Editorial: Equity/inequality, diversity and inclusion in child and adolescent mental health - a perspective from the South Asian region.

Over 1.8 billion people, about a quarter of the world's population live in the seven countries of South Asia: Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka. The population is characterized by a significant demographic youth bulge, with over 40% under the age of 18. This young population poses challenges related to ensuring their well-being and development. Issues such as poverty, undernutrition, lack of early stimulation, limited access to quality education and health care, and gender disparities persist in large parts of South Asia, affecting the lives of many children and adolescents. The promotion of child and adolescent mental health remains a challenge. Accumulating evidence suggests that early interventions can provide long-term health and socioeconomic benefits by prevention of the onset of mental health problems and their development into chronic disorders. This needs to be coupled with specialist services that can cater to the needs of children with greater needs, and support the community and schools-based non-specialist led services. Addressing child and adolescent mental health in South Asia presents a window of opportunity, because this regional youth bulge can contribute significantly to the global economy of the future.

Under-utilisation of noncommunicable disease screening and healthy lifestyle promotion centres: A cross-sectional study from Sri Lanka.

BACKGROUND: Healthy Lifestyle Centres (HLCs) are state-owned, free-of-charge facilities that screen for major noncommunicable disease risks and promote healthy lifestyles among adults older than 35 years in Sri Lanka. The key challenge to their effectiveness is their underutilisation. This study aimed to describe the underutilisation and determine the factors associated, as a precedent of a bigger project that designed and implemented an intervention for its improvement. METHODS: Data derived from a community-based cross-sectional study conducted among 1727 adults (aged 35 to 65 years) recruited using a multi-stage cluster sampling method from two districts (Gampaha and Kalutara) in Sri Lanka. A prior qualitative study was used to identify potential factors to develop the questionnaire which is published separately. Data were obtained using an interviewer-administered questionnaire and analysed using inferential statistics. RESULTS: Forty-two percent (n = 726, 95% CI: 39.7-44.4) had a satisfactory level of awareness on HLCs even though utilisation was only 11.3% (n = 195, 95% CI: 9.80-12.8). Utilisation was significantly associated with 14 factors. The five factors with the highest Odds Ratios (OR) were perceiving screening as useful (OR = 10.2, 95% CI: 4.04-23.4), perceiving as susceptible to NCDs (OR = 6.78, 95% CI: 2.79-16.42) and the presence of peer support for screening and a healthy lifestyle (OR = 3.12, 95% CI: 1.54-6.34), belonging to the second (OR = 3.69, 95% CI: 1.53-8.89) and third lowest (OR = 2.84, 95% CI: 1.02-7.94) household income categories and a higher level of knowledge on HLCs (OR = 1.31, 95% CI: 1.24-1.38). When considering non-utilisation, being a male (OR = 0.18, 95% CI: 0.05-0.52), belonging to an extended family (OR = 0.43, 95% CI: 0.21-0.88), residing within 1-2 km (OR = 0.29, 95% CI: 0.14-0.63) or more than 3 km of the HLC (OR = 0.14, 95% CI: 0.04-0.53), having a higher self-assessed health score (OR = 0.97, 95% CI: 0.95-0.99) and low perceived accessibility to HLCs (OR = 0.12, 95% CI: 0.04-0.36) were significantly associated. CONCLUSION: In conclusion, underutilisation of HLCs is a result of multiple factors operating at different levels. Therefore, interventions aiming to improve HLC utilisation should be complex and multifaceted designs based on these factors rather than merely improving knowledge.

Ambulatory blood pressure levels in individuals with uncontrolled clinic hypertension across Bangladesh, Pakistan, and Sri Lanka.

Hypertension is a leading risk factor for cardiovascular disease in South Asia. The authors aimed to assess the cross-country differences in 24-h ambulatory, daytime, and nighttime systolic blood pressure (SBP) among rural population with uncontrolled clinic hypertension in Bangladesh, Pakistan, and Sri Lanka. The authors studied patients with uncontrolled clinic hypertension (clinic BP ≥ 140/90 mmHg) who underwent ambulatory blood pressure monitoring (ABPM) during the baseline assessment as part of a community-based trial. The authors compared the distribution of ABPM profiles of patients across the three countries, specifically evaluating ambulatory SBP levels with multivariable models that adjusted for patient characteristics. Among the 382 patients (mean age, 58.3 years; 64.7% women), 56.5% exhibited ambulatory hypertension (24-h ambulatory BP ≥ 130/80 mmHg), with wide variation across countries: 72.6% (Bangladesh), 50.0% (Pakistan), and 51.0% (Sri Lanka; P < .05). Compared to Sri Lanka, adjusted mean 24-h ambulatory, daytime, and nighttime SBP were higher by 12.24 mmHg (95% CI 4.28-20.20), 11.96 mmHg (3.87-20.06), and 12.76 mmHg (4.51-21.01) in Bangladesh, separately. However, no significant differences were observed between Pakistan and Sri Lanka (P > .05). Additionally, clinic SBP was significantly associated with 24-h ambulatory (mean 0.38, 95% CI 0.28-0.47), daytime (0.37, 0.27-0.47), and nighttime SBP (0.40, 0.29-0.50) per 1 mmHg increase. The authors observed substantial cross-country differences in the distribution of ABPM profiles among patients with uncontrolled clinic hypertension in rural South Asia. The authors findings indicated the need to incorporate 24-h BP monitoring to mitigate cardiovascular risk, particularly in Bangladesh.

Ocular Dirofilariasis in Migrant from Sri Lanka, Australia.

We describe a case of imported ocular dirofilariasis in Australia, linked to the Hong Kong genotype of Dirofilaria sp., in a migrant from Sri Lanka. Surgical extraction and mitochondrial sequences analyses confirmed this filarioid nematode as the causative agent and a Dirofilaria sp. not previously reported in Australia.

Decreasing incidence of hospital diagnosed CKD/CKDu in North Central Province of Sri Lanka: is it related to provision of drinking water reverse osmosis plants?

BACKGROUND: We assessed the possible impact of provision of reverse osmosis (RO) water on the incidence of hospital diagnosed CKD/CKDu in North Central Province (NCP) of Sri Lanka. METHODS: An ecological study was conducted on data from 2010-2020 on the incidence of hospital diagnosed CKD/CKDu, CKD/CKDu screening and provision of drinking water RO plants in NCP. Analysis was conducted using descriptive statistics, ANOVA and chi-square test. RESULTS: The annual incidence of hospital diagnosed CKD/CKDu (per 100 000 population) in 2010-2013, 2014-2016 and 2017-2020 periods in Anuradhapura district were 129.07, 331.06 and 185.57 (p = 0.002) while in Polonnaruwa district these were 149.29, 326.12 and 296.73 (p = 0.04) respectively. In NCP provision of RO plants commenced after 2011 and the decline in the incidence of hospital diagnosed CKD/CKDu was seen in 25 of the 29 Divisional Secretary Divisions when more than 20% of the families received access to drinking RO water projects. CONCLUSIONS: The annual incidence of hospital diagnosed CKD/CKDu increased in NCP from 2010 to 2016 and continuously decreased thereafter. Continuous declining of CKD/CKDu incidence was seen after more than 20% of the families received access to drinking water RO plants.

Successful Management of Neutropenic Sepsis Is Key to Better Survival of Patients With Blood Cancer in Sri Lanka: Real-World Data From the Resource-Limited Setting.

PURPOSE: Sepsis is the main cause of nonrelapse mortality, and there are no published data on applicability of supportive care protocols from high-income countries such as Sri Lanka. The aim of the study was to investigate management and mortality of neutropenic episodes among Hemato-Oncology patients. MATERIALS AND METHODS: Retrospective analysis of clinical characteristics, management, morbidity, and mortality of neutropenic Hemato-Oncology patients presented to the Lanka Hospital Blood Cancer Centre from January 1, 2019 to December 31, 2019 was performed. RESULTS: A total of 169 neutropenic episodes were identified; 115 (68%) of such episodes were related to chemotherapy. Acute leukemia, lymphoproliferative disorders, and plasma cell disorders accounted for 23%, 69%, and 8% of patients, respectively. The median age of patients who had sepsis was 56 years, whereas that of those who had no sepsis was 53 years (P = .49). The median time to neutropenia was 9 days for those in the sepsis group compared with 8 days in the group that had no sepsis (0.64). The median neutrophil count in the group that had sepsis was 0.06, whereas it was 0.69 in the group that had no sepsis (P ≤ .05). The median time to commencement of antibiotics was 20 minutes. CONCLUSION: To our knowledge, this is the only documented study related to outcome and successful applicability of western supportive care protocols to Sri Lankan patients with neutropenia. In this study, we have shown that neutropenic sepsis can be successfully managed in the setting of limited resources with service development, following guidelines and staff training.

Intimate partner violence, suicide and self-harm in Sri Lanka: Analysis of national data.

There is increasing evidence from South Asia and internationally that intimate partner violence (IPV) is strongly associated with self-harm, however its association with suicide and self-harm has not been extensively examined, nor has this relationship been explored at a national level. Using national datasets, area-level variation in IPV, suicide and self-harm in Sri Lanka were examined. In addition, the association between individual level exposure to past-year IPV and non-fatal self-harm by any household member were explored in a series of multi-level logistic regression models, adjusting for age. Similar patterns in the distribution of suicide and IPV were found, with higher rates evident in post-conflict districts, specifically Batticaloa, Kilinochchi, and Mullaitivu. Experience of past year IPV and its various forms were strongly associated with household-level self-harm in the past year (adjusted odds ratio [AOR] = 3.83 95% CI 2.27-6.46). A similar magnitude was found for physical/sexual abuse (AOR 5.17 95% CI 2.95-9.05) and psychological abuse (AOR 4.64 95% CI 2.50-7.00). A dose-response association was also evident for frequency of abuse, with an increasing risk of household-level self-harm for women reporting abuse 'less often' (AOR 2.95 95% CI 1.46-5.92), and abuse experienced 'daily, weekly, or monthly' (AOR 4.83 95% CI 2.59-9.00), compared to no abuse. This study contributes to a growing body of evidence on the relationship between IPV and suicidal behaviour in South Asia. Addressing IPV and its various forms should be a priority for suicide prevention in Sri Lanka, alongside trauma-informed approaches in post-conflict settings.

Forecasting weekly dengue incidence in Sri Lanka: Modified Autoregressive Integrated Moving Average modeling approach.

Dengue poses a significant and multifaceted public health challenge in Sri Lanka, encompassing both preventive and curative aspects. Accurate dengue incidence forecasting is pivotal for effective surveillance and disease control. To address this, we developed an Autoregressive Integrated Moving Average (ARIMA) model tailored for predicting weekly dengue cases in the Colombo district. The modeling process drew on comprehensive weekly dengue fever data from the Weekly Epidemiological Reports (WER), spanning January 2015 to August 2020. Following rigorous model selection, the ARIMA (2,1,0) model, augmented with an autoregressive component (AR) of order 16, emerged as the best-fitted model. It underwent initial calibration and fine-tuning using data from January 2015 to August 2020, and was validated against independent 2000 data. Selection criteria included parameter significance, the Akaike Information Criterion (AIC), and Schwarz Bayesian Information Criterion (SBIC). Importantly, the residuals of the ARIMA model conformed to the assumptions of randomness, constant variance, and normality affirming its suitability. The forecasts closely matched observed dengue incidence, offering a valuable tool for public health decision-makers. However, an increased percentage error was noted in late 2020, likely attributed to factors including potential underreporting due to COVID-19-related disruptions amid rising dengue cases. This research contributes to the critical task of managing dengue outbreaks and underscores the dynamic challenges posed by external influences on disease surveillance.

Patient Satisfaction on Telehealth Services Used in Urban Sri Lankan Settings, During the COVID-19 Pandemic.

This research intended to assess satisfaction of urban patients on the use of telehealth over the last two years; mainly across the Covid-19 pandemic in Sri Lanka. Most of the telehealth users were the younger patients, and they were generally satisfied with the technical quality, serviced delivery as well as the overall experience. However, telehealth was utilized mainly for delivery of a limited range of services. In the future, Telehealth seems to have great potential to exist as a supplement to conventional appointments.

A real-time PCR for quantification of parasite burden and its correlations with clinical characteristics and anti-rKRP42 IgG level in cutaneous leishmaniasis in Sri Lanka.

In visceral and mucocutaneous leishmaniasis, humoral immune response can reflect disease severity and parasite burden. Cutaneous leishmaniasis (CL) in Sri Lanka is caused by a usually visceralizing parasite, Leishmania donovani. We assessed the parasite burden (relative quantity-RQ) in 190 CL patients using quantitative real-time PCR (qPCR-with primers designed for this study) and smear microscopy, then correlated it with clinical parameters and IgG response. RQ of parasite DNA was determined with human-specific glyceraldehyde 3-phosphate dehydrogenase (GAPDH) as the internal control. The qPCR sensitivity was tested with serially diluted DNA from cultured L. donovani parasites. Smears were assigned a score based on number of parasites per high power field. Data from previous studies were used for comparison and correlation; nested Internal Transcribed Spacer 1 (ITS1) PCR as reference standard (RS) and IgG antibody titers to the Leishmania rKRp42 antigen as the immune response. The qPCR amplified and quantified 86.8% of the samples while demonstrating a fair and significant agreement with ITS1-PCR and microscopy. Parasite burden by qPCR and microscopy were highly correlated (r = 0.76; p = 0.01) but showed no correlation with the IgG response (r = 0.056; p = 0.48). Corresponding mean RQs of IgG titers grouped by percentiles, showed no significant difference (p = 0.93). Mean RQ was higher in early lesions (p = 0.04), decreased with lesion size (p = 0.12) and slightly higher among papules, nodules and wet ulcers (p = 0.72). Our study established qPCR's efficacy in quantifying parasite burden in Sri Lankan CL lesions but no significant correlation was observed between the parasite burden and host IgG response to the Leishmania rKRP42 antigen.

In vitro growth of Leishmania parasites from biopsy samples of suspected cutaneous and visceral leishmaniasis cases in Sri Lanka: An observational study.

Sri Lanka reports a large focus of Leishmania donovani caused cutaneous leishmaniasis (CL). Subsequent emergence of visceral leishmaniasis (VL) was also reported recently. Expansion of the on-going disease outbreak and many complexities indicate urgent need to enhance early case detection methods. In vitro cultivation (IVC) of parasites causing visceral leishmaniasis (VL) is important for disease confirmation and to obtain sufficient quantities of parasites required in many scientific studies. IVC is carried out as a useful second line investigation for direct microscopy negative patients with CL in this setting. Along with the emergence of VL, current study was carried out to evaluate in vitro growth of local VL parasites and to identify their differences associated with in vitro growth characteristics. Routine parasitological diagnostic methods, i.e., light microscopy (LM), polymerase chain reaction (PCR) were used for confirmation of suspected cases. Lesion samples from 125 suspected CL cases and bone marrow or splenic aspirations from 125 suspected VL patients were used to inoculate IVCs. Media M199 (about 70 µl) supplemented with 15-20% of heat inactivated fetal bovine serum was used for initial culturing procedures in capillaries. Capillary cultures were monitored daily. Total of 44 different compositions/conditions were used for evaluating in vitro growth of VL causing parasite. Daily records on parasite counts, morphological appearance (size, shape, and wriggly movements) were maintained. In vitro transformation of Leishmania promastigotes to amastigotes and outcome of the attempts on recovery of live Leishmania from culture stabilates was also compared between CL and VL parasites. Proportion of cultures showing a transformation of promastigotes were 40/45 (88.9%) and 4/10 (40.0%) for CL and VL respectively. In the transformed cultures, parasites showing typical shape, size and movement patterns were less in VL (1/4, 25.0%) compared to CL (28/40, 70.0%). CL cultures showed a growth up to mass culturing level with mean duration of two weeks while it was about five weeks for VL cultures. Proportion of cultures that reached a parasite density of 1 × 106 cells/ml (proceeded to mass cultures) was significantly low in VL (4/10, 40%) as compared to CL (28/40, 70.0%). None of media compositions/conditions were successful for mass culturing of VL parasites while all of them were shown to be useful for growing CL strains. Also in vitro transformation to amastigote form and recovering of culture stabilates were not successful compared to CL. There were clear differences between in vitro growth of Leishmania parasites causing local CL and VL. Further studies are recommended for optimization of in vitro culturing of VL parasite which will be invaluable to enhance case detection in future.

Prevalence of falls and comparison of health-related physical fitness factors between different faller categories among institutionalized older adults in Kandy District of Sri Lanka.

Falls can be identified as one of the main issues in elderly population which can lead to serious consequences. Elderly population can be subdivided as community dwelling older adults and institutionalized older adults. The components of health-related physical fitness factors play an important role in the perspective of healthy ageing. The objective of the study was to determine the prevalence of falls and to compare health-related physical fitness factors between different fall categories among institutionalized older adults. This descriptive cross-sectional study comprised of one hundred and seventy-two elders above 60 years of age, living in registered elder's homes in Kandy District. The prevalence of falls was determined by the number of falls reported by the subjects. They were further categorized as non-fallers, fallers, and frequent fallers depending on the number of falls. Body Mass Index (BMI) for body composition, 2-minute walk test for cardiovascular endurance, 30 second sit to stand test for muscle strength and endurance, hand grip strength for upper body strength, chair sit and reach test for lower body flexibility and back scratch test for upper body flexibility were the measures used to assess health-related physical fitness factors. The prevalence of falls is presented as percentage and the health-related factors were compared between the three faller categories using one-way ANOVA and pairwise comparison was performed using Scheffe test. The prevalence of falls was 47.1%. There was a significant difference in BMI, cardiovascular endurance, and lower body flexibility between the three categories of fallers. Higher BMI, lower cardiovascular endurance and lower flexibility in the lower body were associated with increased prevalence of falls (p<0.05). There was no significant difference in body fat percentage, hand grip strength, lower body muscle strength and endurance and upper body flexibility (p>0.05). The findings suggest that, BMI, cardiovascular endurance, and lower body flexibility must be addressed and managed, while designing intervention programs for falls prevention among institutionalized older adults.

Factors associated with terminated pregnancies in Sri Lanka: A case study of the Sri Lankan Demographic and health survey (DHS) 2016.

Pregnancy termination is considered to have adverse effects on women's health and to have created financial, economic, and social problems in their lives. This study aimed to identify factors associated with pregnancy termination in Sri Lanka. The study used 2016 Sri Lanka Demographic and Health Survey (DHS) data of 16,323 ever-married women aged 15-49, who were clustered in selected enumerated areas. A binary logistic random intercept multilevel model was fitted to find the association between pregnancy termination and the predictor variables in this study. The overall pregnancy termination rate among Sri Lankan women was 16.14%. Increasing age of women was found to be associated with increasing odds of pregnancy termination. Women who were overweight or obese had higher odds of pregnancy termination, with 14% and 36%, respectively, compared to women with a normal weight. With increasing parity, the likelihood of pregnancy termination decreased. Women who used contraceptives had a 24% higher likelihood of pregnancy termination than those who refrained from using them. Cohabiting women had a 57% higher chance of pregnancy termination. Working women had 15% higher odds than unemployed women. Women who experienced domestic violence had a 14% higher odds of pregnancy termination than those who did not. Women from the Northern, Eastern, and North Central provinces had a lower likelihood of pregnancy termination compared to those from the Western province. Women in the urban sector were more likely to terminate their pregnancy than those in the estate sector. Further, women residing in households where indoor smoking was permitted had a 13% greater chance of ending their pregnancy compared to non-smoking households. The study highlights the importance of restructuring education related to health and well-being, family planning, and work-life balancing for both women and their partners, and developing and implementing or strengthening policies and laws related to mitigating pregnancy termination including domestic violence for women.

Seasonal sensitivity of groundwater dissolved organic matter in recognition of chronic kidney disease of unknown etiology: Optical and molecular perspectives.

Chronic kidney disease of unknown etiology (CKDu) has aroused a great concern due to its widespread prevalence in many developing countries. Dissolved organic matter (DOM) has been proved to be associated with CKDu in groundwater. However, the responses of their association to abiotic influencing factors like seasonal variation are not carefully disclosed. Herein, we revealed the seasonal variation of DOM in CKDu related groundwater (CKDu groundwater) and control group (non-CKDu groundwater) collected from Sri Lanka during the dry and wet seasons by excitation-emission matrix spectroscopy and Fourier transform ion cyclotron resonance mass spectrometry. In both CKDu and non-CKDu groundwaters, the input of exogenous DOM during wet season improved the degree of humification and molecular weight of DOM, while oxidative processes during the dry season increased the ratios of oxygen to carbon (O/C). Furthermore, compared with non-CKDu groundwater, more DOM with high O/C enriched in CKDu groundwater during the dry season, indicating stronger oxidative processes in CKDu groundwater. It may result in the enrichment of carboxyl group and induce the enhanced leaching of CKDu-related Si and F-. The receiver operating characteristic (ROC) analysis showed that the CKDu-recognition ability of most optical and molecular indicators was susceptible to seasonal factors and their recognition abilities were stronger in the wet season. The linkage between DOM and CKDu was affected by seasonal factors through the occurrence, mobility, degradation, and toxicity of typical organic molecules (e.g., C17H18O10S). The study provides a new insight into screening pathogenic factors of other endemic diseases related to organic molecules.

Quality of care as perceived by caregivers and residents in aged care homes in Sri Lanka: a qualitative study.

OBJECTIVE: Quality of care determines the physical and psychological wellbeing of aged care residents. The study aims to explore barriers and facilitators of quality of care in aged care homes (ACHs) in Sri Lanka from the perspective of older adults and caregivers. METHODS: This qualitative descriptive exploratory study was conducted in selected five ACHs in Galle District, Sri Lanka, from May 2021 to January 2022. We recruited a purposive sample of residents and caregivers and conducted ten in-depth interviews with ten caregivers and nine focus group discussions with forty-five residents. The data were analysed using the thematic analysis. RESULTS: The majority of caregivers and residents were females. Caregivers and residents were aged 25-35 years and 70-80 years, respectively. Two major themes emerged: (a) barriers of quality of care and (b) facilitators of quality of care. Both residents and caregivers reported a lack of referring system facilities; a lack of financial support on the infrastructure; a lack of financial support in supplying medication and employing human resources; insufficient knowledge of gerontological care and geriatric syndromes for both caregivers and residents; and lack of interest in being a caregiver at the ACHs as barriers in providing quality care. Moreover, caregivers and older people reported donations by philanthropists; supportive leadership; and welfare benefits from the government authorities as facilitators of quality care. Additionally, caregivers reported a lack of in-service programmes for caregivers as a barrier and positive institutional values as a facilitator for providing quality care. CONCLUSION: The available human and physical resources are insufficient to address the demanding needs of residents in ACHs, apart from the received donations. There is a simultaneous need for healthcare policymakers' and social welfare authorities' attention to implementing necessary measures to uplift the quality of care for residents in ACHs to enhance their quality of life.

Pathological characteristics of lung tumors in Sri Lanka 2017-2021.

The prevalence of lung cancer is steadily increasing globally, and it is projected to become the second most prevalent cancer in men by 2030. Lung cancer is the leading cause of cancer-related deaths worldwide, accounting for approximately 3.61% of total fatalities. Despite its significant impact, many Asian countries, including Sri Lanka, lack precise data on the epidemiological patterns of lung tumors. This study pioneers a comprehensive exploration in Sri Lanka, delving into the demographic and clinicopathological characteristics of lung cancer patients. The study included 733 consecutive patients with lung tumors from 2017 to 2021, with a median age of 59 years. The most common site of tumors was the right lower lobe and left upper lobes. Adenocarcinoma was the most prevalent histopathological type of primary malignant lung tumors, while colorectal adenocarcinomas were the most common cause of metastatic deposits in the lungs. The most common benign tumor was hamartoma. Significantly, our findings unveiled associations between patient demographics and tumor types, underscoring the importance of factoring in age and gender in diagnostic assessments. Notably, the absence of a dedicated lung cancer screening program in Sri Lanka underscores the critical reliance on clinical suspicion and accurate diagnostic methods.

Use of Household Insecticides against Mosquitoes in Dengue-Endemic Areas in Sri Lanka.

The use of household insecticides in the formulation of mosquito coils and vaporizers is common among the public to protect against mosquito-borne diseases. However, information regarding the use of these commonly practiced household insecticides is scarce in Sri Lanka. A questionnaire-based survey was directed to 600 households in Colombo, Gampaha, Kandy, Kalutara, Jaffna, and Galle districts in Sri Lanka. Household insecticides were used by the majority of the respondents (57.0%), and electric liquid vaporizers (46.7%) and mosquito coils (45.7%) were the commonly used forms. The active ingredients in mosquito coils were d-trans-allethrin (w/w 0.12%), metofluthrin (w/w 0.005%), and dimefluthrin (w/w 0.01%); in liquid vaporizers, they were prallethrin (w/v 1.24% and w/v 1.26%) and transfluthrin (w/v 0.9%). The majority of the household insecticide consumers were moderately satisfied with the effectiveness of the products (68.6%), and most of the participants used household insecticides daily (35.5%), especially during the evening (41.6%). Most of the consumers were unaware of the chemicals included in household insecticides (62.8%). Mosquito coils were abundantly used by rural area participants (75.8%), whereas liquid vaporizers were the most common among the urban participants (56.4%). The findings indicate that demographic and socioeconomic factors influence household insecticide practices. To our knowledge, this study reveals the use of household insecticides to control mosquitoes for the first time in Sri Lanka and highlights the importance of awareness programs and the proper utilization of these products.

Sri Lanka's COVID-19 response and maintaining health services: implications for future pandemics.

This study examines how Sri Lanka, a lower-middle income country, managed its COVID-19 response and maintained health services. It draws on an extensive document review, key informant interviews and a national survey of public experience and opinion to assess what Sri Lanka did, its effectiveness and why.Owing to a strong health system and luck, Sri Lanka stopped the first wave of COVID-19 infections, and it adopted a 'Zero-COVID' approach with the explicit goal of stopping outbreaks. This was initially effective. Outbreaks reduced healthcare use, but with minimal impact on health outcomes. But from end-2020, Sri Lanka switched its approach to tolerating transmission and mitigation. It took proactive actions to maintain healthcare access, and it pursued a COVID-19 vaccination effort that was successful in covering its adult population rapidly and with minimal disparities. Despite this, widespread transmission during 2021-2022 disrupted health services through the pressure on health facilities of patients with COVID-19 and infection of healthcare workers, and because COVID-19 anxiety discouraged patients from seeking healthcare. This led to substantial mortality and more than 30 000 excess deaths by 2022.We find that Sri Lanka abandoned its initially successful approach, because it failed to understand that its chosen strategy required symptomatic PCR testing in primary care. Failure to invest in testing was compounded by groupthink and a medical culture averse to testing.Sri Lanka's experience confirms that strong public health capacities, robust healthcare systems and intersectoral action are critical for pandemic response. It shows that civilian-military collaboration can be beneficial but contested, and that lack of fiscal space will undermine any response. It also demonstrates that pandemic preparedness cannot guarantee a successful pandemic response. Policy and research must pay more attention to improving decision-making processes when faced with pandemics involving novel pathogens, rapid spread, and substantial scientific uncertainty.