Economic and Disease Burden of Dengue Illness in India

Between 2006 and 2012 India reported an annual average of 20,474 dengue cases. Although dengue has been notifiable since 1996, regional comparisons suggest that reported numbers substantially underrepresent the full impact of the disease. Adjustment for underreporting from a case study in Madurai district and an expert Delphi panel yielded an annual average of 5,778,406 clinically diagnosed dengue cases between 2006 and 2012, or 282 times the reported number per year. The total direct annual medical cost was US$548 million. Ambulatory settings treated 67% of cases representing 18% of costs, whereas 33% of cases were hospitalized, comprising 82% of costs. Eighty percent of expenditures went to private facilities. Including non-medical and indirect costs based on other dengue-endemic countries raises the economic cost to $1.11 billion, or $0.88 per capita. The economic and disease burden of dengue in India is substantially more than captured by officially reported cases, and increased control measures merit serious consideration.     

Phylogeography and Molecular Epidemiology of an Epidemic Strain of Dengue Virus Type 1 in Sri Lanka

In 2009, a severe epidemic of dengue disease occurred in Sri Lanka, with higher mortality and morbidity than any previously recorded epidemic in the country. It corresponded to a shift to dengue virus 1 as the major disease-causing serotype in Sri Lanka. Dengue disease reached epidemic levels in the next 3 years. We report phylogenetic evidence that the 2009 epidemic DENV-1 strain continued to circulate within the population and caused severe disease in the epidemic of 2012. Bayesian phylogeographic analyses suggest that the 2009 Sri Lankan epidemic DENV-1 strain may have traveled directly or indirectly from Thailand through China to Sri Lanka, and after spreading within the Sri Lankan population, it traveled to Pakistan and Singapore. Our findings delineate the dissemination route of a virulent DENV-1 strain in Asia. Understanding such routes will be of particular importance to global control efforts.     

Disease Severity and Mortality Caused by Dengue in a Dominican Pediatric Population

Millions are infected with dengue yearly. We evaluated the epidemiological and clinical characteristics of pediatric patients infected with dengue in the Dominican Republic. The applicability of World Health Organization (WHO) warning signs for predicting severe dengue and mortality was also studied. This study was a cross-sectional retrospective review of patients with a clinical diagnosis of dengue. Univariate and multivariate analyses were performed to evaluate characteristics associated with severity and mortality. The study included 796 subjects: 288 subjects were classified as dengue, 290 subjects had alarm signs, and 207 subjects were classified as severe dengue. Common findings included thrombocytopenia (96%), abdominal pain (71%), and vomiting (59%). The most important factors associated with severe dengue were rash (P < 0.01), severe thrombocytopenia (P < 0.01), and anemia (P < 0.01). These signs and symptoms were also associated with mortality. This study validates the current WHO warning signs of severity. Rash and severe thrombocytopenia may be early warning signs and need additional study.     

Osteoporosis in Sri Lanka

In Sri Lanka the median age, which was 25 in year 1991, is expected to rise to 45 by the year 2041 and half of the population will be over 45 years and vulnerable to osteoporosis. We describe 2 large epidemiological studies done in Sri Lanka. The first one, Galle Prospective Osteoporosis Survey, in its initial phase recruited 350 women randomly from the current voters registers. 42.4% of women in the entire sample and 61.5% in women over 50 years were found to have osteoporosis. The second study was to assess the prevalence of stiffness index with heel ultrasound and calcium intake in a suburban population close to Colombo. We randomised 1250 from electoral register numbers and 986 people consented to participate. Stiffness index start decreasing after the age of 50, which is the average age of age of menopause. In men stiffness decreases after age of 70.     

Scrub Typhus among Pediatric Patients in Dambadeniya:A Base Hospital in Sri Lanka

Abstract. Data on pediatric scrub typhus is uncommon in Sri Lanka and other countries. The objective of this study was to identify the clinical features of patients with scrub typhus at a Base Hospital in Sri Lanka. Sixty patients presenting with suspected scrub typhus were included in the study. Their blood samples were tested for the presence of antibodies against rickettsioses using the reference method. Twenty patients had confirmed scrub typhus and 24 had possible scrub typhus. Their clinical features are discussed in this work.     

Geo-helminth infections in a rural area of Sri Lanka

School children carry the heaviest burden of morbidity due to intestinal helminth infection. The objective of this investigation was to study geo-helminth infections in 349 school children aged 6 to 13 years living in a rural area of Sri Lanka. Stool samples were examined by direct saline smear in an initial survey to determine the prevalence of intestinal parasitic infections and thereafter the children were followed up over a two year period with cross sectional surveys of stool samples being carried out at yearly intervals. Following collection of a stool sample, all the subjects were treated with mebendazole 500 mg as a single dose. Weights and heights were measured using standardized procedures. 2 ml of venous blood were collected from each subject under aseptic conditions to determine hematological indices. The prevalence of geo-helminth infections was low, and the prevalence declined during the two-year period from 5.4% in 1997 to 2.2% in 1998 and 2.0% in 1999 following yearly mass anti-helminth treatment. The incidence density was 0.021 cases per child year. The reduction in the prevalence from the baseline to the second survey is probably due to the reduction of the reservoir of infection among children as a result of mass treatment at baseline. The prevalence of infection during the second and third surveys were almost the same probably due to infections originating from other segments of the untreated population.     

Primary liver cancer in Sri Lanka

In a study of 29 Sri Lankan patients with primary liver cancer, it was found that the highest incidence was in the over 55 year age group and the male:female ratio was 5:1. The ratio of hepatocellular carcinoma to cholangiocarcinoma was 13:1. Seventy-five percent of the males in this study had consumed alcohol. This may account for the higher incidence of cirrhosis and hepatocellular carcinoma among males and the lower incidence in females in this country in this country. The role of additives in local alcoholic beverages, the various alkaloids in decoctions and aflatoxin in articles of diet, await systematic investigation.     

Wuchereria bancrofti antigenaemia in Sri Lanka

The prevalence of Wuchereria bancrofti antigenaemia determined in 353 subjects in Matara, Sri Lanka by Og4C3 ELISA was 20.7%. Positive rates obtained with the same subjects by 1 ml Nuclepore filtration and 60 microl thick blood smear were 11.3% and 7.9%, respectively. Antigen levels were positively associated with microfilaria counts. Two-thirds of antigen-positive and microfilaria-negative (Ag+/Mf-) individuals were > 25-year-old, but younger age groups (< or = 25-year-old) tended to have proportionally more Ag+/Mf- cases. Possible origins of the Ag+/Mf- status are discussed.     

Treating Alcohol Problems in Sri Lanka

Treatment in settings where facilities are limited poses many challenges. Attempts are being made to use untrained but committed people to help dependent persons maintain abstinence after withdrawal. This experience makes us question the need for highly trained specialized staff in helping in this task.     

Tobacco use in a cohort of children in Sri Lanka

This study designed to examine the smoking behaviour and attitude of children were carried out on 3447, 11 to 18 year old Sri Lankan School children. The prevalence of smoking in urban and rural children are 7.2% and 4.3% respectively. 0.5% of children chew tobacco or use tobacco snuff. Friends smoking behaviour and attitude are the best predictors of smoking in children. The knowledge of health hazards of smoking is poor and is related to smoking behaviour.     

Chronic diarrhea after a journey to Sri Lanka

A 51-year-old woman was referred for evaluation of chronic diarrhea. She had spent a 14 day vacation in Sri Lanka three years ago. The clinical examination of the patient was unremarkable. Values for protein, iron, zinc, copper and folic acid were decreased and the Shilling- and D-xylose tests revealed pathological results. Gliadin and Endomysium antibodies were not detectable. Histologic examination of the duodenum displayed chronic duodenitis with increased epithelial regeneration and villous atrophy. In the MRI a segment of the mid small bowel with increased thickness of the intestinal wall was described. Abdominal CT-scans demonstrated multiple, enlarged mesenteric lymph nodes. Laparoscopy with biopsies of the ileum and mesenteric lymph nodes excluded a malignant lymphoma, mycobacteriosis or Whipple's disease. Oral therapy with tetracyclines (250 mg q. i. d.) and substitution of folic acid and iron led to rapid improvement of the clinical symptoms which persisted after cessation of the antibiotic therapy. In view of the clinical course tropical sprue has to be assumed despite the short duration of the journey to a tropical region.