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The World Health Day 2014
April/May 2014, VOLUME 07 ISSUE 03
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Cover Story...
Food Consumption...
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SLMANEWS
THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION
April/May, 2014 Volume 07 Issue 03
Contents
President's Column
Page No. President's message
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Sri Lanka Medical Association Meeting with President on Monday 24 March 2014
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The World Health Day 2014
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Melioidosis 5-7 Treating patients with tropical infectious diseases in Sri Lanka – the need for innovative research 8-9 Food consumption in Sri Lankan adults and epidemic of non-communicable diseases Amendment to Gazette no 1847/56 by Ministry of Higher Education Post Of Joint Editor
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Notice
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Our Advertisers SLMA news Editorial Committee-2014 Editor-In-Chief: Dr. Indika Karunathilake Deputy Editor: Dr. Dinesha Jayasinghe Committee: Dr. Ruvaiz Haniffa Dr. Navoda Atapattu Dr. Ashwini De Abrew Dr. Indira Kahawita Dr. Shihan Azeez Dr. Chiranthi Liyanage Editorial assistance: Dr. Ruchira Sanjaya
GlaxoSmithKline Pharmaceuticals. Hemas pharmaceuticals (pvt) ltd Astron Ltd. Nivasie Developers Malabe (Pvt) Ltd Arpico Pharmaceuticals (Pvt) Ltd Asiri Surgical Hospital PLC Tokyo Cement Company (Lanka) Plc. Durdans Hospital This Source (Pvt.) Ltd Emerchemie NB (Ceylon) Ltd.
Official Newsletter of The Sri Lanka Medical Association. Tele : +94 112 693324 E mail - slma@eureka.lk
Dr. Palitha Abeykoon MD, MMed President, Sri Lanka Medical Association, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka
Publishing and printing assistance by
This Source (Pvt.) Ltd etc., No 3/1, Rajakeeya Mawatha, Colombo 07, Sri Lanka Tele: +94 113 054140 viduranga@thissource.com
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April/May, 2014
President's message
SLMANEWS
From the President…..
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e have just concluded another busy month at the SLMA. I wish to share a few highlights. The Planning for the Annual Scientific Congress and the Annual National Health Run, Walk and Ride scheduled from 13th to 18th July is progressing at a hectic pace and I am thankful to all the colleagues who have so willingly taken on the myriad responsibilities. Thus far we have had exceedingly good responses to all of these events from the Ministry of Health, our partners and sponsors as well as our well wishers and therefore we can confidently expect a very exciting programme of activities in July. I am sure all of the medical colleagues and their families and friends will join us in large numbers for these events. Of course we need to bear in mind that the centerpiece of the whole week is and should be the Scientific Congress and we hope all of the doctors in Sri Lanka will note down the dates 15th – 18th July in their diaries. The Organizing Committee, in close consultation with the Ministry of Health, is taking pains to facilitate your participation. The specifics will be communicated in due course. At the request of our Tobacco and Alcohol Committee we met with the H.E. the President on the 24th of March at which we briefed him on our work in this area and also took up a few additional items for discussion. The President was very appreciative of the work of the SLMA in tobacco and alcohol control and provided further practical guidance on the way forward. One matter of urgency that was taken up was the question of the Gazette Notification in relation to professional courses that the SLMA, SLMC and all of the Colleges were seriously concerned with. We are thankful to the Hon President that he immedi-
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ately assuaged our qualms by advising the Ministry of Higher Education to expedite the amendment of the gazette. We have since been shown the amended version which seems to be acceptable but we should obtain SLMC concurrence too. In commemoration of the World Health Day, SLMA held an extremely well attended symposium on Vector Borne Diseases which is the World Health Day theme this year. The resource persons and the panels and their presentations were uniformly of a very high quality, and the Communicable Diseases Committee has made arrangements to publish the proceedings which should be a valuable resource in these areas. I am also pleased to note the very tangible progress being made by our Committees which form the backbone of the SLMA. In addition to some of the well established ones like Nirogi, Medicines and CD Committees, the newly formed Quality Assurance Working Group has taken definitive steps to introduce simple but extremely valuable quality measures in clinical and public health services. The support from the learned Colleges has been invaluable and this work would be impossible without their full involvement and commitment. If we could set up a few systems this year it will be a major triumph. Our members, in fact everyone, will be pleased to hear that we plan to reprint the masterpiece “History of Medicine..”, the monumental piece of work by Dr. C.G. Uragoda which remains the only authoritative work of its nature and is being used as an essential reference around the world. The Council very reluctantly accepted the request of Prof. Janaka de Silva to resign from the post of Editor of the CMJ, due to his heavy and increasing commitments. On behalf of the entire medical profession I
place on record our deepest gratitude for the immeasurable contribution he made to advance the CMJ to the position of being one of the foremost medical journals. The Council unanimously conferred him with the title of Emeritus Editor. Thank you so much, Janaka. Finally I must mention that the SLMA Council and some of the members have been engaging in very enlightening, sometimes impassioned, discussions on our partnerships and relationships with the corporate sector, particularly their promotional and ethical aspects. As times and the equations keep altering we also need to review our own positions on these partnerships, maintaining our core values, just as much as the philosophies and practices of our partners in the corporate sector inevitably undergo change. This is still a work in progress.
Our members, in fact everyone, will be pleased to hear that we plan to reprint the masterpiece “History of Medicine..”, the monumental piece of work by Dr. C.G. Uragoda which remains the only authoritative work of its nature and is being used as an essential reference around the world.
SLMANEWS
April/May, 2014
Sri Lanka Medical Association Meeting with President on Monday 24 March 2014
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on communicable diseases cause a large number of untimely deaths annually. Many individuals, who are at their prime, fall sick due to such diseases leading to a great loss of productivity. As your Excellency is aware, such illnesses and deaths contribute significantly to poverty and also hinder the development process which is currently in progress. At family level this situation badly affects children’s education and well being. There are several scientifically established strategies to prevent such diseases and their negative consequences, some of which are already being implemented by your government. In this context a delegation from the Sri Lanka Medical Association (SLMA) met H.E. the President Mahinda Rajapaksa on 24th March 2014 to express support for government action on addressing the harms of
tobacco, alcohol and other drug use. His Excellency was briefed that according to available information, a large number of non communicable diseases are caused by drugs substances as alcohol, tobacco and illegal drugs. This results in major costs that the government has to bear and diverts resources which can be better used in the development process. It was also pointed out that effectively addressing the use of such substances is very popular with the people. For example, The National Authority on Tobacco and Alcohol Act, which was established through the leadership of His Excellency, was one of the most popular legislations in the country. Through this Act many evidence based strategies to reduce the initiation and use of tobacco and alcohol has been implemented. Some of them are discontinuation of advertising and sponsorships, prohibition of
vending machines, implementation of health warnings and banning smoking in public places. SLMA played a prominent role in developing and drafting this act, over several years. Some factors leading to consumption of drugs and alcohol such as psychological conditioning was discussed by the delegation. The President of SLMA, Dr Palitha Abeykoon took the opportunity to invite His Excellency to be the Chief Guest at the inauguration of the 127th Anniversary International Medical Congress of SLMA which will take place on the Tuesday 15th July 2014 at the BMICH. The President graciously accepted the invitation of SLMA. The SLMA delegation also brought to His Excellency’s attention the issue of the Gazette notification issued on 31st January 2014 by the Secretary Ministry of Higher Education pertaining to rule 31 of The Universities Act No 16 of 1978. The SLMA informed the President that though he had instructed the relevant Gazette to be withdrawn no action had been initiated to do so. His Excellency informed the SLMA that he would immediately facilitate a meeting with the Secretary Higher Education for the SLMA and the medical profession in general to discuss the issue. Contd. on page 04
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April/May, 2014
The World Health Day 2014
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he World Health Day, celebrated on the 7th April every year marks the founding of the World Health Organization (WHO) in 1948. It provides an opportunity for the WHO to draw attention to public health issues of global interest and significance that warrants such special consideration. This years’ World Health Day was based on Vector Borne Diseases (VBD) with the slogan “Small bite, big threat”. The Sri Lanka Medical Association (SLMA) organized a multitude of programmes to raise awareness and address this emerging public health issue during the first week of April leading up to the World Health Day. A collaborative activity on VBD, organized by the Communicable Diseases Committee (CDC) of the SLMA in partnership with the WHO and the Ministry of Health was held on the 3rd of April 2014 at the SLMA Auditorium. It was under the theme “Vector Borne Diseases: Where are we? Where do we want to be? How do we get there?” The programme comprised of 2 symposia followed by a panel discussion addressing the current status, future trends and preventive measures of VBD in Sri Lanka and focused on major VBDs such as Dengue, Chikungunya, Lymphatic filariasis, Japanese encephalitis, Leishmaniasis, Rickettsioses and Malaria. It was conducted under the patronage of Dr. Palitha Abeykoon,
President of SLMA and Prof. Jeniffer Perera, Chair of CDC and President Elect of SLMA. A congregation of speakers including clinicians, public health specialists, epidemiologists, microbiologists, parasitologists, health administrative officials as well as stakeholders from non-medical sectors such as veterinary researchers participated in the programme. Dr. Firdosi Rustom Mehta, World Health Representative (WR) for Sri Lanka, Dr. Palitha Mahipala, Director General of Health Services, Dr. Sarath Amunugama, Deputy Director General of Public Health Services and Dr. Kamini Mendis, Independent Consultant for Malaria and Tropical Medicine for WHO were among the many resource persons who participated in the programme.
Medical Research Iinstitute; Dr. Dilhani Samarasekera, Filariasis Control Programme; Dr. Nilupa Dissanayake, Veterinary Research Institute, Peradeniya; Dr. Yamuna Siriwardene, Department of Parasitology, Faculty of Medicine, Colombo; Prof. S. A. M. Kularatne, Department of Medicine, Faculty of Medicine, Peradeniya; Prof. Deepika Fernando, Department of Parasitology, Faculty of Medicine, Colombo; Dr. Risintha Premaratne, Director, Malaria Control programme; Prof. Mirani Weerasuriya, Department of Parasitology, Faculty of Medicine, Ruhuna; Dr. Deepa Gamage, Consultant Epidemiologist, Epidemiology Unit; Dr. Samitha Ginige,
The other resource persons were;
Dr. Lakkumar Fernando, Consultant Paediatrician, General Hospital-Negombo; Dr. Sunethra Gunasena, Consultant Virologist,
Prof. Kamini Mendis, Prof Jennifer Perera, Dr.Palitha Abeykoon, Dr Lucian Jayasuriya Lighting the oil lamp
Guests eagerly listening to the discussion
Contd. on page 05 Contd. from page 03
Sri Lanka Medical Association meeting ... As a result of this Presidential intervention the SLMA met the Secretary Ministry of Higher Education on 24th March 2014 and presented the concerns of the entire medical community to him. As a result of this discussion the Secretary Ministry of
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Higher Education by letter dated 27th March 2014 informed the SLMA that the necessary amendments have been done as per the request of the medical community and Gazette has been sent to the legal draftsman for follow up action.
The SLMA places on record it’s sincere thanks to His Excellency the President for his action to resolve this issue which could have seriously affected the quality of training and practice of medicine in Sri Lanka.
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roceedings of the symposium on Melioidosis held on 27th March 2014 at SLMA Auditorium. The resource persons were Dr. Panduka Karunanayake and Dr. Enoka Corea, Senior Lecturers in Medicine and Microbiology, respectively, Faculty of Medicine, Colombo, and Dr. Samitha Ginige, Consultant Epidemiologist, Ministry of Health.
Introduction
Melioidosis, caused by the saprophytic Gram-negative bacillus Burkholderia pseudomallei, is classically
April/May, 2014
MELIOIDOSIS characterized by pneumonia and multiple abscesses, with a mortality rate of up to 40%. It is an important cause of community-acquired sepsis in South-East Asia and Northern Australia. Its known global distribution is expanding, a reflection of improvements in diagnostic microbiology and increasing numbers of cases in travellers and returning military personnel. B. pseudomallei has been classified by the Centers for Disease Control and Prevention as a category B bioterrorism agent, resulting in increased research and understanding
Figure 1. Safety pin appearance
of melioidosis.
Contd. on page 06
Figure 2. Worldwide distribution of melioidosis.
Contd. from page 04
The World... Consultant Epidemiologist, Epidemiology Unit; Dr. Hasitha Perera, Deputy Director, Dengue Control programme; Dr. Ananda Amarasinghe; Consultant Epidemiologist, Epidemiology Unit; Prof. W. Abeywickrama, Department of Parasitology, Faculty of Medicine, Kelaniya; Prof. A. Pathmeswaran, Department of Public
Health, Faculty of Medicine, Kelaniya; Dr. Suneth Agampodi, Department of Community Medicine, Rajarata University and Prof. Senaka Rajapakse, Department of Medicine, Faculty of Medicine, Colombo. The programme was attended by over 100 participants from both medical and non-medical sectors. During
the programme, several key issues faced regarding combating VBDs were brought to light with the contribution of the major stakeholders in this regard in the country and the region. It concluded with the gist of the discussion and the recommendations made, to be compiled and shared with all relevant authorities.
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MELIOIDOSIS Causative organism
This is caused by Burkholderia pseudomallei, which is an aerobic, Gram negative motile bacillus found in water and moist soil. It is able to produce endotoxins, exotoxins and tissue digesting enzymes. Organism gives bipolar staining with methylene blue stain, depicting a safety pin appearance. (Figure 1) Epidemiology
Melioidosis was first identified in Burma in 1911 and named as Whitmore’s Disease. It became prominent during the Vietnam War and was referred to as the "Vietnam time-bomb". Currently melioidosis is endemic in South-East Asia, China, the Indian subcontinent, Thailand and parts of Australia. Multiple cases have also been described in the Caribbean, Middle East, South America, Singapore and Taiwan.The situation in Africa is still uncertain (Figure 2). The disease was first reported in Sri Lanka in 1927. First locally confirmed case was reported in 2005. Sri Lanka is considered as a non-endemic country for melioidosis, even though the country is situated in the endemic belt and has similar weather and environmental conditions. This low incidence may be due to under-diagnosis and under-reporting contributed to by rapid fatality, non specific clinical presentation, low awareness and limited diagnostic facilities. Between 1927 and April 2014, 37 confirmed, culture positive cases acquired in Sri Lanka have been described, two in tourists visiting Sri Lanka and one in a migrant to Norway. Among the 34 indigenous cases there were 10 deaths. In endemic areas, 5-20% of agricultural workers have antibodies indicating exposure to the pathogen. Outbreaks and cases typically occur during the wet season or after periods of heavy rainfall in areas with high hu-
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midity and high temperature. Burkholderia pseudomallei is normally found in soil and water and a history of contact with soil or surface water is therefore almost invariable in patients with melioidosis. Melioidosis is not a highly contagious disease.
Figure 3. A CT showing a left sided psoas abscess from a patient with melioidosis
The most common way of acquiring infection is through contact of skin abrasions with contaminated soil or water. Aspiration or ingestion of contaminated water and inhalation of dust from soil are also responsible for transmission. Sexual and vertical transmission may also be rarely possible. Person-to-person spread has been described but is extremely unusual. Contaminated ground water was implicated in an outbreak in northern Australia. Severe weather events such as flooding, tsunamis and typhoons are also implicated. There is a clear association with increased rainfall with the number and severity of cases. The single most important risk factor for developing severe melioidosis is diabetes mellitus as 60% of patients in Sri Lanka are diabetics. Other risk factors include excessive alcohol consumption, chronic renal disease, and chronic lung disease. Farmers are at an increased risk due to the occupational exposure. (In Thailand 81% of the patients with melioidosis were rice farmers or their family members). Disease manifestations
The incubation period may be as short as 1-3 days, but latent infec-
tions can occur after months to years. Most infections are asymptomatic. Clinical disease can manifest as an acute pulmonary infection which is the commonest manifestation. Localised disease (abscess or granulomatous lesion) and generalised septicemia is seen. Neurological disease is rare. Clinical diagnosis of melioidosis is difficult because there are no specific clinical presentations. According to the ICD 10 classification it may present as acute, sub acute / chronic or as other forms. Acute fulminant melioidosis
The pathological hallmark of acute fulminant melioidosis is acute pyogenic necrotizing inflammation with a case fatality rate of approximately 30%. The majority has an acute fulminant course with high fever, sepsis, pneumonia, gastroenteritis and is rapidly fatal. Differential diagnosis for acute fulminant course can be any community acquired sepsis due to other virulent bacteria such as sepsis due to meningococci, S. aureus, necrotizing fasciitis, severe pneumonia. Some have a less acute progressive course. Their clinical presentation may be as a ‘typhoidal illness’ with swinging fever and weight loss; multiple lung abscesses; liver, spleen, skin, Contd. on page 07
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Contd. from page 06
MELIOIDOSIS subcutaneous tissues abscesses which may coalesce to form larger abscesses; Jaundice; diarrhea; confusion or stupor; and Kussmaul breathing. Poor prognostic factors are shock, absence of fever, leucopenia, azotemia, and abnormal LFTs. Differential diagnosis for less acute progressive course would be typhoid, brucellosis, leptospirosis, malaria, and infective endocarditis. Sub acute and chronic melioidosis
There is a pyogenic or granulomatous inflammation. Histology shows central zones of necrosis with purulent or caseous material, hence could be mistaken as tuberculosis. This form of melioidosis usually presents as single or multiple abscesses. Usual sites are lung, skin, subcutaneous tissues, lymph nodes, bone, joints, liver, spleen, brain, and psoas muscle. (Figure 3). Other forms
These include reactivation of latent infection with immunosuppression, suppurative disease in lower urogenital tract and encephalomyelitis involving the brain stem. Diagnosis
Diagnosis on clinical grounds alone is not possible. A definitive diagnosis is made by culturing the organism from any clinical sample, because the organism is not part of the normal human flora. According to the clinical presentation blood, pus, sputum, urine or any other specimen can be taken. However, it may be difficult to identify the culture due to unfamiliarity of laboratory staff, variable colony morphology and screening test results. Typically, the colonies are pin-point at 24h and give rise to white opaque colonies with beta haemolysis in the well. The colonies gradually become umbonate with reduction of the underlying blood agar. Colonies on MacConkey are pin-point at 24h and become bright pink, lactose posi-
tive after 48h. The ‘characteristic’ wrinkling appearance takes 4-7 days to appear. Some colonies show serous or mucoid variants that do not wrinkle. Gram stain shows the typical safety pin appearance but it may take 48 hours to develop. Oxidase test is usually positive but may be weak. The API commercial identification system may often give mis-identification. Therefore positive identification requires the use of PCR or MALDI-TOF in a reference laboratory. Antibody detection by indirect haemagglutination is not sensitive or specific enough for definitive diagnosis. Treatment
Treatment should be done under 3 categories which are supportive, surgical and specific treatments. Volume support, resuscitation of shock and glycemic control can be done as supportive treatment. If patient is having an abscess surgical drainage shoud be performed. The specific treatment of melioidosis is divided into two stages, an intravenous high intensity phase and an eradication phase to prevent recurrence. Intensive phase should be treated with IV antibiotics. Preferred antibiotics are high dose ceftazidime (+/- cotrimoxazole), carbapenems, coamoxiclav or a combination of chloramphenicol, doxycycline, and cotrimoxazole. Following treatment of the acute disease, it is recommended that eradication (or maintenance) treatment with oral antibiotics to be used for 20 weeks to reduce the rate of recurrence. Coamoxiclav, cotrimoxazole, or a combination of cotrimoxazole and doxycycline or chloramphenicol, doxycycline and cortimoxazole are preferred. Chloramphenicol is no longer routinely recommended for this purpose.High dose ceftazidime is the only antibiotic that has proven value in mortality reduction. It is given as 40
mg/kg for 8 hourly or 19 mg/kg bolus followed by a 3.5mg/kg/h infusion. Other beta lactams, aminoglycosides, fluoroquinolones and macroloides are ineffective in melioidosis. Control and Prevention
Melioidosis is usually acquired from the environment. Person-to-person transmission is unusual and it is, therefore, not contagious. In endemic areas, people (rice-paddy farmers in particular) are advised to avoid contact with soil, mud and surface water where possible and provision of safe drinking water is important. A vaccine is not yet available. Pitfalls in the diagnosis of melioidosis
A specific diagnosis of melioidosis requires awareness on the part of the clinicians and the existance of a laboratory capable of isolating and identifying Burkholderia pseudomallei, a luxury not available in most rural tropical areas, and therefore the disease burden is likely to remain unknown for the foreseeable future. Pitfalls can occur at 3 levels, namely, epidemiological, clinical and laboratory settings. In epidemiological level, as the disease mainly affects the rural populations with poor healthcare where diagnostic facilities are also not easily available, some may die before reaching the hospital undiagnosed. Lack of awareness of the disease and widely variable clinical presentations can lead to underdiagnosis at clinical level. In the laboratory setting, an unusual level of laboratory expertise is needed to identify the pathogen as it has unusual and varied colony appearances and biochemical reactions and does not conform to the text book descriptions even at screening stage. Compiled by Dr. Viraj Thilakarathna, Research Assistant & Professor Jennifer Perera, Chairperson, Subcommittee on Communicable Diseases, Sri Lanka Medical Association.
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Treating patients with tropical infectious diseases in Sri Lanka – the need for innovative research Professor Senaka Rajapakse Project Lead, Tropical Medicine Research Unit Department of Clinical Medicine, Faculty of Medicine, University of Colombo
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ropical infectious diseases cause considerable morbidity and mortality in Sri Lanka, and place a significant burden on the health care system of the country. Many vector-borne diseases and zoonoses are prevalent throughout the country and contribute to varying extents towards the disease burden. Dengue, rickettsial infections, leptospirosis, filariasis, and Japanese encephalitis, remain important diseases; of late, leishmaniasis has been an emerging challenge. Historically, malaria was one of the most important diseases. It was nearly eliminated in the 1960s, however complacency resulted in a resurgence of the disease. Thanks to a concerted and intensive elimination spearheaded by the Anti-Malaria Campaign, indigenous malaria is now eliminated, and the only cases detected since October 2013 are imported ones. The threat of reintroduction of malaria still remains, and vigilance continues. Several tropical infectious diseases continue to cause deaths, albeit in a small proportion of patients. For example, severe leptospirosis results in multiorgan failure, and no specific treatment for the severe icterohaemorrhagic form exists; there is even controversy whether antibiotics alter outcome. In extreme forms, dengue causes a relentlessly progressive, severe illness which culminates in death. The same is true for several other tropical infections. The thrust of control programs has been to reduce incidence, which thus results in reducing morbidity and deaths; elimination of these diseases is the ultimate aim, although this is not universally possible. Several key strategies have tradition-
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ally been employed aimed at reducing the incidence and morbidity of these diseases, viz; control of vectors in the case of vector borne diseases, minimization of exposure risk in the case of both vector borne diseases and zoonoses, surveillance and case detection with early treatment, and improvements in clinical management protocols. While considerable interest has been generated with regards to vaccine development, effective vaccines are not available for many major tropical infections. What is most striking is the paucity of research and development into targeted therapies for tropical diseases. An interesting comparison can be made with HIV infection. Twenty years ago, AIDS was a deadly illness. However, AIDS struck developed countries; and very quickly became one of the highest priorities for therapeutics research and development, with huge funding being pumped in. As a result, HIV is now a treatable illness. In comparison, therapies for certain tropical infectious disease which affect predominantly developing countries have remained unchanged for many years, with only small advances made. While management protocols of many tropical diseases have been strengthened, these protocols and guidelines are based on evidence generated elsewhere. International funding agencies traditionally focus on preventive strategies for tropical diseases, and funding is readily available for this purpose. Vector control and early case detection strategies have been at the forefront of these programs, and these strategies have been very effective in combating diseases like malaria. However, from a clinical standpoint, funding is inadequately directed towards developing specific treatment strategies. In developing countries such as Sri Lanka, funding is received primarily for implementation of treatment strategies already tried and tested elsewhere.
Despite concerted efforts to reduce its incidence, dengue remains a massive problem, hitting the country in waves of epidemics periodically. Dengue is a high profile illness, affecting more affluent populations in urban areas as well as rural areas alike; the resultant media exposure has generated a lot of interest in refining management protocols. Focused efforts by control programs and clinicians in the Ministry of Health have resulted in refinement of management guidelines, and implementation of these guidelines throughout the country. This has led to better clinical management countrywide, and a large reduction in case fatality rates. Conditions like leptospirosis are neglected, to the extent that they do not even stand out as neglected diseases, and are a low priority for funding. Nonetheless leptospirosis causes clinical disease in large numbers of patients each year, mostly farmers in rural areas. Although many people die of leptospirosis each year, deaths due to leptospirosis do not reach the headlines, primarily because of the demographic characteristics of the patients – in simple terms, patients dying of leptospirosis are poor farmers in villages. The economic impact resulting from this is huge, however, as these are productive individuals in their prime of life. Rickettsial infections are on the rise, and are an important cause of acute febrile illness. Significant morbidity occurs as a result of these infections, and mortality is probably underestimated. As mentioned earlier, funding from international agencies is focused on control strategies – vector control, prevention of exposure, surveillance and early case detection, and prophylaxis. There is no doubt that that implementation of tried and tested control and case management strategies are of utmost importance; Contd. on page 09
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Treating... however there is also an urgent need for innovative research regarding clinical management strategies, in particular to combat the most severe and potentially fatal manifestations of some of these diseases. Research into clinical management should focus on three areas; rapid diagnostics, prognostic or predictive markers, and targeted interventions. Rapid diagnosis is important in these conditions, in order to guide clinicians in implementing specific therapy, and prioritize limited resources such as ICU beds. However rapid diagnosis remains a challenge for most tropical infections. Investigations are limited, and are expensive, and their sensitivity and specificity and predictive values in the local context are not clearly known. Over-reliance on traditional gold standards has resulted in difficulties in diagnosis. For example, for leptospirosis, MAT is considered a practical gold standard, however MAT detects both IgM and IgG, and does not reliably differentiate acute from past infection. There is a need to develop simple, inexpensive and reliable rapid diagnostic tests for common tropical infectious diseases, and validate their diagnostic accuracy in the local context, using methods such as Bayasian latent class modeling. The latter assumes that no single test is a gold standard, and that all tests are imperfect. Many tropical infectious diseases have a wide spectrum of clinical manifestations. Many infections are asymptomatic or mild febrile illnesses. A variable proportion develop moderate to severe disease, and a small number develop extremely severe disease. There are currently few useful biochemical markers to predict which patients will develop severe disease. There is a need for further research directed at identifying predictive markers which can be utilized in hospitals with limited facilities. These would guide clinicians in identifying patients
likely to develop severe illness, in order for them to institute higher levels of monitoring and intensive care early on.. Most importantly, there is little innovative research on specific targeted therapies for many of these diseases. The case of malaria is different; a disease where resistance has evolved rapidly, and emergence of resistance has disastrous effects, there are many clinical trials of new antimalarials. The situation is not the same for other diseases. A small group of patients develop extreme manifestations of certain tropical diseases, and these patients die. Dengue is the best example. While refinement of clinical management protocols for dengue and standardization of these protocols across the hospitals in the country have reduced case fatality rates due to dengue, a tiny proportion of patients still succumb to severe dengue. It is postulated that these cases represent a very severe form of disease, brought on by a massively deranged host response together with variations in virulence of the infecting strain. Very little is known about this, and there is no specific treatment. And yet, there is very little research searching for targeted therapies. We are complacent to accept evidence of lack of benefit of treatment strategies, and we do not look for new treatments. There is over-reliance on published data discounting the effects of targeted immunological therapies. The controversy regarding corticosteroids in dengue shock syndrome is a good example. It is generally believed that corticosteroids have no place in the treatment of dengue; the guidelines do not recommend their use, and there is little high quality evidence suggesting that they are of benefit. And yet, have we critically appraised the evidence to determine whether we can confidently state that corticosteroids do not work? Lack of evidence of benefit does not necessarily mean that there is lack of benefit; it simply means that the evidence is not
there. The evidence of lack of benefit with corticosteroids comes from a few small studies, done a long time ago, with poor methodological quality, and mainly in children. While it is true that there is a Cochrane Review on the subject, this review is only as strong as the evidence it reviews, and that evidence is sketchy at best. Over-reliance of this poor quality evidence has discouraged researchers from investigating further into the potential benefits of corticosteroids in extreme cases of dengue, and there is no recent robust RCT examining this. In the absence of such an RCT, there are two schools of thought; there are those who violently oppose the use of steroids, claiming that there is no evidence and that it is not in the guidelines, and those who continue to administer corticosteroids to patients with severe dengue in the hope that it will work as rescue medication. Neither of these policies are healthy. The only way to prove or disprove the benefit of a therapy is through a well designed randomized controlled trial. There are many other examples for other diseases. Many tropical infections result in a grossly deranged immune response which is likely to be the cause of severe clinical illness. While there is an enormous amount of research into therapies for severe sepsis, there is little ongoing research into therapies for extreme cases of tropical infections. Research is primarily driven by funding, and is there lack of funding because these diseases affect the rural poor in third world countries? A paradigm shift is needed. We need to take charge of our own diseases, and build up our own evidence base. This should go hand in hand with strengthening our management protocols through wide exposure and training of doctors. The need for research into rapid diagnostics, prognostic markers, and specific therapies is great. Funding agencies should take cognisance of this, and support local researchers in these fields.
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Food consumption in Sri Lankan adults and epidemic of non-communicable diseases Dr. Ranil Jayawardena MBBS (Colombo), MSc (Glasgow), PhD (Queensland), ARNutr (UK), ARNutr (Australia) Clinical Nutritionist
W
ith recent economic development, urbanization and changes in lifestyle patterns, Sri Lanka is experiencing a nutrition transition with the coexistence of under-nutrition and obesity associated non-communicable diseases (NCDs). A high prevalence of iron deficiency anemia among pregnant women, and subclinical vitamin A deficiency, stunting and wasting among preschool children, are still major public health problems. On the other hand, the prevalence of non-communicable diseases such as diabetes and obesity have increased by few folds during the last two decades. Sri Lanka Diabetes and Cardiovascular Study (SLDCS) reported a high prevalence of diabetes mellitus with one in every five adults aged above 20 years having either diabetes or pre-diabetes. Furthermore, SLDCS revealed the prevalence of hypertension, metabolic syndrome and dysglycaemia were nearly 20%, 25% and 20%, respectively. In the Sri Lankan context, diet-related chronic diseases currently account for an estimated 18.3% of total mortality and 16.7% of hospital expenditure. Although Sri Lanka is a developing country, it has recorded 524 deaths per 100 000 for mortality from cardiovascular and cerebrovascular disease, a figure which is considerably higher than the rate in many affluent countries such as the UK (427), the USA (397), Australia (308) and France (205). Despite Sri Lanka having a very high prevalence of NCDs and associated mortality, little is known about the causative factors. Although these diseases are due to interaction of
genetic and several environmental factors, it is widely believed that the NCD epidemic in the country could be strongly associated with unhealthy dietary habits. Food consumption patterns play an essential role in the maintenance of health and wellbeing at both individual and population levels. Food products supply energy and essential macro- and micronutrients; however, over- or under-nutrition has the potential to cause serious health consequences. A national-level dietary survey has several important functions and provides valuable information. Survey data are also helpful to monitor nutritional status, observe dietary practices and study the relationships between diet and disease. In many countries, periodical national level diet and nutrition surveys are been conducted. For instance; National Diet and Nutrition Survey UK 2008-2012 and Nutritional Intake in India 2004-2005.Unfortunately, there are no a large scale data on dietary intake in Sri Lanka; we have only a food balance sheet which is the only source of getting dietary data, but it is not at the consumption level; it gives the idea about country level food supply. This article is mainly based on a recent publication on dietary patterns of Sri Lankan adults [“Food consumption of Sri Lankan adults: an appraisal of serving characteristics. Public Health Nutrition. 2013 Apr;16(4):6538.”].
1. On average, Sri Lankan adults consumed over 14 portions of starch/d; starchy foods were consumed by all study participants; over 88% met the minimum daily recommendations. Importantly, nearly 65% of adults exceeded the maximum daily recommendation for starch (11 portions/d) and a considerable proportion consumed larger numbers of starch servings daily, particularly men. More than 12% of men consumed >25 starch servings/d. 2. Mean daily intake of fruit (0.43) and vegetable (1.73) portions was well below minimum recommendations (fruits >2 portions/d; vegetables >3 portions/d). The total fruit and vegetable intake was 2.16 portions/d. Only 11.6%, 2.1% and 3.5% of adults consumed the minimum daily recommended servings of vegetables, fruits and fruits and vegetables combined, respectively. Six out of ten adult Sri Lankans sampled did not consume any fruits. 3. Milk and dairy consumption was extremely low; over a third of the population did not consume any dairy products and less than 1% of adults consumed 2 portions of dairy/d. 4. A quarter of Sri Lankans did not report consumption of meat and pulses. Regarding protein consumption, 36.2% attained the minimum Sri Lankan recommendation for protein; and significantly more men than women achieved the recommendation of ≥3 servings of meat or alternatives daily (men 42.6%, women 32.8%; P,0<05).
Major findings Table 1: Comparison of food intake of Sri Lankan adults with national and international food based dietary recommendations Food groups
Average intake of portions
National recommendations
International recommendations
Starch
14
6-11
6-11
Fruits
0.4
2-3
2-4
Vegetables
1.7
3-5
3-5
Fruits and vegetables
2.1
≥ 5
≥5
Meat and pulses
2.8
3-4
2-3
Dairy
0.4
1-2
2-3
Contd. on page 11
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April/May, 2014
Contd. from page 10
Food... A typical Sri Lankan staple meal
An average Sri Lankan adult consumes large portion of rice with little vegetables and meat or alternatives. Figure 1 showsa graphical representation of a typical rice meal.
Figure 1: A typical Sri Lankan rice meal
Figure 2: Proposed sample plate model
Possible consequences of Sri Lankan food consumption pattern
It is not possible to conclude any cause and effect relationship from a cross-sectional data. In fact, it is not feasible to conduct a randomized controlled trial on food consumption patterns and associated diseases. Our data showed that there is a clear unbalanced diet among Sri Lankan adults compared to both local and international dietary recommendations (Table 1). There is empirical evidence on the protective role of fruits and vegetables in NCDs. High fruit and vegetable intake may be inversely associated with diabetes incidence. A diet rich in fruits and vegetables offers the possibility of health benefits beyond that of a protective role against NCDs. Unfortunately, less than 5% of Sri Lankan adults achieve the minimum daily recommendations. Our unpublished qualitative research indicates that vegetable eating as
curry hinders the higher consumption of vegetables. Moreover, a strong spicy flavored curry facilitates higher consumption of starchy foods limiting vegetable consumption. And some of common dishes are not vegetables such as potato curry, ‘polsambol’ and dhal curry. A high-carbohydrate meal leads to negative metabolic consequences such as hyperinsulinaemia, high serum triglycerides and low HDLcholesterol levels. Most Sri Lankans consume the largest starch portion for dinner, which may cause postprandial hyperglycaemia and hypertriacylglycerolaemia. Long term consumption of high carbohydrate meals without much physical activities may lead to obesity, insulin resistance and finally diabetes. More than a fifth of Sri Lankan adults are dysglycaemic; the high consumption of carbohydrates may be associated with the diabetes epidemic in the country. It is not the type of the carbohydrate, all carbohydrates contains same amount of calorie and they convert to glucose sooner or later. Indeed, unrefined carbohydrates (unpolished rice, Kurakkan, atta flour) should be a healthy choice for many of us but the most important dietary measure for preventing this NCD epidemic is consumption of the recommended amount of carbohydrate portion irrespective of the type of the starch. Although average meat and pulses intake was satisfactory in this population, a considerable portion did not consume any meat or alternative. Pulses were the main source of protein, mainly as dhal, the most common curry in the local context, and boiled pulses eaten for breakfast. There is a marked nutritional difference in consuming meat or alternative and pulses as protein sources. Carbohydrates are the main nutrient in all type of pulses whereas protein is the main nutrient in meat and alternatives. Therefore, consumption
of pulses invariably provide large amount of non-protein, starchy calories. Dairy products provide valuable nutrients such as calcium, proteins, vitamins and other minerals. Several epidemiological and intervention studies reveal that dairy consumption is inversely associated with obesity, osteoporosis, diabetes and metabolic syndrome. Dairy intake in the present sample was substantially lower than the Sri Lankan recommendations; over a third of the population did not consume any dairy products and only 5% reached minimum levels. The main reason behind the low dairy consumption could be that dairy products are unaffordable; their price is high mainly due to the lack of local production and their consumption depends largely on imported milk powder. A take home message
Although we have very limited data on our food consumption patterns, it is evident that high carbohydrate meals and low vegetable consumption could be an associated risk factor for current NCD epidemic. Therefore, clinicians should provide simple dietary advices to encourage vegetable intake, while controlling starchy foods. Internationally, “plate model” is considered as a more practical food based dietary approach to guide healthy eating. Figure 2 shows a sample plate model. In this model plate, first quarter is filled by fresh vegetable (mixed salad/ mallum), the second quarter is by a vegetable (bean curry), third quarter should include protein (meat or meat alternative or pulses) and the last quarter is rice. Reference R. Jayawardena, N.M. Byrne, M.J. Soares, P. Katulanda, A.P. Hills. Food consumption of Sri Lankan adults: an appraisal of serving characteristics Public Health Nutrition. 2013 Apr;16(4):653-8.
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April/May, 2014
Amendment to Gazette no 1847/56 by Ministry of Higher Education
T
he gazette no 1847/56 by Ministry of Higher Education was of deep concern for all medical professionals as many felt that it would have grave implications on the quality of medical education and thus, the quality of healthcare in Sri Lanka in the future. As such, a meeting of all Colleges and Associations was convened by the SLMA on 25 February 2014 and a letter was sent to H.E. the President thanking him for initiating action to rescind the subject gazette. This letter was signed by all participating presidents of Colleges and Associations. Subsequently the SLMA had a meeting with H.E. the President on 24 March 2014 at Temple Trees mainly to discuss issues pertaining to the highly prevalent tobacco and alcohol use in the country. During the discussion the Gazette No 1847/56 was also raised and H.E. the President directed the Secretary, Ministry of Higher Education to meet a delegation of doctors from the SLMA and SLMC to resolve the matter expeditiously. As a result representatives of SLMA and SLMC met the Secretary, Ministry of Higher Education. The implications of the gazette notification were explained to the Secretary, Higher Education who
12
agreed to amend rule 31 published in Gazette No 1847/56. We also wish to place on record the initial role played by the President, College of Physicians of Sri Lanka Dr Kirthi Gunasekera in initiat-
ing the convening of the meeting on 25 February 2014. The SLMA wishes to thank all professional colleges and associations for their support on this issue which would help maintain quality and standard of medical education and practice in Sri Lanka.
SLMANEWS
April/May, 2014
13
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April/May, 2014
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