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Abstract Background The COVID-19 pandemic—with its first reported case in Sri Lanka in March 2020—had the potential to impact the risk of re-establishing malaria, a disease which was eliminated from Sri Lanka in 2012. Post-elimination, the country remains highly vulnerable to a return of malaria on account of high vector mosquito densities and the inflow of imported malaria cases. Methods Parallels between COVID-19 and malaria after its elimination as health security threats were drawn, and the many ways in which the COVID-19 pandemic impacted the prevention of re-establishment of malaria programmes in the country in 2020 were examined. The implications of this experience for global health security are analysed. Results In 2020, imported malaria cases were fewer than in the previous 3 years, due to restrictions on international travel. Yet, a high level of malaria case and entomological surveillance was sustained through surveillance strategies modified to focus on quarantine centers, in response to the pandemic. As a result, more imported malaria cases were detected by active case detection than by passive surveillance. Some of the operational shifts adopted by the Anti Malaria Campaign were moving rapidly into functioning as an intersectoral player by reinforcing its collaborations with the Ministries of Aviation and Defense, switching to the use of online communication systems, and integrating and synergizing its field activities with the COVID-19 control programme. Conclusions The experience highlights the need for disease control programmes to be agile, flexible and responsive, and underscores the importance of maintaining even a lean focal programme for diseases such as malaria after they have been eliminated. Sustaining public health leadership and robust technological capacities in communication and data management were paramount in preventing the disruption of the malaria prevention programme during the pandemic and sustaining the malaria-free status of the country.

Abstract Background Imported malaria continues to be reported in Sri Lanka after it was eliminated in 2012, and a few progress to life-threatening severe malaria. Methods Data on imported malaria cases reported in Sri Lanka from 2013 to 2023 were extracted from the national malaria database maintained by the Anti Malaria Campaign (AMC) of Sri Lanka. Case data of severe malaria as defined by the World Health Organization were analysed with regard to patients’ general characteristics and their health-seeking behaviour, and the latter compared with that of uncomplicated malaria patients. Details of the last three cases of severe malaria in 2023 are presented. Results 532 imported malaria cases were diagnosed over 11 years (2013–2023); 46 (8.6%) were severe malaria, of which 45 were Plasmodium falciparum and one Plasmodium vivax. Most severe malaria infections were acquired in Africa. All but one were males, and a majority (87%) were 26–60 years of age. They were mainly Sri Lankan nationals (82.6%). Just over half (56.5%) were treated at government hospitals. The average time between arrival of the person in Sri Lanka and onset of illness was 4 days. 29 cases of severe malaria were compared with 165 uncomplicated malaria cases reported from 2015 to 2023. On average both severe and uncomplicated malaria patients consulted a physician equally early (mean = 1 day) with 93.3% of severe malaria doing so within 3 days. However, the time from the point of consulting a physician to diagnosis of malaria was significantly longer (median 4 days) in severe malaria patients compared to uncomplicated patients (median 1 day) (p = 0.012) as was the time from onset of illness to diagnosis (p = 0.042). All severe patients recovered without sequelae except for one who died. Conclusions The risk of severe malaria among imported cases increases significantly beyond 5 days from the onset of symptoms. Although patients consult a physician early, malaria diagnosis tends to be delayed by physicians because it is now a rare disease. Good access to expert clinical care has maintained case fatality rates of severe malaria at par with those reported elsewhere.

Abstract Background Sri Lanka has maintained a rigorous programme to prevent the re-establishment of malaria ever since the disease was eliminated in October 2012. It includes efforts to sustain case surveillance to ensure early diagnosis and management of malaria. Yet, in April of 2023 the death occurred of an individual with imported malaria. Case presentation The deceased was a 37-year-old Sri Lankan male who returned to Sri Lanka on the 10th of April after a business trip to several countries including Tanzania. He was febrile on arrival and consulted three Allopathic Medical Practitioners in succession in his home town in the Western Province of Sri Lanka, over a period of 5 days starting from the very day that he arrived in the country. Malaria was not tested for at any of these consultations and his clinical condition deteriorated. On the evening of 14th of April he was admitted to the medical intensive care unit of a major private hospital in the capital city of Colombo with multiple organ failure. There, on a request by the treating physician blood was tested for malaria and reported early the next morning as Plasmodium falciparum malaria with a high parasitaemia (> 10%). The patient died shortly after on the 15th of April before any anti-malarial medication was administered. The deceased had been a frequent business traveller to Africa, but with no past history of malaria. He had not taken chemoprophylaxis for malaria on this or previous travels to Africa. Discussion The patient’s P. falciparum infection progressed rapidly over 5 days of arriving in Sri Lanka leading to severe malaria without being diagnosed, despite him seeking healthcare from three different Medical Practitioners. Finally, a diagnosis of malaria was made on admission to an intensive care unit; the patient died before anti-malarial medicines were administered. Conclusions This first death due to severe P. falciparum malaria reported in Sri Lanka after elimination of the disease was due to the delay in diagnosing malaria.

Abstract Given the structural similarity between Zika and dengue viruses, prior infection from one virus is hypothesized to modulate the severity of a subsequent infection from the other virus. A previous paediatric cohort study observed that a prior Zika infection may increase the risk of a subsequent symptomatic or severe dengue infection. The Colombo Dengue study is a prospective hospital-based cohort study in Sri Lanka that recruits symptomatic adult dengue patients within the first three days of fever. Anti-Dengue Envelope and anti-Zika NS1 IgG antibodies were tested by ELISA (Euroimmun, Lubeck, Germany) in all recruited patients. Associations between pre-morbid seroprevalence for either or both infections and adverse clinical outcomes of the current dengue infection were explored. A total of 507 dengue infected patients were assessed of whom 342 (68%) and 132 (26%) patients had anti-dengue IgG and anti-Zika IgG respectively. People with combined prior dengue and zika exposure as well as prior dengue exposure alone, were at increased risk of plasma leakage, compensated and uncompensated shock, and severe dengue (p

Abstract Background Sri Lanka, an island nation, has eliminated endemic malaria transmission. Maintaining elimination in the continued presence of vectors requires vigilance in screening people travelling from high malaria-risk areas and a rapid response with focal screening for infections identified in the community. Such screening requires accurate and very rapid assays that enable an immediate response. Both microscopy and rapid diagnostic tests (RDTs) have limitations including sensitivity and speed in screening large numbers, while polymerase chain reaction (PCR) is practical only as laboratory confirmation. This study assessed the utility of ‘Gazelle’, a novel rapid malaria assay based on magneto-optical detection of haemozoin, a by-product of malaria parasite metabolism. Methods Between October 2020 and March 2021, two groups of individuals were screened for malaria by four methods, namely, microscopy, Rapid Diagnostic Test (RDT), Gazelle and PCR. Passive case detection was carried out for confirmation of diagnosis amongst individuals suspected of having malaria. Individuals at high-risk of acquiring malaria, namely persons returning from malaria endemic countries, were screened by active case detection. Results Of the 440 individuals screened for malaria, nine malaria positives were diagnosed by PCR, microscopy and the HRP2 band of RDT, which included five Plasmodium falciparum infections, two Plasmodium ovale, and one each of Plasmodium vivax and Plasmodium malariae. Gazelle correctly detected the P. vivax, P. ovale and P. malariae infections within the 2 min test time, but did not detect two P. falciparum infections giving a sensitivity of 77.8%. Specificity was 100%. Discussion The Gazelle, a portable bench top device proved useful to screen a large number of blood samples for non-falciparum parasites within 5 minutes of sample input. Species differentiation, and improvement in P. falciparum detection, will be important to broaden utility.

Objective: To compare the DNA sequences of Leishmania (L.)donovani isolated from individuals in two districts of the Northern Province with other parts of Sri Lanka and neighboring countries. Methods: Samples were collected from military personnel at the Army Hospital, Narahenpita, Sri Lanka from November 2018 to March 2020. A portion of the samples was fixed, stained with Giemsa and observed under the light microscope. The genomic The DNA was extracted from the remaining portion of the samples using DNEasy blood tissue kit (Qiagen, Germany) and amplified using Leishmania genus-specific primers for molecular diagnosis initially. DNA was amplified using L. donovani species-specific primers by PCR and the amplified product was sequenced for comparison of nucleotide sequences. Results: Out of 76 suspected patients, at least one biological sample of 45 (59.2%) was positive for L. amastigotes upon microscopy. Overall, 33 (43.4%) were positive in Leishmania genus-specific PCR, but only 23 (30.3%) were positive in L. donovani specific PCR. The dendrogram indicates that the current sequences clustered together with those from Nepal and Gampaha districts (Western Province), Sri Lanka, while the Indian and Eastern African sequences clustered separately. Conclusions: The genetic diversity was low among the isolates, indicating a single and possibly a local point of origin. However, the similarity of Sri Lankan and Nepal strains indicate a possibility of a shared point of origin, which needs more extensive evidence to confirm.

BackgroundAt least a third of dengue patients develop plasma leakage with increased risk of life-threatening complications. Predicting plasma leakage using laboratory parameters obtained in early infection as means of triaging patients for hospital admission is important for resource-limited settings.MethodsA Sri Lankan cohort including 4,768 instances of clinical data from N = 877 patients (60.3% patients with confirmed dengue infection) recorded in the first 96 hours of fever was considered. After excluding incomplete instances, the dataset was randomly split into a development and a test set with 374 (70%) and 172 (30%) patients, respectively. From the development set, five most informative features were selected using the minimum description length (MDL) algorithm. Random forest and light gradient boosting machine (LightGBM) were used to develop a classification model using the development set based on nested cross validation. An ensemble of the learners via average stacking was used as the final model to predict plasma leakage.ResultsLymphocyte count, haemoglobin, haematocrit, age, and aspartate aminotransferase were the most informative features to predict plasma leakage. The final model achieved the area under the receiver operating characteristics curve, AUC = 0.80 with positive predictive value, PPV = 76.9%, negative predictive value, NPV = 72.5%, specificity = 87.9%, and sensitivity = 54.8% on the test set.ConclusionThe early predictors of plasma leakage identified in this study are similar to those identified in several prior studies that used non-machine learning based methods. However, our observations strengthen the evidence base for these predictors by showing their relevance even when individual data points, missing data and non-linear associations were considered. Testing the model on different populations using these low-cost observations would identify further strengths and limitations of the presented model.

The COVID-19 pandemic affected Sri Lanka despite having developed an International Health Regulations (IHR) steering committee in 2016 and a national action plan for health security following the Joint External Evaluation in 2018. Many steps were taken to improve the disaster management skills of healthcare workers even before the COVID-19 outbreak. We interviewed seven public health specialists to obtain their views on the country's response to the pandemic. A thematic analysis was conducted, leading to the emergence of three major themes and seven subthemes. The major themes included health security preparedness; COVID-19 management; and effects of COVID-19. The subthemes were; preparedness prior to pandemic and gaps in the preparedness (under health security preparedness); dual burden for the curative sector, strategies to reduce transmission and barriers to managing COVID-19 (under COVID-19 management) and negative and positive effects of COVID-19 (under effects of COVID-19). When COVID-19 reached Sri Lanka, healthcare workers, border control authorities and those involved with infectious disease control were overwhelmed by the magnitude of the pandemic. Healthcare workers' hesitation to work amidst the pandemic due to fear of infection and possible transmission of infection to their families was a major issue; the demand for personal protective equipment by health workers when stocks were low was also a contributory factor. Lockdowns with curfew and quarantine at government regulated centers were implemented as necessary. Perceptions of the public including permitting healthcare workers to perform field public health services, logistical barriers and lack of human resources were a few of the barriers that were expressed. Some persons did not declare their symptoms, fearing that they would have to be quarantined. The pandemic severely affected the economy and Sri Lanka relied on donations and loans to overcome the situation. Pandemic also brought about innovative methods to maintain and upgrade health service provision. Individuals with non-communicable diseases received their regular medications through the post which reduced their risk of being infected by visiting hospitals. Improvement of laboratory services and quarantine services, a reduction of acute respiratory infections and diarrhoeal diseases, improved intersectoral coordination and public philanthropic response were other positive effects.

Abstract Plasma leakage is a precursor to life-threatening complications of dengue, but this group is poorly defined and not often reported in literature. Patients with Dengue haemorrhagic fever (DHF) as defined in the 1997 World Health Organization classification are often reported, and they all have plasma leakage, but some patients with plasma leakage do not meet the definition of DHF. The study aims to estimate the frequency of plasma leakage and DHF (as a surrogate of plasma leakage) in dengue and its variations based on virus serotype, geography, patient gender and pre-existing immunity to dengue. PUBMED, Scopus, EMBASE, CINAHL and Web of Science were searched for prospective observational studies reporting on plasma leakage or DHF. Quality of data was assessed using the NIH quality assessment tool for cohort studies. Forty-three studies that recruited 15,794 confirmed dengue patients were eligible. Cumulative frequency of plasma leakage was 36.8% (15 studies, 1642/4462, 95% CI 35.4–38.2%), but surprisingly the estimated cumulative frequency of DHF was higher (45.7%, 32 studies, 4758/10417, 95% CI 44.7–46.6%), indicating that current medical literature over-reports DHF or under-reports plasma leakage. Therefore, a reliable estimate for the proportion of dengue patients developing plasma leakage cannot be derived from existing medical literature even after applying rigorous inclusion criteria to select homogenous studies. Plasma leakage is an important marker of “at-risk” dengue patients and standardizing its definition, diagnosis and reporting should be a priority in research and global policy.

Introduction and objectives: Leishmania donovani is the causative organism of leishmaniasis in Sri Lanka. Studies on the immunopathology of leishmaniasis due to L. donovani are limited. The objective of this study was to describe the immunopathological characteristics of cutaneous leishmaniasis in a cohort of Sri Lankan patients. Methodology: Fifty skin biopsies of cutaneous leishmaniasis confirmed by detection of organisms by histology, culture, slit-skin smear, and/or polymerase chain reaction were reviewed. The inflammatory infiltrate was characterized by immunohistochemical staining for CD4, CD8, CD20, and CD68. Associations and correlations between immunohistochemical staining pattern and the parasitic load, and patterns of inflammation were determined. Results: The majority of biopsies showed a CD8+/CD4− T lymphocyte predominant infiltrate (84%, n = 42). A CD68 predominant infiltrate was seen in 16%(n = 8). The mean percentage of CD8+, CD4+, CD20+, and CD68+ inflammatory cells in the biopsies were 56.1% (SD = 16.5%), 2.6% (SD = 4.5%), 12.3% (SD = 10.9%), and 25.7% (SD = 15.8%) respectively. There was no association between the predominant inflammatory cell and the degree of inflammation ( P = .173), presence of high RPI ( P = .922), MRI( P = .367) or presence of granuloma ( P = .247).The percentage of CD4+ cells showed a positive correlation with granuloma formation (Correlation coefficient = .411, P = .03). The percentage of CD20+ cells in the infiltrate showed a positive correlation with the degree of inflammation (Correlation coefficient = .491, P = .02) and the RPI (Correlation coefficient = .334, P = .018). Discussion and Conclusion: Skin biopsies from cutaneous leishmaniasis due to L. donovani infection showed a CD8+/CD4− predominant infiltrate. This is similar to the findings of studies on cutaneous leishmaniasis due to some other species and suggests that the cytotoxic T cell response plays a role in infections due to L. donovani .

Abstract Background Malaria was eliminated from Sri Lanka in 2012, and since then 50–60 imported malaria cases have been reported yearly. The country has remained malaria-free since, except for a single case of indigenous malaria in 2018. Blood donors are routinely screened for malaria, and transfusion malaria has not been reported in the country since 1966. Case presentation A 17-year-old splenectomized beta thalassaemia patient developed a transfusion-induced Plasmodium falciparum malaria infection following a blood transfusion 18 days earlier. The blood donor was an armed forces personnel who returned from South Sudan following a United Nations peace-keeping mission. The blood recipient’s malaria infection took a complicated clinical course with elevated liver enzymes, lowered blood pressure and a prolonged parasite clearance time of 7 days but he recovered fully after two courses of artemether-lumefantrine interrupted by a course of intravenous artesunate. The prolonged parasite clearance is likely due to lack of splenic clearance of dead or damaged intra-erythrocytic parasites (due to a splenectomy) rather than to the parasite strain being resistant to artemisinin or the partner drug. This is corroborated by the fact that the blood donor’s infection responded to artemether-lumefantrine with parasites being cleared on day 3. The blood donor who had not displayed signs or symptoms of malaria, had been screened for malaria on arrival in Sri Lanka and was negative on both microscopy and RDT. At the point of blood donation a blood smear examined microscopically was also reported negative for malaria, but retrospectively, the preserved smear of the donor’s blood was found to contain P. falciparum parasites at a very low density. The donor when tested after the transfusion-induced case was diagnosed, also tested positive for malaria and was treated. Conclusions After malaria elimination, transfusion-induced malaria from blood donors returning from malaria endemic countries poses a threat to preventing the re-establishment of the disease. Improved surveillance of arrivals in Sri Lanka from malaria endemic countries using more sensitive methods for screening than microscopy may be required to reduce this risk. More stringent criteria for selecting blood donors, and more effective methods of screening donors for malaria than microscopy may also be necessary.

All four serotypes of the dengue virus (DENV1–4) cause a phenotypically similar illness, but serial infections from different serotypes increase the risk of severe disease. Thus, genomic surveillance of circulating viruses is important to detect serotype switches that precede community outbreaks of disproportionate magnitude. A phylogenetic analysis was conducted on near full length DENV genomes sequenced from serum collected from a prospective cohort study from the Colombo district, Sri Lanka during a 28-month period using Oxford nanopore technology, and the consensus sequences were analyzed using maximum likelihood and Bayesian evolutionary analysis. From 523 patients, 328 DENV sequences were successfully generated (DENV1: 43, DENV2: 219, DENV3:66). Most circulating sequences originated from a common ancestor that was estimated to have existed from around 2010 for DENV2 and around 2015/2016 for DENV1 and DENV3. Four distinct outbreaks coinciding with monsoon rain seasons were identified during the observation period mostly driven by DENV2 cosmopolitan genotype, except for a large outbreak in 2019 contributed by DENV3 genotype I. This serotype switch did not result in a more clinically severe illness. Phylogeographic analyses showed that all outbreaks started within Colombo city and then spread to the rest of the district. In 2019, DENV3 genotype I, previously, rarely reported in Sri Lanka, is likely to have contributed to a disease outbreak. However, this did not result in more severe disease in those infected, probably due to pre-existing DENV3 immunity in the community. Targeted vector control within Colombo city before anticipated seasonal outbreaks may help to limit the geographic spread of outbreaks.

Abstract Background Sri Lanka sustained its malaria-free status by implementing, among other interventions, three core case detection strategies namely Passive Case Detection (PCD), Reactive Case Detection (RACD) and Proactive Case Detection (PACD). The outcomes of these strategies were analysed in terms of their effectiveness in detecting malaria infections for the period from 2017 to 2019. Methods Comparisons were made between the surveillance methods and between years, based on data obtained from the national malaria database and individual case reports of malaria patients. The number of blood smears examined microscopically was used as the measure of the volume of tests conducted. The yield from each case detection method was calculated as the proportion of blood smears which were positive for malaria. Within RACD and PACD, the yield of sub categories of travel cohorts and spatial cohorts was ascertained for 2019. Results A total of 158 malaria cases were reported in 2017–2019. During this period between 666,325 and 725,149 blood smears were examined annually. PCD detected 95.6 %, with a yield of 16.1 cases per 100,000 blood smears examined. RACD and PACD produced a yield of 11.2 and 0.3, respectively. The yield of screening the sub category of travel cohorts was very high for RACD and PACD being 806.5 and 44.9 malaria cases per 100,000 smears, respectively. Despite over half of the blood smears examined being obtained by screening spatial cohorts within RACD and PACD, the yield of both was zero over all three years. Conclusions The PCD arm of case surveillance is the most effective and, therefore, has to continue and be further strengthened as the mainstay of malaria surveillance. Focus on travel cohorts within RACD and PACD should be even greater. Screening of spatial cohorts, on a routine basis and solely because people are resident in previously malarious areas, may be wasteful, except in situations where the risk of local transmission is very high, or is imminent. These findings may apply more broadly to most countries in the post-elimination phase.

Introduction: Fever and thrombocytopenia, often presenting features of malaria, are also the hallmarks of dengue infections. This study examines the degree and duration of thrombocytopenia in imported malaria infections in Sri Lanka and the extent to which this could provide a false trail in favor of a dengue diagnosis. Methods: The data of all confirmed malaria cases reported in Sri Lanka from 2017 to 2019 were extracted from the national malaria database. These included detailed histories, the time to malaria diagnosis, platelet counts, and in 2019, the trail of diagnostic procedures. Results: Over the 3 years, 158 malaria cases (157 imported and one introduced) were reported. Platelet counts were available in 90.5% (n = 143) of patients among whom 86% (n = 123) showed a thrombocytopenia (

Abstract Prevention of re-establishment (POR) refers to the prevention of malaria outbreak/epidemic occurrence or preventing re-establishment of indigenous malaria in a malaria-free country. Understanding the effectiveness of the various strategies used for POR is, therefore, of vital importance to countries certified as “malaria-free” or to the countries to be thus certified in the near future. This review is based on extensive review of literature on both the POR strategies and elimination schemes of countries, (i) that have reached malaria-free status (e.g. Armenia, Mauritius, Sri Lanka), (ii) those that are reaching pre-elimination stage (e.g. South Korea), and (iii) countries at the control phase (e.g. India). History has clearly shown that poorly implemented POR programmes can result in deadly consequences (e.g. Sri Lanka); conversely, there are examples of robust POR programmes that have sustained malaria free status that can serve as examples to countries working toward elimination. Countries awaiting malaria elimination status should pre-plan their POR strategies. Malaria-free countries face the risk of resurgence mostly due to imported malaria cases; thus, a robust passenger screening programme and cross border collaborations are crucial in a POR setting. In addition, sustained vigilance, and continued funding for the national anti-malarial campaign programme and for related research is of vital importance for POR. With distinct intrinsic potential for malaria in each country, tailor-made POR programmes are built through continuous and robust epidemiological and entomological surveillance, particularly in countries such as Sri Lanka with increased receptivity and vulnerability for malaria transmission. In summary, across all five countries under scrutiny, common strengths of the POR programmes are (i) a multipronged approach, (ii) strong passive, active, and activated passive case detection, (iii) Indoor residual spraying (IRS), and (iv) health education/awareness programmes.

Abstract Background Following malaria elimination, Sri Lanka was free from indigenous transmission for six consecutive years, until the first introduced case was reported in December 2018. The source of transmission (index case) was a member of a group of 32 migrant workers from India and the location of transmission was their residence reporting a high prevalence of the primary vector for malaria. Despite extensive vector control the situation was highly susceptible to onward transmission if another of the group developed malaria. Therefore, Mass Radical Treatment (MRT) of the group of workers for Plasmodium vivax malaria was undertaken to mitigate this risk. Method The workers were screened for malaria by microscopy and RDT, their haemoglobin level assessed, and tested for Glucose 6 phosphate dehydrogenase deficiency (G6PD) using the Care Start RDT and Brewers test prior to treatment with chloroquine (CQ) 25 mg/kg body weight (over three days) and primaquine (PQ) (0.25 mg/kg/day bodyweight for 14 days) following informed consent. All were monitored for adverse events. Results None of the foreign workers were parasitaemic at baseline screening and their haemoglobin levels ranged from 9.7–14.7 g/dl. All 31 individuals (excluding the index case treated previously) were treated with the recommended dose of CQ. The G6PD test results were inconclusive in 45% of the RDT results and were discrepant between the two tests in 31% of the remaining test events. Seven workers who tested G6PD deficient in either test were excluded from PQ and the rest, 24 workers, received PQ. No serious adverse events occurred. Conclusions Mass treatment may be an option in prevention of reintroduction settings for groups of migrants who are likely to be carrying latent malaria infections, and resident in areas of high receptivity. However, in the case of Plasmodium vivax and Plasmodium ovale, a more reliable and affordable point-of-care test for G6PD activity would be required. Most countries which are eliminating malaria now are in the tropical zone and face considerable and similar risks of malaria re-introduction due to massive labour migration between them and neighbouring countries. Regional elimination of malaria should be the focus of global strategy if malaria elimination from countries is to be worthwhile and sustainable.

Abstract Background The 30-year-old armed conflict in Sri Lanka resulted in a general breakdown of civil administration in the Northern and Eastern provinces, leading to mobilisation of many armed forces personnel to assist with reconstruction and resettlement. This occupational group has been identified as a priority risk group for leishmaniasis. Methods Individuals enlisted at all military establishments in Mullaitivu and Kilinochchi districts, Northern Province of Sri Lanka were included. Five thousand individuals were screened for skin lesions between September 2018 and August 2019. Persons with lesions suspected as cutaneous leishmaniasis (CL) were further investigated. Information on sociodemographic/other potential risk factors was obtained through an interviewer-administered structured questionnaire. The diagnosis was confirmed by microscopic visualization of parasitic stages from different samples obtained (skin scraping, lesion aspirate and tissue impression smears), histopathology and polymerase chain reaction DNA amplification. Results Among 5000 individuals screened, 74 individuals were suspected of having CL. Of these, 67.6% (n = 50) patients were confirmed for CL by microscopy. Around two third of both males (67.6%; n = 48) and females (66.6%; n = 2) were positive for Leishmania. The soldiers belonging to 26–35-year age group reported the highest susceptibility (83.3%; OR: 4.83, 95% CI: 3.49–6.20%). Of the sociodemographic factors, age, wearing short-sleeved upper body clothing as the uniform and non-use of insect repellents were identified as significant risk factors. Most of the CL patients had a single lesion (86.0%; n = 43) of an ulcerative type (34.0%; n = 17), mostly on their upper limb (67.9%; n = 34). Lesions were mostly 5–10 mm diameter (59.9%; n = 30) in size with poorly defined margins (72.0%; n = 36). Amongst the diagnostic techniques, microscopic examination of slit skin smear and tissue impression smear were able to discriminate the majority of patients (92.1%; n = 46) for CL. Conclusions In order to highlight the true burden of leishmaniasis in the military personnel, cases of leishmaniasis from military institutes should be recognized as a different entity per say and be included in the national figures so as to depict the real magnitude of the disease burden amongst this high-risk group.

Abstract Malaria was eliminated from Sri Lanka in 2012, and the country received WHO-certification in 2016. The objective of this paper is to describe the epidemiology of malaria elimination in Sri Lanka, and the key technical and operational features of the elimination effort, which may have been central to achieving the goal, even prior to schedule, and despite an ongoing war in parts of the country. Analysis of information and data from the Anti Malaria Campaign (AMC) of Sri Lanka during and before the elimination phase, and the experiences of the author(s) who directed and/or implemented the elimination programme or supported it form the basis of this paper. The key epidemiological features of malaria on the path to elimination included a steady reduction of case incidence from 1999 onwards, and the simultaneous elimination of both Plasmodium falciparum and Plasmodium vivax. Against the backdrop of a good health infrastructure the AMC, a specialized programme within the Ministry of Health operated through a decentralized provincial health system to implement accepted strategies for the elimination of malaria. Careful planning combined with expertise on malaria control at the Central level with dedicated staff at all levels at the Centre and on the ground in all districts, for several years, was the foundation of this success. The stringent implementation of anti-relapse treatment for P. vivax through a strong collaboration with the military in whose cadres most of the malaria cases were clustered in the last few years of transmission would have supported the relatively rapid elimination of P. vivax. A robust case and entomological surveillance and investigation system described here enabled a highly focused approach to delivering interventions leading to the interruption of transmission.

Abstract Background There has been no local transmission of malaria in Sri Lanka for 6 years following elimination of the disease in 2012. Malaria vectors are prevalent in parts of the country, and imported malaria cases continue to be reported. The country is therefore at risk of malaria being re-established. The first case of introduced vivax malaria in the country is reported here, and the surveillance and response system that contained the further spread of this infection is described. Methods Diagnosis of malaria was based on microscopy and rapid diagnostic tests. Entomological surveillance for anophelines used standard techniques for larval and adult surveys. Genotyping of parasite isolates was done using a multi-locus direct sequencing approach, combined with cloning and restriction fragment length polymorphism analyses. Treatment of vivax malaria infections was according to the national malaria treatment guidelines. Results An imported vivax malaria case was detected in a foreign migrant followed by a Plasmodium vivax infection in a Sri Lankan national who visited the residence of the former. The link between the two cases was established by tracing the occurrence of events and by demonstrating genetic identity between the parasite isolates. Effective surveillance was conducted, and a prompt response was mounted by the Anti Malaria Campaign. No further transmission occurred as a result. Conclusions Evidence points to the case of malaria in the Sri Lankan national being an introduced malaria case transmitted locally from an infection in the foreign migrant labourer, which was the index case. Case detection, treatment and investigation, followed by prompt action prevented further transmission of these infections. Entomological surveillance and vector control at the site of transmission were critically important to prevent further transmission. The case is a reminder that the risk of re-establishment of the disease in the country is high, and that the surveillance and response system needs to be sustained in this form at least until the Southeast Asian region is free of malaria. Several countries that are on track to eliminate malaria in the coming years are in a similar situation of receptivity and vulnerability. Regional elimination of malaria must therefore be considered a priority if the gains of global malaria elimination are to be sustained.

IntroductionThe cost in managing hospitalised dengue patients varies across countries depending on access to healthcare, management guidelines, and state sponsored subsidies. For health budget planning, locally relevant, accurate costing data from prospective studies, is essential.ObjectiveTo characterise the direct costs of managing hospitalised patients with suspected dengue infection in Sri Lanka.MethodsColombo Dengue Study is a prospective single centre cohort study in Sri Lanka recruiting suspected hospitalised dengue fever patients in the first three days of fever and following them up until discharge. The diagnosis of dengue is retrospectively confirmed and the cohort therefore has a group of non-dengue fever patients with a phenotypically similar illness, managed as dengue while in hospital. The direct costs of hospital admission (base and investigation costs, excluding medication) were calculated for all recruited patients and compared between dengue and non-dengue categories as well as across subgroups (demographic, clinical or temporal) within each of these categories. We also explored if excluding dengue upfront, would lead to an overall cost saving in several hypothetical scenarios.ResultsFrom October 2017 to February 2020, 431 adult dengue patients and 256 non-dengue fever patients were recruited. The hospitalisation costs were USD 18.02 (SD: 4.42) and USD 17.55 (SD: 4.09) per patient per day for dengue and non-dengue patients respectively (p>0.05). Laboratory investigations (haematological, biochemical and imaging) accounted for more than 50% of the total cost. The costs were largely homogenous in all subgroups within or across dengue and non-dengue categories. Excluding dengue upfront by subsidised viral genomic testing may yield overall cost savings for non-dengue patients.ConclusionAs non-dengue patients incur a similar cost per day as the dengue patients, confirming dengue diagnosis using subsidised tests for patients presenting in the first three days of fever may be cost-efficient.

Abstract Background The country received malaria-free certification from WHO in September 2016, becoming only the second country in the WHO South East Asia region to be declared malaria-free. Imported malaria cases continue to be reported, with 278 cases reported between 2013 and 2017. The diagnosis of a severe Plasmodium vivax patient co-infected with HIV and tuberculosis is discussed with an overview of the rapid response mounted by the Anti Malaria Campaign (AMC), Sri Lanka. Case presentation A Sri Lankan gem miner who returned from Madagascar on the 6th of April 2018 presented to a private hospital for a malaria diagnostic test on the 21st April, 2 days after the onset of fever. He came on his own for this test due to the awareness he had regarding the risk of imported malaria. As the patient was positive for P. vivax malaria, he was admitted to a government hospital for further management. The patient had features of severe malaria upon admission with a systolic BP

Abstract Background In special circumstances, establishing public private partnerships for malaria elimination may achieve targets faster than the state sector acting by itself. Following the end of the separatist war in Sri Lanka in 2009, the Anti Malaria Campaign (AMC) of Sri Lanka intensified malaria surveillance jointly with a private sector partner, Tropical and Environmental Diseases and Health Associates Private Limited (TEDHA) with a view to achieving malaria elimination targets by 2014. Methods This is a case study on how public private partnerships can be effectively utilized to achieve malaria elimination goals. TEDHA established 50 Malaria Diagnostic Laboratories and 17 entomology surveillance sentinel sites in consultation with the AMC in areas difficult to access by government officials (five districts in two provinces affected by war). Results TEDHA screened 994,448 individuals for malaria, of which 243,867 were screened at mobile malaria clinics as compared to 1,102,054 screened by the AMC. Nine malaria positives were diagnosed by TEDHA, while the AMC diagnosed 103 malaria cases in the same districts in parallel. Over 13,000 entomological activity days were completed. Relevant information was shared with AMC and the data recorded in the health information system. Conclusions A successful public-private partnership model for malaria elimination was initiated at a time when the health system was in disarray in war ravaged areas of Sri Lanka. This ensured a high annual blood examination rate and screening of vulnerable people in receptive areas. These were important for certification of malaria-free status which Sri Lanka eventually received in 2016.

Abstract Objective Aspirin is a commonly used medicine for primary and secondary prevention of cardiovascular diseases. It is an acidic medicine associated with gastric irritation and acid reflux, which in turn can lead to low oral pH levels. Therefore, it is important to understand the association between aspirin and oral pH levels in order to achieve an optimum oral health condition among patients who take aspirin on prescription. Results Out of 373 patients, 162 (44%) were males and 245 (66%) were on aspirin. 71% of aspirin taking patients and 29% of non-aspirin taking patients had oral pH less than 6.5 (P

After eliminating local malaria transmission and being certified as a malaria-free country, Sri Lanka is facing the challenge of imported malaria. At the same time, the country has the unique opportunity to be a case study for other countries in a similar situation by approaching this issue systematically, guided by evidence. This study demonstrates the importance of developing a mechanism to detect imported malaria and adopting an evidence-based approach to study the resistance of imported malaria to anti-malarial medicines. This is a prospective study of patients diagnosed with imported malaria in Sri Lanka and treated according to the national treatment guidelines, over 24 months (2015/2016). The clinical features, time to diagnosis, origin of the infection, infecting species, parasite density and the treatment given were recorded. All patients were followed up for 28 days, and in the case of Plasmodium vivax and P. ovale infections, the follow up period was extended to 12 months to establish treatment failures and relapses. Fifty nine uncomplicated and 15 severe imported malaria cases were reported in Sri Lanka during the study period. Most of these infections originated in either Sub-Saharan Africa or South and Southeast Asia. Having a P. vivax infection and low parasitic counts were significantly associated with relative diagnostic delay. One of the 14 uncomplicated P. falciparum patients and two of the 12 severe P. falciparum malaria patients who were followed up till day 28 had a late clinical failure. The others responded adequately to treatment both clinically and parasitologically. There was no treatment failure reported amongst any other species. This study, which is the first to assess the therapeutic response of imported malaria in Sri Lanka after elimination, demonstrates that the current antimalarial treatment policies and strategies in Sri Lanka have been effective against infections acquired overseas up until the end of year 2016.