHC) were, 82.9 fl (SD 11.5), 27.6 (SD-3.6) pg/cell and 32.9g/dl (SD 1.8) respectively. Sensitivity and specificity of haemoglobin colour scale method was 50% (95% CI 29.0-71.0%) and 76.3% (95% CI 66.9-83.7%) respectively. Sensitivity and specificity of conjunctival method in detecting anaemia during pregnancy was 18.8% (95% CI 11.9-28.4) and 69.3% (95% CI 58.2- 78.6%). CONCLUSIONS: Prevalence of anaemia in the district of Anuradhapura was less than 50% of the estimated prevalence for Sri Lanka. Both haemoglobin colour scale and conjunctival method were having low validity in detecting anaemia in pregnancy.

Inadequacy of the risk factor based approach to detect gestational diabetes mellitus.

OBJECTIVE: To evaluate the present risk factor based approach in diagnosis of gestational diabetes mellitus (GDM) in Sri Lanka in comparison with new guidelines proposed by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). METHODS: A community based cross sectional descriptive study was conducted among pregnant women with gestational age of 24-28 weeks and residing in Anuradhapura district. All eligible pregnant women from selected Medical Officers of Health areas were invited to participate. The 75 g oral glucose tolerance test was carried out among all participants. RESULTS: According to IADPSG criteria, 36 (8.9%) of pregnant women had GDM, compared to 29 (7.2%) according to WHO criteria. Prevalence of GDM in the study population (positive by one or both methods) was 10.6% (n=43) (95% CI 7.9-13.9%). Of these 43 women,22 (51.1%) had positive results by both methods. Seven (16.3%) and 14 (32.6%) mothers were positive only according to WHO and IADPSG criteria respectively. Out of 29 mothers who fulfilled WHO criteria, only one had an abnormal fasting plasma glucose, but 28 had abnormal 2 hour values. A total of 170 (42.0%) participants had at least one risk factor or early indicator of GDM. A risk based approach would have detected only 22 GDM patients according to IADPSG criteria, missing 14 cases (38.9%) who did not have any of the risk factors for GDM. CONCLUSIONS: The risk factor based approach misses more than one third of GDM cases. Urgent revision of current GDM screening guidelines is recommended.