Prevalence and predictors of default with tuberculosis treatment in Sri Lanka

The objectives of this study were to determine the default rate and predictors for default in patients undergoing antituberculosis treatment. All consenting patients with a confirmed diagnosis of tuberculosis admitted to a unit of the Chest Hospital, Welisara, Sri Lanka from April 2001 to April 2002 were recruited into the study. Personal and follow-up data were recorded on a pre-tested questionnaire and data sheet, respectively. A defaulter was defined as a patient who interrupted treatment for more than two consecutive months before the end of the course of treatment. Of the 892 patients recruited, 770 were new cases and 122 were relapses. The default rates were 10.3% (95% CI: 8.3-12.6) and 30.3% (95% CI: 22.7-38.1) among new cases and retreatment cases, respectively, during the intensive phase of treatment and 10.9% (95% CI:8.7-13.3) and 16.5% (95% CI:9.7-25.5), respectively, during the continuation phase. Ninety percent of new cases and 94% of retreatment cases were sputum positive for acid-fast bacilli at diagnosis. Two hundred five patients (22.9%) defaulted on treatment (95% CI: 20.3-25.8). Using logistic regression analysis, regular smokers (OR = 1.9), smear positive patients who were previous defaulters (OR = 2.4) and patients having involvement of less than 3 zones of the lung on chest x-ray (OR = 0.5) were more likely to default compared to patients who did not smoke regularly, smear positive patients who had relapsed after taking the full course of treatment and patients with less lung involvement. Skilled and unskilled laborers were the most likely occupation to default (OR = 2.03) followed by sales personnel (OR = 2.00), compared to the unemployed or home-bound. A high default rate of 23% was observed among the study participants. Smoking status, occupation, history of treatment compliance of the patient, and extent of lung involvement were predictors for defaulting.

Fetal effects of environmental exposure of pregnant women to organophosphorus compounds in a rural farming community in Sri Lanka

BACKGROUND

The possible deleterious effects of low-grade, chronic environmental and occupational exposure to organophosphorus compounds (OPCs) are not well documented.

OBJECTIVE

To investigate the possible effects of low-level, chronic exposure of pregnant mothers to OPCs on the fetus by measuring OPC levels, and using markers of OPC exposure, oxidative stress and oxidative tissue damage.

METHODS

Toxicity was assessed by measuring (i) OPC levels in breast milk and plasma from maternal and cord blood using gas chromatography, (ii) maternal and fetal butyrylcholinesterase (BChE) activity using inhibition assays, (iii) antioxidant status of the fetus using superoxide dismutase activity assays, (iv) oxidative stress in the fetus by determining malondialdehyde (MDA) concentrations, and (v) examining for fetal DNA fragmentation using electrophoresis. Samples were obtained from consenting mothers living in a farming community in southern Sri Lanka at the end of the pesticide spray season (study group) and just before the commencement of the spray season (in-between spray season; control group).

RESULTS

Organophosphate residues were detected in only two subjects (chlorpyrifos in maternal and cord blood of one during the spray season and dimethoate in breast milk of another during the in between spray season), but the test employed was capable of only detecting concentrations above 0.05 mg/l. However, cord blood obtained during the spray season showed significant inhibition of BChE activity, increased oxidative stress and more DNA fragmentation when compared with cord blood obtained during the in-between spray season.

CONCLUSIONS

Inhibition of cord blood BChE activity indicates fetal exposure to organophosphorus compounds during times when there is a high probability of environmental drift. This provides a plausible explanation for the increased oxidative stress and high DNA fragmentation in the fetus. Long-term outcomes of such exposures are unknown.

Schizophrenia treatment in the developing world: an interregional and multinational cost-effectiveness analysis

OBJECTIVE

Schizophrenia is a highly disabling disease and is costly to treat. We set out to establish what are the most cost-effective interventions applicable to developing regions and countries.

METHODS

Analysis was undertaken at the level of three WHO subregions spanning the Americas, Africa and South-East Asia, and subsequently in three member states (Chile, Nigeria and Sri Lanka). A state transition model was used to estimate the population-level health impact of older and newer antipsychotic drugs, alone or in combination with psychosocial intervention. Total population-level costs (in international dollars or local currencies) and effectiveness (measured in disability-adjusted life years averted) were combined to form cost-effectiveness ratios.

FINDINGS

The most cost-effective interventions were those using older antipsychotic drugs combined with psychosocial treatment, delivered via a community-based service model (I$ 2350-7158 per disability-adjusted life year averted across the three subregions, I$ 1670-3400 following country-level contextualisation within each of these subregions). The relative cost-effectiveness of interventions making use of newer, "atypical" antipsychotic drugs is estimated to be much less favourable.

CONCLUSION

By moving to a community-based service model and selecting efficient treatment options, the cost of substantially increasing treatment coverage is not high (less than I$ 1 investment per capita). Taken together with other priority-setting criteria such as disease severity, vulnerability and human rights protection, this study suggests that a great deal more could be done for persons and families living under the spectre of this disorder.

Impact of low-level exposure to organophosphates on human reproduction and survival

Despite their widespread and longstanding use for the public good, organophosphate (OP) pesticides have led to many adverse effects on human health. Environmental exposure to OPs and adverse reproductive outcomes in men and women working on or living near farms are increasingly reported worldwide. The aim of the current review is to determine whether exposure to OPs, at levels lower than that which results in clinical manifestations of acute OP poisoning, leads to an adverse impact on fertility, growth and development, and to highlight possible effects for further investigation. There is evidence of impaired fertility due to a reduction in semen quality and possibly lower testosterone levels in exposed males. There is also evidence of impairment of fetal growth and development brought about by prenatal exposure to OPs. Paraoxonase gene (PON1) activity in the fetus and during early childhood makes the fetus and child more vulnerable to OP poisoning, suggesting that OP exposure has a greater impact on fetal and infant growth and development than on adults when exposed to the same concentrations of pesticides. This review raises concerns that exposure to OP pesticides at levels currently regarded as safe adversely affect human reproductive function and survival.

Chronic renal failure in North Central Province of Sri Lanka: an environmentally induced disease

This study was conducted to determine the aetiology of chronic renal failure (CRF) in the North Central Province of Sri Lanka. Patients (n=183) with CRF of unknown aetiology were compared with controls (n=200) who had no evidence of chronic renal dysfunction. Exposure to possible risk factors were determined by an interviewer-administered questionnaire. Being a farmer (P<0.001), using pesticides (P<0.001), drinking well water (P<0.001), a family history of renal dysfunction (P=0.001), use of ayurvedic treatment (P<0.001) and a history of snake bite (P<0.001) were risk factors for CRF of unknown aetiology. Using logistic regression analysis, a family history of chronic renal disease, taking ayurvedic treatment and history of snake bite were found to be significant predictors for CRF of unknown aetiology. There is evidence to support an environmental aetiology to CRF in Sri Lanka.

The efficacy of micronutrient supplementation in reducing the prevalence of anaemia and deficiencies of zinc and iron among adolescents in Sri Lanka

OBJECTIVE

To determine the effectiveness of combined iron and zinc over the iron or zinc-only supplementation in correcting deficiency and possible interactive effects in a group of adolescent school children.

SUBJECTS AND METHODS

Schoolchildren (n=821) of 12-16 years of age were randomized into four groups and supplemented with iron (50 mg/day), zinc (14 mg/day), iron+zinc or placebo capsules 5 days per week for 24 weeks. Anthropometry, and haemoglobin (Hb), serum zinc (SZn) and serum ferritin (SF) concentrations were determined before and after the intervention.

RESULTS

There were no significant effects between-groups in their weight, height and Hb concentrations with the intervention when compared with the placebo group. Iron-only and combination-supplemented groups had reached mean SF concentrations of 55.1 microg/l with no difference between them (P=0.99). The zinc-only group had a mean change of 4.3 micromol//l whereas the combine-supplemented group had a mean change of 4.0 micromol/l (P=0.82). The prevalence of anaemia was found to be 70.3% in the iron group at baseline; this was reduced to 14.5% after the supplementation. In the combine-supplemented group anaemia, prevalence was reduced from 64.8 to 19.3%.

CONCLUSIONS

Zinc alone or in combination with iron has not shown a significant improvement in growth in adolescence. Severe and moderate forms of anaemia were successfully treated in children who received iron supplementation. Initial high prevalence of low SZn and iron stores was significantly improved with micronutrient supplementation.

Nutrient intake and growth of adolescents in southern Sri Lanka

OBJECTIVE

Growth and dietary intake data are essential for formulation of nutritional policies and interventions for children.

DESIGN

945 school children (11-16 years) were subjected to growth assessment and their nutrient intake was determined using the 24-hour dietary recall method on three consecutive days.

RESULTS

21.3% of boys and 21.1% of girls were stunted (-2SD below the median height-for-age). 141 (14.9%) children were both stunted and wasted (-2 SD below the median weight-for-age). Mean body mass index of girls was significantly higher (p < 0.001) than boys at all ages. The mean daily dietary intake of energy was 3.2 (+/- 2.4) MJ, protein 29.1 (+/- 2.1) g, fat 4.5 (+/- 1.1) g, iron 11.5 (+/- 1.0) mg, and zinc 0.8 (+/- 0.7) mg among boys. Among girls, energy intake was 4.2 (+/- 1.8) MJ, protein 29.0 (+/- 2.3) g, fat 4.4 (+/- 1.0) g, iron 11.4 (+/- 1.0) mg, and zinc 0.5 (+/- 0.6) mg. Fat comprised about 4.0% of the daily energy intake.

CONCLUSIONS

High rate of growth deficiency and undernutrition among adolescents mandates innovative nutritional intervention strategies. The observed mean intakes of nutrients in the sample showed a worrisome deviation from the recommendations of the dietary guidelines for Sri Lanka.

Low folic acid status and its association with anaemia in urban adolescent girls and women of childbearing age in Sri Lanka

Folic acid deficiency is implicated in the aetiology of nutritional anaemia and adverse pregnancy outcomes for the fetus. Data on folic acid status among adolescent girls and non-pregnant, non-lactating young women are limited. We assessed folic acid status in a random sample of 552 subjects (277 adolescent girls aged 15-18.9 years and 275 women aged 19-30 years) living in Colombo, Sri Lanka. The association of low folic acid status with anaemia was evaluated. Socio-economic, food intake and anthropometric data were obtained. Hb, serum folic acid, vitamin B12 and ferritin and plasma homocysteine concentrations were measured. Forty-three per cent of subjects studied had low serum folic acid concentrations (<3 ng/ml) and 47 % had low Fe stores (serum ferritin <20 microg/l). Overall prevalence of anaemia was 12.9 %, and 43.9 % of anaemic subjects had both low folic acid status and depleted Fe stores (serum ferritin <12 microg/l). Both low folate status and depleted Fe stores were significantly associated with anaemia (odds ratio = 2.32; 95 % CI 1.34, 4.01 and odds ratio = 5.98; 95 % CI 3.36, 10.63, respectively). Serum folic acid concentration was associated (r = 0.108, P = 0.015) with folate intake as indicated by a computed folate index. Folate index was associated inversely with household size and positively with economic status and education level. In this study population low folic acid status, besides depleted Fe stores, was associated with anaemia. The high prevalence of low folic acid status observed highlights the need for nutrition education to improve intakes of folate, Fe and other micronutrients among adolescent girls and young women.

A randomized, double-blind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children

A double-blind, placebo-controlled trial of nine months duration was carried out to investigate the impact of malaria and its prevention on the educational attainment of school children in a malaria-endemic area in southern Sri Lanka where both Plasmodium falciparum and P. vivax infections are prevalent. A total of 587 children attending grades 1-5 in four schools and resident in the area were randomly allocated to chloroquine (n = 295) and placebo (n = 292) arms. Language and mathematics scores of end-of-term school examinations for 1998 and 1999 and number of days absent and reasons for absenteeism during seven months pre-intervention and nine months of the intervention were recorded. The results indicate that there were no differences in language (95% confidence interval [CI] = 48.44-53.78 in chloroquine group and 50.43-55.81 in placebo group) and mathematics (95% CI = 49.24-54.38 in chloroquine group and 51.12-56.38 in placebo group) scores between the two groups prior to the intervention. During the intervention, the malaria incidence rate decreased by 55% (95% CI = 49-61%) and school absenteeism due to malaria was reduced by 62.5% (95% CI = 57-68%) in children who received chloroquine compared with the placebo group. Post-intervention, children who received chloroquine scored approximately 26% higher in both language (95% CI = 21-31%) and mathematics (95% CI = 23-33%) than children who received placebo. In a multivariate model, educational attainment was significantly associated with taking chloroquine prophylaxis and absenteeism due to malaria (P < 0.001 for both) but not due to health causes other than malaria or non-health causes. Language scores were associated with number of malaria attacks (P < 0.022). Educational attainment was significantly better among children whose compliance to chloroquine prophylaxis was higher (P < 0.001). The data suggest that malarial attacks have an adverse impact on the educational attainment of the school child and prevention of these attacks significantly improves educational attainment of children living in malaria-endemic areas.

Short-term impact of an acute attack of malaria on the cognitive performance of schoolchildren living in a malaria-endemic area of Sri Lanka

A prospective study was conducted from January 1998 to November 1999 in a malaria-endemic area of Sri Lanka to determine the short-term impact of an acute attack of malaria on the cognitive performance of 648 schoolchildren attending grades 1 to 5 (mostly aged 6-11 years) in 4 schools. Three groups were studied comprising children with malaria, children with non-malarial fever, and healthy controls. Cognitive performance in language and mathematics at the time of presentation and 2 weeks later was assessed. At the time of presentation, children with malaria scored significantly less in both mathematics and language than children with non-malarial fever and healthy controls. Two weeks later, the mathematics and language scores of children with malaria improved but the scores were significantly lower than the scores of children with non-malarial fever (P < 0.001) and controls (P < 0.001). Having malaria was a significant predictor of cognitive performance after controlling for other confounding factors. These findings suggest that an acute attack of uncomplicated malaria causes significant short-term impairment of cognitive performance. The impairment persists for more than 2 weeks and appears to be cumulative with repeated attacks of malaria.

Prevalence and severity of micronutrient deficiency: a cross-sectional study among adolescents in Sri Lanka

In order to determine the prevalence of micronutrient deficiencies (iron, zinc and folate) in Sri Lankan adolescent school children and the extent to which multiple micronutrient deficiencies exist in this population, a cross-sectional survey (2003) in the Galle district of the micronutrient and anthropometric status of 945 school children of ages 12-16 years was performed. The prevalence of anemia (Hb < 120.0 g/L) was 49.5% in males and 58.1% in females (overall 54.8%, gender difference, P = 0.004). In anemic children 30.2% of males and 47.8% of females were iron deficient (serum ferritin < 30.0 microg/L). Folate deficiency (<6.80 nmol/L) was found in 54.6% and 52.5% of boys and girls respectively whereas zinc deficiency (<9.95 micromol/L) occurred in 51.5% and 58.3%. Anemic boys had a 1.5 (95% confidence interval (CI) 0.9-2.6) and 1.6-fold (CI; 1.1-2.6) greater risk of being stunted and underweight, whereas the risk among anemic girls was 1.7 (CI; 1.1-2.7) and 1.0 (CI; 0.7-1.5) for being stunted and underweight. The relative risks of having at least two deficiencies in iron, zinc and folate among anemic children were 1.6 (CI; 0.6-4.2) among boys and 0.8 (CI; 0.5-1.5) among girls. Iron deficient subjects had a significantly increased risk of 1.8 (CI, 1.1-3.0) of being deficient in folate and 1.7 (CI, 1.2-2.6) of being deficient in zinc. Zinc deficient subjects had a risk of 1.3 (CI, 1.0-1.8) being iron deficient and 1.2 (CI, 0.9-1.7) of being folate deficient. Multiple micronutrient deficiencies are prevalent in Sri Lankan adolescents.

Hyperhomocysteinaemia in Sri Lankan patients with coronary artery disease

OBJECTIVE

To determine the association between hyperhomocysteinaemia and coronary artery disease (CAD) in a sample of Sri Lankans.

DESIGN

A case control study.

SETTING

Asiri Hospital, Kirula Road, Colombo 5, Sri Lanka.

SUBJECTS

105 patients with coronary artery disease and 112 controls.

METHOD

Fasting serum homocysteine levels were measured in 105 patients diagnosed as having CAD and in 112 unmatched controls. All patients admitted with clinical, electrocardiographical, biochemical or echocardiographical evidence of CAD were included in the study. Controls were selected from subjects admitted for health screening.

RESULTS

105 patients with CAD and 112 controls (unmatched for age and sex) were studied. A serum homocysteine level in excess of 18.2 mumol/l was considered high. Confounding effects of other conventional risk factors for CAD were controlled using multivariate logical regression analysis.

CONCLUSION

Hyperhomocysteinaemia is significantly associated with CAD. Multivariate logistic regression analysis indicated that the association between hyperhomocysteinaemia and CAD was confounded by other risk factors. However, statistical analysis revealed a significant independent association between hyperhomocysteinaemia and CAD (adjusted odds ratio = 2.881).