Anti-tuberculosis drug inducd hepatitis - a Sri Lankan experience.

OBJECTIVE: To assess the incidence of anti-tuberculosis (TB) drug induced hepatitis (AIH) in Sri Lankan patients, determine risk factors of AIH, and to address management options in AIH. DESIGN: A prospective study. SETTING: Chest Hospital, Welisara, Sri Lanka, from April 2001 to April 2002. PATIENTS: Seven hundred and eighty three patients with a confirmed diagnosis of TB and resident in the Colombo and Gampaha districts who presented to Chest Hospital, Welisara, Sri Lanka. METHODS: WHO recommended treatment was commenced in all cases. AIH was diagnosed when patients complained of decreased appetite with nausea or vomiting and elevated serum bilirubin (SB; >1.1 mg/dL) or elevated serum alanine transferase (ALT; > 3 times upper limit of normal). RESULTS: Of 783 enrolled patients, 74 (9.5%) developed AIH, the majority (58%) developing AIH within the first 2 weeks of the intensive phase of treatment. AIH was more common among patients over 60 years (p = 0.018), who developed pulmonary TB (p = 0.028), and in patients weighing 33-55 kg (p = 0.004). Age, weight and rifampicin overdosage were significant predictors of AIH. Of the 74 AIH patients, standard treatment was restarted in 60, treatment modified in six, two defaulted and six died. CONCLUSIONS: The incidence of AIH in Sri Lanka is 9.5% in treated patients. AIH was associated with age, low body weight and rifampicin overdosage.

Morbidity pattern and household cost of hospitalisation for non-communicable diseases (NCDs): a cross-sectional study at tertiary care level.

OBJECTIVE: To determine the pattern of morbidity and the demographic and socioeconomic characteristics of patients seeking in-patient services for noncommunicable diseases (NCDs) in medical units of a tertiary care hospital, and to estimate the economic burden imposed by these admissions on the households. METHODS: A descriptive cross-sectional study was conducted in medical units of the Colombo North Teaching Hospital, Ragama. Data were collected using a pre-tested interviewer-administered questionnaire. Morbidity patterns and demographic and socio-economic characteristics of patients with NCDs were determined. Direct and indirect components of the household cost of hospital stay were estimated. RESULTS: Fifty five per cent of the patients men male and the largest age group (11%) was 50-54 years. Seventy per cent were above 40 years of age, and 63% represented social classes 4 and 5. Diseases of the circulatory system were the commonest (31%). Median household cost of the total hospital stay was Rs. 852.00 (inter-quartile range Rs. 351.00-1885.00) of which 70% were direct costs. Median daily cost was Rs. 340.00 (interquartile range Rs.165.00-666.00). Only 44% of patients incurred an indirect cost. Cost of travelling was the main contributor (36%) to the household cost. Laboratory investigations contributed 16%. CONCLUSIONS: Most patients seeking in-patient services were from a poor socioeconomic background. The economic burden imposed by the admission to the household was mainly due to direct costs incurred for travelling and investigations.

Hospitalisation trends due to selected non-communicable diseases in Sri Lanka, 2005-2010.

OBJECTIVES: To project hospitalisation trends due to selected non-communicable diseases (NCD) from 2005 to 2010. DESIGN: Morbidity data, maintained at the Medical Statistics Unit of the Ministry of Health, from 1981 to 2000, were used to model trends of hospitalisation due to diabetes mellitus, hypertensive disease and ischaemic heart disease. Linear and quadratic trends were used to model morbidity trends. RESULTS: For all three diseases considered, the increase in the incidence of hospitalisation is exponential. An increase is estimated in the incidence of hospitalisation by 36%, 40% and 29% due to diabetes mellitus, hypertensive disease and ischaemic heart disease, respectively, in 2010 as compared to 2005. The greatest burden and the largest increase in the rate of hospitalisation will be due to hypertensive disease. CONCLUSIONS: There will be an exponential increase in hospitalisation due to diabetes, hypertension and ischaemic heart disease. The health sector should provide additional resources to meet the demand.

Seroprevalence of rubella antibodies among pregnant females in Sri Lanka.

The purpose of this study was to determine the seroprevalence of rubella antibodies among pregnant females in the Kalutara District of Sri Lanka, and to identify factors associated with susceptibility to rubella infection among pregnant females. A cross-sectional clinic-based study was conducted among 620 pregnant women attending antenatal clinics and residing in the district for more than one month. Data on the pregnant females and the socio-economic characteristics of the families were obtained using an interviewer-administered structured questionnaire. Three milliliters of blood was obtained to measure rubella-specific IgG antibody levels by ELISA (enzyme linked immunosorbent assay) tests. Overall, 76% of pregnant females were seropositive for rubella antibodies. Seropositivity in pregnant females increased with age. Susceptibility to rubella was significantly associated with rubella immunization status. Given the high susceptibility rate to rubella infection among pregnant females, it is imperative that any vaccination strategy in the short-term should focus on reducing the number of susceptible women of child-bearing age.

Use of routinely collected past surveillance data in identifying and mapping high-risk areas in a malaria endemic area of Sri Lanka.

Stratification of malaria endemic areas on eco-epidemiological criteria is an important step in planning and implementing malaria control programs. The uses of stratification of malaria endemic areas lead to better targeting of control measures such as residual insecticide spraying in countries where unstable malaria transmission occur. In this study, two methods that can be used for stratification of malaria endemic areas in Sri Lanka using routinely collected surveillance data over a period of 9 years are described. In the first method, the median Annual Parasite Incidence (API) was used as the criterion to classify an area as at risk for malaria while in the second method, the API and the Falciparum Rate (FR) were used as the criteria. Risk maps were produced by plotting the results of the analyses on maps generated by EPIMAP. The potential uses of risk maps are discussed.

A safety and efficacy trial of artesunate, sulphadoxine-pyrimethamine and primaquine in P falciparum malaria.

OBJECTIVE: To determine effectiveness and safety of the combination of artesunate, sulphadoxine + pyrimethamine and primaquine in the treatment of P falciparum malaria. DESIGN: A hospital based prospective study. SETTING: Base Hospital, Moneragala. METHODS: In 30 P falciparum infected patients admitted to the hospital, blood was taken for estimation of haemoglobin, white cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, bilirubin and creatinine. They were administered artesunate, sulphadoxine + pyrimethamine (S + P) and primaquine on day 0 (artesunate 4 mg/kg, sulphadoxine 25 mg/kg, pyrimethamine 1.25 mg/kg and primaquine 0.75 mg/kg), and only artesunate on days 1 and 2 (artesunate 4 mg/kg each day). Blood was examined for malarial parasites, and patients were assessed on days 1, 2, 7, 14, 21 and 28. Patients assessed the severity of selected symptoms. Biochemical analyses were done on day 0 and repeated on days 7 and 28. RESULTS: Eight patients presented with fever which resolved in 7 patients in 48 hours. Asexual parasites were cleared in 80% of the 30 patients within 24 hours of treatment and in all 30 by day 7. Gametocytaemia cleared in all patients by day 14. There were no adverse effects experienced by the patients. The white cell and differential counts, liver enzymes and creatinine levels were within normal limits on all follow up days. CONCLUSIONS: The combination of artesunate, S + P and primaquine was found to be effective and safe in the treatment of uncomplicated P falciparum malaria.

Strategies for immunisation against rubella: evidence from a study in the Kalutara District.

OBJECTIVE: To simulate different immunisation programs against rubella and estimate the proportion of the population susceptible to rubella infection of each. METHODS: The impact of 3 immunisation schedules on the susceptibility of women of childbearing age and the community to rubella infection was simulated using a probabilistic approach. The first schedule involved selective immunisation of 12-year old girls, the second immunisation of all children at 3 years of age for different immunisation coverages, and the third comprised a combination of the first two. The proportion of different segments of the population currently susceptible to rubella was obtained from a field study conducted in the Kalutara District in 1999. RESULTS: An immunisation program of 12-year old girls will reduce the susceptibility to rubella in 5 years in only the 15 to 19 year age group. In 10 years, the susceptibility in both the 15 to 19 and 20 to 24 year age groups will be reduced. Immunisation only of children at 3 years will take 20 years for a reduction in the susceptibility to rubella infection in the 15 to 19 year and the 20 to 24 year age groups, and the proportion of the population susceptible to rubella can be reduced to less than 10% in 20 years if 90% coverage is attained. If a combination of the two strategies i.e. selective immunisation of girls at 12 years for 10 years and immunisation of all children at 3 years is adopted, the proportion of the community susceptible to rubella will be less than 14% in 10 years. CONCLUSIONS: The combination of immunising girls at 12 years of age for 10 years and all children at 3 years of age against rubella is recommended for Sri Lanka to reduce the risk of congenital rubella syndrome in the short term and the proportion susceptible to rubella in the community in the long term.

Geo-helminth infections in a rural area of Sri Lanka.

School children carry the heaviest burden of morbidity due to intestinal helminth infection. The objective of this investigation was to study geo-helminth infections in 349 school children aged 6 to 13 years living in a rural area of Sri Lanka. Stool samples were examined by direct saline smear in an initial survey to determine the prevalence of intestinal parasitic infections and thereafter the children were followed up over a two year period with cross sectional surveys of stool samples being carried out at yearly intervals. Following collection of a stool sample, all the subjects were treated with mebendazole 500 mg as a single dose. Weights and heights were measured using standardized procedures. 2 ml of venous blood were collected from each subject under aseptic conditions to determine hematological indices. The prevalence of geo-helminth infections was low, and the prevalence declined during the two-year period from 5.4% in 1997 to 2.2% in 1998 and 2.0% in 1999 following yearly mass anti-helminth treatment. The incidence density was 0.021 cases per child year. The reduction in the prevalence from the baseline to the second survey is probably due to the reduction of the reservoir of infection among children as a result of mass treatment at baseline. The prevalence of infection during the second and third surveys were almost the same probably due to infections originating from other segments of the untreated population.

Clinical diagnosis of uncomplicated malaria in Sri Lanka.

To assess the possibility of developing a protocol for the clinical diagnosis of malaria, a study was done at the regional laboratory of the Anti-Malaria Campaign in Puttalam, Sri Lanka. Of a group of 502 patients, who suspected they were suffering from malaria, 97 had a positive blood film for malaria parasites (71 Plasmodium vivax and 26 P. falciparum). There were no important differences in signs and symptoms between those with positive and those with negative blood films. It is argued that it is unlikely that health workers can improve on the diagnosis of malaria made by the patients themselves, if laboratory facilities are not available. For Sri Lanka the best option is to expand the number of facilities where microscopic examination for malaria parasites can take place.

Early diagnosis and treatment of malaria in a refugee population in Sri Lanka.

To provide early diagnosis and prompt treatment for malaria, two interventions were compared in refugee camps in Kalpitiya, Sri Lanka. Community health volunteers (HV's) were trained in diagnosis and management of malaria on clinical grounds, while a field laboratory was established in another group of camps providing treatment after laboratory confirmation of a malarial infection. Patients with fever sought treatment from HV's on average after 2.74 days and from the field laboratory after 3.20 days. Although acceptance of both interventions was high, the effective catchment areas, especially of the HV's were small. Large numbers of health volunteers would be needed to cover all families, making it difficult to sustain supervision and necessary logistic support. For every malaria patient treated by HV's, three others would receive anti-malarial drugs unnecessarily. The maintenance of a field laboratory with a microscopist of the Anti-Malaria Campaign is not an economically viable option. Training of HV's in microscopy with a mechanism for cost recovery should be given serious consideration. HV's and diagnosis and treatment centers should be able to handle a wide spectrum of common diseases. A better option for Sri Lanka in the short term might be to improve existing general health facilities that are accessible to the refugee population.