Browsing by Subject "Sri Lanka"

Developing nations in Asia are posed to experience a significant increase in the population of older adults living in their respective societies. Over the coming decades, India, the second most populous country in the entire world, is poised to experience a significant increase in its elder population. India's population of adults 60 years of age or older is projected to increase from 8% to 19% of the countries total population by the year 2050. Figures predict that by mid-century, 323 million people in India will be aged 60 years or older, more than the total current U.S. population. As the demographic structure of India is making a dramatic shift, concerns regarding the health and wellbeing of the growing Indian elder population are emerging, as is the growing concern for social policy. In addition, Sri Lanka is the fastest aging nation in South Asia. Multiple factors, including an increase in the number of people considered to be the "oldest old" (80+ years of age), a decrease in the number of working age adults, and increases in disability amongst the elderly, could necessitate an increased need for institutionalization of elderly Sri Lankans into long-term care facilities.

This project aims to study aging in south Asia from two different perspectives. An analysis of existing data from Southern India was done to examine the attitudes and beliefs of Indian elders towards aging and support systems for the elderly. Mental health of Indian elders was assessed and logistic regression analysis was conducted to examine possible correlations between attitudes and beliefs of the elderly and elder mental health. In addition, a qualitative descriptive study of Sri Lankan elder homes was carried out in the southern district of Galle, Sri Lanka. A convenience sampling method was used to identify six elder homes located in the area, and visits were made to each of the homes. During the visits, elder home mangers were interviewed in order to gain general information on the functioning and history of the elder homes, as well as general information on the residents living at the facilities.

Results from the Kerala Aging Survey revealed that psychological distress was present for over one third of elders in Kerala. Rates of psychological distress were higher for women, the poor, and those with advanced age. Elder women appear to be especially vulnerable to psychological distress in old age. Elders believe that children are responsible for supporting parents in their old age; lack of satisfaction with support received from children was associated with the presence of psychological distress amongst elders. For the qualitative study on Sri Lankan elders homes, it was found that both familial and community support are significant factors in the long-term care of elderly Sri Lankans. Though many elder home residents had been diagnosed with a chronic NCD or disability, lack of familial support was consistently identified as the driving force necessitating the elderly to reside at the long-term care facilities. With little or no financial assistance from the government, the facilities themselves all relied heavily on donations from the community to function on a daily basis.

Background: Lower respiratory tract infection (LRTI) is one of the most common reasons for hospitalization globally. Inappropriate antimicrobial prescriptions are common for LRTI, which might lead to antimicrobial resistance (AMR) and poor patient outcomes. In this study, we identified the proportion of receiving appropriate antimicrobial prescriptions and features associated with inappropriate prescriptions among inpatients with LRTI in Sri Lanka. Methods: We conducted a point-prevalence study of antimicrobial prescription among inpatients at 5 public hospitals in southern Sri Lanka in June-August 2017. Sociodemographic and clinical data were extracted from the medical chart and descriptive analyses were performed. The appropriateness of prescriptions for LRTI was evaluated according to the 2016 National Guidelines by the Sri Lanka College of Microbiologists. Multivariable logistic regression was used to identify features associated with inappropriate antimicrobial prescriptions. Results: Of 935 surveyed patients who were receiving antimicrobials, 187 were receiving antimicrobials for the treatment of LRTI. Of these 187 patients, 121 (64.7%) were adults ≥18 years old, and 101 (54.0%) were male. The average number of antimicrobials per LRTI patient was 1.7±0.0. Adults and children received similar numbers (1.8±0.1 vs 1.5±0.1, respectively; P = 0.167), and penicillins, third-generation cephalosporins, and macrolides were the most commonly prescribed antimicrobials in both age groups. Only 65 (34.8%) patients received guideline-concordant therapies for LRTI. There was no difference in receiving guideline-concordant therapy among different age groups (≤5, 5-17, 18-64, ≥65 years old; P = 0.580) or ward types (medical, pediatric, mixed medical/ surgical ward, intensive care; P = 0.299). Among patients receiving inappropriate antimicrobial prescriptions, undertreatment accounted for the largest proportion (55.7%), followed by partially-concordant prescriptions (30.3%). The potential risk factors for non guideline-concordant antimicrobial prescription was the numbers of antimicrobials (OR, 0.10; 95% CI, 0.05-0.21), diabetes mellitus (OR, 5.22; 95% CI, 1.22-22.27), and methicillin-resistant Staphylococcus aureus (MRSA) treatment (OR, 4.96; 95% CI, 1.74-14.13). Conclusions: This study showed a high proportion of inappropriate prescriptions of antimicrobials for LRTI in southern Sri Lanka. Further studies are needed to identify reasons for inappropriate prescriptions and targets for antimicrobial stewardship interventions.

Abstract

Objective: The aim of this study was to determine the epidemiology of Chikungunya as an etiology of acute febrile illness in southern Sri Lanka.

MethodAs part of the Duke-Ruhuna post-Tsunami response, a joint research team established a prospective study of acute febrile illness. Between February and November 2007, the investigators enrolled 1079 patients > 2 years of age who presented with fever (>38°C tympanic) to the acute care clinics and emergency department of Teaching Hospital Karapitiya, Sri Lanka. We obtained paired sera from participants for Chikungunya diagnosis including IgG Indirect immunofluorescent assay (IFA), PCR, virus isolation, and sequencing.

Results: Of the 797 patients with available paired sera, 109 (13.7%) screened positive for Chikungunya IgG using IFA. Using a 4-fold rise in acute and convalescent sera, we identified 28(3.5%) acute infections. Additionally, we identified 12 past infections based on the presence of antibodies in both acute and convalescent sera. Among the 28 seroconversions, 10 were isolated by culture and 18 by PCR. Those with acute infections were older (40 years compared to 30 years, p=0.07), more likely males (82% compared to 60%, p=0.02) and were more often admitted to the hospital (93% vs 71%, p=0.001) compared to those without acute Chikungunya infection. Participants with acute Chikungunya infection were more likely to have joint pain (RR: 3.12, CI: 1.39, 7.00, p=0.004), muscle pain (RR: 4.86, CI: 1.87, 12.67, p=<0.001), rash (RR: 5.49, CI: 1.83, 16.45, p=0.001) and conjunctival injection (RR: 3.36, CI: 1.59, 7.10, p=0.001) than those without acute Chikungunya infection. Furthermore, viral Sequencing data confirmed the presence of epidemic African strain throughout the study.

Conclusion:Chikungunya virus was present in southern Sri Lanka and should be considered in the differential diagnosis of acute febrile illnesses. Our limited data suggest infection with the recently identified epidemic strain.

Despite numerous studies demonstrating high rates of discrimination and poor mental health among transgender people in Western countries, little research has been conducted on this population in Sri Lanka. As such, the primary objective of this study was to assess the prevalence of discrimination experienced by transgender people in the workplace, health care, and family settings. Additionally, we investigated the potential association between discrimination and adverse mental health outcomes, including current depression, anxiety disorders, and low self-esteem. In Galle, 100 transgender participants were recruited through snowball sampling and then completed the survey through face-to-face interviews. The survey consisted of five sections: sociodemographic information, mental health scales, and discrimination experience in the workplace, health care, and family settings. We reported the prevalence of discrimination and adverse mental health outcomes. We also estimated the prevalence ratios of current depression and anxiety disorder, which are associated with work inaccessibility and workplace discrimination, adjusting for age, education, and gender identity in separate Poisson regression models. The study found that school harassment (67%), workplace insults (63.5%), and work inaccessibility (47.4%) were the most commonly reported types of discrimination among transgender participants. Among them, the prevalence of current depression, anxiety disorder, and low self-esteem were 44%, 38%, and 81%, respectively. Furthermore, work inaccessibility was associated with a 16% increase in the prevalence of depression. Workplace discrimination, as measured by two categories (1 or 2 types of discrimination, ≥3 types of discrimination) was associated with greater prevalence (41%-56%) of depression and anxiety (22% - 46%) than non-discrimination, although all of those associations were not statistically significant. The high prevalence of discrimination against transgender people presented in the study highlights the urgent need for legislative changes to protect their rights. Future studies should aim to identify coping resources and develop evidence-based interventions to minimize the adverse mental health consequences of discrimination. It is expected that the researchers and transgender voluntary groups who had been involved in the study may transform the study results into meaningful real-world interventions.

Background: The role of grandparents has changed in response to social, economic and demographic factors, which may operate both in favour of or against the relationship between grandparents and their grandchildren. The potential positive impact of the grandparent-grandchild relationship on the development of adolescent grandchildren has been increasingly recognized, although relatively few studies have directly related this relationship to measures of child well-being. This study aims to examine the association between grandparent-grandchild interactions and socio-emotional and cognitive outcomes among adolescent grandchildren in Sri Lanka. Methods: This cross-sectional study was conducted within schools, temples, homes and community buildings in Galle District. An interviewer-assisted survey was used to collect data about the adolescent participants’ demographics, family and household information, grandparent relationships, empathy, and socio-emotional development. A cognitive test was used to assess the adolescents’ cognitive development. Univariate, bivariate and multivariate analyses were used to examine the association between the grandparent-grandchild relationship and adolescent outcomes. Results: Our results indicate that grandparent-grandchild relationships are significantly associated with adolescent socio-emotional and cognitive development. Conclusions: This study underlines the importance of the grandparent-grandchild relationship.

The Assistant and Registered Medical Officers (AMO/RMOs) of Sri Lanka have held a major role in health care delivery, particularly in rural areas. The Sri Lankan government decided to discontinue the AMO training program in 1995 and to phase out the profession completely, without conducting any research on what the impact of this policy decision may be. Fifteen semi-structured interviews were conducted with a purposeful sample of practicing AMO/RMOs from May to July 2012 to gain qualitative preliminary data on how the AMO/RMO profession is viewed by those who work within it. Interviews were conducted primarily in English, with simultaneous translation into Sinhala by a research assistant where necessary. Interview transcripts were reviewed for repeated words and phrases, and overarching themes were drawn from these textual patterns. Analysis of the transcribed interviews yielded themes regarding lack of educational and promotional opportunity, similarities and differences between RMOs and Medical Officers (MOs), barriers to quality of care, gaps in supervision, level of job satisfaction, the nature of working relationships with other health professions, and predictions about the future of the AMO/RMO profession. This preliminary and exploratory data can be used to inform more comprehensive and objective research on the role and impact of AMO/RMOs in the future. It can also inform policy decisions and recommendations regarding health workforce composition and shortage, task-shifting, and use of mid-level providers.

Objectives

Inappropriate antimicrobial use is associated with adverse drug effects and antimicrobial resistance. Understanding prescribing practices is important for optimizing antimicrobial use. We investigated the prevalence, types, and indications for antimicrobials in Sri Lanka.

Methods

A point-prevalence study was conducted among inpatients at tertiary (1), secondary (1), and primary-level (3) public hospitals in Southern Province, Sri Lanka. From June-Aug 2017, all patients in medical, surgical, pediatric, and intensive care wards were included. Charts were assessed for systemic antibiotic, antifungal, and antiviral use in 1-day point-prevalence studies. Demographics, clinical characteristics, and antimicrobial use data were recorded from charts. Hospital and patient characteristics associated with antimicrobial therapy were assessed using the Chi-square test and Kruskall-Wallis tests. Potentially inappropriate antimicrobial use was defined as the receipt of two beta-lactam antibiotics or two antibiotics with activity against anaerobes or Pseudomonas aeruginosa.

Results

A total of 1,709 patients were included (69.6% tertiary, 21.7% secondary, and 8.7% primary). Patients were in medical (55.2%), surgical, (27.2%), pediatric (12.9%), and intensive care wards (4.7%). Overall, 54.7% (95% CI, 52.3%-57.1%) of patients were receiving antimicrobials. Antimicrobial use prevalence was similar across hospital type (p= 0.439), but varied by ward type: 43.1% in medical, 68.0% in surgical, 61.1% in pediatric, and 97.6% in intensive care wards (p<0.001). Commonly used antimicrobials were amoxicillin/clavulanate (33.8%), 3rd-generation cephalosporins (23.6%), metronidazole (16.6%), narrow and extended-spectrum penicillins (15.8%), clarithromycin (12.3%), 2nd-generation cephalosporins (10.7%), and carbapenems (10.4%). Common antimicrobial indications were lower respiratory infections (20.7%), soft tissue infections (9.4%), urinary tract infections (9.7%), and surgical prophylaxis (7.8%). Of patients receiving antimicrobials, potential inappropriate use was seen: 9.2% double anaerobic coverage, 7.6% double beta-lactam coverage, and 1.5% double P. aeruginosa coverage.

Conclusions

We report the first point-prevalence study of antimicrobial use in public hospitals in southern Sri Lanka. Over half of inpatients were receiving antimicrobials. High antimicrobial use and potentially inappropriate antimicrobial use should be addressed by future antimicrobial stewardship efforts.

Little is known about the general health concerns of three-wheel drivers, who provide an important transport service through many South Asian nations, including Sri Lanka. In order to fill this gap in the literature, a two-stage qualitative study was employed to determine the types of health concerns that three-wheel drivers in Galle, Sri Lanka experience. The first stage employed one-on-one semi-structured interviews relating to personal health with 20 three-wheel drivers. The second stage consisted of two semi-structured focus groups, one with five participants and the other with eight. The most common health concern among three-wheel drivers at this site was musculoskeletal pain in the back, shoulders, and knees. The most common health risk factors were alcohol consumption, tobacco use, lack of physical activity, and poor utilization of routine examinations. An unexpected finding was the relative lack of road traffic accidents and injuries. Based on these findings, government or private health initiatives aimed at three-wheel drivers might seek to intervene on modifiable risk factors such as substance use and failure to seek well care. Health officials might also encourage three-wheel manufacturers to re-think their design to reduce musculoskeletal stress. The information collected was used to design a survey instrument, which will be used in future research to quantify three-wheel driver health concerns on a larger scale in Sri Lanka.

Background: Acute febrile respiratory illnesses, including influenza, account for a large proportion of ambulatory care visits worldwide. In the developed world, these encounters commonly result in unwarranted antibiotic prescriptions; data from more resource-limited settings are lacking. The purpose of this study was to describe the epidemiology of influenza among outpatients in southern Sri Lanka and to determine if access to rapid influenza test results was associated with decreased antibiotic prescriptions.

Methods: In this pretest- posttest study, consecutive patients presenting from March 2013- April 2014 to the Outpatient Department of the largest tertiary care hospital in southern Sri Lanka were surveyed for influenza-like illness (ILI). Patients meeting World Health Organization criteria for ILI-- acute onset of fever ≥38.0°C and cough in the prior 7 days--were enrolled. Consenting patients were administered a structured questionnaire, physical examination, and nasal/nasopharyngeal sampling. Rapid influenza A/B testing (Veritor System, Becton Dickinson) was performed on all patients, but test results were only released to patients and clinicians during the second phase of the study (December 2013- April 2014).

Results: We enrolled 397 patients with ILI, with 217 (54.7%) adults ≥12 years and 188 (47.4%) females. A total of 179 (45.8%) tested positive for influenza by rapid testing, with April- July 2013 and September- November 2013 being the periods with the highest proportion of ILI due to influenza. A total of 310 (78.1%) patients with ILI received a prescription for an antibiotic from their outpatient provider. The proportion of patients prescribed antibiotics decreased from 81.4% in the first phase to 66.3% in the second phase (p=.005); among rapid influenza-positive patients, antibiotic prescriptions decreased from 83.7% in the first phase to 56.3% in the second phase (p=.001). On multivariable analysis, having a positive rapid influenza test available to clinicians was associated with decreased antibiotic use (OR 0.20, 95% CI 0.05- 0.82).

Conclusions: Influenza virus accounted for almost 50% of acute febrile respiratory illness in this study, but most patients were prescribed antibiotics. Providing rapid influenza test results to clinicians was associated with fewer antibiotic prescriptions, but overall prescription of antibiotics remained high. In this developing country setting, a multi-faceted approach that includes improved access to rapid diagnostic tests may help decrease antibiotic use and combat antimicrobial resistance.

Influenza causes an estimated 3 to 5 million cases of severe illness annually, along with substantial morbidity and mortality, particularly among low and middle-income countries (LMICs). The most effective way to decrease the burden of influenza is vaccination. Currently, Sri Lanka has no influenza vaccination policies and does not offer vaccination within the public healthcare sector. Therefore, a cost-effectiveness analysis of influenza vaccine implementation for the Sri Lankan population was performed. A static Markov model that did not account for transmission dynamics was used for this study. The model followed a theoretical cohort of Sri Lankans from all ages through two potential scenarios: universal influenza vaccination and no influenza vaccination across twelve-monthly cycles. Cost-effectiveness was analyzed using a governmental perspective at the national level. Costs for the study were broken down into three categories: direct, indirect, and vaccine costs. All costs were identified from previous literature for the local context. Vaccine efficacy was expressed as a range (48% to 72%) identified from a previous meta-analysis investigating similar settings. One model arm was considered cost-effective if the ICER was below a three-fold gross domestic product (GDP) per capita per DALY averted limit and highly cost-effective if below a one-fold GDP per capita per DALY averted limit. Utilizing TreeAge Pro software, we conducted both probabilistic sensitivity analyses and one-way sensitivity analyses for all model variables. The vaccination model arm reduced all influenza outcomes by approximately 60% (170,283 episodes, 3,167 hospitalizations, and 152 deaths) compared to no vaccination. By implementing vaccination earlier in the year, this reduction in the influenza disease burden was maximized. Vaccination was considered cost-effective compared to no vaccination, with a base case incremental cost-effectiveness ratio (ICER) estimated at Rs. 968,071.45 /DALY (5,418.62 USD/DALY). Sensitivity analysis identified that the ICER was sensitive to implementation month, monthly probability of contracting influenza, cost of vaccination, and years of life disabled. Due to only considering a one-year period, the implementation month had the most substantial effect on the ICER because no potential rollover effects of vaccination could be seen for the later implementation months. Probabilistic sensitivity analyses were performed on all variables, and there was a 99% probability that vaccination was cost-effective below a WTP threshold of 1,157,047.92 Rs/DALY (6,476.38 USD/DALY). No value for a variable within our estimated ranges resulted in ICERs above the WTP threshold of Rs. 2,066,157 (USD 11,556) per DALY averted. In conclusion, vaccination was considered cost-effective when compared to the implementation of no vaccine. However, due to a lack of national data, large-scale national studies are needed to determine better the influenza disease burden, at-risk population, and implementation cost.

The mosquito-borne dengue viruses (DENV 1, 2, 3, and 4) have a rapidly expanding geographic range and have become endemic in over 100 countries with tropical and subtropical climates, including Sri Lanka. In Sri Lanka, dengue outbreaks have occurred primarily in Colombo, the capital, since the 1960s; however, recent reports suggest transmission throughout the island, with a second focus in the port city of Galle in the Southern Province. To better assess the emergence of dengue among fever-causing agents in the Southern Province of Sri Lanka, we collected epidemiological and clinical characteristics, as well as acute and convalescent sera, from febrile patients of 1 year of age or older without a defined source between June 1, 2012 and December 31, 2012 and compared with similar data collected in 2007. We performed whole genome sequencing on representative dengue isolates from Colombo and Galle to assess relatedness. Through serological testing for DENV IgM and IgG antibodies, virus isolation, and molecular testing, we confirmed acute dengue in 64.83% of the febrile population which was composed of DENV1 (93.8%) and DENV4 (6.2 %) serotypes. We did not detect DENV1 in 2007, nor did we detect DENV2 or DENV3 in 2012. Phylogenetic analysis of whole genome sequence from representative samples from 2012 demonstrated that most DENV 1 strains (25 of 26 tested) belonged to genotype 1 which was closely related to strains previously reported in Colombo during the 2009-2010 dengue season and that all DENV4 strains belong to genotype 1 These results support the spread of dengue virus strains from Colombo to southern Sri Lanka, but the timing and directionality of that movement remain unknown.

Background: Sri Lanka is experiencing an epidemic of road traffic crashes and injuries but little is known about the burden among adolescents and associated risk factors. The objective of this paper is to assess the prevalence of road traffic crashes and injuries among adolescents aged 16-18 years old and to estimate the effect of risk factors, including demographic characteristics, behaviors and built environment characteristics around school, on the occurrence of both crashes and near misses. Methods: First, A survey was anonymously administered to determine demographics, behavior, and experience of road traffic crashes and related injuries among adolescents from 16 public high schools in Galle, Sri Lanka. Second, a built environment observation was also conducted near school surroundings. Descriptive analysis and multivariate regression analysis was conducted to assess the relationship between built environment and road traffic crashes/near misses by using STATA. The results were displayed in the map by using ArcGIS. Results: Among 1307 students from 16 public high schools aged between 16-18 years old, 206 students self-reported road traffic crash involvement in the past 6 months with 98 students reporting minor injury and 7 students suffering severe injury. In addition, 27.8% of respondents were involved in near misses in the past 6 months. Male students, who demonstrated poor road behaviors, and students who experienced near misses are more likely to be involved in road traffic crashes. Additionally, more than half of the roads around these schools are in poor condition with little infrastructures to separate pedestrians and cyclists from vehicles. The occurrence of road traffic crashes and the severity of road traffic injuries are significantly related to some environmental characteristics, which tend to include road type and road visibility. Conclusions: Adolescents in Galle, Sri Lanka are facing a comparatively high burden of road traffic crashes. Conducting intervention programs among male students and improving built environment on the way to school are potential effective strategies to prevent adolescents from road traffic crashes and injuries.