Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Association of depression, anxiety and stress among outpatients with rheumatoid arthritis at a tertiary care hospital in Sri Lanka; a cross-sectional study(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2021) Wijewantha, K.S.L.; Wijewardena, D.L.T.M.; Wijethunga, W.T.N.K.; de Silva, N.L.; Fernando, S.D.Introduction: Depression, anxiety and stress and their associated factors, in patients with rheumatoid arthritis, vary across regions. Sri Lankan studies assessing the prevalence and associations of these factors are lacking. Objectives: To describe the prevalence and factors associated with depression, anxiety and stress among patients with Rheumatoid arthritis at specialised Rheumatology clinics of the National Hospital Sri Lanka. Methods: A cross-sectional study was carried out at three rheumatology clinics at the National Hospital of Sri Lanka. Sociodemographic and clinical data including the Clinical Disease Activity Index (CDAI) was recorded using an interviewer-administered questionnaire. The validated Depression, Anxiety, Stress Scale-21 was used. Analysis was done using descriptive analysis and chi-square. Results: The prevalence of depression, anxiety and stress in the study cohort (n= 118) was 50.93%, 57.41% and 47.17% respectively. Majority of the patients were in the moderate (39%) and high disease activity groups (36%). Increased prevalence of all three was observed with reduced functional status. Depression was observed among those > 60 years (p=0.035) and with CDAI >22.1 (p=0.004). Anxiety was observed with increased CDAI >22.1 (p=0.023). Stress was associated with unemployment (p=0.009) and morning stiffness > 60 minutes (p=0.001). Diabetes (p=0.016), ischemic heart disease (p= 0.042) and dyslipidaemia (p=0.005) were adversely associated with depression. Anxiety was associated with dyslipidaemia (p=0.005). Conclusions: Prevalence of depression, anxiety and stress is high and interferes with the quality of life and disease prognosis. Disease activity, functional deterioration as well as the presence of co-morbidities are associated with these mental health issues.Item Chemoprophylaxis for malaria: A costly approach to prevent re-establishment of malaria in Sri Lanka(Sri Lanka Medical Association, 2021) Muzrif, M.M.; Mendis, K.N.; Weerasekera, C.J.; Karunaratna, S.; Wickremasinghe, R.; Ranaweera, K.D.N.P.; Fernando, S.D.Introduction and Objectives As a measure to prevent the re-establishment of malaria in the country, the Anti Malaria Campaign (AMC) provides antimalarial chemoprophylactic medicines for up to six months free-of-charge to anyone travelling to malaria endemic countries. The objective of this study was to identify the trends of chemoprophylaxis prescription by the AMC and the costs involved. Methods Data were extracted from the national malaria database regarding the number of travellers issued with antimalarial chemoprophylactic medicines during the years 2017-2019. The amount spent for purchase of antimalarial chemoprophylactic medicines was determined. Results Over the three year period the overall number of individuals issued with antimalarial chemoprophylaxis increased (1714 in 2017, 2600 in 2018 and 3053 in 2019). The number of travellers obtaining chemoprophylaxis for malaria when travelling to African countries reduced, while the number travelling to India increased. The cost incurred to the Government of Sri Lanka to purchase mefloquine and doxycycline for prophylaxis was USD 45,755, while the cost to purchase CQ over the three year period for prophylaxis alone was USD 310,714. The total cost incurred to purchase the prophylactic antimalarials have also increased significantly over the three year period, the cost being eleven times higher in 2019 than in 2017. Conclusion Chemoprophylaxis against malaria remains an important strategy to sustain the malaria elimination status in Sri Lanka, and the cost of this intervention is considerable and increasing over time. The local production of anti malarials might be warranted if it will reduce the cost of chemoprophylaxis.Item Clinicopathological Profile of Cutaneous Leishmaniasis in Army Personnel in the Kilinochchi and Mulllativu Districts of Sri Lanka(Sri Lanka Medical Association, 2020) Wijesinghe, H.D.; Gunathilaka, N.; Semege, S.; Pathirana, K.P.N.; Manamperi, N.; de Silva, M.V.C.; Fernando, S.D.INTRODUCTION AND OBJECTIVES: Leishmaniasis is caused by an intra cellular protozoan of the genus Leishmania. The clinicopathological profile of cutaneous leishmaniasis (CL) varies according to the species. Leishmania donovani is the causative organism for leishmaniasis in Sri Lanka. This study describes the clinicopathological features of cutaneous leishmaniasis among army personnel serving in two Northern districts of the country. METHODS: In this collaborative cross-sectional study, the histopathology of fifty cases of CL confirmed by at least two methods (slit skin smear, lesion aspirate, tissue impression and histology) were reviewed. The parasitic load was assessed semi-quantitatively. The histological features were correlated with the clinical presentation and organism load. RESULTS: The majority (89.8%; n=44) presented with a single lesion mostly located in the upper limb (69.4%, n=34). The lesion types included papule (34.7%, n=17), nodule (32.7%, n=16) and ulcer (30.6%, n=15). Evolution time of lesions averaged 31.55 weeks. Epidermal changes were observed in 49 and included hyperkeratosis (90.0%; n=45), acanthosis (44.0%; n=22), atrophy (34.0%; n=17) and interface change (66%; n=33). Dermal changes were seen in all cases and characterized by a lymphohistioplasmacytic inflammatory infiltrate of variable intensity with ill-formed granuloma in 19 cases (38%) and well-formed epithelioid granulomas in 22 cases (44%). Focal necrosis was present in 20 % (n=10). Leishmania amastigote forms were observed in 88% (n=44). Transepidermal elimination (P=0.025), granuloma (P=0.027) formation and type of lesion (P=0.034) were significantly associated with organism load with granuloma formation being associated with reduction in organism load. CONCLUSION: Histopathological changes were characterised by a diffuse lymphohistioplasmacytic infiltrate, ill-defined granuloma or well-formed granuloma. Well-formed granulomata were associated with a reduction in organism load.Item First report of V1016G and S989P knockdown resistant (kdr) mutations in pyrethroid-resistant Sri Lankan Aedes aegypti mosquitoes(BioMed Central, 2018) Fernando, S.D.; Hapugoda, M.; Perera, R.; Saavedra-Rodriguez, K.; Black WC 4th; de Silva, N.K.; ; ;BACKGROUND: Dengue is a serious arboviral disease in Sri Lanka with a large number of dengue fever (DF) cases every year. Control of the primary vector Aedes aegypti depends upon larval habitat source reduction and insecticide application. However, increases in the number of reported cases suggest the inefficiency of current control strategies and the possibility of resistance to currently used insecticides. Early detection of mutations in the voltage-gated sodium channel (vgsc) gene that confer knockdown resistance (kdr) to pyrethroid insecticides is important in resistance management in vector populations. RESULTS: Resistance to pyrethroid insecticides was detected in the three populations studied. Polymerase chain reaction was used to detect the presence of two kdr mutations F1534C and V1016G. During this process a S989P mutation was also detected in pyrethroid-resistant Ae. aegypti populations. These mutations were found to be widespread and frequent in the collections studied. CONCLUSIONS: To our knowledge, this study reveals for the first time the presence of V1016G and S989P mutant alleles in the vgsc of Sri Lankan Ae. aegypti populations. The spread of the mutant alleles throughout the country poses a threat of increased resistance to pyrethroids. Long-term insecticide applications and indiscriminate use of pyrethroids has led to the evolution of resistance. More strategic and diverse strategies, including novel insecticides with new modes of action and community participation, should be engaged for Ae. aegypti control.Item Should chemoprophylaxis be a main strategy for preventing re-introduction of malaria in highly receptive areas? Sri Lanka a case in point(BioMed Central, 2017) Wickremasinghe, A.R.; Wickremasinghe, R.; Herath, H.D.B.; Fernando, S.D.BACKGROUND: Imported malaria cases continue to be reported in Sri Lanka, which was declared 'malaria-free' by the World Health Organization in September 2016. Chemoprophylaxis, a recommended strategy for malaria prevention for visitors travelling to malaria-endemic countries from Sri Lanka is available free of charge. The strategy of providing chemoprophylaxis to visitors to a neighbouring malaria-endemic country within the perspective of a country that has successfully eliminated malaria but is highly receptive was assessed, taking Sri Lanka as a case in point. METHODS: The risk of a Sri Lankan national acquiring malaria during a visit to India, a malaria-endemic country, was calculated for the period 2008-2013. The cost of providing prophylaxis for Sri Lankan nationals travelling to India for 1, 2 and 4 weeks was estimated for that same period. RESULTS: The risk of a Sri Lankan traveller to India acquiring malaria ranged from 5.25 per 100,000 travellers in 2012 to 13.45 per 100,000 travellers in 2010. If 50% of cases were missed by the Sri Lankan healthcare system, then the risk of acquiring malaria in India among returning Sri Lankans would double. The 95% confidence intervals for both risks are small. As chloroquine is the chemoprophylactic drug recommended for travellers to India by the Anti Malaria Campaign of Sri Lanka, the costs of chemoprophylaxis for travellers for a 1-, 2- and 4-weeks stay in India on average are US$ 41,604, 48,538 and 62,407, respectively. If all Sri Lankan travellers to India are provided with chemoprophylaxis for four weeks, it will comprise 0.65% of the national malaria control programme budget. CONCLUSIONS: Based on the low risk of acquiring malaria among Sri Lankan travellers returning from India and the high receptivity in previously malarious areas of the country, chemoprophylaxis should not be considered a major strategy in the prevention of re-introduction. In areas with high receptivity, universal access to quality-assured diagnosis and treatment cannot be compromised at whatever cost.Item The need for preventive and curative services for malaria when the military is deployed in endemic overseas territories: a case study and lessons learned(BioMed Central, 2017) Fernando, S.D.; Booso, R.; Dharmawardena, P.; Harintheran, A.; Raviraj, K.; Rodrigo., C.; Danansuriya, M.; Wickremasinghe, A.R.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.Item Contribution of the private sector healthcare service providers to malaria diagnosis in a prevention of re-introduction setting(BioMed Central, 2016) Fernando, S.D.; Dharmawardena, P.; Epasinghe, G.; Senanayake, N.; Rodrigo, C.; Premaratna, R.; Wickremasinghe, R.BACKGROUND: Sri Lanka is currently in the prevention of re-introduction phase of malaria. The engagement of the private sector health care institutions in malaria surveillance is important. The purpose of the study was to determine the number of diagnostic tests carried out, the number of positive cases identified and the referral system for diagnosis in the private sector and to estimate the costs involved. METHODS: This prospective study of private sector laboratories within the Colombo District of Sri Lanka was carried out over a 6-month period in 2015. The management of registered private sector laboratories was contacted individually and the purpose of the study was explained. A reporting format was developed and introduced for monthly reporting. RESULTS: Forty-one laboratories were eligible to be included in the study and 28 participated by reporting data on a monthly basis. Excluding blood bank samples and routine testing for foreign employment, malaria diagnostic tests were carried out on 973 individuals during the 6-month period and nine malaria cases were identified. In 2015, a total of 36 malaria cases were reported from Sri Lanka. Of these, 24 (67 %) were diagnosed in the Colombo District and 50 % of them were diagnosed in private hospitals. CONCLUSIONS: An equal number of cases were diagnosed from the private sector and government sector in the Colombo District in 2015. The private sector being a major contributor in the detection of imported malaria cases in the country should be actively engaged in the national malaria surveillance system.Item Importance of active case detection in a malaria elimination programme(The Bulletin of the Sri Lanka College of Microbiologists, 2014) Wickremasinghe, R.; Fernando, S.D.; Thiliekaratne, J.; Wijeyaratne, P.M.; Wickremasinghe, A.R.INTRODUCTION AND OBJECTIVES: Malaria surveillance methods routinely used in Sri Lanka are passive and active case detection (PCD, ACD) and activated passive case detection (APCD). Active case detection is carried out by mobile malaria clinics. Tropical and Environmental Diseases and Health Associates (TEDHA) an implementation partner of the Anti Malaria Campaign (AMC) carries out APCD and ACD in four districts in Sri Lanka namely Trincomalee, Batticaloa, Ampara and Mannar, complementing the parasitological surveillance activities carried out by the AMC. DESIGN, SETTING AND METHODS: The ACD programme of TEDHA involves screening of populations irrespective of the presence of fever or any other signs or symptoms of malaria to detect infections and residual parasite carriers. TEDHA screens a) high risk populations using ACD through mobile malaria clinics including armed forces personnel and b) pregnant females who visit antenatal clinics for asymptomatic malaria infections during their first trimester. Populations are selected in consultation with the Regional Malaria Officer of the AMC thus avoiding any overlap with the population screened by the government. RESULTS: TEDHA screened 387.309 individuals between January 2010 and December 2012, for malaria by ACD including high risk groups and pregnant women and diagnosed eight malaria positive cases (7 Ptasmodium vivax infections and one mixed infection with P. vivax and Plasmodium falciparum}. All these cases were from the Mannar district amongst resettled populations and army personnel. During this period 125 cases were detected in the Mannar district by the Anti Malaria Campaign by passive case detection. No cases of malaria were detected by ACD by the AMC. CONCLUSIONS: The progress made by Sri Lanka in the malaria elimination drive is largely due to increased surveillance and judicious use of control methods. The country now needs to focus on enhanced surveillance to be malaria free and to prevent re-introduction of malaria into the country. As highlighted here, ACD played a major role in interrupting malaria transmission in the country. ACKNOWLEDGEMENTS: Financial assistance by the Global Fund (Grant, No. PR2 SRL809G11-M) is gratefully acknowledged. The authors would like to acknowledge the support given by the staff of TED HA.Item Impact of mass chemotherapy filariasis control programme on soil-transmitted helminth infections in Ragama(Sri Lanka Medical Association, 2003) de Silva, N.R.; Pathmeswaran, A.; Fernando, S.D.; Weerasinghe, C.R.; Selvaratnam, R.R.; Padmasiri, E.A.OBJECTIVE: To assess the impact of using albendazole in the'national Mass Drug Administration (MDA) programme for filariasis control, on soil-transmitted helminth (STH) infections'in Ragama. METHODS: The prevalence and intensity of STH infections was assessed before and after introduction of albendazole into the MDA programme in the Ragama MOH area, which has endemic transmission of both lymphatic filariasis and STH. Children attending Year 3 classes in 6 schools (selected in a random stratified manner) were examined during a baseline survey in March-May 2002. The follow-up survey (Sept-Oct) covered Year 4 children in the same schools after the MDA programme in July. All stool samples were examined on the day of collection using the modified Kato-Katz technique. RESULTS: The cumulative prevalence of STH infection was very low in both surveys: 4.5% (12/265) at baseline, and 2.0% (5/252) at follow-up. Trichuriasis was. the commonest infection (4.1% and 1.6%), followed by ascariasis (0.8% and 0.4%). The species prevalence rates, cumulative prevalence, and mean egg counts all declined from baseline to follow-up, but the differences were not statistically significant. The majority of children (85%) examined in the follow-up survey said they had taken both diethylcarbamazine citrate and albendazole during the MDA programme. CONCLUSIONS: Although it is possible that inclusion of albendazole in the MDA programme had an impact on STH infections, it is unlikely that any resultant decline in prevalence will have a significant impact on the health of schoolchildren in the Ragama MOH area since prevalence rates are now very low.Item Climate change and malaria(United Nations Publications, 2010) Wickremasinghe, R.; Wickremasinghe, A.R.; Fernando, S.D.