Improving access to quality family planning services in Nepal and Sri Lanka: insights from a South-South learning exchange.

Nepal and Sri Lanka ministries of health shared best practices and learnings, in a South-South learning exchange (SSLE) to improve access to quality and rights-based family planning services. The SSLE between the two countries followed a five-step methodology designed by the WHO, under the Family Planning Accelerator project. SSLE between the two countries started in January 2020 and is still continuing. Both countries started implementation of the learnings (step 4) at the time of preparing this manuscript (December 2021). An independent consultant from Sri Lanka carried out an evaluation, to inform future SSLEs. The evaluation included a desk review on SSLE and family planning in both countries and key informant interviews with Sri Lanka Ministries Health, WHO CO, external partners. A final evaluation of the outcomes/impact is planned in December 2022. The SSLE resulted in a systematic cross-country transfer of knowledge and implementation of the learnings. Sri Lanka implemented a web-based system for logistics management of family planning commodities and Nepal commenced implementing integrated family planning services in a decentralised environment using a lifecycle approach to improve postpartum family planning uptake. The success of this SSLE is attributed to the rigorous methodology, country-led designing of the learning agenda and process, extensive communication amongst the teams, a focus on outcomes, commitment and leadership by ministries of health in both countries. Learning and technical assistance needs of countries can be met by SSLE if national contexts, availability of resources are considered.

Active screening of patients with diabetes mellitus for pulmonary tuberculosis in a tertiary care hospital in Sri Lanka.

End TB strategy by the WHO suggest active screening of high-risk populations for tuberculosis (TB) to improve case detection. Present study generates evidence for the effectiveness of screening patients with diabetes mellitus (DM) for Pulmonary TB (PTB). A study was conducted among 4548 systematically recruited patients over 45 years attending DM clinic at the National Hospital of Sri Lanka. The study units followed an algorithm specifying TB symptom and risk factor screening for all, followed by investigations and clinical assessments for those indicated. Bacteriologically confirmed or clinically diagnosed PTB were presented as proportions with 95% CI. Mean (SD) age was 62·5 (29·1) years. Among patients who completed all indicated steps of algorithm, 3500 (76·9%) were investigated and 127 (2·8%) underwent clinical assessment. Proportion of bacteriologically confirmed PTB patients was 0·1% (n = 6,95%CI = 0·0-0·3%). None were detected clinically. Analysis revealed PTB detection rates among males aged ≥60 years with HbA1c ≥ 8 to be 0·4% (n = 2, 95%CI = 0·0-1·4%). The study concludes that active screening for PTB among all DM patients at clinic settings in Sri Lanka, to be non-effective measure to enhance TB case finding. However, the sub-category of diabetic males with uncontrolled diabetics who are over 60 years of age is recommended as an option to consider for active screening for PTB.

Success of malaria chemoprophylaxis for outbound civil and military travellers in prevention of reintroduction of malaria in Sri Lanka.

BACKGROUND: Sri Lanka was certified as malaria-free in September 2016. However, the continuous presence of the malaria vector poses serious risks of reintroduction of the disease. Chemoprophylaxis and advice on malaria preventive behaviour for international travellers is a key strategy adopted to reduce the risk of imported malaria. METHODS: We conducted an efficiency study of malaria chemoprophylaxis for civilian and military travellers who requested travel advice from the Anti Malaria Campaign (AMC) prior to departure. The AMC is the only agency that can issue malaria chemoprophylaxis to travellers and hence this sample is representative of all such individuals seeking travel advice in Sri Lanka. RESULTS: A total of 544 (400 civilians and 144 military) travellers were interviewed prior to departure and after return. The majority travelled to African destinations (516/544 [94.8%]) and were prescribed mefloquine (517/544 [95%]). Chemoprophylaxis was well tolerated and discontinuation due to adverse events was minimal. Regular chemoprophylaxis was reported by 505 (92.8%) participants while overseas. The protective efficacy of chemoprophylaxis was 100% among those who complied with the full course. CONCLUSIONS: The compliance with chemoprophylaxis and its protective efficacy were satisfactory in this study. It is an effective tool in preventing imported malaria to post-elimination Sri Lanka.

The need for preventive and curative services for malaria when the military is deployed in endemic overseas territories: a case study and lessons learned.

BACKGROUND: Sri Lanka has been free from indigenous malaria since November 2012 and received the WHO certificate for malaria-free status in September 2016. Due to increased global travel, imported malaria cases continue to be reported in the country. Military personnel returning home from international peace-keeping missions in malaria endemic countries represent a key risk group in terms of imported malaria. The present study intended to characterize the potential causes of a malaria outbreak among the Sri Lankan security forces personnel deployed in the Central African Republic (CAR). METHODS: Data were collected from a cross-sectional survey distributed among Sri Lankan Air Force personnel who had returned from United Nations peace-keeping missions in the CAR region. A pre-tested questionnaire was used for the data collection, and focus group discussions were also conducted. RESULTS: One hundred twenty male Air Force personnel were interviewed (out of a group of 122 officers and airmen). All participants were deployed in the CAR for 14 months and were aware of the existence of chemoprophylaxis against malaria. The majority of the subjects (92.5%, 111/120) also knew that prophylaxis should be started prior to departure. However, the regular use of chemoprophylaxis was reported by only 61.7% (74/120) of the sample. Overall, 30.8% of the participants (37/120) had 44 symptomatic episodes of malaria during deployment, and one person succumbed to severe malaria. All cases were associated with noncompliance with chemoprophylaxis. CONCLUSION: Better coordination with overseas healthcare services and the establishment of directly observed chemoprophylaxis may help to avoid similar outbreaks in the future.

Challenges for achieving safe and effective radical cure of Plasmodium vivax: a round table discussion of the APMEN Vivax Working Group.

The delivery of safe and effective radical cure for Plasmodium vivax is one of the greatest challenges for achieving malaria elimination from the Asia-Pacific by 2030. During the annual meeting of the Asia Pacific Malaria Elimination Network Vivax Working Group in October 2016, a round table discussion was held to discuss the programmatic issues hindering the widespread use of primaquine (PQ) radical cure. Participants included 73 representatives from 16 partner countries and 33 institutional partners and other research institutes. In this meeting report, the key discussion points are presented and grouped into five themes: (i) current barriers for glucose-6-phosphate deficiency (G6PD) testing prior to PQ radical cure, (ii) necessary properties of G6PD tests for wide scale deployment, (iii) the promotion of G6PD testing, (iv) improving adherence to PQ regimens and (v) the challenges for future tafenoquine (TQ) roll out. Robust point of care (PoC) G6PD tests are needed, which are suitable and cost-effective for clinical settings with limited infrastructure. An affordable and competitive test price is needed, accompanied by sustainable funding for the product with appropriate training of healthcare staff, and robust quality control and assurance processes. In the absence of quantitative PoC G6PD tests, G6PD status can be gauged with qualitative diagnostics, however none of the available tests is currently sensitive enough to guide TQ treatment. TQ introduction will require overcoming additional challenges including the management of severely and intermediately G6PD deficient individuals. Robust strategies are needed to ensure that effective treatment practices can be deployed widely, and these should ensure that the caveats are outweighed by  the benefits of radical cure for both the patients and the community. Widespread access to quality controlled G6PD testing will be critical.

Diagnostic challenges and case management of the first imported case of Plasmodium knowlesi in Sri Lanka.

BACKGROUND: Sri Lanka has achieved 'malaria-free' status and is now in the phase of prevention of re-introduction of malaria. Imported malaria remains a challenge to resurgence of the disease. The diagnostic challenges encountered and the rapid response initiated to manage a Plasmodium infection, which was later confirmed as Plasmodium knowlesi, the first reported case from Sri Lanka, is discussed. CASE PRESENTATION: An army officer who returned from Malaysia in October 2016 was found to be positive for Plasmodium both by microscopy and rapid diagnostic test (RDT) by the Anti Malaria Campaign Sri Lanka (AMC) during his third visit to a health care provider. Microscopy findings were suspicious of P. knowlesi infection as the smears showed parasite stages similar to both Plasmodium malariae and Plasmodium falciparum. Nested PCR at AMC confirmed Plasmodium genus, but not the species. In the absence of species confirmation, the patient was treated as a case of P. falciparum. The presence of P. knowlesi was later confirmed by a semi-nested PCR assay performed at the Environmental Health Institute, National Environmental Agency in Singapore. The parasite strain was also characterized by sequencing the circumsporozoite gene. Extensive case investigation including parasitological and entomological surveillance was carried out. CONCLUSIONS: Plasmodium knowlesi should be suspected in patients returning from countries in the South Asian region where the parasite is prevalent and when blood smear results are inconclusive.

Genetic, familial and environmental correlates of asthma among early adolescents in Sri Lanka: a case control study.

BACKGROUND: Despite advances in management, the mortality and morbidity due to asthma are increasing globally. Identification of specific correlates in the local context is useful in disease management. The objective of this study was to estimate the prevalence and to describe selected correlates of asthma among12-14 year old school children in a district in Sri Lanka. METHOD: A school based cross-sectional study was conducted using a self administered questionnaire. Multi-staged stratified cluster sampling was used to select 42 classes in grades 7, 8 and 9. "Current asthma" (CA)(case) was defined as 'having Physician Diagnosed Asthma (PDA) and having had wheezing during the previous 12 months'. For each case, two healthy controls were selected from the same class to assess correlates. Information on correlates was collected by trained field midwives during home visits. Backward stepwise logistic regression model was used for analysis of correlates. Skin Prick Testing was carried out among asthmatics together with their healthy siblings using standard extracts of House Dust Mite (HDM), cockroach and Blomia. Ethical clearance was obtained from Ethical Review Committee, Faculty of Medicine, Colombo. RESULTS: Out of 1483 subjects participated, 753 were females (50.8%). The prevalence rates for current wheezing (CW), ever wheezing (EW), current asthma (CA), and physician diagnosed asthma (PDA) were 16.7%, 19.4%, 10.7% and 14.5% respectively. A total of 158 CA cases were identified. Information on correlates of asthma was collected for 145 CA cases (97.9%) and for 285 controls (96.6%). The unconfounded predictors of having CA among adolescents in the present sample were; only child in the family (OR = 4.2, 95% CI: 1.7-9.9); first born of the family (OR = 2.6 95% CI: 1.3-5.2); presence of allergic rhinitis (OR = 2.7, 95% CI: 1.6-4.6); family history of asthma (OR = 1.8, 95% CI: 1.1-3.2); family history of allergic rhinitis (OR = 1.9, 95% CI: 1.1-3.2); family history of eczema (OR = 1.8, 95% CI: 1.0-3.2). Higher risk of sensitization to cockroach, HDM and Blomia was seen among asthmatics compared to healthy siblings. CONCLUSION: A significant proportion of students reported to have asthma. Atopy and other genetic and environmental correlates should be considered as important correlates in asthma management among early adolescents in Sri Lanka.

Psychometric properties of the Sinhala version of the PedsQL™ 4.0 Generic Core Scales in early adolescents in Sri Lanka.

BACKGROUND: The concept Health related Quality of life (HRQOL) is increasingly recognized as an important health outcome measure in clinical and research fields. The present study attempted to evaluate the psychometric properties of the Sinhala version of the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0) Generic Core Scales among adolescents in Sri Lanka. METHODS: The original US PedsQL™ was translated into Sinhala and conceptually validated according to international guidelines. A cross-sectional study was conducted among 142 healthy school going adolescents (12-14 years), their parents (n = 120) and a group of adolescents with asthma who attended asthma clinics (n = 115). Reliability was assessed using Cronbach's alpha and validity by examining scale structure, exploring inter-scale correlations and comparing across known groups (healthy vs. chronically ill). RESULTS: The PedsQL™ Sinhala version was found to be acceptable with minimal missing responses. All scales demonstrated satisfactory reliability. Cronbach's alpha for the total scale scores was 0.85 for adolescent self-report while for the parent proxy-report for the healthy group it was 0.86. No floor effects were observed. Ceiling effects were noticed in self-report and parent proxy-report for the healthy group. Overall results of the multi trait scaling analysis confirmed the scale structure with 74% item-convergent validity, 88% item-discriminant validity and an overall scaling success of 72%. Moderate to high correlations were shown among the domains of teen self-report (Spearman rho = .37-.54) and between teen self-report and parent proxy-reports (Spearman rho = .41-.57). The PedsQL™ tool was able to discriminate between the quality of life in healthy adolescents and adolescents with asthma. CONCLUSION: The findings support the reliability and validity of the Sinhala version of the PedsQL™ 4.0 Generic Core Scales as a generic instrument to measure HRQOL among early adolescents in Sri Lanka in a population setting.