Kosala Weerakoon | Rajarata University of Sri Lanka (original) (raw)

Papers by Kosala Weerakoon

Research paper thumbnail of Outstation state medical faculties in Sri Lanka: nobody’s children when it comes to sustainability!

Anuradhapura Medical Journal

The trend of establishing new outstation MBBS degree programs The extraordinary gazette issued by... more The trend of establishing new outstation MBBS degree programs The extraordinary gazette issued by the Minister of Higher Education of Sri Lanka, on 20 th March 2023 gave clearance to the Uva Wellassa University to establish a Faculty of Medicine under the Universities Act of Sri Lanka, and to run a MBBS degree program. This is the 12 th MBBS degree program in the state university system under the purview of the University Grants Commission (UGC). These 12 MBBS degree programs and the one offered by the Faculty of Medicine of the General Sir John Kotelawala Defence University (KDU), which is established under a separate parliamentary Act, are the MBBS degree programs delivered by government institutes in Sri Lanka. Of the 12 MBBS degree programs under the purview of the UGC, six have been established over the last 17 years. Five of the recently-established MBBS degree programs are in 'outstation' universities (Rajarata, Eastern, Wayamba, Sabaragamuwa and Uva Wellassa Universities), and the other is at the University of Moratuwa, located within the Western province.

Research paper thumbnail of Ensuring responsible conduct of research and publications in Sri Lankan context: an eye-opener

Anuradhapura Medical Journal

Research paper thumbnail of Placing Leishmaniasis in the Limelight through the Communicable Disease Surveillance System: An Experience from Sri Lanka

Pathogens

Having an effective surveillance system is imperative to take timely and appropriate actions for ... more Having an effective surveillance system is imperative to take timely and appropriate actions for disease control and prevention. In Sri Lanka, leishmaniasis was declared as a notifiable disease in 2008. This paper presents a comprehensive compilation of the up-to-date documents on the communicable disease and leishmaniasis surveillance in Sri Lanka in order to describe the importance of the existing leishmaniasis surveillance system and to identify gaps that need to be addressed. The documents perused included circulars, reports, manuals, guidelines, ordinances, presentations, and published articles. The disease trends reported were linked to important landmarks in leishmaniasis surveillance. The findings suggest that there is a well-established surveillance system in Sri Lanka having a massive impact on increased case detection, resulting in im-proved attention on leishmaniasis. However, the system is not without its short comings and there is room for further improvements.

Research paper thumbnail of Clinico-epidemiology and aetiopathogenesis of gallstone disease in the South Asian region: a scoping review protocol

BMJ Open

IntroductionPathogenesis of gallstones (GS) is multifactorial and is influenced by numerous envir... more IntroductionPathogenesis of gallstones (GS) is multifactorial and is influenced by numerous environmental and genetic risk factors. As a result, clinico-epidemiology and aetiopathogenesis of GS vary in different populations. Understanding the aetiopathogenesis of GS for different populations is imperative in control and prevention of GS disease and its associated complications. This protocol describes the methodology of a scoping review which focuses on synthesising the most updated knowledge on GS disease in South Asia.Methods and analysisThe scoping review proposed in this protocol will be guided by Arksey and O’Malley’s framework and the Joanna Briggs Institute Reviewers’ Manual. Accordingly, population, concept and context strategy will be used to formulate the scoping review question, eligibility criteria and search strategy. In the search, electronic databases, MEDLINE/PubMed, ScienceDirect, Scopus, Cochrane library, CINAHL, Trip, and Google scholar, as well as various grey li...

Research paper thumbnail of Serological Evidence of Thailand Virus-Related Hantavirus Infection among Suspected Leptospirosis Patients in Kandy, Sri Lanka

Japanese Journal of Infectious Diseases

A cross-sectional study was undertaken to determine the current prevalence of leptospirosis and h... more A cross-sectional study was undertaken to determine the current prevalence of leptospirosis and hantaviral infections, and the socio-demographic characteristics and risk factors of infected patients, in Kandy, Sri Lanka. This report discusses the serological evidence of hantavirus infections among 105 suspected leptospirosis patients, 8 of whom had hantavirus antibodies. Serotyping ELISA showed that these 8 patients had high optical density values for Thailand virus. Most of the sera showed that the focus reduction neutralization test titer against Thailand virus was higher than that against Seoul virus, thereby suggesting that the hantaviral antibodies found in Sri Lanka are different from Seoul virus but closely related to Thailand virus. These findings imply that the hantaviral infection found in Kandy, Sri Lanka appears to be due to a virus similar to Thailand virus. Epidemiological analysis revealed that the association between hantavirus infection and socio-demographic characteristics was not statistically significant.

Research paper thumbnail of Social and Health Impact of Flying Hymenoptera Stings: Experience in a Region of Central Hill Country of Sri Lanka

Asian Pacific journal of health sciences, Sep 26, 2020

Objectives: Stinging by Asian giant honey bee and hornets is a common environmental hazard leadin... more Objectives: Stinging by Asian giant honey bee and hornets is a common environmental hazard leading to many hospital admissions in Sri Lanka. This study aims to study the social and health impact of flying hymenoptera stings in a region of the central hill country of Sri Lanka. Methodology: The study was carried out at the two base Hospitals in Teldeniya and Rikillagaskada, Sri Lanka. All the patients presented to these hospitals following a wasp or big bee singing, during the period of 2011-2010 were included in the study. Results: There was a total of 80 patients in this study cohort, with 54 (32%) of them being victims of Horne stings and the rest being big bee stings (n = 26, 68%). The mean age of the total group was 45 years (SD = 16). Stings occurrence between 9.00 am and 3.00 pm was more frequent. The majority of the big bee stings (n = 26, 48%) had occurred while working in tea estates, whereas the hornet attacks were frequent around the dwellings (n = 12, 46%), head and neck (n = 72, 90%), upper limbs (n = 48, 60%), chest (n = 28, 35%), and back of the chest (n = 24, 30%) were the commonly involved body regions. Conclusions: Hymenoptera stings have a significant social and health impact in a region of the central hill country of Sri Lanka. Although pain and swelling were the most common adverse effect, life-threatening anaphylaxis was not reported in this study group. Even though electrocardiogram changes were more common among big bee groups, none of them were fatal.

Research paper thumbnail of Anuradhapura Medical Journal (AMJ): Swimming against the tide

Anuradhapura Medical Journal, 2022

Research paper thumbnail of Massive Tick Bites Causing Spotted Fever Rickettsial Infection: A Hazard in a Tea Plantation, Sri Lanka

Wilderness & Environmental Medicine, 2021

Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SF... more Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SFG) rickettsial infection is common. In most cases, the history of tick bite is obscure and eschars are not present. A 45-y-old female experienced massive tick bites while working in her tea plantation. She developed fever 2 d after exposure, but the diagnosis of SFG infection was not considered until a skin rash appeared on the eighth day. She had a very high titer of antirickettsial antibodies detected by immunofluorescence assay and responded to doxycycline. Here, we highlight the high risk of exposure to ticks and tick bites within tea estates and its causal relationship to SFG infection, which is increasing in Sri Lanka. Active case detection, notification, surveillance, and community awareness are imperative. Possible preventative measures for tick bites have to be introduced. There is a need to explore the effectiveness of local remedies currently in use.

Research paper thumbnail of Acute Kidney Injury Following Star Fruit Ingestion: A Case Series

Wilderness & Environmental Medicine, 2021

Star fruit (Averrhoa carambola) is a popular fruit in many tropical countries, including Sri Lank... more Star fruit (Averrhoa carambola) is a popular fruit in many tropical countries, including Sri Lanka. It is rich in oxalic acid, which is nephrotoxic in higher concentrations. The development of both acute (AKI) and chronic kidney injury after oxalate nephropathy is often underrecognized. Here we discuss the risk factors, clinical features, treatment, and outcomes of 4 patients who developed AKI after star fruit ingestion. Baseline clinical characteristics, the amount of star fruit ingested, clinical presentation, investigation, and outcome of the patients (ages 28, 50, 54, and 55 y; all male) were traced. More common symptoms of acute star fruit intoxication were nausea, vomiting, and abdominal and back pain, followed by low urine output and high serum creatinine over hours to days. Urinary analysis of all patients demonstrated oxalate crystals. Histopathologic examination of renal tissues of all 4 patients revealed acute tubular damage with calcium oxalate crystals, interstitial edema, and inflammatory cellular infiltration. The presence of calcium oxalate crystals was further confirmed with the brilliant birefringence seen under polarized light. Two patients needed intermittent hemodialysis over a week owing to oliguria and uremia. The other 2 patients did not require hemodialysis and had improvement of renal function with supportive treatment. All had high renal function on discharge but were back to normal within a month. This study highlights AKI as a serious complication of star fruit ingestion. The type and quantity of star fruit ingested and some patient factors may play a role in the pathogenesis of AKI. Public education about this serious uncommon complication is important.

Research paper thumbnail of Intra-aural tick bite causing unilateral facial nerve palsy in 29 cases over 16 years in Kandy, Sri Lanka: is rickettsial aetiology possible?

BMC Infectious Diseases, 2018

Background: Over the last two decades intra-aural tick infestation (otoacariasis) has been a comm... more Background: Over the last two decades intra-aural tick infestation (otoacariasis) has been a common occurrence in the hilly central region in Sri Lanka. Very occasional detection of isolated unilateral facial nerve palsy associated with otoacariasis attributed to toxin damage of the nerve prompted us to study the clinico-epidemiology and aetio-pathology of the problem. Methods: All cases having isolated unilateral facial nerve palsy associated with otoacariasis presented to, Ear Nose and Throat clinic at General Hospital Kandy, Sri Lanka from 2001 to 2016 were included in the study. The facial palsies were assessed with nerve conduction studies and, harvested ticks were identified. Results: There were 29 patients with mean age of 46 years (range 22-76 years) with male to female ratio of 1:1.9. First 12 patients without specific treatment took 1-55 months for recovery and 4 had axonal degeneration. Last 5 patients were treated with doxycycline and recovered in 4 weeks. They had strong sero-conversion of immunofluorescence antibodies against spotted fever rickettsioses and the tick harvested from the last patient was PCR positive for rickettsial DNA. Identified ticks belonged to Dermacentor, Amblyomma, Rhipicephalus and Hyalomma species. Conclusions: On contrary to popular toxin theory, we were able to demonstrate treatable rickettsial aetio-pathology as the cause of otoacariasis associated lower motor facial palsy in Sri Lanka.

Research paper thumbnail of Normality data of eGFR and validity of commonly used screening tests for CKD in an area with endemic CKD of unknown etiology; need for age and sex based precise cutoff values

BMC Nephrology, 2019

Background: Chronic Kidney Disease in certain part of Sri Lanka and increasing burden of CKD in s... more Background: Chronic Kidney Disease in certain part of Sri Lanka and increasing burden of CKD in some other countries is a global public health problem. While the underlying causes of majority of cases are unknown, effective control and prevention strategies are yet to be taken. Though the disease has been identify more than decade ago, baseline data on renal function are not available. This study reports the age and sex disaggregated data of renal functions among screening participants of the Anuradhapura, the district with the highest disease burden in Sri Lanka. Methods: The screening prorgramme was done as a part of CKD control programme of Anuradhapura. All screening centers were visited and information and urine sample collection tubes were distributed before the screening date. A serum and urine sample was taken from all participants. In a subsample, urine sulfosalicylic acid test (SSA Test), urine dipstick test, urine albumin to creatinine ratio (UACR) and urine protein to creatinine ratio (UPCR) was done. Results: The study sample included 7768 apparently healthy people aging 18 to 93 years and females (n = 5522) accounted for 71.1% of the sample. Mean age of the participants was 45.9 (SD 14.1) years. Mean eGFR in this population was 90.8 mL/min/1.73m 2 (SD 24.6) with a significantly lower eGFR (88.1 mL/min/1.73m 2) among males compared to female (92.8 mL/min/1.73m 2). Mean eGFR was 115 mL/min/1.73m 2 (SE .5) among participants aging less than 30 and this value drastically reduced to 59.1 mL/min/1.73m 2 (SE 1.2) among people aging more than 70 years. Proportion of people having reduction of eGFR compatible with mild, moderate, severe and kidney failure categories was 33.

Research paper thumbnail of Comparison of Kato Katz, antibody-based ELISA and droplet digital PCR diagnosis of schistosomiasis japonica: Lessons learnt from a setting of low infection intensity

PLOS Neglected Tropical Diseases, 2019

Background Zoonotic schistosomiasis in Asia, caused by Schistosoma japonicum, remains a major pub... more Background Zoonotic schistosomiasis in Asia, caused by Schistosoma japonicum, remains a major public health concern in China and the Philippines. The developing epidemiological and socioeconomic picture of the disease in endemic areas necessitates the development of affordable and highly accurate field diagnostics as an important component in evaluating ongoing integrated control and elimination efforts. Methods Three diagnostic methods, namely Kato-Katz (KK) stool microscopy, ELISA and droplet digital (dd) PCR assays, were compared by detecting infection in a total of 412 participants from an area moderately endemic for schistosomiasis in the Philippines. Results This comprehensive comparison further defined the diagnostic performance and features for each assay. Compared with the ddPCR assay analysing DNA from faeces (F_ddPCR), which exhibited the highest sensitivity, the SjSAP4 + Sj23-LHD-ELISA had the best accuracy (67.2%) among all five ELISA assays assessed. Schistosomiasis prevalence determined by the SjSAP4 + Sj23-LHD-ELISA and ddPCRs was similar and was at least 2.5 times higher than obtained with the KK method. However, the agreement between these assays was low. In terms of cost and logistical convenience, the SjSAP4 + Sj23-LHD-ELISA represents a cost-effective assay with considerable diagnostic merits. In contrast, although the ddPCR assays exhibited a high level of diagnostic performance, the high cost and the need for specialized equipment presents a major obstacle in their application in screening campaigns.

Research paper thumbnail of DNA Diagnostics for Schistosomiasis Control

Tropical medicine and infectious disease, 2018

Despite extensive efforts over the last few decades, the global disease burden of schistosomiasis... more Despite extensive efforts over the last few decades, the global disease burden of schistosomiasis still remains unacceptably high. This could partly be attributed to the lack of accurate diagnostic tools for detecting human and animal schistosome infections in endemic areas. In low transmission and low prevalence areas where schistosomiasis elimination is targeted, case detection requires a test that is highly sensitive. Diagnostic tests with low sensitivity will miss individuals with low infection intensity and these will continue to contribute to transmission, thereby interfering with the efficacy of the control measures operating. Of the many diagnostic approaches undertaken to date, the detection of schistosome DNA using DNA amplification techniques including polymerase chain reaction (PCR) provide valuable adjuncts to more conventional microscopic and serological methods, due their accuracy, high sensitivity, and the capacity to detect early pre-patent infections. Furthermore, ...

Research paper thumbnail of PCR-based diagnosis of human schistosomiasis japonica and co-infections with intestinal protozoa

Research paper thumbnail of Co-parasitism of intestinal protozoa and Schistosoma japonicum in a rural community in the Philippines

Infectious Diseases of Poverty, 2018

Background: Co-parasitism is a frequent occurrence in impoverished communities in the tropics res... more Background: Co-parasitism is a frequent occurrence in impoverished communities in the tropics resulting in a considerable disease burden. While there are extensive reports of intestinal helminthiases, including schistosomiasis japonica, the occurrence and extent of diseases caused by intestinal protozoa (IP) have yet to be investigated in depth in the Philippines. We present a detailed analysis of polyparasitism in a rural community of Northern Samar, focusing on co-infections of IP with Schistosoma japonicum. Methods: A descriptive cross sectional study was carried out in 2015 across 18 barangays (villages) endemic for S. japonicum in Northern Samar, the Philippines to assess the burden of human schistosomiasis and IP infections. Faecal samples collected from 412 participants from the 18 barangays were included in the final molecular analysis. A multiplex quantitative PCR assay was developed and used for the detection of Blastocystis spp., Entamoeba histolytica, Cryptosporidium spp. and Giardia duodenalis in stool samples. The findings were combined with previous results of droplet digital PCR diagnosis of individuals from the same 18 barangays infected with S. japonicum determined using the same stool samples for analysis. Results: Mean age of the study participants was 40.3 years (95% CI: 38.8-41.8) with 53% (n = 218) being males. Prevalence of S. japonicum (74.5%) and Blastocystis spp. (58.7%) was significantly higher compared to other infections, with E. histolytica having the lowest prevalence (12.1%). A majority of individuals were infected with more than one parasite with two infections being most common (n = 175, 42.5%). The prevalence of individuals with two parasites was significantly higher than all others with 27.9% (n = 115) subjects harbouring a single parasite species. Of individuals with two infections, S. japonicum and Blastocystis spp. were the most common combination (n = 110, 62.9%). Examining age within the population, 58.5% (n = 38) of school-aged children and 60.1% (n = 14) of women of child bearing age harboured at least two parasite species. Conclusions: The study revealed that polyparasitism with IP infections and schistosomiasis japonica is highly prevalent in individuals in Northern Samar which likely contributes to the significant public health and socioeconomic burden suffered by this population. More generally, the findings are of relevance when considering implementation of integrated control strategies for intestinal parasites.

Research paper thumbnail of Testing of water samples for environmental DNA as a surveillance tool to assess the risk of schistosome infection in a locality

International Journal of Infectious Diseases, 2018

The neglected tropical disease of schistosomiasis is caused by waterborne parasitic blood flukes ... more The neglected tropical disease of schistosomiasis is caused by waterborne parasitic blood flukes of the genus Schistosoma whose life cycle involves an intermediate freshwater snail host and a definitive human host. As recently highlighted, schistosomiasis still causes extensive morbidity in Southeast Asia, South America, parts of the Middle East, and, most notably, in sub-Saharan Africa. 1 Worryingly, an outbreak of urogenital schistosomiasis, imported by individuals infected most likely in Senegal, West Africa, was reported recently in Corsica, France with more than 120 tourists or local people infected. 2 It is now generally accepted that the elimination of schistosomiasis will only be achieved through a multifaceted intervention approach, including snail control, targeted health education, improved water, sanitation and hygiene facilities, drug treatment, tailored surveillance-response mechanisms and accurate diagnostics that will be key to eventual success. 1 Currently schistosomiasis diagnosis primarily involves the detection of worm antigens in serum or eggs in excreta. 1,3 In addition to the clinical diagnosis of schistosome infections, tools for detecting Schistosoma spp. transmission in snail hosts and the environment will be critically important if the ultimate goal of schistosomiasis elimination is to be achieved.

Research paper thumbnail of Revisiting clinico-epidemiological pattern of human rickettsial infections in the central region of Sri Lanka: a hospital based descriptive study

BMC Research Notes, 2017

Background: This study revisits the clinico-epidemiology and serological patterns of rickettsiose... more Background: This study revisits the clinico-epidemiology and serological patterns of rickettsioses in the central region of Sri Lanka and highlights the need of advanced diagnostics for precise identification of species responsible for rickettsioses. Methods: The patients treated for rickettsioses between November 2009 and October 2011 were recruited for the study from Teaching Hospital, Peradeniya. Clinical characteristics and serology results were used for diagnosis. Results: Study included 210 patients (mean age 44 years ± 3.2) and of them 188 (90%) had positive IgG and/or IgM sero-reactivity for spotted fever group (SFG). Of them, 134 had IgG titre ≥1/256 for SFG and presented with fever and skin rash. They also had headache [n = 119 (89%)], myalgia [n = 103 (77%)], arthralgia [n = 89 (66%)] of large joints, conjunctival injections [n = 83 (62%)], thrombocytopenia (n = 78.58%), anaemia (n = 14.10%), leukocytosis [n = 35 (26%)], leucopenia [n = 17 (13%)], elevated aspartate transaminase [n = 69 (52%)] and alanine transaminase [n = 73 (55%)]. Conclusions: Predominance of SFG rickettsioses are reiterated, possibly transmitted by ticks. Joint disease is common with occasional fern leaf skin necrosis. Changing socioeconomic conditions, vegetations, contact with domestic and wild animals, abundance of vectors would have contributed for emergence and sustenance of SFG in the region. Further research is needed to identify the causative agents and the mode of transmission.

Research paper thumbnail of Clinicopathological findings, treatment response and predictors of long-term outcome in a cohort of lupus nephritis patients managed according to the Euro-lupus regime: a retrospective analysis in Sri Lanka

BMC research notes, Jan 2, 2017

Despite the improvement in survival of patients with lupus nephritis (LN) globally, there is spar... more Despite the improvement in survival of patients with lupus nephritis (LN) globally, there is sparse data from Sri Lanka (SL). The current study aims to describe the clinicopathological findings, treatment response and predictors of long-term outcome of patients with WHO class III-IV LN in SL, managed according to the Euro-lupus regime. Of 72 patients, 64 were females. In half of them, LN was diagnosed within the 1st year of the illness. The most common presenting feature was sub-nephrotic proteinuria. Sixteen and twenty patients had nephrotic syndrome and abnormal renal function respectively at the time of diagnosis. Fifty-four patients (75%) responded to the Euro-lupus regimen [CR, 20 (28%); PR, 34(47%)]. Later at 6 months, 65 patients (90%) achieved remission [CR, 31(43%); PR, 34 (47%)]. Seven patients experienced treatment failure. During the total duration of follow up, 54 patients remained in complete or partial remission, 26 developed renal relapses, and 19 suffered severe inf...

Research paper thumbnail of Diagnosing schistosomiasis-induced liver morbidity: implications for global control

International Journal of Infectious Diseases, 2017

Background: Subclinical morbidity due to schistosomiasis was evaluated in 565 patients, and the e... more Background: Subclinical morbidity due to schistosomiasis was evaluated in 565 patients, and the enhanced liver fibrosis (ELF) test was assessed for the first time as a potential screening tool for disease. Methods: The prevalence and intensity of infection were determined by Kato-Katz thick smear stool examination at baseline and 2 years after curative treatment. The degree of hepatic fibrosis was assessed by ultrasound. Non-invasive serum biomarkers of hepatic fibrosis were also evaluated. Results: The baseline human prevalence and infection intensity were found to be moderately high at 34% and 123 eggs per gram, respectively. However, hepatic parenchymal fibrosis occurred in 50% of subjects, with grade II fibrosis in 19% and grade III in 6%. The ELF score and higher serum levels of tissue inhibitor of metalloproteinase 1 (TIMP-1) and hyaluronic acid (HA) correlated with the grade of liver fibrosis. Conclusions: The findings of this study demonstrated that praziquantel treatment had a short-term impact on both the prevalence and intensity of infection, but less of an impact on established morbidity. Higher TIMP-1 and HA serum levels, and an ELF cutoff score of 8 were found to be correlated with the grade of liver fibrosis; these values may, therefore, assist physicians in identifying individuals at greater risk of disease.

Research paper thumbnail of Efficacy of intravenous hydrocortisone administered 2–4 h prior to antivenom as prophylaxis against adverse drug reactions to snake antivenom in Sri Lanka: An open labelled randomized controlled trial

Toxicon, 2016

The prevention of adverse drug reactions to antivenom serum poses a formidable challenge in the m... more The prevention of adverse drug reactions to antivenom serum poses a formidable challenge in the management of snakebite. Hydrocortisone is being used concurrently with antivenom in order to prevent these adverse drug reactions without a proven benefit. However, all previous studies seemed to ignore the testing of effectiveness of hydrocortisone therapy during its pharmacological effects, which come hours later. On this principle, we aimed to test the effectiveness of intravenous hydrocortisone given 2 h or more prior to the commencement of antivenom therapy to reduce adverse drug reactions to antivenom. In an open-labelled randomized controlled trial, patients with a history of snakebite were randomly assigned to receive either 500 mg intravenous hydrocortisone bolus given 2 h or more prior to antivenom therapy (Group A) or at the time of antivenom therapy (Group B). The primary endpoint was the reduction of adverse drug reactions to antivenom of any grade of severity within the first 48 h. This trial has been registered with the "Sri Lanka Clinical Trials Registry", number SLCTR/2010/005. A total of 236 patients were randomized to group A or Group B. In the group A, 38 participants received hydrocortisone 2 h before administration of antivenom whilst 33 received hydrocortisone less than 2 h before administration of antivenom. In the Group B, 84 participants received hydrocortisone at the time of antivenom therapy. In Group A (n, 38), and Group B (n, 84), 15 patients (39%) and 29 patients (35%) developed reactions respectively and the difference is not significant (p = 0.598). Moreover, hydrocortisone therapy did not significantly reduce the occurrence of antievnom reactions of any grade of severity. Further, it didn't delay the occurrence of antivenom reactions in patients who received hydrocortisone either more than 2 h or less than 2 h before the antivenom as opposed to the control group (group B). Intravenous hydrocortisone shows no difference in the timing, rate or severity of adverse drug reactions to antivenom when administered simultaneously and up to 4 h prior to antivenom.

Research paper thumbnail of Outstation state medical faculties in Sri Lanka: nobody’s children when it comes to sustainability!

Anuradhapura Medical Journal

The trend of establishing new outstation MBBS degree programs The extraordinary gazette issued by... more The trend of establishing new outstation MBBS degree programs The extraordinary gazette issued by the Minister of Higher Education of Sri Lanka, on 20 th March 2023 gave clearance to the Uva Wellassa University to establish a Faculty of Medicine under the Universities Act of Sri Lanka, and to run a MBBS degree program. This is the 12 th MBBS degree program in the state university system under the purview of the University Grants Commission (UGC). These 12 MBBS degree programs and the one offered by the Faculty of Medicine of the General Sir John Kotelawala Defence University (KDU), which is established under a separate parliamentary Act, are the MBBS degree programs delivered by government institutes in Sri Lanka. Of the 12 MBBS degree programs under the purview of the UGC, six have been established over the last 17 years. Five of the recently-established MBBS degree programs are in 'outstation' universities (Rajarata, Eastern, Wayamba, Sabaragamuwa and Uva Wellassa Universities), and the other is at the University of Moratuwa, located within the Western province.

Research paper thumbnail of Ensuring responsible conduct of research and publications in Sri Lankan context: an eye-opener

Anuradhapura Medical Journal

Research paper thumbnail of Placing Leishmaniasis in the Limelight through the Communicable Disease Surveillance System: An Experience from Sri Lanka

Pathogens

Having an effective surveillance system is imperative to take timely and appropriate actions for ... more Having an effective surveillance system is imperative to take timely and appropriate actions for disease control and prevention. In Sri Lanka, leishmaniasis was declared as a notifiable disease in 2008. This paper presents a comprehensive compilation of the up-to-date documents on the communicable disease and leishmaniasis surveillance in Sri Lanka in order to describe the importance of the existing leishmaniasis surveillance system and to identify gaps that need to be addressed. The documents perused included circulars, reports, manuals, guidelines, ordinances, presentations, and published articles. The disease trends reported were linked to important landmarks in leishmaniasis surveillance. The findings suggest that there is a well-established surveillance system in Sri Lanka having a massive impact on increased case detection, resulting in im-proved attention on leishmaniasis. However, the system is not without its short comings and there is room for further improvements.

Research paper thumbnail of Clinico-epidemiology and aetiopathogenesis of gallstone disease in the South Asian region: a scoping review protocol

BMJ Open

IntroductionPathogenesis of gallstones (GS) is multifactorial and is influenced by numerous envir... more IntroductionPathogenesis of gallstones (GS) is multifactorial and is influenced by numerous environmental and genetic risk factors. As a result, clinico-epidemiology and aetiopathogenesis of GS vary in different populations. Understanding the aetiopathogenesis of GS for different populations is imperative in control and prevention of GS disease and its associated complications. This protocol describes the methodology of a scoping review which focuses on synthesising the most updated knowledge on GS disease in South Asia.Methods and analysisThe scoping review proposed in this protocol will be guided by Arksey and O’Malley’s framework and the Joanna Briggs Institute Reviewers’ Manual. Accordingly, population, concept and context strategy will be used to formulate the scoping review question, eligibility criteria and search strategy. In the search, electronic databases, MEDLINE/PubMed, ScienceDirect, Scopus, Cochrane library, CINAHL, Trip, and Google scholar, as well as various grey li...

Research paper thumbnail of Serological Evidence of Thailand Virus-Related Hantavirus Infection among Suspected Leptospirosis Patients in Kandy, Sri Lanka

Japanese Journal of Infectious Diseases

A cross-sectional study was undertaken to determine the current prevalence of leptospirosis and h... more A cross-sectional study was undertaken to determine the current prevalence of leptospirosis and hantaviral infections, and the socio-demographic characteristics and risk factors of infected patients, in Kandy, Sri Lanka. This report discusses the serological evidence of hantavirus infections among 105 suspected leptospirosis patients, 8 of whom had hantavirus antibodies. Serotyping ELISA showed that these 8 patients had high optical density values for Thailand virus. Most of the sera showed that the focus reduction neutralization test titer against Thailand virus was higher than that against Seoul virus, thereby suggesting that the hantaviral antibodies found in Sri Lanka are different from Seoul virus but closely related to Thailand virus. These findings imply that the hantaviral infection found in Kandy, Sri Lanka appears to be due to a virus similar to Thailand virus. Epidemiological analysis revealed that the association between hantavirus infection and socio-demographic characteristics was not statistically significant.

Research paper thumbnail of Social and Health Impact of Flying Hymenoptera Stings: Experience in a Region of Central Hill Country of Sri Lanka

Asian Pacific journal of health sciences, Sep 26, 2020

Objectives: Stinging by Asian giant honey bee and hornets is a common environmental hazard leadin... more Objectives: Stinging by Asian giant honey bee and hornets is a common environmental hazard leading to many hospital admissions in Sri Lanka. This study aims to study the social and health impact of flying hymenoptera stings in a region of the central hill country of Sri Lanka. Methodology: The study was carried out at the two base Hospitals in Teldeniya and Rikillagaskada, Sri Lanka. All the patients presented to these hospitals following a wasp or big bee singing, during the period of 2011-2010 were included in the study. Results: There was a total of 80 patients in this study cohort, with 54 (32%) of them being victims of Horne stings and the rest being big bee stings (n = 26, 68%). The mean age of the total group was 45 years (SD = 16). Stings occurrence between 9.00 am and 3.00 pm was more frequent. The majority of the big bee stings (n = 26, 48%) had occurred while working in tea estates, whereas the hornet attacks were frequent around the dwellings (n = 12, 46%), head and neck (n = 72, 90%), upper limbs (n = 48, 60%), chest (n = 28, 35%), and back of the chest (n = 24, 30%) were the commonly involved body regions. Conclusions: Hymenoptera stings have a significant social and health impact in a region of the central hill country of Sri Lanka. Although pain and swelling were the most common adverse effect, life-threatening anaphylaxis was not reported in this study group. Even though electrocardiogram changes were more common among big bee groups, none of them were fatal.

Research paper thumbnail of Anuradhapura Medical Journal (AMJ): Swimming against the tide

Anuradhapura Medical Journal, 2022

Research paper thumbnail of Massive Tick Bites Causing Spotted Fever Rickettsial Infection: A Hazard in a Tea Plantation, Sri Lanka

Wilderness & Environmental Medicine, 2021

Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SF... more Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SFG) rickettsial infection is common. In most cases, the history of tick bite is obscure and eschars are not present. A 45-y-old female experienced massive tick bites while working in her tea plantation. She developed fever 2 d after exposure, but the diagnosis of SFG infection was not considered until a skin rash appeared on the eighth day. She had a very high titer of antirickettsial antibodies detected by immunofluorescence assay and responded to doxycycline. Here, we highlight the high risk of exposure to ticks and tick bites within tea estates and its causal relationship to SFG infection, which is increasing in Sri Lanka. Active case detection, notification, surveillance, and community awareness are imperative. Possible preventative measures for tick bites have to be introduced. There is a need to explore the effectiveness of local remedies currently in use.

Research paper thumbnail of Acute Kidney Injury Following Star Fruit Ingestion: A Case Series

Wilderness & Environmental Medicine, 2021

Star fruit (Averrhoa carambola) is a popular fruit in many tropical countries, including Sri Lank... more Star fruit (Averrhoa carambola) is a popular fruit in many tropical countries, including Sri Lanka. It is rich in oxalic acid, which is nephrotoxic in higher concentrations. The development of both acute (AKI) and chronic kidney injury after oxalate nephropathy is often underrecognized. Here we discuss the risk factors, clinical features, treatment, and outcomes of 4 patients who developed AKI after star fruit ingestion. Baseline clinical characteristics, the amount of star fruit ingested, clinical presentation, investigation, and outcome of the patients (ages 28, 50, 54, and 55 y; all male) were traced. More common symptoms of acute star fruit intoxication were nausea, vomiting, and abdominal and back pain, followed by low urine output and high serum creatinine over hours to days. Urinary analysis of all patients demonstrated oxalate crystals. Histopathologic examination of renal tissues of all 4 patients revealed acute tubular damage with calcium oxalate crystals, interstitial edema, and inflammatory cellular infiltration. The presence of calcium oxalate crystals was further confirmed with the brilliant birefringence seen under polarized light. Two patients needed intermittent hemodialysis over a week owing to oliguria and uremia. The other 2 patients did not require hemodialysis and had improvement of renal function with supportive treatment. All had high renal function on discharge but were back to normal within a month. This study highlights AKI as a serious complication of star fruit ingestion. The type and quantity of star fruit ingested and some patient factors may play a role in the pathogenesis of AKI. Public education about this serious uncommon complication is important.

Research paper thumbnail of Intra-aural tick bite causing unilateral facial nerve palsy in 29 cases over 16 years in Kandy, Sri Lanka: is rickettsial aetiology possible?

BMC Infectious Diseases, 2018

Background: Over the last two decades intra-aural tick infestation (otoacariasis) has been a comm... more Background: Over the last two decades intra-aural tick infestation (otoacariasis) has been a common occurrence in the hilly central region in Sri Lanka. Very occasional detection of isolated unilateral facial nerve palsy associated with otoacariasis attributed to toxin damage of the nerve prompted us to study the clinico-epidemiology and aetio-pathology of the problem. Methods: All cases having isolated unilateral facial nerve palsy associated with otoacariasis presented to, Ear Nose and Throat clinic at General Hospital Kandy, Sri Lanka from 2001 to 2016 were included in the study. The facial palsies were assessed with nerve conduction studies and, harvested ticks were identified. Results: There were 29 patients with mean age of 46 years (range 22-76 years) with male to female ratio of 1:1.9. First 12 patients without specific treatment took 1-55 months for recovery and 4 had axonal degeneration. Last 5 patients were treated with doxycycline and recovered in 4 weeks. They had strong sero-conversion of immunofluorescence antibodies against spotted fever rickettsioses and the tick harvested from the last patient was PCR positive for rickettsial DNA. Identified ticks belonged to Dermacentor, Amblyomma, Rhipicephalus and Hyalomma species. Conclusions: On contrary to popular toxin theory, we were able to demonstrate treatable rickettsial aetio-pathology as the cause of otoacariasis associated lower motor facial palsy in Sri Lanka.

Research paper thumbnail of Normality data of eGFR and validity of commonly used screening tests for CKD in an area with endemic CKD of unknown etiology; need for age and sex based precise cutoff values

BMC Nephrology, 2019

Background: Chronic Kidney Disease in certain part of Sri Lanka and increasing burden of CKD in s... more Background: Chronic Kidney Disease in certain part of Sri Lanka and increasing burden of CKD in some other countries is a global public health problem. While the underlying causes of majority of cases are unknown, effective control and prevention strategies are yet to be taken. Though the disease has been identify more than decade ago, baseline data on renal function are not available. This study reports the age and sex disaggregated data of renal functions among screening participants of the Anuradhapura, the district with the highest disease burden in Sri Lanka. Methods: The screening prorgramme was done as a part of CKD control programme of Anuradhapura. All screening centers were visited and information and urine sample collection tubes were distributed before the screening date. A serum and urine sample was taken from all participants. In a subsample, urine sulfosalicylic acid test (SSA Test), urine dipstick test, urine albumin to creatinine ratio (UACR) and urine protein to creatinine ratio (UPCR) was done. Results: The study sample included 7768 apparently healthy people aging 18 to 93 years and females (n = 5522) accounted for 71.1% of the sample. Mean age of the participants was 45.9 (SD 14.1) years. Mean eGFR in this population was 90.8 mL/min/1.73m 2 (SD 24.6) with a significantly lower eGFR (88.1 mL/min/1.73m 2) among males compared to female (92.8 mL/min/1.73m 2). Mean eGFR was 115 mL/min/1.73m 2 (SE .5) among participants aging less than 30 and this value drastically reduced to 59.1 mL/min/1.73m 2 (SE 1.2) among people aging more than 70 years. Proportion of people having reduction of eGFR compatible with mild, moderate, severe and kidney failure categories was 33.

Research paper thumbnail of Comparison of Kato Katz, antibody-based ELISA and droplet digital PCR diagnosis of schistosomiasis japonica: Lessons learnt from a setting of low infection intensity

PLOS Neglected Tropical Diseases, 2019

Background Zoonotic schistosomiasis in Asia, caused by Schistosoma japonicum, remains a major pub... more Background Zoonotic schistosomiasis in Asia, caused by Schistosoma japonicum, remains a major public health concern in China and the Philippines. The developing epidemiological and socioeconomic picture of the disease in endemic areas necessitates the development of affordable and highly accurate field diagnostics as an important component in evaluating ongoing integrated control and elimination efforts. Methods Three diagnostic methods, namely Kato-Katz (KK) stool microscopy, ELISA and droplet digital (dd) PCR assays, were compared by detecting infection in a total of 412 participants from an area moderately endemic for schistosomiasis in the Philippines. Results This comprehensive comparison further defined the diagnostic performance and features for each assay. Compared with the ddPCR assay analysing DNA from faeces (F_ddPCR), which exhibited the highest sensitivity, the SjSAP4 + Sj23-LHD-ELISA had the best accuracy (67.2%) among all five ELISA assays assessed. Schistosomiasis prevalence determined by the SjSAP4 + Sj23-LHD-ELISA and ddPCRs was similar and was at least 2.5 times higher than obtained with the KK method. However, the agreement between these assays was low. In terms of cost and logistical convenience, the SjSAP4 + Sj23-LHD-ELISA represents a cost-effective assay with considerable diagnostic merits. In contrast, although the ddPCR assays exhibited a high level of diagnostic performance, the high cost and the need for specialized equipment presents a major obstacle in their application in screening campaigns.

Research paper thumbnail of DNA Diagnostics for Schistosomiasis Control

Tropical medicine and infectious disease, 2018

Despite extensive efforts over the last few decades, the global disease burden of schistosomiasis... more Despite extensive efforts over the last few decades, the global disease burden of schistosomiasis still remains unacceptably high. This could partly be attributed to the lack of accurate diagnostic tools for detecting human and animal schistosome infections in endemic areas. In low transmission and low prevalence areas where schistosomiasis elimination is targeted, case detection requires a test that is highly sensitive. Diagnostic tests with low sensitivity will miss individuals with low infection intensity and these will continue to contribute to transmission, thereby interfering with the efficacy of the control measures operating. Of the many diagnostic approaches undertaken to date, the detection of schistosome DNA using DNA amplification techniques including polymerase chain reaction (PCR) provide valuable adjuncts to more conventional microscopic and serological methods, due their accuracy, high sensitivity, and the capacity to detect early pre-patent infections. Furthermore, ...

Research paper thumbnail of PCR-based diagnosis of human schistosomiasis japonica and co-infections with intestinal protozoa

Research paper thumbnail of Co-parasitism of intestinal protozoa and Schistosoma japonicum in a rural community in the Philippines

Infectious Diseases of Poverty, 2018

Background: Co-parasitism is a frequent occurrence in impoverished communities in the tropics res... more Background: Co-parasitism is a frequent occurrence in impoverished communities in the tropics resulting in a considerable disease burden. While there are extensive reports of intestinal helminthiases, including schistosomiasis japonica, the occurrence and extent of diseases caused by intestinal protozoa (IP) have yet to be investigated in depth in the Philippines. We present a detailed analysis of polyparasitism in a rural community of Northern Samar, focusing on co-infections of IP with Schistosoma japonicum. Methods: A descriptive cross sectional study was carried out in 2015 across 18 barangays (villages) endemic for S. japonicum in Northern Samar, the Philippines to assess the burden of human schistosomiasis and IP infections. Faecal samples collected from 412 participants from the 18 barangays were included in the final molecular analysis. A multiplex quantitative PCR assay was developed and used for the detection of Blastocystis spp., Entamoeba histolytica, Cryptosporidium spp. and Giardia duodenalis in stool samples. The findings were combined with previous results of droplet digital PCR diagnosis of individuals from the same 18 barangays infected with S. japonicum determined using the same stool samples for analysis. Results: Mean age of the study participants was 40.3 years (95% CI: 38.8-41.8) with 53% (n = 218) being males. Prevalence of S. japonicum (74.5%) and Blastocystis spp. (58.7%) was significantly higher compared to other infections, with E. histolytica having the lowest prevalence (12.1%). A majority of individuals were infected with more than one parasite with two infections being most common (n = 175, 42.5%). The prevalence of individuals with two parasites was significantly higher than all others with 27.9% (n = 115) subjects harbouring a single parasite species. Of individuals with two infections, S. japonicum and Blastocystis spp. were the most common combination (n = 110, 62.9%). Examining age within the population, 58.5% (n = 38) of school-aged children and 60.1% (n = 14) of women of child bearing age harboured at least two parasite species. Conclusions: The study revealed that polyparasitism with IP infections and schistosomiasis japonica is highly prevalent in individuals in Northern Samar which likely contributes to the significant public health and socioeconomic burden suffered by this population. More generally, the findings are of relevance when considering implementation of integrated control strategies for intestinal parasites.

Research paper thumbnail of Testing of water samples for environmental DNA as a surveillance tool to assess the risk of schistosome infection in a locality

International Journal of Infectious Diseases, 2018

The neglected tropical disease of schistosomiasis is caused by waterborne parasitic blood flukes ... more The neglected tropical disease of schistosomiasis is caused by waterborne parasitic blood flukes of the genus Schistosoma whose life cycle involves an intermediate freshwater snail host and a definitive human host. As recently highlighted, schistosomiasis still causes extensive morbidity in Southeast Asia, South America, parts of the Middle East, and, most notably, in sub-Saharan Africa. 1 Worryingly, an outbreak of urogenital schistosomiasis, imported by individuals infected most likely in Senegal, West Africa, was reported recently in Corsica, France with more than 120 tourists or local people infected. 2 It is now generally accepted that the elimination of schistosomiasis will only be achieved through a multifaceted intervention approach, including snail control, targeted health education, improved water, sanitation and hygiene facilities, drug treatment, tailored surveillance-response mechanisms and accurate diagnostics that will be key to eventual success. 1 Currently schistosomiasis diagnosis primarily involves the detection of worm antigens in serum or eggs in excreta. 1,3 In addition to the clinical diagnosis of schistosome infections, tools for detecting Schistosoma spp. transmission in snail hosts and the environment will be critically important if the ultimate goal of schistosomiasis elimination is to be achieved.

Research paper thumbnail of Revisiting clinico-epidemiological pattern of human rickettsial infections in the central region of Sri Lanka: a hospital based descriptive study

BMC Research Notes, 2017

Background: This study revisits the clinico-epidemiology and serological patterns of rickettsiose... more Background: This study revisits the clinico-epidemiology and serological patterns of rickettsioses in the central region of Sri Lanka and highlights the need of advanced diagnostics for precise identification of species responsible for rickettsioses. Methods: The patients treated for rickettsioses between November 2009 and October 2011 were recruited for the study from Teaching Hospital, Peradeniya. Clinical characteristics and serology results were used for diagnosis. Results: Study included 210 patients (mean age 44 years ± 3.2) and of them 188 (90%) had positive IgG and/or IgM sero-reactivity for spotted fever group (SFG). Of them, 134 had IgG titre ≥1/256 for SFG and presented with fever and skin rash. They also had headache [n = 119 (89%)], myalgia [n = 103 (77%)], arthralgia [n = 89 (66%)] of large joints, conjunctival injections [n = 83 (62%)], thrombocytopenia (n = 78.58%), anaemia (n = 14.10%), leukocytosis [n = 35 (26%)], leucopenia [n = 17 (13%)], elevated aspartate transaminase [n = 69 (52%)] and alanine transaminase [n = 73 (55%)]. Conclusions: Predominance of SFG rickettsioses are reiterated, possibly transmitted by ticks. Joint disease is common with occasional fern leaf skin necrosis. Changing socioeconomic conditions, vegetations, contact with domestic and wild animals, abundance of vectors would have contributed for emergence and sustenance of SFG in the region. Further research is needed to identify the causative agents and the mode of transmission.

Research paper thumbnail of Clinicopathological findings, treatment response and predictors of long-term outcome in a cohort of lupus nephritis patients managed according to the Euro-lupus regime: a retrospective analysis in Sri Lanka

BMC research notes, Jan 2, 2017

Despite the improvement in survival of patients with lupus nephritis (LN) globally, there is spar... more Despite the improvement in survival of patients with lupus nephritis (LN) globally, there is sparse data from Sri Lanka (SL). The current study aims to describe the clinicopathological findings, treatment response and predictors of long-term outcome of patients with WHO class III-IV LN in SL, managed according to the Euro-lupus regime. Of 72 patients, 64 were females. In half of them, LN was diagnosed within the 1st year of the illness. The most common presenting feature was sub-nephrotic proteinuria. Sixteen and twenty patients had nephrotic syndrome and abnormal renal function respectively at the time of diagnosis. Fifty-four patients (75%) responded to the Euro-lupus regimen [CR, 20 (28%); PR, 34(47%)]. Later at 6 months, 65 patients (90%) achieved remission [CR, 31(43%); PR, 34 (47%)]. Seven patients experienced treatment failure. During the total duration of follow up, 54 patients remained in complete or partial remission, 26 developed renal relapses, and 19 suffered severe inf...

Research paper thumbnail of Diagnosing schistosomiasis-induced liver morbidity: implications for global control

International Journal of Infectious Diseases, 2017

Background: Subclinical morbidity due to schistosomiasis was evaluated in 565 patients, and the e... more Background: Subclinical morbidity due to schistosomiasis was evaluated in 565 patients, and the enhanced liver fibrosis (ELF) test was assessed for the first time as a potential screening tool for disease. Methods: The prevalence and intensity of infection were determined by Kato-Katz thick smear stool examination at baseline and 2 years after curative treatment. The degree of hepatic fibrosis was assessed by ultrasound. Non-invasive serum biomarkers of hepatic fibrosis were also evaluated. Results: The baseline human prevalence and infection intensity were found to be moderately high at 34% and 123 eggs per gram, respectively. However, hepatic parenchymal fibrosis occurred in 50% of subjects, with grade II fibrosis in 19% and grade III in 6%. The ELF score and higher serum levels of tissue inhibitor of metalloproteinase 1 (TIMP-1) and hyaluronic acid (HA) correlated with the grade of liver fibrosis. Conclusions: The findings of this study demonstrated that praziquantel treatment had a short-term impact on both the prevalence and intensity of infection, but less of an impact on established morbidity. Higher TIMP-1 and HA serum levels, and an ELF cutoff score of 8 were found to be correlated with the grade of liver fibrosis; these values may, therefore, assist physicians in identifying individuals at greater risk of disease.

Research paper thumbnail of Efficacy of intravenous hydrocortisone administered 2–4 h prior to antivenom as prophylaxis against adverse drug reactions to snake antivenom in Sri Lanka: An open labelled randomized controlled trial

Toxicon, 2016

The prevention of adverse drug reactions to antivenom serum poses a formidable challenge in the m... more The prevention of adverse drug reactions to antivenom serum poses a formidable challenge in the management of snakebite. Hydrocortisone is being used concurrently with antivenom in order to prevent these adverse drug reactions without a proven benefit. However, all previous studies seemed to ignore the testing of effectiveness of hydrocortisone therapy during its pharmacological effects, which come hours later. On this principle, we aimed to test the effectiveness of intravenous hydrocortisone given 2 h or more prior to the commencement of antivenom therapy to reduce adverse drug reactions to antivenom. In an open-labelled randomized controlled trial, patients with a history of snakebite were randomly assigned to receive either 500 mg intravenous hydrocortisone bolus given 2 h or more prior to antivenom therapy (Group A) or at the time of antivenom therapy (Group B). The primary endpoint was the reduction of adverse drug reactions to antivenom of any grade of severity within the first 48 h. This trial has been registered with the "Sri Lanka Clinical Trials Registry", number SLCTR/2010/005. A total of 236 patients were randomized to group A or Group B. In the group A, 38 participants received hydrocortisone 2 h before administration of antivenom whilst 33 received hydrocortisone less than 2 h before administration of antivenom. In the Group B, 84 participants received hydrocortisone at the time of antivenom therapy. In Group A (n, 38), and Group B (n, 84), 15 patients (39%) and 29 patients (35%) developed reactions respectively and the difference is not significant (p = 0.598). Moreover, hydrocortisone therapy did not significantly reduce the occurrence of antievnom reactions of any grade of severity. Further, it didn't delay the occurrence of antivenom reactions in patients who received hydrocortisone either more than 2 h or less than 2 h before the antivenom as opposed to the control group (group B). Intravenous hydrocortisone shows no difference in the timing, rate or severity of adverse drug reactions to antivenom when administered simultaneously and up to 4 h prior to antivenom.