Effect of repeated mass chemotherapy for filariasis control on soil-transmitted helminth infections in Sri Lanka.

BACKGROUND: In July 2006 Sri Lanka completed 5 rounds of annual mass drug administration (MDA) with diethylcarbamazine citrate (DEC) and albendazole as part of its national programme for elimination of lymphatic filariasis (LF). Albendazole is highly effective against soil-transmitted helminths (STH). This study was carried out to assess the effect of repeated annual MDA on STH infections in the Western Province of Sri Lanka, an area co-endemic for LF and STH. METHODS: Faecal samples were obtained (during August-September 2006), from grade 5 students in 17 schools in the Western Province that were included in a national survey of schoolchildren's health in 2003, and examined using the modified Kato-Katz technique. The prevalence and intensity of roundworm, whipworm and hookworm infections in 2003 and 2006 were compared. RRESULTS:Faecal samples from 255 children were examined in 2003; 448 were examined in 2006. Roundworm prevalence was marginally lower in 2006 (4.0%) than in 2003 (4.7%), as was hookworm (0.2% vs 0.4%), whereas whipworm prevalence was higher (13.8% vs 9.4%). These differences as well as that between the geometric mean egg counts were not statistically significant. Compliance with MDA in 2006, as reported by the schoolchildren examined, was only 59%. CCONCLUSIONS:Four annual rounds of MDA with DEC and albendazole had virtually no effect on STH infections in the study area.

An intervention study to monitor weight gain in infants using a home based complementary food recipe and a hand blender.

OBJECTIVES: To assess the efficacy of a home made energy dense weaning food, containing 110-130 kcal (26-30kJ) per 100 ml on prevention of growth faltering during infancy. METHODOLOGY: Infants attending four child health welfare clinics in the Medical Officer of Health (Ragama) area were recruited at the age of 4 months. The intervention group received a specially designed hand blender, recipe and advice to prepare a weaning food. The control group received weaning foods without any intervention. They were followed up monthly up to the age of 12 months. RESULTS: 152 infants completed the study (83 from intervention group). The infants in the intervention group gained significantly more weight than the control group (intervention group 2.43 +/- 0.72 kg, control group 2.02 +/-0.62 kg, p = 0.0002). Both groups showed a drop in the Z score for mean weight for age during the study period but this was less marked in the intervention group. CONCLUSIONS: A high energy density home made complementary food was effective in improving the weight gain of infants during the weaning period.

Factors associated with home deliveries in Thampalakamam, Trincomalee.

INTRODUCTION: In Sri Lanka, more than 95% of women deliver in hospital. There is regional variation in the rate of home deliveries, and in some areas a significant number of mothers deliver at home. OBJECTIVE: The objective of the present study was to identify the factors associated with home deliveries in Thampalakamam, Trincomalee. METHODOLOGY: Ours was a community based, exploratory type of case control study. Cases were home deliveries during the period from Jan 1, 2000 to Dec 31, 2002 in Thampalakamam Divisonal Director of Health Services (DDHS) area. Controls were institutional deliveries among women residing in Thampalakamam DDHS area during the same period. A total of 139 cases and 278 controls were identified for this study. Data was collected at the household level using an interviewer-administered questionnaire. RESULTS: The following factors were found to have strong association with home deliveries: being a Muslim (OR = 33.0, 95% CI 16.8-64.8), low (< grade 5) maternal education (OR = 3.5, 95% CI 1.8-6.6), parity more than 3 (OR = 3.2, 95% CI 1.5-6.6) not being visited by a public health midwife (OR = 2.4, 95% CI 0.8-6.9), not being seen by a medical officer during the antenatal period (OR = 7.0, 95% CI 0.6-83.3). Lack of transport (35.5%) was mentioned as main reason for home deliveries by the women. Of the home deliveries 95% were assisted by a traditional birth attendant. CONCLUSIONS: Poor education of women and deficiencies in the delivery of antenatal care were found to be important risk factors for home deliveries.

Admission to medical schools in Sri Lanka: predictive validity of selection criteria.

OBJECTIVE: To assess the extent to which current selection criteria predict success in Sri Lanka's medical schools. METHODS: The study sample consisted of all students selected to all six medical schools in two consecutive entry cohorts. The aggregate marks of these students at the General Certificate of Education (GCE) Advanced Level examination, the district of entry, admission category, candidate type (school/private) and gender, were identified as entry point variables. Success in medical school was measured in four ways: the ability to pass the first summative examination and the final examination at the first attempt, and obtaining honours in either examination. Multivariate analysis using logistic regression was used to assess the extent to which these entry point factors predict variability in outcome measures. RESULTS: Aggregate scores among the 1740 students in the study sample ranged from 212 to 356, with a median of 285. The male:female ratio was 1.4:1. Private candidates (taking the examination for the third time) accounted for 22% of students. Being a school candidate, female and having a higher aggregate score, were the only independent predictors of success for all four outcome measures. The aggregate score alone accounted for only 1-7% of the variation in performance in medical school. CONCLUSIONS: Marks obtained at the A Level examination (the only academic criterion currently used for selection of medical students in Sri Lanka) is a poor predictor of success in medical school.

Efficacy of rivastigmine on activities of daily living in Sri Lankan patients with Alzheimer disease and on improving caregiver burden: a prospective study.

OBJECTIVE: This open label, parallel group, prospective cohort study investigated the efficacy of rivastigmine treatment on activities of daily living (ADL) in patients with mild to moderate Alzheimer's disease (AD) and the possible benefits of this therapy on caregiver stress levels. METHODS: Thirty eight consecutive patients with mild to moderate AD were recruited; 22 received rivastigmine 3-6 mg twice daily (treatment group) for 20 weeks. Sixteen patients who did not receive rivastigmine served as the control group. The 17-item ADL Index was used to assess ADL and to determine the presence of functional deterioration. Caregivers were evaluated with the Caregiver Stress Scale (CSS). Each patient was required to have a committed caregiver and all caregivers were interviewed and administered the ADL Index and the Caregiver Stress Scale (CSS) at the start of treatment (week 0) and at the end of 20 weeks of treatment (week 20). RESULTS: Patients in the control group showed a significant decline in ADL Index score at 20 weeks compared to rivastigmine-treated patients (difference in mean ADL Index score = 8.5; p < 0.001). At week 20, mean change from baseline scores for CSS total and individual domain scores were better for caregivers in the treatment group than those in the control group (CSS total mean difference = 19.2). CONCLUSION: We conclude that treatment of AD patients with rivastigmine for 20 weeks produces a significant improvement in patient ADL functioning, and lower levels of caregiver stress.

Health status of primary schoolchildren in Sri Lanka.

OBJECTIVE: To assess health status of 9-10-year old school children in Sri Lanka. DESIGN: A cross-sectional, descriptive study. Schools were selected to obtain a sample representative at national and provincial levels and 20 children were randomly selected from Grade 5 classes in each school. MEASUREMENTS: Children were examined for Bitot's spots and goitre. Height, weight, and visual acuity were measured according to standard procedures. Haemoglobin level was measured using finger-prick blood and a HemoCue meter. Geohelminth infections were quantified by faecal examination using the modified Kato-Katz technique. Height for age Z-scores (HAZ) and body mass index (BMI) were calculated as indicators of nutritional status. RESULTS: Two thousand five hundred and twenty eight children (1351 boys) from 144 schools (140 state schools and four private schools) were examined. Nationally, 15.5% of children were stunted (HAZ lower than -2.0 SD); 52.6% were thin (BMI < 5th centile of age- and sex-matched reference population); 3.1% were overweight (BMI > 85th centile); 12.1% were anaemic; 0.3% had Bitot's spots; 3% had a visible or palpable goitre; 4.6% were shortsighted; and 6.9% had one or more soil-transmitted nematode infection. Among children on whom anthropometry, haemoglobin and faecal examinations were all done, 64.6% (1332/2063) were thin, stunted, anaemic or infected with worms. A much higher proportion of children in the Northern and Eastern provinces had health problems when compared to the other provinces. CONCLUSIONS: The majority of older primary schoolchildren in Sri Lanka are undernourished. Anaemia, vitamin A deficiency, iodine deficiency and soil-transmitted nematode infections affect a much smaller proportion of them.

Estimates of disease burden due to land-snake bite in Sri Lankan hospitals.

Snake bite is a common cause of hospital admission in Sri Lanka. Despite this, there have been no countrywide studies or national estimates of disease burden due to snake bites in Sri Lankan hospitals. We assessed the disease burden due to snake bite in our hospitals and estimated the frequency of admissions due to bites by different snake species. Sri Lanka was divided into four zones based on climate and topography. Hospital morbidity and mortality data, which are available on an administrative district basis, were collated for the four zones. A survey of opinion among specialist physicians (the Delphi technique) was used to estimate the proportion of bites by different species, and requirements for anti-venom (AV) and intensive care facilities for management of snake bites in hospitals in each of the four zones. A study of hospital admissions due to snake bites in seven selected hospitals was also performed to validate the opinion survey. There was a clear difference in the incidence of hospital admissions due to snake bites in the different zones. Estimates of hospital admissions due to bites by different species also varied considerably between zones. These trends corresponded to estimates of requirements of AV and other supportive health care. Health care planning using data based on environmental information, rather than merely on political boundaries, could lead to targeted distribution of AV and intensive care requirements to manage snake bites.

Comparison of one week and two weeks of triple therapy for the eradication of Helicobacter pylori in a Sri Lankan population: a randomised, controlled study.

INTRODUCTION: Resistance of Helicobacter pylori to antibiotics may be particularly high in parts of the tropics. Infection may prove difficult to eradicate in such situations, and there is some evidence of benefit in increasing the duration of treatment (triple therapy) from 1 week to 2 or 3 weeks. AIM: To assess the efficacy and tolerability of 1 week versus 2 weeks of triple therapy for eradication of H. pylori in a Sri Lankan population. METHODS: Eighty two patients aged 18-70 years with gastritis or peptic ulcer and testing positive for H. pylori infection were randomly allocated to two treatment groups. Both groups received omeprazole 20 mg, clarithromycin 250 mg, and tinidazole 500 mg. Group A (n = 42) received the trial medication twice daily for 1 week and the Group B (n = 40) twice daily for 2 weeks. H. pylori eradication was defined as a negative 14C labelled urea breath test at 2 weeks after completion of the therapy. RESULTS: H. pylori infection was eradicated in 36 (85.7%) patients in Group A and 36 (90%) patients in Group B (p = 0.9). Twenty three (55%) patients in Group A and 17 (43%) in Group B reported adverse effects attributable to trial medication (p = 0.387); none were serious. Three (7.5%) patients in Group B discontinued treatment due to adverse events that developed on days 7, 9 and 10. CONCLUSION: Twice daily treatment with clarithromycin, tinidazole, and omeprazole for 1 week is well tolerated and provides as good a rate of H. pylori eradication as 2-week therapy in Sri Lankan patients.

Selection of students for admission to a medical school in Sri Lanka.

OBJECTIVES: To assess the extent to which selected entry point factors predicted success in a Sri Lankan medical school. METHODS: The study sample consisted of all students in two consecutive entry cohorts. Marks obtained at the national university entrance examination in physics, chemistry, botany and zoology; the aggregate marks of these four subjects (the only academic criterion used in selection); the district of entry (the other, non-academic criterion); and gender, were identified as entry point variables. Success in a medical school was measured in five ways, including whether a student had passed all examinations in the medical faculty at first attempt or not. Multiple logistic regression was used to assess the extent to which the selected entry point factors could predict variability in outcome measures. RESULTS: Of 331 students, 6.6% were merit quota admissions, and 19.4% were from 'underprivileged' districts; 46.8% were women. Of the entry point factors, being female and obtaining an aggregate of > or =280 (of a possible 400) were the only independent predictors of success in all outcome measures. Obtaining at least grade B in zoology was also an independent predictor of passing all examinations at first attempt. The aggregate score alone accounted for only 2-5% of variance in a medical school performance. There was no association between admission from an underprivileged district and any of the outcome measures. CONCLUSIONS: The one and only measure of academic performance used for selection of students admitted to our medical schools, is a very weak predictor of success in a medical school.

Nutritional status and productivity of Sri Lankan tea pluckers.

OBJECTIVE: To assess the impact of nutritional status on productivity of tea pluckers. DESIGN: Cross-sectional, analytical. SETTING AND PARTICIPANTS OF STUDY: All tea pluckers in five divisions of a tea estate in Hatton. MEASUREMENTS: A dietary survey was conducted using the 24 h dietary recall method. Nutritional status was assessed by measurement of body mass index (BMI) and haemoglobin (Hb) levels, and faeces were examined for helminth ova. The daily weight of tea leaves plucked and the number of days worked by each woman during the preceding month were noted from production records. RESULTS: Three hundred and four women (mean age 37.8 years, SD 8.4) were examined. The majority (59.9%) had evidence of chronic energy deficiency (BMI < 18.5). Almost all (94.4%) were anaemic (Hb < 13.3 g/dl, altitude adjusted cutoff). Mean daily iron intake was 8.7 mg (SD 2.3 mg), 45.9% of the national recommended dietary allowance. Only 10.1% had hookworm infection, all of light intensity. Multivariate regression analysis showed that dietary iron intake, the number of children and the number of children below 5 years, but not hookworm infection, were independently associated with Hb (p < 0.05). There was a strong positive correlation between monthly productivity and Hb, but not with BMI. Variation in Hb levels accounted for 65% of variation in productivity (adjusted R2 = 0.651). CONCLUSIONS: Most of the study population had chronic energy deficiency and anaemia. Dietary inadequacy of iron is a much more important causative factor than hookworm infection. Productivity was strongly associated with the degree of anaemia but not with BMI.

Compliance with the mass chemotherapy program for lymphatic filariasis.

OBJECTIVE: To evaluate compliance with the single dose mass chemotherapy program for control of filariasis, and to determine factors influencing compliance in the Gampaha district. DESIGN: A prospective study employing a pre-tested self-administered questionnaire. METHODS: Four groups comprising individuals over one year old with residence in the Gampaha district for over one year were surveyed. Data collection was started two weeks after the mass chemotherapy program. RESULTS: 2300 questionnaires were distributed, 1983 (86.2%) were returned, and 1935 (84.1%) were sufficiently complete for analysis (857 males; mean age 39 years, SD = 19.5). Over 96% had heard of filariasis and the mass chemotherapy program, but only 60.3% of those over 11 years of age were aware of asymptomatic carriage of the parasite. 1289 (66.6%) out of the total sample surveyed (1935 individuals) had obtained the diethylcarbamazine tablets, and 1221 (63.1%) had taken the drug. Of the possible demographic factors that could have influenced compliance only educational level seemed to play an independent significant role, compliance being lowest at both extremes of educational level. The main problem with compliance was obtaining the drug from distribution centres. CONCLUSIONS: Compliance with the mass chemotherapy program to control filariasis needs improvement. Strategies should include a better system for distributing the drug, and altering the content of the publicity material used by the program to target less compliant groups, and improve aspects of knowledge regarding filariasis that seem inadequate at present.