Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country.

AIMS: Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation. MATERIALS AND METHODS: We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance. RESULTS: Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9-66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4-40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8-15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2-9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8-3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1-2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6-11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2-0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3-0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7-32.7) reduced the likelihood of treatment delays. CONCLUSIONS: Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

Correction: Double burden of maternal and child malnutrition and socioeconomic status in urban Sri Lanka.

[This corrects the article DOI: 10.1371/journal.pone.0224222.].

Double burden of maternal and child malnutrition and socioeconomic status in urban Sri Lanka.

Child malnutrition and maternal obesity are serious public health issues in Sri Lanka. This study explores the associations between socioeconomic status and the double burden of malnutrition among school-aged children and within their household. A total of 543 primary school children aged 5-10 years (204 boys and 339 girls) in Gampaha District, Sri Lanka, were included in the analysis. The nutritional statuses of thinness, normal, overweight, and obesity for children and mothers were defined according to WHO growth references and body mass index. Maternal education, household equivalent income, and maternal employment were used as socioeconomic status indicators. The proportion of child thinness and overweight was 19.3% and 13.4%, respectively, and that of maternal overweight (body mass index ≥ 25 kg/m2) was 36.5%. A positive correlation was found between maternal body mass index and the child's body mass index for age z-score in older boys and younger girls. A multivariate stepwise logistic regression analysis showed that lower education of mothers posed a higher association with child thinness (adjusted odds ratio = 2.33, 95% confidence interval: 1.08-5.00). Mothers with overweight and obesity were less likely to have a child with thinness (adjusted odds ratio = 0.30, 95% confidence interval: 0.16-0.58). Maternal employment status and household equivalent income were not significantly, but marginally, associated with child overweight and obesity. Socioeconomic inequality combined with maternal nutritional status affected child malnutrition. These findings suggest that the underlying circumstances within households should be considered to improve child malnutrition.

The Diversity of Human Dirofilariasis in Western Sri Lanka.

BACKGROUND: Human dirofilariasis is an emerging zoonosis in many countries. Dirofilariasis caused by Dirofilaria repens may present with diverse clinical manifestations in humans due to aberrant localization of worm lesions causing diagnostic dilemmas. The aim of this retrospective study was to describe and update the demography and clinical spectrum of human dirofilariasis in western Sri Lanka. Nematode or nematode fragments isolated from excision biopsies that were confirmed as D. repens at the Department of Parasitology, Faculty of Medicine, University of Kelaniya, Sri Lanka, between 2012 and 2018 were included. Data on age, gender, and clinical details were obtained from case files. Identity of worms was established by morphometry and cuticle characteristics on wet-mount preparation. Specimens from unusual case presentations were further analyzed by PCR with specific primers for internal transcribed spacer region 2 (ITS2) of the ribosomal DNA. RESULTS: Sixteen nematode specimens isolated from subconjunctiva (n=2), subcutaneous (n=13) and intramuscular (n=1) locations were identified as D. repens by morphometry (average length 11.5 cm) and the characteristic longitudinal striations on cuticle visualized by microscopy. The age distribution of cases ranged from 1 to 65 years with a mean of 21.5. Females were more frequently affected (n=10, 62.5%) and worm locations were commonest in the orbital region (5/16) and scrotum (3/16). Imaging techniques were of use in detecting infections in deeper tissue levels. PCR analysis of DNA extracted from a worm in an intramuscular granuloma of the temporal region elicited the expected band at 484bp for D. repens. CONCLUSIONS: Human dirofilariasis is on an upward trend in incidence. Imaging techniques were of use in clinical diagnosis and molecular speciation in establishing the species identity in unusual case presentations. We suggest a more conservative approach in the management of human dirofilariasis and recommend a one health approach for control.

Behavioral, familial and comorbid illness risk factors of colorectal cancer: a case control study

Introduction: Though colorectal cancer is a disease of public health importance, there is little evidence about risk factors of colorectal cancer in South Asians. Objectives: We aimed to determine the behavioral, familial and comorbid illness risk factors for colorectal cancer among Sri Lankan adults. Methods: We conducted this study among 325 participants (65 incident colorectal cancer cases, 130 hospital and 130 community controls) in five major health care institutions and communities in areas with high incidence in Sri Lanka. Behavioral, genetic and comorbid risk factors were assessed through an interviewer administered questionnaire. Risk factors were evaluated using bivariate and multivariate logistic regression. Results: Adjusted logistic regression showed that frequent consumption of red meat (OR 3.06, 95% CI 1.26-7.43) and deep fried food (OR 2.54, 95% CI 1.22-5.39), hypertension ≥ 10 years (OR 3.3, 95% CI 1.3-8.6), colorectal cancer (OR 4.91, 95% CI 1.70-14.18) and other cancers (OR 3.0, 95% CI 1.14-7.81) among first degree relatives and age >50 years (OR 2.6, 95% CI 1.1 to 5.9) were significant risk factors compared to hospital controls. Frequent consumption of deep fried food (OR 4.2, 95% CI 1.7-10.1), being an ever smoker (OR 3.2, 95% CI 1.1-9.3), a current or former drinker (OR 5.4, 95% CI 1.1-27.8) and hypertension ≥ 10 (OR 5.1, 95% CI 1.7-15.6) were risk factors compared to community controls. Conclusion: The behavioral, familial and comorbid illness risk factors identified should be considered in designing preventive strategies and identifying high-risk individuals for screening for colorectal cancer.

Beyond survival: 5-year neurodevelopmental follow-up of a cohort of preterm infants in Colombo, Sri Lanka.

BACKGROUND: There is a lack of information on long-term neurodevelopmental outcome in preterm neonates in low- and middle-income countries. OBJECTIVES: To describe the developmental attainments of preterm neonates followed up for 5 years and to identify the risk factors for impairment. METHOD: A prospective descriptive cohort study was undertaken in neonates of 34 weeks gestation born within a period of 12 months at a single tertiary maternity and neonatal unit in Colombo, Sri Lanka. Infants were assessed for neurodevelopment using the Bayley Infant and Toddler III® Assessments at 6, 12 and 24 months of corrected age and school readiness assessment at 5 years. RESULTS: Fifty-one infants were assessed at least once, 45 were assessed at 2 years and 39 had a final assessment at 5 years. Neurodevelopmental attainment deteriorated significantly in the cognitive and motor composite scores from 6 to 24 months (p < 0.05). By 5 years the number of children with delay in cognitive, language and motor domains had reduced significantly from 24 months (p < 0.05) but the cognitive skills remained most affected (10/39). At 5 years, 13 of 39 children had a confirmed diagnosis of a neurodevelopmental disorder: eight had attention deficit hyperactivity disorder, three autism spectrum disorder, one cerebral palsy and one visual impairment. Surfactant administration and retinopathy of prematurity were the most significant risks for delayed development at 5 years (p < 0.05). CONCLUSION: Deterioration of cognitive and motor composite scores over the first 24 months highlights the need for regular surveillance of premature infants. There was a discrepancy between the diagnosis of neurodevelopmental delay at 24 months and at 5 years. But the notable impact on school readiness skills requires public health initiatives to cater for the needs of these children.

The impact of multiple interventions to reduce household exposure to second-hand tobacco smoke among women: a cluster randomized controlled trial in Kalutara district, Sri Lanka.

BACKGROUND: Second-hand smoke (SHS) in households remains a serious public health problem in Sri Lanka, partly due to a lack of voluntary prohibitions of tobacco smoking inside houses. Women are especially at risk of being exposed. Effective community based interventions to reduce the SHS in households targeting women is scarce. The objective of this study was to examine the impact of a multi-component intervention on household SHS exposure among Sri Lankan women. METHODS: Thirty clusters of 25 women (aged 18-65) from 750 households were randomized into the intervention and control groups. Women in the intervention group were exposed to activities which focused on improving knowledge on the health effects of SHS, attitudes towards SHS exposure, right to a smoke-free living and women empowerment against smoking. The duration of the intervention was six months. The comparison group received no intervention. The primary outcome of interest was self-reported SHS exposure in the household within 7 days prior to data collection. The secondary outcomes were exposure in the past 30 days, knowledge of the health risks of exposure, attitudes towards exposure, right to smoke-free living, women empowerment against smoking, and smoking inside the homes. RESULTS: Final assessment was in 329 (89.6%) in the intervention group and 309 (85.8%) in the comparison group. Following the intervention, significantly lower proportion of women in the intervention group as compared to the control group reported SHS exposure in their households within 7-days (9.2% vs. 15.3%, p = 0.02) and 30-days (13.6% vs. 21.6%, p = 0.008) prior to the post survey. As compared to the control group, significantly higher median scores were observed in the intervention group on the knowledge of the health risks of exposure to SHS (p < 0.001), attitudes on exposure to SHS (p = 0.004), right to smoke free living (p = 0.001) and women empowerment (p < 0.001). CONCLUSION: Multi-component intervention activities were effective in reducing household exposure to SHS among women. TRIAL REGISTRATION: Sri Lanka Clinical Trials Registry SLCTR/2014/033.

Out-of-pocket expenditure in accessing healthcare services among Chronic Kidney Disease patients in Anuradhapura District

Introduction: Chronic Kidney Disease (CKD) has significant economic impact on both patients' households and the country. Objectives: To assess the out-of-pocket (OOP) expenditure of accessing health services among CKD patients in Anuradhapura District Methods: This community based cross-sectional study included a representative sample of 1174 registered CKD patients from all 19 Medical Officer of Health areas in the District of Anuradhapura. Trained para-medical staff visited the households and administered an interviewer administered questionnaire to gather information. Results: A total of 1118 CKD patients participated. Mean age was 58.3 (SD 10.8) years. Fifty nine (5.3%) patients had been hospitalized during the six months preceding data collection. The total OOP for a hospital admission for one patient was Rs. 3625 (IQR 1650-8760). Thirty eight (3.4%) patients were on dialysis. The median direct cost per patient for an episode of dialysis was Rs.595 (IQR 415-995) while the median direct cost for a dialysis patient per month was Rs.5490 (IQR 3950-10934). In the study population a total of 1095 (98.0%) had attended clinic at least once during the six months preceding the study. The OOP expenditure for a single clinic visit for one patient was Rs.434 (IQR 200- 860). Conclusions: CKD patients living in the Anuradhapura District spent significant amounts on accessing health care which can worsen their economic hardships. Planned interventions are warranted in order to improve their quality of life and financial situation.

Knowledge, attitudes and practices regarding handling mercury containing medical devices among nurses in a tertiary care paediatric hospital in Sri Lanka.

BACKGROUND: Mercury is a highly toxic heavy metal used in many medical devices in the healthcare sector, making nurses one of the vulnerable occupational groups. OBJECTIVE: To assess knowledge, attitudes and practices regarding handling mercury containing devices and factors associated with knowledge among nurses in a paediatric hospital in Sri Lanka. METHODS: A descriptive cross-sectional study was conducted among nurses (n = 538) working in Lady Ridgeway Hospital, Sri Lanka. Information on the use of mercury containing medical devices, accidental exposure, management of spillage and disposal was gathered using a self-administered questionnaire. RESULTS: A total of 472 nurses responded with a response rate of 87.7%. Of the 347 mercury thermometer users, 67.1% had experienced breakages while among 405 mercury sphygmomanometer users, 20.0% had experienced mercury spillages, during a three months period prior to the study. A majority (56.8%) had 'good' overall knowledge regarding mercury and its adverse effects while 94.1% had favorable attitudes towards protecting themselves/others from mercury. Practices related to managing a mercury spill were poor. Work experience >10 years (p = 0.032) and favorable attitude (p = 0.007) were associated with good knowledge while having a training on managing a mercury spillage was not (p = 0.850). CONCLUSIONS: Gaps in practices on managing a mercury spillage were evident. Current training programmes were not found to be effective.

Intimate partner violence in Sri Lanka: a scoping review.

South Asia is considered to have a high prevalence of intimate partner violence (IPV) against women. Therefore the World Health Organisation has called for context-specific information about IPV from different regions. A scoping review of published and gray literature over the last 35 years was conducted using Arksey and O'Malley's framework. Reported prevalence of IPV in Sri Lanka ranged from 20-72%, with recent reports of rates ranging from 25- 35%. Most research about IPV has been conducted in a few provinces and is based on the experience of legally married women. Individual, family, and societal risk factors for IPV have been studied, but their complex relationships have not been comprehensively investigated. Health consequences of IPV have been reported, with particular attention to physical health, but women are likely to underreport sexual violence. Women seek support mainly from informal networks, with only a few visiting agencies to obtain help. Little research has focused on health sector responses to IPV and their effectiveness. More research is needed on how to challenge gendered perceptions about IPV. Researchers should capture the experience of women in dating/cohabiting relationships and women in vulnerable sectors (post-conflict areas and rural areas), and assess how to effectively provide services to them. A critical evaluation of existing services and programmes is also needed to advance evidence informed programme and policy changes in Sri Lanka.

Prevalence of enterobiasis among primary school children in Ragama, Sri Lanka.

OBJECTIVES: To determine the prevalence of enterobiasis among school children in Ragama Medical Officer of Health (MOH) region and the association between clinical features, potential risk factors and infection status. DESIGN: Cross sectional study. SETTING: School based. Participants 260 school children aged 5-7 years, attending five state schools in the Ragama MOH region. MAIN OUTCOME MEASURES: Prevalence of Enterobius vermicularis infection as diagnosed using adhesive cellophane tapes on the perianal skin on 2 consecutive days. RESULTS: The overall prevalence of enterobiasis was 38%. The risk factors significant on a univariate analysis were male gender, maternal under-education, non-permanency of paternal employment, more household members, more siblings in a family, more persons sleeping with an index child and lack of recent deworming. On a multivariate model more household members, more children in a household, more persons sleeping with the index child, non-permanency of paternal employment and lack of recent deworming were significantly associated with infection. None of the clinical manifestations evaluated (peri-anal itching, insomnia, abdominal pain, and enuresis) showed a significant association with enterobiasis. CONCLUSIONS: Enterobiasis is highly prevalent among primary school children in Ragama.

Prevalence of childhood atopic diseases in the Western Province of Sri Lanka.

BACKGROUND: Atopic diseases in children are major public health problems around the world and the prevalence is increasing. Our objective was to assess the prevalence of atopic diseases in schoolchildren in the Western Province of Sri Lanka. METHODS: Children attending grade 5 in 17 schools in the Western Province of Sri Lanka were recruited to the study. Data were collected using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, which was filled by the parent/guardian of the selected children. RESULTS: A total of 640 schoolchildren were recruited. Their mean age was 10 years (SD +/- 0.5) and 55.9% of the study population was boys. Prevalence (95% CI) of asthma, rhinitis and eczema was 17% (13.7-20.3), 21.4% (17.8-25.1) and 5% (3.1-7.0) respectively, while 33.7% (29.6-37.9) had one or more diseases. Only the prevalence of allergic rhinitis showed a statistically significant difference between the two sexes, being more common in boys. Less than 30% of affected children's parents recognised that their child had either asthma or rhinitis, whereas a higher number of parents (54.2%) recognised that their child had eczema. Among children with asthma, 44.4% had rhinitis. CONCLUSIONS: The prevalence of atopic diseases in schoolchildren in grade 5 in the Western Province of Sri Lanka is as common as in other countries in the south Asian region. Parental recognition of these conditions was not satisfactory.

Alcohol and tobacco use among males in two districts in Sri Lanka.

OBJECTIVES: To investigate the prevalence and consumption of tobacco and alcohol among males in the Colombo and Polonnaruwa districts. DESIGN: A cross-sectional study based on multistage cluster sampling was carried out in four Medical Officer of Health (MOH) areas in the Colombo (urban) and Polonnaruwa (rural) districts to assess the prevalence of tobacco and alcohol use. The Public Health Midwife areas were considered as primary clusters. The sample consisted of males over 18 years. There were 1318 from the Colombo District and 1366 from the Polonnaruwa District. The quantity frequency method was used to assess consumption. RESULTS: Abstinence was significantly higher in the rural areas (75.2%) compared to urban areas (56.6%) (p < 0.001). Prevalence of current drinking in the urban areas (32.9%) was significantly higher than in rural areas (20.8%) (p < 0.001). Alcohol consumption in the urban areas (33.1 units/week) was significantly higher than in rural areas (20.9) (p < 0.004). 51.6/1000 males in the urban areas and 14.6/1000 males in rural areas consumed daily. The prevalence of current smoking was also higher in the urban areas (29.9%) than (p = 0.052) in rural areas (24.4%). CONCLUSION: High-risk alcohol consumption was prevalent especially in urban areas as indicated by the mean alcohol consumption and number who consumed spirits daily. The prevalence of smoking is much lower than in many Asian countries but similar to western Europe.

Sleeping arrangements under long-lasting impregnated mosquito nets: differences during low and high malaria transmission seasons.

Sleeping arrangements under long-lasting impregnated nets (LLIN) were recorded in 2467 households during the low malaria transmission season (May-June 2007) and the same families were followed up during the high malaria transmission season (December 2007-January 2008) in two malaria-endemic areas of Sri Lanka. Approximately 800 households each from the three main ethnic groups were studied. The number of families lost to follow-up was 68. A significant increase was seen in the proportion of households using LLINs the previous night during the high transmission season (96%) compared with the low transmission season (90%) (P< or =0.001 for all three ethnic groups). When sleeping arrangements of the entire population were considered, priority to sleep under the LLIN was given to children under 5 years during both seasons. The percentage of children under five who slept under a LLIN increased from 75% during the low transmission season to 90% during the high transmission season. Utilisation of LLINs by pregnant women was low; only approximately 45% of pregnant women reported sleeping under a LLIN during both seasons. The study suggests the possible need for re-focusing of health education messages regarding the importance of LLIN use among pregnant women.

The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths.

BACKGROUND: Envenoming resulting from snakebites is an important public health problem in many tropical and subtropical countries. Few attempts have been made to quantify the burden, and recent estimates all suffer from the lack of an objective and reproducible methodology. In an attempt to provide an accurate, up-to-date estimate of the scale of the global problem, we developed a new method to estimate the disease burden due to snakebites. METHODS AND FINDINGS: The global estimates were based on regional estimates that were, in turn, derived from data available for countries within a defined region. Three main strategies were used to obtain primary data: electronic searching for publications on snakebite, extraction of relevant country-specific mortality data from databases maintained by United Nations organizations, and identification of grey literature by discussion with key informants. Countries were grouped into 21 distinct geographic regions that are as epidemiologically homogenous as possible, in line with the Global Burden of Disease 2005 study (Global Burden Project of the World Bank). Incidence rates for envenoming were extracted from publications and used to estimate the number of envenomings for individual countries; if no data were available for a particular country, the lowest incidence rate within a neighbouring country was used. Where death registration data were reliable, reported deaths from snakebite were used; in other countries, deaths were estimated on the basis of observed mortality rates and the at-risk population. We estimate that, globally, at least 421,000 envenomings and 20,000 deaths occur each year due to snakebite. These figures may be as high as 1,841,000 envenomings and 94,000 deaths. Based on the fact that envenoming occurs in about one in every four snakebites, between 1.2 million and 5.5 million snakebites could occur annually. CONCLUSIONS: Snakebites cause considerable morbidity and mortality worldwide. The highest burden exists in South Asia, Southeast Asia, and sub-Saharan Africa.

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. RESULTS: 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%. CONCLUSIONS: Four annual rounds of MDA with DEC and albendazole had virtually no effect on STH infections in the study area.

Community factors affecting long-lasting impregnated mosquito net use for malaria control in Sri Lanka.

The Anti Malaria Campaign distributed approximately 300,000 long-lasting impregnated nets (LLINs) to malaria-endemic areas in Sri Lanka during the years 2005 to 2007. We conducted a community-based cross-sectional survey among 2467 households distributed among the three major ethnic groups of Sri Lanka to study the perceptions and practices with regard to the use of LLINs in order to improve their use. In a majority of households the number of LLINs available was not sufficient for the number of people, although there was a small percentage of households that had excess nets. The information and advice given at the time of distribution regarding use of the nets differed amongst the three groups and was not consistent. Dissemination of this knowledge within the family was not observed. A relationship between knowledge regarding LLINs and reported practices on washing and drying of LLINs was found. It was noted that net shape may influence net use, with cone shaped nets being more popular. Efforts to increase knowledge on LLINs using behaviour change communication techniques would have more effectively contributed to achieve planned outcomes. Proper use of LLINs will undoubtedly contribute to further reduction of malaria in Sri Lanka.