A self-applied valid scale for rapid tracking of household food insecurity among pregnant women in Sri Lanka.

Rapid household food insecurity (HFI) tracking has been identified as a priority in the context of the COVID-19 pandemic and its aftermath. We report the validation of the Latin American and Caribbean Food Security Scale (Escala Latinoamericana y Caribena de Seguridad Alimentaria [ELCSA]) among pregnant women in Sri Lanka. The eight-item adult version of the ELCSA was translated from English to Sinhala and Tamil. Cognitive testing (on 10 pregnant women and five local experts) and psychometric validation of the self-administered HFI tool were conducted among pregnant women (n = 269) attending the special clinics of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura in February 2020. We assessed the psychometric properties and fit using a one parameter logistic model (Rasch model analysis) using STATA Version 14 and WINSTEP software Version 4.3.4. Concurrent validity was tested using psychological distress. The scale was internally consistent (Cronbach's alpha = 0.79) and had a good model fit (Rasch items infit statistic range: 0.85 to 1.07). Item 8 ('did not eat for the whole day') was removed from the model fit analysis, as it was not affirmed by respondent. Item severity scores ranged from -2.15 for 'not eating a diverse diet' to 4.43 for 'not eating during the whole day'. Concurrent validity between HFI and psychological distress was confirmed (r = 0.15, p < 0.05). The self-applied version of ELCSA-pregnancy in Sri Lanka (ELCSA-P-SL) is a valid and feasible valid tool. We recommend it to track HFI among pregnant women in lower income countries during the COVID-19 pandemic.

Body image perception and body dissatisfaction among rural Sri Lankan adolescents; do they have a better understanding about their weight?

Introduction: Adolescents have high vulnerability for body image distortions which may result in many psychological and physical problems. Objectives: This study aimed to determine body image perception and dissatisfaction among rural schooling adolescents in Sri Lanka. Methods: Adolescents (aged 13-16 years) were selected using probability-based sampling framework. Self-administered figure rating scale was used to assess perceived current (PCBS) and ideal (IBS) body size and body discrepancy score (BDS = PCBS ­ IBS). Pubertal stage was assessed with pubertal development scale. Anthropometry was done according to WHO guidelines. Results: Of 3128 students studied, 47.8% were boys. Median PCBS was 4 (inter quartile range 1) for boys and 4 (2) for girls. Boys aspire a larger body size compared to girls and the respective median IBS were 5 (0) and 4 (1). More boys (70.4%, n = 1053) than girls (66.4%, n = 1084) were dissatisfied about their current body size; χ2 = 5.5, df = 1, p < 0.05. Overweight students recorded higher PCBS and were more dissatisfied with their body size when compared to others. Nearly half of boys and 29.6% girls wanted to have a larger body size than their current. The main influencing factor of body dissatisfaction was body mass index. Conclusions: Body dissatisfaction is evident even among rural adolescents, affecting boys more than girls. Many students show a desire to have a larger body size than their current. This study also provides valid and reliable tools to assess body dissatisfaction and pubertal development in Sinhala speaking adolescents.

Stigma associated with cutaneous leishmaniasis in rural Sri Lanka: development of a conceptual framework.

BACKGROUND: There is limited knowledge about the stigma associated with cutaneous leishmaniasis (CL) in Sri Lanka. To ensure that leishmaniasis researchers focus on CL-associated stigma, we provide an evidence-based framework that can be used in future research. METHODS: We conducted a systematic review on CL-associated stigma using international evidence and carried out a multimethod qualitative study in the Anuradhapura district in Sri Lanka. Based on that, we identified manifestations of stigma, drivers and facilitators that we synthesised to develop a conceptual framework on CL-associated stigma. RESULTS: Our framework consists of drivers, facilitators and self-stigma experienced by people with CL. Stigma drivers included fear, misbeliefs and misconceptions about CL; the belief that wounds are disfiguring; the treatment burden and implied blame. Facilitators that reduced stigma included knowledge of the curability of CL and awareness that CL is not contagious. The nature of social interactions in rural communities enhanced stigma formation. We identified various enacted, felt and internalised stigma experiences of people with CL. CONCLUSIONS: We developed a conceptual framework of the stigma associated with CL that can be used to develop targeted interventions to increase CL awareness, address stigma and improve the quality of life for CL patients.

Utility of quantitative polymerase chain reaction in leptospirosis diagnosis: association of level of leptospiremia and clinical manifestations in Sri Lanka.

BACKGROUND: Quantitative polymerase chain reaction (qPCR), despite cost and logistical challenges, has the potential to provide accurate and timely diagnosis for leptospirosis at the point-of-care in endemic areas. We studied optimal sample types for qPCR, timing of sampling, and clinical manifestations in relation to quantitative leptospiremia. METHODS: A new qPCR assay using pathogenic Leptospira-specific 16S ribosomal RNA (rRNA) gene Taqman primers and an optimized temperature stepdown protocol was used to analyze patient blood samples. Serum was compared with whole blood as sample source. Quantitative leptospiremia was compared with clinical manifestations of leptospirosis and outcome. RESULTS: The diagnostic sensitivity of qPCR of whole blood and serum was 18.4% (95% confidence interval [CI]: 9.97%-31.4%) and 51.0% (95% CI: 37.5%-64.4%) respectively. The qPCR on suspected cases confirmed infection in 58 of 381 cases (15.2%). Of these, 6 cases confirmed by nested polymerase chain reaction (PCR) and sequencing were serologically negative using a standard but not regionally optimized microscopic agglutination test panel. The bacterial load in serum/blood ranged from 10(2) to 10(6) Leptospira/mL. Median leptospiral load for uncomplicated, renal failure, myocarditis, and multi-organ failure patients were 8616, 11007, 36100, and 15882 Leptospira/mL respectively. The qPCR window of positivity ranged from day 2 to day 15; sensitivity of qPCR was not affected by the length of the interval between the onset of symptoms and sample collection (P = .328). CONCLUSIONS: Quantitative PCR shows potential as a valid diagnostic test with a wider window of positivity than previously thought. Quantitative leptospiremia in serum/whole blood samples did not directly correlate with clinical manifestations of outcome in this patient population.

Predictors of the development of myocarditis or acute renal failure in patients with leptospirosis: an observational study.

BACKGROUND: Leptospirosis has a varied clinical presentation with complications like myocarditis and acute renal failure. There are many predictors of severity and mortality including clinical and laboratory parameters. Early detection and treatment can reduce complications. Therefore recognizing the early predictors of the complications of leptospirosis is important in patient management. This study was aimed at determining the clinical and laboratory predictors of myocarditis or acute renal failure. METHODS: This was a prospective descriptive study carried out in the Teaching Hospital, Kandy, from 1st July 2007 to 31st July 2008. Patients with clinical features compatible with leptospirosis case definition were confirmed using the Microscopic Agglutination Test (MAT). Clinical features and laboratory measures done on admission were recorded. Patients were observed for the development of acute renal failure or myocarditis. Chi-square statistics, Fisher's exact test and Mann-Whitney U test were used to compare patients with and without complications. A logistic regression model was used to select final predictor variables. RESULTS: Sixty two confirmed leptospirosis patients were included in the study. Seven patients (11.3%) developed acute renal failure and five (8.1%) developed myocarditis while three (4.8%) had both acute renal failure and myocarditis. Conjunctival suffusion - 40 (64.5%), muscle tenderness - 28 (45.1%), oliguria - 20 (32.2%), jaundice - 12 (19.3%), hepatomegaly - 10 (16.1%), arrhythmias (irregular radial pulse) - 8 (12.9%), chest pain - 6 (9.7%), bleeding - 5 (8.1%), and shortness of breath (SOB) 4 (6.4%) were the common clinical features present among the patients. Out of these, only oliguria {odds ratio (OR) = 4.14 and 95% confidence interval (CI) 1.003-17.261}, jaundice (OR = 5.13 and 95% CI 1.149-28.003), and arrhythmias (OR = 5.774 and 95% CI 1.001-34.692), were predictors of myocarditis or acute renal failure and none of the laboratory measures could predict the two complications. CONCLUSIONS: This study shows that out of clinical and laboratory variables, only oliguria, jaundice and arrhythmia are strong predictors of development of acute renal failure or myocarditis in patients with leptospirosis presented to Teaching Hospital of Kandy, Sri Lanka.

Asthma in a prospective cohort of rural pregnant women from Sri Lanka: Need for better care during the pre-conceptional and antenatal period.

OBJECTIVES: To describe the epidemiology and the effect of asthma on pregnancy outcomes in pregnant women from a rural geography. METHODS: We conducted a prospective cohort study in Anuradhapura district, Sri Lanka enrolling all eligible pregnant women registered in the maternal care program. An interviewer-administered questionnaire-based symptom analysis and clinical assessment was conducted in the first and second trimesters. RESULTS: We recruited 3374 pregnant women aged 15-48 years at conception. Self-reported physician-diagnosed asthma prevalence was 6.6% (n = 223) with only 41.7% (n = 93) on regular medical follow-up for asthma. The prevalence of wheeze reduced from pre-pregnancy (67.0%) to the first (46.4%) and second trimesters (47.7%; p<0.01). Of the 73 asthmatic women who did not have wheeze in the last 3 months preceding pregnancy, new-onset wheeze was reported by 6(8.2%) and 12(16.4%) in the first and second trimester, respectively. Pregnant women who sought medical care for asthma in the private sector had a lower likelihood of developing new-onset wheeze in the first trimester (p = 0.03; unadjusted OR = 0.94;95%CI 0.89-0.99). Thirty-four (33.3%) pregnant women had at least one hospital admission due to exacerbation of wheeze during the first and second trimester. The prevalence of low birth weight (16.0%) was higher among pregnant asthmatic women. CONCLUSION: This study reports the high prevalence of asthma and asthma-associated pregnancy outcomes in women from a rural geography signifying the importance of targeted management.

Community Engagement in Cutaneous Leishmaniasis Research in Brazil, Ethiopia, and Sri Lanka: A Decolonial Approach for Global Health.

Cutaneous leishmaniasis (CL) is a parasitic skin disease endemic in at least 88 countries where it presents an urgent, albeit often "neglected" public health problem. In this paper, we discuss our model of decolonial community engagement in the ECLIPSE global health research program, which aims to improve physical and mental health outcomes for people with CL. The ECLIPSE program has four interlinked phases and underpinning each of these phases is sustained and robust community engagement and involvement that guides and informs all activities in ECLIPSE. Our decolonial approach implies that the model for community engagement will be different in Brazil, Ethiopia and Sri Lanka. Indeed, we adopt a critical anthropological approach to engaging with community members and it is precisely this approach we evaluate in this paper. The data and material we draw on were collected through qualitative research methods during community engagement activities. We established 13 Community Advisory Groups (CAGs): in Brazil (n = 4), Ethiopia (n = 6), and Sri Lanka (n = 3). We identified four overarching themes during a thematic analysis of the data set: (1) Establishing community advisory groups, (2) CAG membership and community representation, (3) Culturally appropriate and context-bespoke engagement, and (4) Relationships between researchers and community members. During our first period of ECLIPSE community engagement, we have debunked myths (for instance about communities being "disempowered"), critiqued our own practices (changing approaches in bringing together CAG members) and celebrated successes (notably fruitful online engagement during a challenging COVID-19 pandemic context). Our evaluation revealed a gap between the exemplary community engagement frameworks available in the literature and the messy, everyday reality of working in communities. In the ECLIPSE program, we have translated ideal(istic) principles espoused by such community engagement guidance into the practical realities of "doing engagement" in low-resourced communities. Our community engagement was underpinned by such ideal principles, but adapted to local sociocultural contexts, working within certain funding and regulatory constraints imposed on researchers. We conclude with a set of lessons learned and recommendations for the conduct of decolonial community engagement in global health research.

Duration of exclusive breastfeeding; validity of retrospective assessment at nine months of age.

BACKGROUND: In cross sectional, case control and retrospective cohort studies, duration of Exclusive Breastfeeding (EBF) usually depends on maternal recall. Retrospective data are often subjected to recall bias and could lead to a potential for exposure misclassification. The purpose of the present paper is to assess the validity of maternal recall of EBF duration during infancy, after cessation of EBF and to evaluate the two methods to collect retrospective data on EBF. METHODS: A cohort study was carried out in Naula Medical Officer of Health (MOH) area. Study cohort included all infants born during the months of February to April 2008 and currently residing in Naula MOH area. Baseline data collection was carried out using the pregnancy record, the child health development record and by using an interviewer administered structured questionnaire. Data extraction from the pregnancy record and the child health development record were carried out by public health midwives. The interviewer administered structured questionnaire was administered by the MOH during the follow-up visits. Duration of EBF was assessed in three ways; based on prospective data since birth: Retrospective data based on an event calendar: and the Mother reported EBF duration. RESULTS: A total of 114 mother-infant pairs were recruited and followed up. Proportion of infants receiving EBF up to the completion of the sixth month by the three methods were; data since birth (actual EBF rate) - 23.9%; mother reported data - 77.7% and event calendar method - 41.3%. Median duration of EBF reported in the three methods was 5, 6, and 5 respectively. A statistically significant difference was observed in these differences from Kaplan-Meire Survival analysis (Log rank test - Chi square-63.4, p < 0.001). Validity of retrospective methods was analysed using data since birth as the gold standard. Sensitivity of both methods to detect exclusively breastfed babies were 100.0%. Specificity of mother recall data was 26.2% (95%CI-17.9, 36.8%) compared to 75.0% (95% CI-64.5, 83.2%) in the event calendar method. CONCLUSIONS: Retrospective evaluation methods systematically overestimate the duration of EBF. Maternal recall data provide highly unspecific data whereas use of an event calendar provided more valid data. Reporting of data accrual methods in breastfeeding studies will allow the readers to interpret findings accurately and the use of event calendars rather than direct questioning as a valid method of determining EBF is recommended.

Next-Generation Sequencing Analysis of Pathogenic Leptospira: A Way Forward for Understanding Infectious Disease Dynamics in Low/Middle-Income, Disease-Endemic Settings.

In the current genomic era, knowledge of diversity of Leptospira, the spirochetal agents of leptospirosis, is changing rapidly. Next-generation sequencing has decreased in price and increased in scale, with the potential to democratize large-scale analysis of pathogens in resource-limited, low/middle-income (LMIC) regions. Consequently, the molecular classification of Leptospira, a pathogen disproportionately affecting LMIC countries, has changed dramatically over the last decade. Leptospira classification and molecular understandings of pathogen diversity have rapidly evolved, now most precisely based on core genome analysis supplemented by new insights provided by culture-independent methods directly using body fluids such as blood and urine. In places where leptospirosis disease burden is highest, genomic technologies have not been available, and serology-based methods remain the mainstay of leptospiral classification. Understanding the epidemiology, pathogenesis, and ultimately new approaches to treating and preventing leptospirosis requires detailed knowledge of regionally circulating Leptospira in highly endemic settings. Next-generation sequencing-based, culture-independent typing overcomes the limitation of culture isolation of Leptospira from clinical samples, with promise of providing public health-actionable information applicable to leptospirosis-endemic LMIC settings.

Measuring Responsive Feeding in Sri Lanka: Development of the Responsive Feeding Practices Assessment Tool.

OBJECTIVE: To develop and validate a tool focusing on responsive feeding (RF) practices among mothers and infants aged between 6 and 12 months in Sri Lanka. DESIGN: A comprehensive review, an in-depth qualitative study, and a cross-sectional study were carried out. SETTING: Anuradhapura District, Sri Lanka. PARTICIPANTS: Sample of mother-infant pairs (n = 170). VARIABLES MEASURED: Items were developed by extracting data from a previous in-depth qualitative study on RF, informed by currently available RF items. ANALYSIS: Content validation was performed among experts using standard techniques, followed by cognitive interviews among mothers. Structural validity was assessed using principal component analysis. Test-retest reliability was done with a sample of 50 mothers. RESULTS: Cognitive validation with mothers confirmed the applicability and comprehensiveness of the tool. The tool possessed good reliability with an intraclass correlation of 0.80 and internal consistency of 0.79. The principal component analysis showed a clear 3 factor solution. The 3 factors were interpreted as responsive communication during feeding, appropriate feeding, attentive to child's signals, and proactive preparation of the feeding environment. The final version of the tool consisted of 15 items. CONCLUSIONS AND IMPLICATIONS: The 15-item Responsive Feeding Practices Assessment Tool is a valid tool to assess RF.

Clinical spectrum of endemic leptospirosis in relation to cytokine response.

OBJECTIVES: To describe the clinical spectrum and the cytokine response of leptospirosis patients in an endemic setting of Sri Lanka. METHODS: Patients presenting to the university teaching hospital, Anuradhapura, Sri Lanka with a leptospirosis-compatible illness were recruited over a period of 12 months starting from June 2012. Daily clinical and biochemical parameters of the patients were prospectively assessed with a follow-up of 14 days after discharge. A magnetic bead-based multiplex cytokine kit was used to detect 17 cytokines. RESULTS: Of the 142 clinically suspected leptospirosis patients recruited, 47 were confirmed and, 29 cases were labeled as "probable." Thrombocytopenia and leukocytosis were observed at least once during the hospital stay among 76(54%) and 39(28%) patients, respectively. Acute kidney injury was observed in 31 patients (22%) and it was significantly higher among confirmed and probable cases. Hu TNF-α and IL-1ß were detected only in patients without complications. Hu MIP-1b levels were significantly higher among patients with complications. During the convalescence period, all tested serum cytokine levels were lower compared to the acute sample, except for IL-8. The cytokine response during the acute phase clustered in four different groups. High serum creatinine was associated GM-CSF, high IL-5 and IL-6 level were correlates with lung involvement and saturation drop. The patients with high billirubin (direct)>7 mmol/l had high IL-13 levels. CONCLUSIONS: Results of this study confirms that the knowledge on cytokine response in leptospirosis could be more complex than other similar tropical disease, and biosignatures that provide diagnostic and prognostic information for human leptospirosis remain to be discovered.

Determinants of leptospirosis in Sri Lanka: study protocol.

BACKGROUND: Leptospirosis is becoming a major public health threat in Sri Lanka as well as in other countries. We designed a case control study to determine the factors associated with local transmission of leptospirosis in Sri Lanka, in order to identify major modifiable determinants of leptospirosis. The purpose of this paper is to describe the study protocol in detail prior to the publishing of the study results, so that the readership will be able to understand and interpret the study results effectively. METHODS: A hospital based partially matched case control design is proposed. The study will be conducted in three selected leptospirosis endemic districts in central Sri Lanka. Case selection will include screening all acute fever patients admitted to selected wards to select probable cases of leptospirosis and case confirmation using an array of standard laboratory criteria. Age and sex matched group of acute fever patients with other confirmed diagnosis will be used as controls. Case to control ratio will be 1:2. A minimum sample of 144 cases is required to detect 20% exposure with 95% two sided confidence level and 80% power. A pre tested interviewer administered structured questionnaire will be used to collect data from participants. Variables included in the proposed study will be evaluated using conceptual hierarch of variables in three levels; Exposure variables as proximal; reservoir and environmental variables as intermediate; socio-demographic variables as distal. This conceptual hierarch hypothesised that the distal and intermediate variables are mediated through the proximal variables but not directly. A logistic regression model will be used to analyse the probable determinants of leptospirosis. This model will evaluate the effect of same level and upper level variables on the outcome leptospirosis, using three blocks. DISCUSSION: The present national control programme of leptospirosis is hampered by lack of baseline data on leptospirosis disease transmission. The present study will be able to provide these essential information for formulation of better control strategies.

Incidence and effects of Varicella Zoster Virus infection on academic activities of medical undergraduates--a five-year follow-up study from Sri Lanka.

BACKGROUND: The adult population in Sri Lanka is having high level of susceptibility for Varicella Zoster Virus (VZV) infection. Among medical undergraduates, 47% are VZV seronegative. The purpose of the present study was to determine the incidence of VZV infection in medical undergraduates in Sri Lanka, and to describe the effects of VZV infection on their academic activities. METHODS: A retrospective cohort of medical undergraduates' susceptible for VZV infection was selected from the University of Peradeniya, Sri Lanka. Data on the incidence of VZV infection (Chickenpox) during their undergraduate period was collected using a self-administered structured questionnaire. A second questionnaire was administered to collect data on the details of VZV infection and the impact of it on their academic activities. VZV incidence rate was calculated as the number of infections per 1,000 person years of exposure. Descriptive statistics were used to describe the impact of VZV infection on academic activities. RESULTS: Out of the 172 susceptible cohort, 153 medical undergraduates were followed up. 47 students reported VZV infection during the follow up period and 43 of them participated in the study. The cumulative incidence of VZV infection during the period of five and half years of medical training was 30.7%. Incidence density of VZV infection among medical undergraduates in this cohort was 65.1 per 1,000 person years of follow-up. A total of 377 working days were lost by 43 students due to the VZV infection, averaging 8.8 days per undergraduate. Total academic losses for the study cohort were; 205 lectures, 17 practicals, 13 dissection sessions, 11 tutorials, 124 days of clinical training and 107 days of professorial clinical appointments. According to their perception they lost 1,927 study hours due to the illness (Median 50 hours per undergraduate). CONCLUSIONS: The incidence of VZV infection among Sri Lankan medical undergraduates is very high and the impact of this infection on academic activities causes severe disruption of their undergraduate life. VZV immunization for susceptible new entrant medical undergraduates is recommended.

Evaluation of surveillance case definition in the diagnosis of leptospirosis, using the Microscopic Agglutination Test: a validation study.

BACKGROUND: Leptospirosis is endemic in both urban and rural areas of Sri Lanka and there had been many out breaks in the recent past. This study was aimed at validating the leptospirosis surveillance case definition, using the Microscopic Agglutination Test (MAT). METHODS: The study population consisted of patients with undiagnosed acute febrile illness who were admitted to the medical wards of the Teaching Hospital Kandy, from 1st July 2007 to 31st July 2008. The subjects were screened to diagnose leptospirosis according to the leptospirosis case definition. MAT was performed on blood samples taken from each patient on the 7th day of fever. Leptospirosis case definition was evaluated in regard to sensitivity, specificity and predictive values, using a MAT titre >or= 1:800 for confirming leptospirosis. RESULTS: A total of 123 patients were initially recruited of which 73 had clinical features compatible with the surveillance case definition. Out of the 73 only 57 had a positive MAT result (true positives) leaving 16 as false positives. Out of the 50 who didn't have clinical features compatible with the case definition 45 had a negative MAT as well (true negatives), therefore 5 were false negatives. Total number of MAT positives was 62 out of 123. According to these results the test sensitivity was 91.94%, specificity 73.77%, positive predictive value and negative predictive values were 78.08% and 90% respectively. Diagnostic accuracy of the test was 82.93%. CONCLUSION: This study confirms that the surveillance case definition has a very high sensitivity and negative predictive value with an average specificity in diagnosing leptospirosis, based on a MAT titre of >or= 1: 800.

Incidence and predictors of onboard injuries among Sri Lankan flight attendants.

BACKGROUND: Occupational injuries among flight attendants have not been given appropriate attention in Sri Lanka. The purpose of this study was to estimate the incidence of onboard injury among Sri Lankan flight attendants and to describe the determinants of onboard injury. METHODS: A descriptive cross-sectional study was carried out among Sri Lankan flight attendants. All flight attendants undergoing their annual health and first aid training were invited to participate. Flight attendants who flew continuously for a six-month period prior to data collection were included in the study sample. Recall history of injuries for a period of six months was recorded. RESULTS: The study sample consisted of 98 (30.4%) male and 224 (69.6%) female flight attendants. The mean age of the study sample was 31 years (SD = 8) and the average duration of service was 10 years (SD = 7). A total of 100 onboard falls, slips or trips in the previous six months were reported by 52 (16.1%) respondents. Of the total sample, 128 (39.8%) cabin crew members reported an injury in the six months preceding the study. This represents a total injury incidence of 795 per 1000 person per year. The leading causes of injury was pulling, pushing or lifting (60.2%). The commonest type of injuries were strains and sprains (52.3%). Turbulence related injuries were reported by 38 (29.7%) flight attendants. The upper limbs (44.5%) and the back (32%) were the commonest sites affected. After controlling for other factors, female flight attendants had 2.9 times higher risk (95% CI 1.2-7.2) of sustaining and injury than males. Irrespective of sex, body weight less than 56 kilograms (OR 2.9, 95% CI 1.4-5.8) and less than seven years of on board experience (OR 10.5, 95% CI 3.6-31.0) were associated with higher risk of injury. CONCLUSION: Work related injury is a major occupational hazard to flight attendants. Appropriate preventive strategies are required to minimize them.

A Case-Control Study of Environmental and Occupational Risks of Leptospirosis in Sri Lanka.

Sri Lanka has one of the highest incidences of human leptospirosis worldwide. Outbreaks of this zoonotic infection are related to the monsoons and flooding. The study investigates risk factors associated with environmental, animal and occupational exposure while acknowledging the potential bias due to hanta viral infections in the study samples. Data were obtained from structured interviews with 483 patients (276 cases and 207 controls). Risk exposures were studied for the entire population and for two stratified occupational groups: non-paddy workers and paddy workers. A higher odds ratio (OR) of leptospirosis transmission for paddy workers was observed compared to non-paddy workers (OR 1.905, 95% CI 1.274-2.856). Rat exposure was not associated with a significant higher risk for any of the groups. Instead, cattle and household animals seemed to be important for transmission of leptospirosis to humans, especially among non-paddy workers (OR 10.655, 95% CI 1.213-93.582). Leptospirosis in paddy workers was associated with environmental factors linked to contamination and wetness in paddy fields. Interestingly, abandoned paddy fields were found to have a protective effect against transmission to paddy workers (OR 0.421, 95% CI 0.237-0.748). Keeping animals on these dryer fields may act as a boundary for contamination of paddy fields with infectious animal urine. This finding may be considered as a public health intervention targeting leptospirosis among paddy workers.

Correction to: A Case-Control Study of Environmental and Occupational Risks of Leptospirosis in Sri Lanka.

The original version of this article unfortunately contained a mistake in one of the co-author's family name. The correct name should be Janith Warnasekara instead of Janith Warnasuriya. The original article has been corrected.

Development and validation of the Social Capital Assessment Tool in pregnancy for Maternal Health in Low and middle income countries (LSCAT-MH).

OBJECTIVES: Social capital which implies 'features of social organisation, such as trust, norms and networks that can improve the efficiency of society by facilitating coordinated actions' is rarely assessed in relation to maternal health in low/middle-income countries (LMICs). A main reason for this research gap could be the unavailability of a specific tool to measure social capital in pregnancy. The study developed and validated an instrument to measure social capital among pregnant women. SETTING: We developed the tool based on World Bank Social Capital Assessment Tool and its adaptations identified as applicable to LMIC from an initial systematic review. The study was conducted in Anuradhapura district in the North Central Province of Sri Lanka. Validation process was conducted in urban, rural and resettled communities. PARTICIPANTS: Study participants of the cognitive validation included pregnant women from the three communities, and an expert panel including a social scientist, methodological expert, subject expert, public health officers. The psychometric validation was performed on 439 pregnant women permanently residing in the three communities. RESULTS: The 24-item Low and middle income countries Social Capital Assessment Tool for Maternal Health (LSCAT-MH) demonstrated high internal consistency (Cronbach's α=0.94). Factor analytical methods suggested a four-factor model of (1) neighbourhood networks (structural bonding), (2) domestic and neighbourhood cohesion (cognitive bonding), (3) social contribution and (4) social participation (structural bridging). Concurrent validity with antenatal mental ill health was confirmed through a negative correlation with the Edinburgh Postpartum Depression Scale. Test-retest reliability was high with intraclass correlation of 0.71 and a Pearson correlation of 0.83. CONCLUSION: The LSCAT-MH is a psychometrically valid and reliable tool to measure social capital in pregnancy. Predictive validity was not tested as the study was not a longitudinal follow-up.