Identifying poor concordance between the ‘planned’ and the ‘hidden’ curricula at a time of curriculum change in a Sri Lankan medical school using the Dundee Ready Education Environment Measure.

Introduction: Often there is a ‘hidden’ curriculum running alongside the planned curriculum as published in official statements of a medical school. The two aspects of the curriculum may not be in concordance, especially in a phase of change. In this study Dundee Ready Education Environment Measure (DREEM) was used as the tool to determine the level of concordance between two curricula. Method: The DREEM questionnaires were administered face-to-face to two batches of undergraduate medical students of Faculty of Medicine, University of Kelaniya, Sri Lanka. One batch was the first group to follow the integrated curriculum and the other was the last group to follow the discipline-based curriculum. Results: The total scores of both batches indicated a reasonably positive overall perception of the education environment, but still with considerable room for improvement. The scores of third year male students for the domains of student perception of learning and teaching were significantly lower than their female colleagues and the seniors, thus indicating where interventions should be prioritised. By analysing the responses to individual items, a collection of items which were perceived negatively by both batches of students were identified. The items represented all domains with variable degree. Discussion: In addition to its multiple utilities, a careful and deep interpretation of the DREEM results can be used to identify a group affected specifically by the educational environment, possibly caused by a lack of concordance between the planned and the hidden curricula of the same institution.

A case of imported malaria: the first report of a Plasmodium malariae infection in Sri Lanka after 37 years.

We report a case of Plasmodium falciparum and P. malariae mixed infection in a patient who had been living in Malawi. This is the first case of P. malariae reported in Sri Lanka in 4 decades. The presence of both parasites was confirmed by microscopy and polymerase chain reaction (PCR). The history strongly indicated that the infection had been acquired from Malawi. The patient had liver dysfunction and a transient glomerulonephritis, both of which subsided with antimalarial treatment.

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.

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.

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.

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.

Chloroquine resistant falciparum malaria among security forces personnel in the Northern Province of Sri Lanka.

OBJECTIVE: To determine the occurrence and species distribution of malaria and the extent of chloroquine resistance among security forces personnel in a selected region of the Northern Province of Sri Lanka. DESIGN: A descriptive study. SETTING: Mannar District in the Northern Province. METHODS: Nine hundred and seventy five security personnel were screened for malaria by microscopy. Those who were positive were treated with chloroquine and were subjected to 28 day in vivo assay to determine chloroquine resistance. In vitro microtest assay was performed to determine the response of Plasmodium falciparum isolates to chloroquine in vitro. RESULTS: Of the 975 personnel screened, 181 (18.6%) were positive for malaria. P. falciparum was the predominant species (n = 125; 69.1%). The rest were due to P. vivax (n = 42; 23.2%) and mixed infections (n = 14; 7.7%). This was an inversion of the usual species distribution pattern in the country. In vivo assay revealed 38 (53.5%) P. falciparum infections as chloroquine resistant. Fifteen of 23 (65.2%) P. falciparum isolates showed evidence of resistance in vitro. None of the P. vivax infections showed evidence of chloroquine resistance. There was no significant difference in the severity of clinical disease between chloroquine resistant and sensitive infections at first presentation. Recrudescent P. falciparum infections had significantly lower mean parasite densities as well as lower clinical scores at recrudescence than at first presentation. CONCLUSION: Results demonstrate the high prevalence of malaria and chloroquine resistance in the study area and explains several contributory factors for this. There is an urgent need to review antimalarial drug policies in Sri Lanka.

Intestinal parasitoses and the nutritional status of Veddah children in Sri Lanka.

This study describes and compares the intestinal parasitoses and nutritional statuses of primary school children of Veddah (local indigenous population) and Sinhalese (more advanced society) in rural Sri Lanka. Children attending years 1-3 (age range 6-15 years) at Dambana Primary School (Veddah) and Wewatta Primary School (Sinhalese) were included in the study. Stools and blood samples were examined for evidence of intestinal parasites and anemia. The heights and weights of the children were measured and anthropometric indices calculated. There was a high prevalence of G. intestinalis and B. hominis (Giardia 7.8% and 6.2%; Blastocystis 17.2% and 17.3% at Dambana and Wewatta, respectively) in both communities, the predominant helminth being N. americanus (20.3% at Dambana and 14.8% at Wewatta; p>0.05). Other geohelminth infections were scarce in both communities. A greater proportion of boys than girls were underweight and stunted in both communities. Wasting and anemia was significantly high among the Veddah children.

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.

Severe hepatic dysfunction associated with falciparum malaria.

We describe severe hepatic dysfunction associated with an attack of falciparum malaria in six Sri Lankan patients. Clinicians working in areas endemic for malaria should be made aware of this unusual complication.

Gender differences in undergraduate medical examination results in Sri Lanka.

OBJECTIVE: To identify possible gender related differences in performance at undergraduate medical examinations in Sri Lanka. STUDY DESIGN AND METHODS: Results of examinations conducted by the faculty of medicine, University of Kelaniya in 1997 and 1998, and data published by the University Grants Commission (UGC) on final examinations conducted by 4 other Sri Lankan medical faculties (in the Universities of Colombo, Peradeniya, Ruhuna and Jaffna) in 1996 and 1997, were analysed for sex related differences. RESULTS: The proportion of women in each batch of students who sat for 8 examinations conducted at the faculty of medicine, University of Kelaniya in 1997 and 1998, ranged from 40.7 to 48.4% (average 44.3%). Among students sitting for the final MBBS examinations in other medical faculties in 1996 and 1997, the proportion of women ranged from 37.3% in Peradeniya to 53.7% in Jaffna. The proportions of women who obtained "classes" were higher than that of men in 12/15 examinations, with statistically significant differences in four. Higher proportions of men were referred or failed in all 8 examinations analysed; the differences were statistically significant in two. CONCLUSIONS: Women appear to do marginally better than men in undergraduate medical examinations in Sri Lanka.

The pattern of hypogammaglobulinaemia in Sri Lankan children.

OBJECTIVE: To evaluate the prevalence of hypogammaglobulinaemia in Sri Lankan children who present with recurrent or severe bacterial infections. DESIGN: A descriptive study. SETTING: Medical Research Institute (MRI), Colombo. SUBJECTS: 100 children between the ages of four months to twelve years referred to the Department of Immunology, MRI, for evaluation of immune status during four years from 1993 to 1997. MEASUREMENTS: Immunoglobulin G, A and M levels were measured using radial immunodiffusion technique. RESULTS: 22 out of 100 children had an underlying antibody deficiency, of whom IgA deficiency was the commonest (18 patients). Two patients had low IgG and A and elevated IgM levels, and they were diagnosed as having X linked-hyper-IgM syndrome. One patient had deficient IgA and IgM, and all three immunoglobulins were deficient in another. CONCLUSIONS: Results indicate that IgA deficiency is the commonest immunodeficiency in Sri Lanka, which is comparable with studies done in the West. This study also shows the need to improve the standard of care in patients with immunodeficiency.

Routine use of mebendazole in pregnancy.

INTRODUCTION: The Ministry of Health has recommended the routine administration of a broad spectrum anthelmintic to all pregnant women after completion of the first trimester of pregnancy. OBJECTIVE: To estimate prevalence and intensity of geohelminth infections in pregnant women attending an antenatal clinic in Ragama and determine the use of anthelmintics by them. METHODS: Women on their first visit to antenatal clinics of the University Obstetrics Unit, General Hospital Colombo North, Ragama, during July-August 1995, were recruited for the study. Demographic details, duration of pregnancy and a history of using anthelmintics during the current pregnancy were noted. A stool sample was obtained and examined using modified Kato-Katz technique. RESULTS: 309 pregnant women were studied [mean age 26.6 years (SD 5.3)]. 94 (30.4%) had taken an anthelmintic during the current pregnancy. 78 (25.2%) had taken it in the second trimester, 9 (2.9%) in the third, 6 (1.8%) in the first, and one was uncertain of the timing. Stool samples were obtained from 181 women giving a compliance rate of 58.6%. Prevalence of geohelminth infections were: whipworm 10%, hookworm 2.2%, roundworm 1.1%. The intensities of the infections were mild. 157 (86.7%) did not have any geohelminth infection. Of the 181 women whose stools were examined, 52 had taken an anthelmintic. There was no significant difference in the prevalence of geohelminth infections between this group (6/52; 11.2%) and those who had not taken an anthelmintic (18/129; 13.9%) (Chi-square test). CONCLUSION: It may not be necessary to treat all pregnant women in Sri Lanka with anthelmintics, as some areas have a low prevalence of infection. Routine anthelmintic therapy could-be limited to areas where prevalence rates are known to be high.