Impact of COVID-19 pandemic on health service utilisation and household economy of pregnant and postpartum women: a cross-sectional study from rural Sri Lanka.

OBJECTIVES: This study aims to describe how household economies and health service utilisation of pregnant and postpartum women were affected during the pandemic. DESIGN: A cross-sectional study. SETTING: This study was conducted in the Anuradhapura district, Sri Lanka. PARTICIPANTS: The study participants were 1460 pregnant and postpartum women recruited for the Rajarata Pregnancy Cohort during the initial stage of the COVID-19 pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: Household economic (income, poverty, nutritional and health expenditures) and health service utilisation details during the COVID-19 pandemic were gathered through telephone interviews. Sociodemographic and economic data were obtained from the cohort baseline and analysed with descriptive and non-parametric analysis. RESULTS: Out of the 1460 women in the sample, 55.3% (n=807) were pregnant and 44.7% (n=653) were postpartum women. Of the total sample, 1172 (80.3%) women participated in the economic component. The monthly household income (median (IQR)=212.39 (159.29-265.49)) reduced (median (IQR)=159.29 (106.20-212.39)) in 50.5% (n=592) families during the pandemic (Z=-8.555, p<0.001). Only 10.3% (n=61) of affected families had received financial assistance from the government, which was only 46.4% of the affected income. The nutritional expenditure of pregnant women was reduced (Z=-2.023, p=0.043) by 6.7%. During the pandemic, 103 (8.8%) families with pregnant or postpartum women were pushed into poverty, and families who were pushed into poverty did not receive any financial assistance. The majority of women (n=1096, 83.3%) were satisfied with the free public health services provided by the public health midwife during the pandemic. CONCLUSION: During the early stages of the pandemic, healthcare utilisation of pregnant women was minimally affected. Even before the country's current economic crisis, the household economies of pregnant women in rural Sri Lanka were severely affected, pushing families into poverty due to the pandemic. The impact of COVID-19 and the aftermath on pregnant women will have many consequences if the policies and strategies are not revised to address this issue.

Postdischarge outcomes of COVID-19 patients from South Asia: a prospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may cause clinical manifestations that last for weeks or months after hospital discharge. The manifestations are heterogeneous and vary in their frequency. Their multisystem nature requires a holistic approach to management. There are sparse data from the South Asian region on the outcomes of hospital-discharged COVID-19 patients. We assessed the posthospital discharge outcomes of a cohort of Sri Lankan COVID-19 patients and explored the factors that influenced these outcomes. METHODS: Data were prospectively collected from patients who were discharged following an admission to the Nawaloka Hospital, Sri Lanka with COVID-19 from March to June 2021. At discharge, their demographic, clinical and laboratory findings were recorded. The patients were categorised as having mild, moderate and severe COVID-19, based on the Sri Lanka Ministry of Health COVID-19 guidelines. Following discharge, information on health status, complications and outcomes was collected through clinic visits and preplanned telephone interviews. A validated (in Sri Lanka) version of the Short Form 36 health survey questionnaire (SF-36) was used to assess multi-item dimensions health status of the patients at 1, 2 and 3 mo postdischarge. RESULTS: We collected data on 203 patients (male, n=111 [54.7%]). The level of vaccination was significantly associated with disease severity (p<0.001). Early recovery was seen in the mild group compared with the moderate and severe groups. At 3 mo, on average 98% of mild and 90% of moderate/severe patients had recovered. Based on the SF-36, physical functioning dimensions, role limitation due to physical and emotional health, energy/ fatigue, emotional well-being, social functioning, pain and general health were significantly different in the moderate/severe vs mild COVID-19 groups at 1, 2 and 3 mo postdischarge (p<0.05). Twenty-three patients developed complications, of which the most common were myocardial infarction with heart failure (n=6/23; 26.1%), cerebrovascular accident (n=6/23; 26.1%) and respiratory tract infections (n=3/23; 13.01%) and there were six deaths. CONCLUSIONS: In our cohort, receiving two doses of the COVID-19 vaccine was associated with reduced disease severity. Those with mild disease recovered faster than those with moderate/severe disease. At 3 mo posthospital discharge, >90% had recovered.

Prevalence of depression among students at a Sri Lankan University: A study using the Patient Health Questionnaire-9 (PHQ-9) during the COVID-19 pandemic.

BACKGROUND: The prevalence of mental health disorders is known to be high among university students globally. Currently there are only a few studies on depression among university students in Sri Lanka. The aim of this study was to screen for the prevalence of Major Depressive Disorder (MDD) and other forms of depression, and to evaluate the factors associated with MDD. METHODS: A cross sectional survey using the Patient Health Questionnaire (PHQ-9) was conducted among 637, second-year students from the faculties of Management Studies & Commerce, Science and Medicine at the University of Jaffna, during the Coronavirus (COVID-19) pandemic. Bivariate associations were assessed using chi-squared tests. Logistic regression was used to evaluate factors associated with any type of ragging. RESULTS: MDD was considered to have been experienced by 31% of the students. From all three faculties, 70% of the students claimed to have experienced some form of depression ranging from mild to severe. The factor associated with MDD was the students' ethnicity. CONCLUSION: Due to the high MDD risk among university students, it is imperative to develop psychosocial interventions to ensure early detection of mental health disorders and provide adequate support to safeguard this vulnerable population.

The Impact of the COVID-19 Pandemic and Lockdowns on Self-Poisoning and Suicide in Sri Lanka: An Interrupted Time Series Analysis.

Evidence from high-income countries suggests that the impact of COVID-19 on suicide and self-harm has been limited, but evidence from low- and middle-income countries is lacking. Using data from a hospital-based self-poisoning register (January 2019-December 2021) and data from national records (2016-2021) of suicide in Sri Lanka, we aimed to assess the impact of the pandemic on both self-poisoning and suicide. We examined changes in admissions for self-poisoning and suicide using interrupted time series (ITS) analysis. For the self-poisoning hospital admission ITS models, we defined the lockdown periods as follows: (i) pre-lockdown: 01/01/2019-19/03/2020; (ii) first lockdown: 20/03/2020-27/06/2020; (iii) post-first lockdown: 28/06/2020-11/05/2021; (iv) second lockdown: 12/05/2021-21/06/2021; and (v) post-second lockdown: 22/06/2021-31/12/2021. For suicide, we defined the intervention according to the pandemic period. We found that during lockdown periods, there was a reduction in hospital admissions for self-poisoning, with evidence that admission following self-poisoning remained lower during the pandemic than would be expected based on pre-pandemic trends. In contrast, there was no evidence that the rate of suicide in the pandemic period differed from that which would be expected. As the long-term socioeconomic impacts of the pandemic are realised, it will be important to track rates of self-harm and suicide in LMICs to inform prevention.

Extending and Strengthening Routine DHIS2 Surveillance Systems for COVID-19 Responses in Sierra Leone, Sri Lanka, and Uganda.

The COVID-19 pandemic challenged countries to protect their populations from this emerging disease. One aspect of that challenge was to rapidly modify national surveillance systems or create new systems that would effectively detect new cases of COVID-19. Fifty-five countries leveraged past investments in District Health Information Software version 2 (DHIS2) to quickly adapt their national public health surveillance systems for COVID-19 case reporting and response activities. We provide background on DHIS2 and describe case studies from Sierra Leone, Sri Lanka, and Uganda to illustrate how the DHIS2 platform, its community of practice, long-term capacity building, and local autonomy enabled countries to establish an effective COVID-19 response. With these case studies, we provide valuable insights and recommendations for strategies that can be used for national electronic disease surveillance platforms to detect new and emerging pathogens and respond to public health emergencies.

Sexual dysfunction among men with diabetes; a cross-sectional study at a specialised diabetes clinic in Sri Lanka.

BACKGROUND: Male sexual dysfunction in diabetes is often an unrevealed clinical issue. Though many publications report the prevalence, there is limited data on its associations, impact, and health-seeking behaviour. The objectives were to assess the prevalence of male sexual dysfunction, its associations, impact and treatment-seeking among men with diabetes in a selected tertiary care Diabetes Clinic. METHODS: A cross-sectional study was conducted at the Diabetes Clinic, National Hospital of Sri Lanka, from January to September 2020. Men with diabetes aged 18 to 70 years undergoing annual assessment were recruited consecutively. Socio-demographic and clinical information were collected using an interviewer-administered questionnaire. Erectile dysfunction (ED), premature ejaculation, mental health and quality of life were assessed using validated self-administered questionnaires. Cardiovascular autonomic reflex tests and total testosterone levels were performed. Penile colour Doppler ultrasonography was performed on consenting participants with erectile dysfunction. Associations were assessed using the chi-square test or Fisher's exact for dichotomous variables and independent sample t-test for continuous variables. RESULTS: Two hundred and twelve participants were recruited with a mean age of 54.1 (SD = 10.1) years. Erectile dysfunction was present in 168 (79.2%), (mild: 45, mild-moderate: 56, moderate: 26, severe: 41). Premature ejaculation was present in 26 (18.7%). Libido was low among 16%. Sexual dysfunction was not revealed to a health provider by 85.6% despite 60.5% experiencing psychological and/or relationship effects. Out of 18 who sought treatment, only 4 achieved a good response. Mean age (55.4 ± 9.5 vs 48.7 ± 10.6 years, p < 0.001) and duration of diabetes (10.9 ± 7.6 vs 5.8 ± 4.6 years, p < 0.001) were higher while eGFR was lower (73.9 ± 27.7 vs 100.51 ± 28.08 years, p < 0.008) among those with ED compared to those without. Diabetic retinopathy (4% vs 42%, p < 0.001), peripheral neuropathy (17.9% vs 38.4%, p = 0.041) and lower limb arterial disease (0% vs 12.2%, p = 0.04) were associated with ED. Arterial insufficiency was seen among 50% of the participants who underwent penile colour Doppler ultrasonography. CONCLUSIONS: Male sexual dysfunction is a pervasive yet underappreciated problem in diabetes care despite its effect on the individual. Patient and disease characteristics would guide the identification of high-risk individuals for targeted screening in clinical practice.

Child emotional and behavioral difficulties and parent stress during COVID-19 lockdown in Sri Lankan families.

INTRODUCTION: Understanding parents' and children's mental health issues would help design population-specific intervention programs. The present study explored parents' perceived stress and child emotions and behavior during the COVID-19 lockdown among Sri Lankan families. METHODS: A cross-sectional survey was conducted among Sri Lankan parents of children aged 11 to 17 years. Validated instruments (Perceived Stress Scale-PSS and Strengths and Difficulties Questionnaire-SDQ) evaluated parental stress, child emotions, and hyperactivity/inattention. Multiple linear regression assessed the predictors of mental health issues, including the interaction between age and gender. RESULTS: Three hundred fifty-five parents responded to the survey (mothers:76%). One-third of parents experienced difficulties with their children during the pandemic. Emotions and hyperactivity-inattention problems measured via the SDQ scale were high among 38% of children, while the perceived stress was high in 79.2% of parents. Overall, child emotions and hyperactivity-inattention increased with decreasing age, increasing parent stress, having middle-income compared to high-income, and having a family member/close relative tested positive for COVID-19. Hyperactivity-inattention (29.3%) was more than the emotional problems (22%) among children. The emotional problems were reported more with increasing parent stress, while child hyperactivity-inattention alone was reported more with decreasing age, middle-income compared to high-income families, and increasing parent stress. Also, the interaction effect of age and gender indicated that higher age was related to greater parent-reported hyperactivity-inattention problems in males. CONCLUSIONS: The findings highlight how the COVID-19 crisis and social isolation have contributed to increased parental stress and child emotional and hyperactivity-inattention problems. In addition to cautioning the healthcare workers, socio-culturally appropriate preventive and supportive mental health programs may help deal with further waves of COVID-19 or any other adverse circumstances.

Molecular Epidemiology of AY.28 and AY.104 Delta Sub-lineages in Sri Lanka.

Background: The worst SARS-CoV-2 outbreak in Sri Lanka was due to the two Sri Lankan delta sub-lineages AY.28 and AY.104. We proceeded to further characterize the mutations and clinical disease severity of these two sub-lineages. Methods: 705 delta SARS-CoV-2 genomes sequenced by our laboratory from mid-May to November 2021 using Illumina and Oxford Nanopore were included in the analysis. The clinical disease severity of 440/705 individuals were further analyzed to determine if infection with either AY.28 or AY.104 was associated with more severe disease. Sub-genomic RNA (sg-RNA) expression was analyzed using periscope. Results: AY.28 was the dominant variant throughout the outbreak, accounting for 67.7% of infections during the peak of the outbreak. AY.28 had three lineage defining mutations in the spike protein: A222V (92.80%), A701S (88.06%), and A1078S (92.04%) and seven in the ORF1a: R24C, K634N, P1640L, A2994V, A3209V, V3718A, and T3750I. AY.104 was characterized by the high prevalence of T95I (90.81%) and T572L (65.01%) mutations in the spike protein and by the absence of P1640L (94.28%) in ORF1a with the presence of A1918V (98.58%) mutation. The mean sgRNA expression levels of ORF6 in AY.28 were significantly higher compared to AY.104 (p < 0.0001) and B.1.617.2 (p < 0.01). Also, ORF3a showed significantly higher sgRNA expression in AY.28 compared to AY.104 (p < 0.0001). There was no difference in the clinical disease severity or duration of hospitalization in individuals infected with these sub lineages. Conclusions: Therefore, AY.28 and AY.104 appear to have a fitness advantage over the parental delta variant (B.1.617.2), while AY.28 also had a higher expression of sg-RNA compared to other sub-lineages. The clinical implications of these should be further investigated.

Undergraduate perceptions on transitioning into E-learning for continuation of higher education during the COVID pandemic in a developing country: a cross-sectional study from Sri Lanka.

BACKGROUND: The higher education was significantly influenced by the COVID pandemic within many developing countries, including Sri Lanka, necessitating to adopt more E-Learning opportunities. Therefore, this study was conducted to characterize the perceptions of Sri Lankan undergraduates to accept E-Learning in higher education, during the COVID crisis. METHOD: A total of 657 randomly selected undergraduates of three state universities in Sri Lanka, were recruited as the study population. Information on Socio-demographic factors, Knowledge, Attitudes and Practices on E-Learning methods were acquired using an interviewer administered questionnaire. A Probit regression model was fitted to identify the driving factors for the willingness of undergraduates to engage in E-Learning. RESULTS: Around, 80.2% of the respondents were females. Majority were residing in semi-urban areas (44.7%), followed by rural areas (39.9%). More than two third of the respondents were familiar with E-Learning and different Learning Management Systems (LMS) that facilitate E-Learning (68.9%). Majority of the respondents (73.7%) were using different E-Learning platforms, mostly 2 to 3 days per week (25.7%). Only around one third (36.4%) had received any formal training in using LMS or other E-Learning platforms. Smart phones (77.8%) were found to be the most preferred device used for E-Learning activities, followed by computers and laptops (21.3%). Meanwhile, LMS/MOODLE (45.4%), WhatsApp/Viber (33.0%) and Zoom (32.7%), were the most commonly used E-Learning platforms. The average acceptance of E-Learning methods was found to be 70.7% among Sri Lankan undergraduates during the COVID epidemic. Based on the Probit regression, nature of the residing locality (P=0.009), family income (P=0.048), academic field (P<0.001) and year (P=0.028), knowledge on Information and Communications Technology [ICT] (P=0.012), and previous training experiences on E-Learning (P<0.001) were found as significant drivers that influence the acceptance of E-Learning practices of the Sri Lankan undergraduates. CONCLUSION: Adopting E-learning into higher education sector could be recognized as a viable solution to facilitate the higher education during a crisis like COVID. However, relevant authorities in Sri Lanka should take immediate actions to empower the physical resources for E-Learning, improve the basic telecommunication infrastructure and conduct appropriate training programmes to promote E-Learning among Sri Lankan undergraduates.

Immune responses to Sinopharm/BBIBP-CorV in individuals in Sri Lanka.

As there are limited data of the immunogenicity of the Sinopharm/BBIBP-CorV in different populations, antibody responses against different SARS-CoV-2 variants of concern and T cell responses, we investigated the immunogenicity of the vaccine, in individuals in Sri Lanka. SARS-CoV-2-specific antibodies were measured in 282 individuals who were seronegative at baseline, and ACE2 receptor blocking antibodies, antibodies to the receptor-binding domain (RBD) of the wild-type (WT), alpha, beta and delta variants, ex vivo and cultured IFNγ ELISpot assays, intracellular cytokine secretion assays and B cell ELISpot assays were carried out in a sub cohort of the vaccinees at 4 and 6 weeks (2 weeks after the second dose). Ninety-five percent of the vaccinees seroconverted, although the seroconversion rates were significantly lower (p < 0.001) in individuals >60 years (93.3%) compared to those who were 20-39 years (98.9%); 81.25% had ACE2 receptor blocking antibodies at 6 weeks, and there was no difference in these antibody titres in vaccine sera compared to convalescent sera (p = 0.44). Vaccinees had significantly less (p < 0.0001) antibodies to the RBD of WT and alpha, although there was no difference in antibodies to the RBD of beta and delta compared to convalescent sera; 27.7% of 46.4% of vaccinees had ex vivo IFNγ and cultured ELISpot responses respectively, and IFNγ and CD107a responses were detected by flow cytometry. Sinopharm/BBIBP-CorV appeared to induce a similar level of antibody responses against ACE2 receptor, delta and beta as seen following natural infection.

South Asia's evolving tobacco hydra: moving from quandary to hope.

The South Asian region occupies a unique place in global tobacco control because of a broad spectrum of widely used tobacco products and the consequent mix of local and transnational tobacco industries. Cigarette use is especially high among males in many countries, while bidis are widely used in India, Bangladesh and Sri Lanka, and are very inexpensive. Smokeless tobacco use is a global problem, but the bulk of use is in South Asia and there is emerging promotion of newly developed tobacco and nicotine products across the region. With the transnational cigarette industry contributing a significant amount in taxes, the bidi industry employing millions of workers and many farmers engaged in tobacco farming, the industry is powerful and exploits this when countering proposed advancements in tobacco control policy. Despite industry interference and major challenges, this region has achieved remarkable successes in tobacco control, including large pictorial warnings that cover up to 80%-90% of the pack in some countries, stringent rules on depiction of tobacco in movies, bans on advertising and promotion, and smoke-free public places. Key challenges include increasing the tax component of retail prices and reducing tax concessions, regulating newly developed products and countering the aggressive tactics of the tobacco industry. Strategies to advance tobacco control in the region may also include standardised packaging of tobacco products, sustained mass media campaigns to warn the population of the harms of tobacco use and promote use of available cost-covered cessation services, and supply-side measures such as vendor licensing.

Feasibility of using telephone interviews and internet-based message services during the COVID-19 pandemic in rural Sri Lanka: experiences of the Rajarata Pregnancy Cohort.

The COVID-19 pandemic has challenged population health researchers to use remote data collection methods to avoid face-to-face interaction. A proper assessment of the feasibility of these methods in low-resource settings is lacking. We share our experience from telephone interviews conducted among pregnant women in the Rajarata Pregnancy Cohort in Sri Lanka. Among 3374 participants, 3284 (98.4%) and 496 (14.7%) had mobile and fixed-access phones respectively. During interviews, 1576 (51.9%) of participants were non-contactable. Of these, there were 157 (5.1%) wrong numbers, 889 (29.1%) were unavailable/phone switched off and 479 (15.7%) didn't answer their phone. Telephone interviews were completed only among 1438 (42.6%). Of these, 476 (33.1%) used messaging apps. In this local setting, these methods led to selection bias and inequity in health message delivery. If other ways to target vulnerable people in rural areas are not in place, the adoption of a telephone-based strategy to health message delivery may worsen health disparity during the COVID-19 pandemic. These facts aid in the planning and implementation of research and health promotion initiatives in rural areas of low- and middle-income nations throughout the world.

An Innovative Telemedicine Initiative From Sri Lanka: The Value of Volunteerism in a Resource-Constrained Scenario During the COVID-19 Pandemic.

The unprecedented rise in COVID-19 cases in Sri Lanka since July 2021 led to a situation where the health system was getting overwhelmed. The priority shifted toward triaging patients and identifying those who need immediate medical intervention and managing the rest in home settings. An integrated patient management system where patients could access a medical professional through a short messages service (SMS) and calling system was established. This service provided telephone triage, patient advice, and coordinated with the national ambulance system to evacuate ill patients. This integrated helpline system had a major impact on the management of the recent surge of COVID-19 pandemic in Sri Lanka by patients needing urgent care were directed for hospitalization and the rest managed at home with support, reassurance, and guidance. The numbers of oxygen-dependent patients and deaths declined rapidly and the number of available beds increased. The system played a major role in bringing the crisis under control. Despite many challenges, this innovative integrated system is a unique example of medical volunteerism. The pandemic catalyzed the utilization of information and communication technologies effectively by providing healthcare with a reduction of the burden on healthcare institutions and professionals.

Reactogenicity to ChAdOx1 nCoV-19 vaccine in health care workers: A multicenter observational study in Sri Lanka.

Introduction: The acceptability of a vaccine is an important factor during mass vaccination programs and this is largely dependent on the symptoms of local and systemic reactogenicity. There is paucity of data on the systemic and local reactions experienced by COVD-19 vaccine recipients in South Asia. Objectives: To identify the early local and systemic reactogenicity of ChAdOx1 nCoV-19 vaccine. Method: A multicenter observational study was performed to identify the reactogenicity to ChAdOx1 nCoV-19 vaccine in healthcare workers following the first dose. Results: There were 4478 participants with a median age of 42 years (IQR 34-51) and 2863 (63.9%) were females. At least one symptom of reactogenicity was reported by 4151 (92.7%). Local reactions were reported by 2612 (58.3%). Systemic reactions were bodyache (3244,72.4%), fatigue (2379, 53.1%), headache (2277, 50.8%), fever (2290, 51.1%), feverishness (1912, 42.7%) and chills (2295, 51.3%). Lower age (p<0.0001) and female gender (p 0.002) were associated with a higher frequency of developing systemic reactions. There was no association between reactogenicity and comorbidities. There were 342 (7.6%) reports of palpitations and one case of ventricular bigeminy. There was one report of anaphylaxis and hospital admissions were reported by 24 (0.5%). One vaccine recipient was managed for possible aseptic meningitis. Conclusion: This study demonstrates that early systemic and local reactions are common. Systemic reactions were more frequent in females and in the younger population. Most symptoms were self- limiting and did not require medical attention or hospital admission. ChAdOx1 nCoV-19 vaccine appears safe in the studied population.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial.

INTRODUCTION: Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention. METHODS AND ANALYSIS: A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19. ETHICS AND DISSEMINATION: The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER: SLCTR/2019/006, U1111-1220-8046.