Human papillomavirus (HPV) vaccination program in Sri Lanka: Ongoing costs and operational context of a routinized program

Existing evidence on the cost of human papillomavirus (HPV) vaccination programs has focused on pilot and demonstration projects or initial introductions, which resulted in a perceived high cost. We aimed to study the ongoing cost and operational context of an established HPV vaccination program in Sri Lanka. We conducted a retrospective operational research and microcosting study focusing on 2019. We collected data from 30 divisional health units, 10 districts, and the central level. We then evaluated financial and economic costs, reported by level of the health system, program activity, cost types, and per dose delivered. In 2019, Sri Lanka delivered a total of 314,815 doses of HPV vaccine. In our study sample, 95 % of the HPV vaccination sessions took place at schools, with peaks of delivery in February-March and September-October. The weighted mean financial cost per dose delivered was $0.27 (95 % confidence interval [CI]: $0.15-$0.39) and the economic cost per dose was $3.88 (95 % CI: $2.67-$5.10), excluding the cost of vaccines and supplies. Most of the cost was borne by the divisional health unit level. Service delivery and social mobilization were major contributors to overall costs at the divisional health unit level, and vaccine collection or distribution and storage were the most costly activities at the district and central levels. Cost drivers included the opportunity cost of health worker and non-health worker time at the divisional health unit level and capital costs for vehicles and equipment, along with fuel, maintenance, and energy, at the district and central levels. This study provides new evidence on the cost and cost drivers of a routinized HPV vaccination program. Results can be used for financial planning purposes in Sri Lanka and may inform other countries as they consider use of HPV vaccines.

Predictive modelling for COVID-19 outbreak control: lessons from the navy cluster in Sri Lanka

In response to an outbreak of coronavirus disease 2019 (COVID-19) within a cluster of Navy personnel in Sri Lanka commencing from 22nd April 2020, an aggressive outbreak management program was launched by the Epidemiology Unit of the Ministry of Health. To predict the possible number of cases within the susceptible population under four social distancing scenarios, the COVID-19 Hospital Impact Model for Epidemics (CHIME) was used. With increasing social distancing, the epidemiological curve flattened, and its peak shifted to the right. The observed or actually reported number of cases was above the projected number of cases at the onset; however, subsequently, it fell below all predicted trends. Predictive modelling is a useful tool for the control of outbreaks such as COVID-19 in a closed community.

Prevalence and risk factors for impaired kidney function in the district of Anuradhapura, Sri Lanka: a cross-sectional population-representative survey in those at risk of chronic kidney disease of unknown aetiology

BACKGROUND

Over the last 20 years there have been reports of a form of chronic kidney disease of unknown cause (CKDu) affecting rural communities in the North Central Province of Sri Lanka. Valid prevalence estimates, using a standardised methodology, are needed to assess the burden of disease, assess secular trends, and perform international comparisons.

METHODS

We conducted a cross-sectional representative population survey in five study areas with different expected prevalences of CKDu. We used a proxy definition of CKDu involving a single measure of impaired kidney function (eGFR< 60 mL/min/1.7m², using the CKD-Epi formula) in the absence of hypertension, diabetes or heavy proteinuria.

RESULTS

A total of 4803 participants (88.7%) took part in the study and 202 (6.0%; 95% CI 5.2-6.8) had a low eGFR in the absence of hypertension, diabetes and heavy proteinuria and hence met the criteria for proxy CKDu. The proportion of males (11.2%; 95% CI 9.2-13.1) were triple than the females (3.7%; 95% CI 2.9-4.5). Advancing age and history of CKD among parents or siblings were risk factors for low GFR among both males and females while smoking was found to be a risk factor among males.

CONCLUSIONS

These data, collected using a standardised methodology demonstrate a high prevalence of impaired kidney function, not due to known causes of kidney disease, in the selected study areas of the Anuradhapura district of Sri Lanka. The aetiology of CKDu in Sri Lanka remains unclear and there is a need for longitudinal studies to describe the natural history and to better characterise risk factors for the decline in kidney function.

Prevalence and risk factors for impaired kidney function in the district of Anuradhapura, Sri Lanka: a cross-sectional population-representative survey in those at risk of chronic kidney disease of unknown aetiology

Background

Over the last 20 years there have been reports of a form of chronic kidney disease of unknown cause (CKDu) affecting rural communities in the North Central Province of Sri Lanka. Valid prevalence estimates, using a standardised methodology, are needed to assess the burden of disease, assess secular trends, and perform international comparisons.

Methods

We conducted a cross-sectional representative population survey in five study areas with different expected prevalences of CKDu. We used a proxy definition of CKDu involving a single measure of impaired kidney function (eGFR< 60 mL/min/1.7m², using the CKD-Epi formula) in the absence of hypertension, diabetes or heavy proteinuria.

Results

A total of 4803 participants (88.7%) took part in the study and 202 (6.0%; 95% CI 5.2–6.8) had a low eGFR in the absence of hypertension, diabetes and heavy proteinuria and hence met the criteria for proxy CKDu. The proportion of males (11.2%; 95% CI 9.2–13.1) were triple than the females (3.7%; 95% CI 2.9–4.5). Advancing age and history of CKD among parents or siblings were risk factors for low GFR among both males and females while smoking was found to be a risk factor among males.

Conclusions

These data, collected using a standardised methodology demonstrate a high prevalence of impaired kidney function, not due to known causes of kidney disease, in the selected study areas of the Anuradhapura district of Sri Lanka. The aetiology of CKDu in Sri Lanka remains unclear and there is a need for longitudinal studies to describe the natural history and to better characterise risk factors for the decline in kidney function.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7117-2) contains supplementary material, which is available to authorized users.

Efficacy of high dose Vitamin D supplementation in improving serum 25(OH)D among migrant and non migrant population: a retrospective study

BACKGROUND

Higher dose of vitamin D supplementation 50000 IU is required for those whose serum 25(OH)D levels are 50 nmol/L and below. The increment in serum 25(OH)D though not significantly affected by race, sex or age it is negatively correlated to the baseline 25(OH)D concentration. This study investigated whether the mean increase in serum 25(OH)D will be higher among participants with lower baseline 25(OH)D levels and whether the duration of supplementation has an influence on the serum 25(OH)D achieved.

METHODS

A clinical audit of patients' medical records from a community health centre in Melbourne for the period 01.01.2010 to 31-12.2012 was undertaken. Paired sample t test was used to determine difference in pre and post dose serum 25(OH)D. Simple and multiple linear regressions were used to examine the association between the difference in pre and post dose serum 25(OH)D and duration of supplementation and baseline serum 25(OH)D, adjusting for socio-demographic factors.

RESULTS

A total of 205 patients were included in the study. Mean difference in serum 25(OH)D was highest 52.8 nmol/L (95 % CI: 46.63-58.92) among those whose serum 25(OH)D was below 25 nmol/L at baseline. Baseline 25(OH)D alone accounted for 13.7 % of variance in the effect size (F(2, 202) = 16.0. p < 0.001), with the effect size significantly higher among participants with a baseline 25(OH)D level of 25-49 nmol/L (β = 11.93, 95 % CI: 0.48, 23.40, p < 0.05). Mean serum 25(OH)D difference was highest, 47.53 nmol/L (95 % CI: 40.95-54.11) when measured within 3 months of supplementation. Duration of supplementation explained 2.9 % of the variance in the effect size (F (1, 203) = 6.11, p < 0.05) and there was an inverse relationship between the length of supplementation and mean pre and post supplementation serum 25(OH)D difference (β = -1.45, 95 % CI: -2.62, -0.29, p = 0.014).

CONCLUSION

Following 50000 IU vitamin D3 for 12 months mean serum 25(OH)D increase was highest among those whose baseline serum 25(OH)D was lower. Migrants especially dark-skinned are at a high risk for vitamin D deficiency in Australia. High dose vitamin D3 50000 IU (cholecalciferol) is effective in achieving sufficient serum 25(OH)D among these populations who tend to have lower baseline serum 25(OH)D.

Can oral vitamin D prevent the cardiovascular diseases among migrants in Australia? Provider perspective using Markov modelling

The study was designed to model the effectiveness and cost effectiveness of oral Vitamin D supplementation as a primary prevention strategy for cardiovascular disease among a migrant population in Australia. It was carried out in the Community Health Service, Kensington, Melbourne. Best-case scenario analysis using a Markov model was employed to look at the health care providers' perspective. Adult migrants who were vitamin D deficient and free from cardiovascular disease visiting the medical centre at least once during the period from 1 January 2010 to 31 December 2012 were included in the study. The blood pressure-lowering effect of vitamin D was taken from a published meta-analysis and applied in the Framingham 10 year cardiovascular risk algorithm (with and without oral vitamin D supplements) to generate the probabilities of cardiovascular events. A Markov decision model was used to estimate the provider costs associated with the events and treatments. Uncertainties were derived by Monte Carlo simulation. Vitamin D oral supplementation (1000 IU/day) for 10 years could potentially prevent 31 (interquartile range (IQR) 26 to 37) non-fatal and 11 (IQR 10 to 15) fatal cardiovascular events in a migrant population of 10,000 assuming 100% compliance. The provider perspective incremental cost effectiveness per year of life saved was AU$3,992 (IQR 583 to 8558). This study suggests subsidised supplementation of oral vitamin D may be a cost effective intervention to reduce non-fatal and fatal cardiovascular outcomes in high-risk migrant populations.

Assessment of vitamin D and its association with cardiovascular disease risk factors in an adult migrant population: an audit of patient records at a Community Health Centre in Kensington, Melbourne, Australia

Background

Vitamin D deficiency is a global public health problem associated with increased risk of cardio-metabolic diseases and osteoarthritis. Migrants with dark skin settled in temperate climates are at greater risk of both vitamin D deficiency and cardiovascular diseases. This study aims to identify the risk of vitamin D deficiency and associations with cardiovascular disease in a migrant population in Australia.

Methods

An audit was carried out at a Community Health Service in Kensington, Melbourne which, services a large migrant population. Data from the clinical records of all adults who visited the medical centre at least once during the period from 1^st January 2010 to 31^st December 2012 was extracted. The future (10 year) coronary heart disease risk was estimated using Framingham Risk Score.

Results

The centre has given higher priority to vitamin D testing in migrants, those middle-aged, females and those with diabetes and osteoarthritis. Migrants from countries located in lower latitude regions (Latitude N23⁰ to S23⁰) were 1.48 (95% C.I. 1.32-1.65) times more likely to develop vitamin D deficiency post migration and 0.44 (95% C.I. 0.31-0.62) times less likely to have a >15% 10-year risk of coronary heart disease when compared to their Australian-born counterparts.

Conclusions

Adherence to a high risk strategy for vitamin D testing was observed in the centre. Pre-migration latitude is an important factor for vitamin D deficiency (lower the latitude higher the risk) and in predicting future risk of cardiovascular disease in migrants. These findings suggest that a targeted approach for vitamin D testing, including zone of origin might better identify individuals at higher risk of both vitamin D deficiency and cardiovascular disease.

Risk factors for 'small for gestational age babies'

OBJECTIVE

To identify the risk factors for small for gestational age (SGA) babies.

METHODS

The present study was a nested case control study which was carried out by two Medical Officers of Health areas (The field level administrative unit responsible for provision of preventive and promotive health services) in Colombo district. SGA babies were identified using 'weight for gestational age' curves developed for Sri Lankan babies. Newborns of 1,200 pregnant women, who were identified within the first 8 wk of amenorrhea and who delivered in selected hospitals were included in the study. Sample size was calculated as n=167 cases and 4 n=668 controls, with four controls for each case. A case was defined as a newborn whose birth weight was less than the 10th percentile of the weight for gestational age, the control being a newborn whose birth weight was between the 10th and the 90th percentile of the weight for gestational age.

RESULTS

Multivariate analysis identified 7 significant risk factors as, number of live born children=0, inadequate weight gain during pregnancy according to initial BMI, maximum and minimum physical work, mother's pre-pregnant weight less than 38 kg, high level of stress at second trimester, presence of pregnancy induced hypertension (PIH) and inadequate support from husband.

CONCLUSION

The risk factors indicate the directions for planning intervention programs.

Development of birth weight for gestational age charts in a Sri Lankan setting - methodological issues

BACKGROUND

This study was taken up to identify the main types of low birth weight (LBW) for the development of weight for gestational age charts relevant to the country/regional level for the formulation of preventive strategies.

MATERIALS AND METHODS

A sample of mothers registered by Public Health Midwives (PHMs) from two Medical Officers of Health (MOH) areas in Colombo district were followed up until delivery in five selected hospitals. Period of gestation (POG) was assessed between 10 and 12 weeks using ultrasonography. Records of 474 mother/newborn pairs were used for development of gestational age-related birth weight charts for each sex and POG. Mothers with one or more risk factors for LBW were excluded. Mothers with POG less than 38 weeks and more than 40 weeks were limited. Information on all possible risk factors contributing to LBW were assessed.

RESULTS

Incidence of small for gestational age (SGA) assessed using the 10 th centile value for each POG, was 19.0% for males and 18.0% for females. Percentages of symmetrical and asymmetrical SGA newborns were 72.1% and 27.9%, respectively.

CONCLUSION

The charts were developed paying attention to all methodological aspects that highlighted the key issues relevant to development of weight for gestational age charts in a developing country setting. As action was taken to minimize the biases introduced by such issues, the charts developed could be used for assessment of incidence and risk factors for SGA until charts based on national level data are available.