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Introduction: Sri Lanka implemented the National Programme for Elimination of Lymphatic Filariasis (NPELF) in its endemic regions in 2002. Five annual rounds of mass drug administration using the two-drug combination diethylcarbamazine (DEC) and albendazole led to sustained reductions in infection rates below threshold levels. In 2016, WHO validated that Sri Lanka eliminated lymphatic filariasis as a public health problem., Objective: To explore the impact of the NPELF on lymphatic filariasis morbidity in Sri Lanka., Methods: Passive Case Detection (PCD) data maintained in filaria clinic registries from 2006-2022 for lymphoedema and hospital admission data for managing hydroceles/spermatoceles from 2007-2022 were analyzed. The morbidity status in 2022 and trends in overall and district-wise PCD rates were assessed. Poisson log-linear models were used to assess the trends in PCD for endemic regions, including district-wise trends and hospital admissions for the management of hydroceles/spermatoceles., Results: In 2022, there were 566 new lymphoedema case visits. The mean (SD) age was 53.9 (16.0) years. The staging was done for 94% of cases, of which 79% were in the early stages (57.3% and 21.4% in stages two and one, respectively). Western Province had the highest caseload (52%), followed by the Southern (32%) and Northwestern (16%) Provinces, respectively. The reported lymphoedema PCD rate in 2022 was 0.61 per 10,000 endemic population. The overall PCD rate showed a decline of 7.6% (95%CI: 4.9% - 10.3%) per year (P < 0.0001) from 2007 to 2022. A steady decline was observed in Colombo, Gampaha and Kurunegala districts, while Kalutara remained static and other districts showed a decline in recent years. Further, admissions for inpatient management of hydroceles/spermatoceles showed a declining trend after 2015., Conclusions: The PCD rates of lymphoedema and hydroceles/spermatoceles showed a declining trend in Sri Lanka after the implementation of the NPELF., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gunaratna et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Simulation is accepted as an effective method of learning procedural skills. However, the translational outcomes of skills acquired through simulation still warrants investigation. We designed this study to assess if skills laboratory training in addition to bedside learning (intervention group [IG]) would provide better learning results than bedside learning alone (control group [CG]) in the context of venipuncture training. This prospective, cluster-randomized, single-blind study took place at the Faculty of Medicine, University of Kelaniya, Sri Lanka. Seventeen clusters of second-year medical students were randomly assigned to either IG or CG. The IG trained on venipuncture in the skills laboratory, receiving instruction after modified Payton's Four Step Method. Following the training, students of both IG and CG underwent bedside learning for one month. Afterward, students of both groups performed venipuncture on actual patients in a clinical setting. An independent, blinded assessor scored students' performance using the Integrated Procedural Protocol Instrument (IPPI) and a checklist. Patients assessed students' performance with the Communication Assessment Tool (CAT). Eight and nine clusters were randomized to the intervention and control groups, respectively. IG completed significantly more single steps of the procedure correctly (IG: 19.36 ± 3.87 for checklist items; CG: 15.57 ± 4.95; p < 0.001). IG also scored significantly better on IPPI ratings (median: IG: 27 (12) vs. CG: 21 (8); p < 0.001). Rated by patients, students' communication skills did not significantly differ between the two groups. Simulation-based venipuncture training enabled students to perform the procedure on actual patients with a higher technical accuracy than students who learned venipuncture at the bedside. Students were able to transfer the skills acquired through venipuncture training at the skill laboratory to the bedside., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Leptospirosis is the most widespread zoonosis in the world. The disease is more prevalent in tropical regions where the majority of developing countries are located. Leptospirosis is considered a protean manifestation zoonosis with severity of the disease ranging from a mild febrile illness to a severe and life-threatening illness. Clinical symptoms of leptospirosis overlap with other tropical febrile illnesses. Early, rapid, and definitive diagnosis is important for effective patient management. Since Polymerase Chain Reaction (PCR)-based assays are not readily available in most clinical settings, there is a need for an affordable, simple, and rapid diagnostic test. Quantitative PCR (qPCR) and Recombinase Polymerase Amplification (RPA) were implemented at the Faculty of Medicine, University of Kelaniya, and a prospective study to evaluate RPA for diagnosis of acute phase of leptospirosis was conducted. Results indicate that RPA and qPCR were positive in 81% (98/121) of the total positive and acute clinical samples. Of the 81 positive MAT confirmed patients 60 (74%) and 53 (65%) were positive with qPCR and RPA respectively. Retrospective evaluation revealed a high diagnostic accuracy (sensitivity-70% and specificity-87%) of RPA compared to MAT as the reference gold standard. Results further suggest that there is no significant difference between the two assays, qPCR and RPA-SwiftX (P = 0.40). Laboratory procedures for the extraction and detection by qPCR in the laboratory have been optimized to obtain results within 6 hours. However, the RPA-SwiftX method under field conditions took 35 minutes. The RPA-SwiftX method could replace the qPCR which shows similar sensitivity and specificity. Therefore, RPA established under the current study presents a powerful tool for the early and rapid diagnosis of leptospirosis at point-of-care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Uduwawala et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Three Anopheles stephensi biotypes have historically been differentiated through variations in the mode numbers of egg ridges and adult spiracular indices. Anopheles stephensi odorant-binding protein 1 gene (AsteObp1) sequences in Iran and Afghanistan have been recently interpreted to suggest that the three biotypes are sibling species. AsteObp1 intron 1 sequences, mode numbers of egg ridges and spiracular indices of An. stephensi in Jaffna city in Sri Lanka were therefore investigated in field-collected mosquitoes and short-term laboratory colonies established from them. AsteObp1 intron 1 sequences revealed the region to be polymorphic with four unique sequences, ASJF1-4, present in both short-term laboratory colonies and field-collected An. stephensi. The spiracular index did not relate to the mode number of egg ridges in Jaffna An. stephensi. The results suggested that numbers of egg ridges, spiracular indices and AsteObp1 intron 1 sequences were not useful for differentiating An. stephensi biotypes in Jaffna. It is proposed that the observed differences between An. stephensi mosquitoes in Jaffna now result from normal population variance in the context of rapidly changing bionomics in India and northern Sri Lanka., (© 2022 Royal Entomological Society.)

Introduction: The acceptability of a vaccine is an important factor during mass vaccination programs and this is largely dependent on the symptoms of local and systemic reactogenicity. There is paucity of data on the systemic and local reactions experienced by COVD-19 vaccine recipients in South Asia., Objectives: To identify the early local and systemic reactogenicity of ChAdOx1 nCoV-19 vaccine., Method: A multicenter observational study was performed to identify the reactogenicity to ChAdOx1 nCoV-19 vaccine in healthcare workers following the first dose., Results: There were 4478 participants with a median age of 42 years (IQR 34-51) and 2863 (63.9%) were females. At least one symptom of reactogenicity was reported by 4151 (92.7%). Local reactions were reported by 2612 (58.3%). Systemic reactions were bodyache (3244,72.4%), fatigue (2379, 53.1%), headache (2277, 50.8%), fever (2290, 51.1%), feverishness (1912, 42.7%) and chills (2295, 51.3%). Lower age (p<0.0001) and female gender (p 0.002) were associated with a higher frequency of developing systemic reactions. There was no association between reactogenicity and comorbidities. There were 342 (7.6%) reports of palpitations and one case of ventricular bigeminy. There was one report of anaphylaxis and hospital admissions were reported by 24 (0.5%). One vaccine recipient was managed for possible aseptic meningitis., Conclusion: This study demonstrates that early systemic and local reactions are common. Systemic reactions were more frequent in females and in the younger population. Most symptoms were self- limiting and did not require medical attention or hospital admission. ChAdOx1 nCoV-19 vaccine appears safe in the studied population.

Objectives: Dengue viral infection is an ongoing epidemic in Sri Lanka, causing significant mortality and morbidity. A descriptive-analytical study was carried out using serologically confirmed Dengue patients during a 6 month period. The relationship between the elevation of hepatic enzymes and severity of Dengue was assessed after stratifying recorded maximum AST/ALT (SGOT/SGPT) values 2-15 times elevated and by the phases of the illness. Sensitivity, specificity, predictive values, and ROC curves were assessed using maximum values for AST and ALT., Results: Out of 255 patients, 107(42%) were females. The majority (52.9%) were in the 20-39 year age group. Only 19.6% had DHF. No statistically significant difference was noticed in the values of maximum transaminases during the febrile phase among DF and DHF patients. Higher sensitivity and low specificity with the 1-5 times elevation range was noticed, and a higher cut-off level of more than 5 times elevation showed low sensitivity and higher specificity. The combination of both transaminases cut-offs with age and sex also does not show clinically significant predictability of severe disease. The AST and ALT elevations are not showing discriminatory predictive value on dengue severity. As different serotypes cause different epidemics, it is important to carry out large-scale specific studies considering the serotypes.

Background: The larval bionomics of Aedes across the Jaffna peninsula in northern Sri Lanka was investigated to obtain information needed for developing more effective larval source reduction measures to control endemic arboviral diseases., Methods: The habitats of preimaginal stages of Aedes mosquitoes were surveyed, and ovitrap collections were carried out in densely populated areas of the Jaffna peninsula. Aedes larval productivities were analysed against habitat characteristics, rainfall and dengue incidence. Adults emerging from collected larvae were tested for dengue virus (DENV)., Results: Only Aedes aegypti, Ae. albopictus and Ae. vittatus were identified in the field habitat collections and ovitraps. Aedes aegypti was the predominant species in both the field habitat and ovitrap collections, followed by Ae. albopictus and small numbers of Ae. vittatus. Tires and open drains were the preferred field habitats for Ae. aegypti, although larval productivity was higher in discarded plastic containers. The three Aedes species differed in field habitat preferences. Concomitant presence of the three Aedes species was observed in the field habitats and ovitraps. Larval productivities were inversely correlated with the salinity of the field habitat. Rainfall in the preceding month significantly correlated with larval productivity in the field habitats. DENV serotype 2 was detected in Ae. aegypti collected from ovitraps in the city of Jaffna. High Breteau, House and Container indices of 5.1, 5.1 and 7.9%, respectively, were observed in the field habitat surveys and ovitrap indices of up to 92% were found in Jaffna city., Conclusions: Aedes larval indices in populated areas of the peninsula showed a high potential for dengue epidemics. Unacceptable littering practices, failure to implement existing dengue control guidelines, vertical transmission of DENV in vector mosquitoes and preimaginal development in brackish water and open surface drains, as well as in domestic wells that provide potable water, are serious constraints to the current Aedes larval source reduction methods used to control dengue in the Jaffna peninsula. Similar shortcomings in arboviral disease control are likely present in other resource-constrained tropical coastal zones worldwide.

Background: The first case of a coronavirus 2019 (COVID-19) infection in a Sri Lankan was reported on March 11, 2020. The situation in Sri Lanka changed with the rapid increase of personnel contracting COVID-19 in a naval base camp that housed more than 4000 people. This provided a unique opportunity to study the effectiveness of hydroxychloroquine (HCQ) for post-exposure prophylaxis (PEP), while taking stringent, non-pharmacologic, public health measures to prevent spread. Our aim is to study the effectiveness and safety of HCQ for PEP among naval personnel with exposure to COVID-19-positive patients., Methods/design: This is a placebo-controlled, randomized, clinical trial carried out in the naval base camp and quarantine centers of the Sri Lanka Navy, Ministry of Defense, Sri Lanka. Navy personnel who are exposed to a patient with confirmed COVID-19 infection but test negative for the virus on reverse real-time polymerase chain reaction (rRT-PCR) at recruitment will be randomized, 200 to each arm, to receive HCQ or placebo and monitored for the development of symptoms or rRT-PCR positivity for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus for 14 days., Discussion: This trial will provide high-quality evidence of the effectiveness and safety of HCQ as PEP for COVID-19. The study design is unique due to the circumstances of the outbreak in a confined area among otherwise healthy adults, at a relatively early stage of its spread., Trial Registration: Sri Lanka Clinical Trials Registry (SLCTR) SLCTR/2020/011 . Registered on 04 May 2020.

Background: Malaria was eliminated from Sri Lanka in 2013. However, the influx of infected travelers and the presence of potent anopheline vectors can re-initiate transmission in Jaffna city, which is separated by a narrow strait from the malaria-endemic Indian state of Tamil Nadu., Methods: Anopheline larvae were collected from different habitats in Jaffna city and the susceptibility of emergent adults to DDT, malathion and deltamethrin investigated., Results: Anopheline larvae were found in wells, surface-exposed drains, ponds, water puddles and water storage tanks, with many containing polluted, alkaline and brackish water. Anopheles culicifacies, An. subpictus, An. stephensi and An. varuna were identified in the collections. Adults of the four anopheline species were resistant to DDT. Anopheles subpictus and An. stephensi were resistant while An. culicifacies and An. varuna were possibly resistant to deltamethrin. Anopheles stephensi was resistant, An. subpictus possibly resistant while An. varuna and An. culicifacies were susceptible to malathion. DNA sequencing showed a L1014F (TTA to TTC) mutation in the IIS6 transmembrane segment of the voltage-gated sodium channel protein in deltamethrin-resistant An. subpictus-a mutation previously observed in India but not Sri Lanka., Conclusion: Anopheles subpictus in Jaffna, like An. stephensi, may have recently originated in coastal Tamil Nadu. Besides infected overseas travelers, wind- and boat-borne carriage of Plasmodium-infected anophelines across the Palk Strait can potentially reintroduce malaria transmission to Jaffna city. Adaptation to diverse larval habitats and resistance to common insecticides in anophelines are identified as potential problems for vector control should this happen.

Background: Suicide only present the tip of the iceberg of maternal mental health issues. Only a fraction of pregnant women with suicidal ideation proceeds to intentional self-harm (ISH) and even a smaller proportion are fatal. The purpose of the present study was to determine the prevalence of depression, suicidal ideation (present and past) and history of ISH among pregnant mothers in rural Sri Lanka., Methods: We have conducted a hospital based cross sectional study in the third largest hospital in Sri Lanka and an another tertiary care center. Pregnant women admitted to hospital at term were included as study participants. The Edinburgh Postpartum Depression Scale (EPDS), a self-administered questionnaire for demographic and clinical data and a data extraction sheet to get pregnancy related data from the pregnancy record was used., Results: The study sample consisted of 475 pregnant women in their third trimester. For the tenth question of EPDS "the thought of harming myself has occurred to me during last seven days" was answered as "yes quite a lot" by four (0.8%), "yes sometimes" by eleven (2.3%) and hardly ever by 13 (2.7%). Two additional pregnant women reported that they had suicidal ideation during the early part of the current pregnancy period though they are not having it now. Four (0.8%) pregnant women reported having a history of ISH during the current pregnancy. History of ISH prior to this pregnancy was reported by eight women and five of them were reported to hospitals, while others were managed at home. Of the 475 pregnant females included in the study, 126 (26.5%) had an EPDS score more than nine, showing probable anxiety and depression. Pregnant women who had primary/post-primary or tertiary education compared to those who were in-between those two categories were at higher risk of high EPDS score with a OR of 1.94 (95% CI 1.1-3.3). Reported suicidal ideation prior to pregnancy was also associated with high EPDS with a OR of 6.4 (95% CI 2.3-17.5)., Conclusions: Based on our data, we conservatively estimate around 500 pregnant women each year having suicidal ideation and, 130 ISH annually in Anuradhapura, which should be considered as a high priority for an urgent intervention.

Background: Sri Lanka has been malaria-free since 2013 but re-introduction of malaria transmission by infected overseas travelers is possible due to a prevalence of potent malaria vectors. Knowledge of the insecticide resistance status among Anopheles vectors is important if vector control has to be reintroduced in the island. The present study investigated the insecticide susceptibility levels and resistance mechanisms of Anopheles sundaicus (sensu lato) (previously classified as Anopheles subpictus species B) an important malaria vector in the Jaffna Peninsula and it surroundings in northern Sri Lanka after indoor residual spraying of insecticides was terminated in 2013., Results: Species-specific PCR assays identified An. sundaicus (s.l.) in four locations in the Jaffna and adjacent Kilinochchi districts. Bioassays confirmed that An. sundaicus (s.l.) collected in Kilinochchi were completely susceptible to 0.05% deltamethrin and 5% malathion and resistant to 4% dichlorodiphenyltrichloroethane (DDT), whereas those from Jaffna were relatively susceptible to all three insecticides. Kilinochchi populations of An. sundaicus (s.l.) showed significantly higher glutathione S-transferase activity than population from Jaffna. However, Jaffna An. sundaicus (s.l.) had significantly higher Propoxur-resistant acetylcholinesterase activity. Activities of non-specific esterases and monooxygenases were not significantly elevated in An. sundaicus (s.l.) collected in both districts., Conclusions: The susceptibility to malathion and deltamethrin in An. sundaicus (s.l.) suggests that they can be still used for controlling this potential malaria vector in the Jaffna Peninsula and adjacent areas. Continuing country-wide studies on other malaria vectors and their insecticide susceptibilities are important in this regard.

Human brugian filariasis has re-emerged in Sri Lanka after a quiescent period of four decades. This study investigated the prevalence of canine and feline filarial parasites in three localities with human sub-periodic brugian filariasis, in order to determine their potential reservoir status. All reachable dogs and cats, both stray and domestic, within a 350m radius of an index case of brugian filariasis in three locations (Madampe, Wattala and Weliweriya) were screened for microfilariae using Giemsa stained thick blood smears. A representative sample of canine and feline blood samples positive for Brugia spp. microfilariae by microscopy, from each of the three locations, were further analyzed by PCR with specific primers for internal transcribed spacer region 2 (ITS2) of the ribosomal DNA. A total of 250 dogs and 134 cats were screened. The overall microfilaraemia rates were high among both dogs (68.8%) and cats (47.8%). The prevalence of microfilaraemia was significantly higher among dogs than cats (p<0.05). Two filarial species were identified based on morphology of microfilariae: Dirofilaria (Nochtiella) repens (dogs, 54.4% and cats, 34.3%) and Brugia spp. (dogs, 51.6% and cats, 30.6%). PCR analysis of canine (n = 53) and feline (n = 24) samples elicited bands in the region of 615bp, which confirmed Brugia malayi infection. Co-infection with D.(N.) repens was detected by PCR with an additional band at 484bp, in 36 canine and 17 feline samples. Overall microfilaraemia rates of dogs (81.8%) and cats (75%) in Madampe (rural) were significantly higher than in urbanized Wattala (dogs, 62.4% and cats, 26.0%) (p<0.05). High rates of zoonotic filarial infections strongly implicate dogs and cats as potential reservoirs for human dirofilariasis and brugian filariasis in Sri Lanka., Competing Interests: The authors have declared that no competing interests exist.

Background: Post-mass drug administration (MDA) surveillance during the lymphatic filariasis (LF) elimination program in Sri Lanka, revealed the re-emergence of brugian filariasis after four decades. This study was done with the objectives of investigating the epidemiology and age-specific vulnerability to infection. Surveillance was done using night blood smears (NBS) and the Brugia rapid test (BRT), to detect microfilaria (MF) and anti-Brugia IgG4 antibodies in blood samples collected from an age-stratified population enrolled from two high-risk study areas (SA)s, Pubudugama and Wedamulla in the Gampaha District. The periodicity of the re-emergent Brugia spp. was characterized by quantitative estimation of MF in blood collected periodically over 24 h using nucleopore-membrane filtration method., Results: Of 994 participants [Pubudugama 467 (47.9%) and Wedamulla 527 (53%)] screened by NBS, two and zero cases were positive for MF at Pubudugama (MF rate, 0.43) and Wedamulla (MF rate, 0), respectively, with an overall MF rate of 0.2. Of the two MF positives, one participant had a W. bancrofti while the other had a Brugia spp. infection. Of 984 valid BRT test readings [Pubudugama (n = 461) and Wedamulla (n = 523)], two and seven were positive for anti-brugia antibodies by BRT at Pubudugama (antibody rate 0.43) and Wedamulla (antibody rate 1.34), respectively, with an overall antibody rate of 0.91. Both MF positives detected from SAs and two of three other Brugia spp. MF positives detected at routine surveillance by the National Anti-Filariasis Campaign (AFC) tested negative by the BRT. Association of Brugia spp. infections with age were not evident due to the low case numbers. MF was observed in the peripheral circulation throughout the day (subperiodic) with peak counts occurring at 21 h indicating nocturnal sub-periodicity., Conclusions: There is the low-level persistence of bancroftian filariasis and re-emergence of brugian filariasis in the Gampaha District, Sri Lanka. The periodicity pattern of the re-emergent Brugia spp. suggests a zoonotic origin, which causes concern as MDA may not be an effective strategy for control. The importance of continuing surveillance is emphasized in countries that have reached LF elimination targets to sustain programmatic gains.

Background: The identification of species B and E in the Anopheles culicifacies complex in the Indian subcontinent has been based on Y-chromosome karyotype. Since no detectable variations were previously found in DNA markers commonly used for sibling species identification, further molecular characterization using cytochrome oxidase subunit I (COI) and microsatellite markers was carried out on Y-chromosome karyotyped Anopheles culicifacies specie B and E from Unnichchai, Kallady and Ranawarunawa in Sri Lanka., Findings: COI sequence analysis (n = 22) revealed the presence of nine unique haplotypes with six in each species. Three haplotypes were shared by both species. The two sibling species had a pairwise FST value of 1.338 (p < 0.05) with the number of migrants (Nm) value <1. The genetic structure analysis resulted in two genetic clusters not 100% associated with karyotypes. While none of the species B were incorrectly assigned two were inconclusive. Five out of 26 specimens karyotyped as species E were incorrectly assigned, while further 9 were inconclusive., Conclusions: The new molecular data support the existence of two genetically different populations of the Culicifacies Complex in Sri Lanka that are not associated with the Y-chromosome karyotype. Detailed analysis with more microsatellite markers and assortative mating experiments are needed to establish the presence of the two genetically distinct populations and relate them to Y-chromosome morphology.

The mainly fresh water arboviral vector Aedes aegypti L. (Diptera: Culicidae) can also undergo pre-imaginal development in brackish water of up to 15 ppt (parts per thousand) salt in coastal areas. We investigated differences in salinity tolerance, egg laying preference, egg hatching and larval development times and resistance to common insecticides in Ae. aegypti collected from brackish and fresh water habitats in Jaffna, Sri Lanka. Brackish water-derived Ae. aegypti were more tolerant of salinity than fresh water-derived Ae. aegypti and this difference was only partly reduced after their transfer to fresh water for up to five generations. Brackish water-derived Ae. aegypti did not significantly discriminate between 10 ppt salt brackish water and fresh water for oviposition, while fresh water-derived Ae. aegypti preferred fresh water. The hatching of eggs from both brackish and fresh water-derived Ae. aegypti was less efficient and the time taken for larvae to develop into pupae was prolonged in 10 ppt salt brackish water. Ae. aegypti isolated from coastal brackish water were less resistant to the organophosphate insecticide malathion than inland fresh water Ae. aegypti. Brackish and fresh water-derived Ae. aegypti however were able to mate and produce viable offspring in the laboratory. The results suggest that development in brackish water is characterised by pertinent biological changes, and that there is restricted genetic exchange between coastal brackish and inland fresh water Ae. aegypti isolates from sites 5 km apart. The findings highlight the need for monitoring Ae. aegypti developing in coastal brackish waters and extending vector control measures to their habitats.

Background: Anopheles barbirostris is a vector of malaria in Sri Lanka. The taxon exists as a species complex in the Southeast Asian region. Previous studies using molecular markers suggest that there are more than 4 distinct clades within the An. barbirostris complex in Southeast Asia. The present study characterizes Sri Lankan An. barbirostris using mtDNA cytochrome oxidase subunit I (COI) and ribosomal RNA internal transcribed spacer 2 (ITS2) gene sequences., Findings: DNA was extracted from morphologically identified An. barbirostris specimens from Sri Lanka, the COI and ITS2 regions amplified and their sequences analysed by comparison with other GenBank entries. Maximum likelihood trees suggested that Sri Lankan An. barbirostris constitute a different molecular type most closely related to clade I., Conclusions: Considering the uncorrected p distances between the clade I and Sri Lankan specimens it is fair to assume that the specimens collected from widely separated locations in Sri Lanka with morphology characteristic of An. barbirostris s.l. form a new molecular type with close resemblance to An. barbirostris s.s from Indonesia and Thailand.

Anopheles subpictus Grassi s.l. (Diptera: Culicidae) functions as a secondary malaria vector to Anopheles culicifacies Giles s.l. (Diptera: Culicidae) in Sri Lanka. The taxon A. subpictus is reported to exist as a species complex comprising four sibling species (A-D) that can be differentiated through polytene chromosome banding patterns and stage-specific morphometric traits in India. Based on the morphological characteristics described for the Indian Subpictus Complex, the presence of all four sibling species has been described in Sri Lanka. As sibling species show distinct bio-ecological characteristics that are important for devising appropriate vector control measures, a study was carried out in six districts in the dry zone of Sri Lanka. The results confirm the presence of all four sibling species, with species C predominating in inland areas and species B in coastal areas. Species C and D were indoor-resting and indoor-feeding, while species B was outdoor-resting with no significant preference for indoor- or outdoor-resting. Species B showed distinct morphological variation in the ornamentation of wings and palpi. Blood meal analysis revealed that species B, C, and D can feed on humans as well as cattle. The differential bio-ecological traits shown by the members of the Subpictus Complex are important for developing appropriate vector control measures in Sri Lanka.

Background: Anopheles subpictus sensu lato is a major malaria vector in South and Southeast Asia. Based initially on polytene chromosome inversion polymorphism, and subsequently on morphological characterization, four sibling species A-D were reported from India. The present study uses molecular methods to further characterize and identify sibling species in Sri Lanka., Methods: Mosquitoes from Sri Lanka were morphologically identified to species and sequenced for the ribosomal internal transcribed spacer-2 (ITS2) and the mitochondrial cytochrome c oxidase subunit-I (COI) genes. These sequences, together with others from GenBank, were used to construct phylogenetic trees and parsimony haplotype networks and to test for genetic population structure., Results: Both ITS2 and COI sequences revealed two divergent clades indicating that the Subpictus complex in Sri Lanka is composed of two genetically distinct species that correspond to species A and species B from India. Phylogenetic analysis showed that species A and species B do not form a monophyletic clade but instead share genetic similarity with Anopheles vagus and Anopheles sundaicus s.l., respectively. An allele specific identification method based on ITS2 variation was developed for the reliable identification of species A and B in Sri Lanka., Conclusion: Further multidisciplinary studies are needed to establish the species status of all chromosomal forms in the Subpictus complex. This study emphasizes the difficulties in using morphological characters for species identification in An. subpictus s.l. in Sri Lanka and demonstrates the utility of an allele specific identification method that can be used to characterize the differential bio-ecological traits of species A and B in Sri Lanka.

Larvae of Culex (Lutzia) Fuscanus were collected from ovitraps in a natural breeding site. Collected larvae were used to establish a self-mating colony, and larval progeny were then used to determine their predatory efficacy on larvae of 3 vector mosquito species, Aedes aegypti, Anopheles subpictus, and Cx. tritaeniorhynchus. Statistical analysis revealed that Cx. fuscanus showed greater feeding efficacy for Ae. aegypti than for Cx. tritaeniorhynchus and An. subpictus. The natural predatory role of this species can potentially be exploited for biological control of mosquito vectors in Sri Lanka.

Background: Although an initial IFA-IgG titer greater or equal to 1/64 or 1/128 is considered positive in presumptive diagnosis, in clinical practice in an endemic setting for rickettsioses in Sri Lanka, some patients with IFA-IgG titer of 1/128 for either spotted fever group (SFG) or scrub typhus (ST) did not respond to treatment., Findings: To determine a clinically helpful diagnostic algorithm, IFA-IgG results of serologically confirmed treatment responders were analyzed in relation to duration of illness at sampling. Of 146 suspected SFG, 3 responders of 25 patients had titers ≤1/128 with < 7 days of illness while all 9 with titers ≥1/256 responded (false negative with 1/256 cutoff was 12%, false positive was 0%). For illness > 7 days, the false negative and positive rates were 4.3% (3/59) and 11.3% (6/53). Of 115 suspected ST, false negative and positive rates with ≥1/256 cutoff at <7 days of illness were 14.2% (2/14) and 0% (0/8) respectively while > 7 days, false negative and positive rates were 2% (1/51) and 0% (0/42)., Conclusions: For clinical decision making, duration of illness at sampling is important in interpreting serology results in an endemic setting. If sample is obtained ≤7 day of illness, an IgG titer of ≤1/128 requires a follow up sample in the diagnosis and > 7 days of illness, a single ≥1/256 titer is diagnostic for all ST and 90% of SFG.

Background: Anopheles subpictus s.l., an important malaria vector in Sri Lanka, is a complex of four morphologically identified sibling species A-D. Species A-D reportedly differ in bio-ecological traits that are important for vector control. We investigated possible variations that had not been reported previously, in the susceptibility to common insecticides and resistance mechanisms among the An. subpictus sibling species., Methods: Adult An. subpictus were collected from localities in four administrative districts in the dry zone of Sri Lanka. Single female isoprogeny lines were established and sibling species status determined according to reported egg morphology. World Health Organization's standard protocols were used for insecticide bioassays and biochemical assays to determine insecticide susceptibility and resistance mechanisms. Susceptibility of mosquitoes was tested against DDT (5%), malathion (4%), deltamethrin (0.05%) and λ-cyhalothrin (0.05%). Biochemical basis for resistance was determined through assaying for esterase, glutathione-S-transferase and monooxygenase activities and the insensitivity of acetycholinesterase (AChE) to propoxur inhibition., Results: All sibling species were highly resistant to DDT. However there were significant differences among the sibling species in their susceptibility to the other tested insecticides. Few species A could be collected for testing, and where testing was possible, species A tended to behave more similarly to species C and D than to B. Species B was more susceptible to all the tested insecticides than the other sibling species. This difference may be attributed to the predominance of species B in coastal areas where selection pressure due to indoor residual spraying of insecticides (IRS) was lower. However there were significant differences between the more inland species C and D mainly towards pyrethroids. Higher GST activities in species C and D might have contributed to their greater DDT resistance than species B. Malathion resistance in both species C and D may be caused by elevated GST activity and an altered insensitive target site in AChE. In addition, a carboxylesterase based malathion resistance mechanisms was also detected in species C and D. Elevated esterase levels in species C and D might have contributed to the low levels of pyrethroid resistance. However an absence of elevated activity of monooxygenases in species B, C and D indicates that monooxygenases are unlikely to be the cause of this partial resistance to pyrethroids., Conclusions: The differences in insecticide susceptibility and insecticide resistance mechanism shown by An. subpictus sibling species are important considerations for developing the malaria control and eradication program in Sri Lanka. Similar studies on species complexes of other anopheline vectors of malaria are necessary for effective malaria control worldwide. The differential susceptibility findings are also consistent with most, if not all, morphologically identified An. subpictus species B in Sri Lanka belonging to the An. sundaicus complex. There is a need therefore to develop molecular techniques that can be used to differentiate morphologically similar anopheline species in field conditions for more effective vector control.

Background: Anopheles annularis s.l. is a wide spread malaria vector in South and Southeast Asia, including Sri Lanka. The taxon An. annularis is a complex of two sibling species viz. A and B, that are differentiated by chromosome banding patterns and ribosomal gene sequences in India. Only species A is reported to be a malaria vector in India while the occurrence of sibling species in Sri Lanka has not been documented previously., Findings: Anopheline larvae were collected at a site in the Jaffna district, which lies within the dry zone of Sri Lanka, and reared in the laboratory. Emerged adults were identified using standard keys. DNA sequences of the D3 domain of 28S ribosomal DNA (rDNA) and the internal transcribed spacer-2 (ITS-2) of the morphologically identified An. annularis were determined. BLASTn searches against corresponding An. annularis sequences in GenBank and construction of phylogenetic trees from D3 and ITS-2 rDNA sequences showed that the Sri Lankan specimens, and An. annularis s.l. specimens from several Southeast Asian countries were closely related to species A of the Indian An. annularis complex., Conclusions: The results show the presence of the malaria vector An. annularis species A in Sri Lanka and Southeast Asia. Because An. annularis vectors have been long associated with malaria transmission in irrigated agricultural areas in the Sri Lankan dry zone, continued monitoring of An. annularis populations, and their sibling species status, in these areas need to be integral to malaria control and eradication efforts in the island.

Aedes aegypti (Linnaeus) and Aedes albopictus Skuse mosquitoes transmit serious human arboviral diseases including yellow fever, dengue and chikungunya in many tropical and sub-tropical countries. Females of the two species have adapted to undergo preimaginal development in natural or artificial collections of freshwater near human habitations and feed on human blood. While there is an effective vaccine against yellow fever, the control of dengue and chikungunya is mainly dependent on reducing freshwater preimaginal development habitats of the two vectors. We show here that Ae. aegypti and Ae. albopictus lay eggs and their larvae survive to emerge as adults in brackish water (water with <0.5 ppt or parts per thousand, 0.5-30 ppt and >30 ppt salt are termed fresh, brackish and saline respectively). Brackish water with salinity of 2 to 15 ppt in discarded plastic and glass containers, abandoned fishing boats and unused wells in coastal peri-urban environment were found to contain Ae. aegypti and Ae. albopictus larvae. Relatively high incidence of dengue in Jaffna city, Sri Lanka was observed in the vicinity of brackish water habitats containing Ae. aegypti larvae. These observations raise the possibility that brackish water-adapted Ae. aegypti and Ae. albopictus may play a hitherto unrecognized role in transmitting dengue, chikungunya and yellow fever in coastal urban areas. National and international health authorities therefore need to take the findings into consideration and extend their vector control efforts, which are presently focused on urban freshwater habitats, to include brackish water larval development habitats.

Following progressive reduction in confirmed cases of malaria from 2002 to 2007 (41,411 cases in 2002, 10,510 cases in 2003, 3,720 cases in 2004, 1,640 cases in 2005, 591 cases in 2006, and 198 cases in 2007). Sri Lanka entered the pre-elimination stage of malaria in 2008. One case of indigenous malaria and four other cases of imported malaria are highlighted here, as the only patients who presented to the Professorial Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka over the past eight years, in contrast to treating several patients a week about a decade ago. Therefore, at the eve of elimination of malaria from Sri Lanka, it is likely that the infection is mostly encountered among travellers who return from endemic areas, or among the military who serve in un-cleared areas of Northern Sri Lanka. They may act as potential sources of introducing malaria as until malaria eradication is carried out. These cases highlight that change in the symptomatology, forgetfulness regarding malaria as a cause of acute febrile illness and deterioration of the competency of microscopists as a consequence of the low disease incidence, which are all likely to contribute to the delay in the diagnosis. The importance regarding awareness of new malaria treatment regimens, treatment under direct observation, prompt notification of suspected or diagnosed cases of malaria and avoiding blind use of anti-malarials are among the other responsibilities expected of all clinicians who manage patients in countries reaching malaria elimination.

A Sri Lankan fever cohort (n = 292 patients; 17.8% prevalence) was used to assess two standard diagnostic Chikungunya IgM tests. The immunochromatographic test (ICT) acute sample sensitivity (SN) was 1.9 to 3.9%, and specificity (SP) was 92.5 to 95.0%. The enzyme-linked immunosorbent assay (ELISA) gave an acute sample SN of 3.9% and an SP of 92.5% and a convalescent sample SN of 84% and an SP of 91%. These assays are not suitable for the acute diagnosis of Chikungunya virus infection.

Background: Anopheles subpictus sensu lato, a widespread vector of malaria in Asia, is reportedly composed of four sibling species A-D based on distinct cytogenetic and morphological characteristics. However An. subpictus species B specimens in Sri Lanka are termed An. subpictus B/ An. sundaicus because of recent genetic data. Differences in salinity tolerance and coastal/inland prevalence of An. subpictus sibling species that were not previously established in Sri Lanka are presented here., Results: Specimens with morphological characteristics of all four Indian An. subpictus sibling species were found in Sri Lanka. Sibling species A, C and D tended to be predominant in inland, and An. subpictus species B/An. sundaicus, in coastal localities. Sibling species C was predominant in both adult and larval inland collections. Larvae of An. subpictus B/An. sundaicus were found in inland and coastal sites, including a lagoon, with salinity varying from 0 to 30 ppt. An. subpictus sibling species A, C and D larvae were present in water of salinity between 0 to 4 ppt. An. subpictus C, D and An. subpictus B/An. sundaicus larvae showed compatible differential salinity tolerance in laboratory tests. The first instar larvae of An. subpictus B/An. sundaicus showed 100% survival up to 15 ppt in comparison to species C and D where the corresponding values were 3 ppt and 6 ppt respectively. However all third instar larvae of An. subpictus B/An. sundaicus survived up to 30 ppt salinity whereas An. subpictus C and D tolerated up to 4 ppt and 8 ppt salinity respectively., Conclusions: The results suggest that An. subpictus species B/An. sundaicus breed in fresh, brackish and nearly saline water while An. subpictus species C and D do so in fresh and less brackish waters in Sri Lanka, as in India. Because of the established role of An. sundaicus s.l. and An. subpictus s.l. as malaria vectors, the findings indicate a need for greater monitoring of brackish water breeding habitats in Asia. Tolerance to 15 ppt salinity may also constitute a simple method for differentiating An. subpictus B/An. sundaicus larvae from those of An. subpictus species C and D in field studies.

Background: Anopheles subpictus sensu lato, a widespread malaria vector in Asia, is reportedly composed of four sibling species A - D. Mosquitoes morphologically identified as belonging to the Subpictus complex were collected from different locations near the east coast of Sri Lanka, and specific ribosomal DNA sequences determined to validate their taxonomic status., Methods: Anopheles subpictus s.l. larvae and blood-fed adults were collected from different locations in the Eastern province and their sibling species status was determined based on published morphological characteristics. DNA sequences of the D3 domain of 28 S ribosomal DNA (rDNA) and the internal transcribed spacer -2 (ITS-2) of mosquitoes morphologically identified as An. subpictus sibling species A, B, C and D were determined., Results: Phylogenetic analysis based on D3 domain of rDNA resulted in two clades: one clade with mosquitoes identified as An. subpictus species A, C, D and some mosquitoes identified as species B, and another clade with a majority of mosquitoes identified as species B with D3 sequences that were identical to Anopheles sundaicus cytotype D. Analysis of ITS-2 sequences confirmed a close relationship between a majority of mosquitoes identified as An. subpictus B with members of the An. sundaicus complex and others identified as An. subpictus B with An. subpictus s.l., Conclusions: The study suggests that published morphological characteristics are not specific enough to identify some members of the Subpictus complex, particularly species B. The sequences of the ITS-2 and D3 domain of rDNA suggest that a majority that were identified morphologically as An. subpictus species B in the east coast of Sri Lanka, and some identified elsewhere in SE Asia as An. subpictus s.l., are in fact members of the Sundaicus complex based on genetic similarity to An. sundaicus s.l. In view of the well-known ability of An. sundaicus s.l. to breed in brackish and fresh water and its proven ability to transmit malaria in coastal areas of many Southeast Asian countries, the present findings have significant implications for malaria control in Sri Lanka and neighbouring countries.

Background: Anopheles culicifacies is the major vector of both falciparum and vivax malaria in Sri Lanka, while Anopheles subpictus and certain other species function as secondary vectors. In Sri Lanka, An. culicifacies is present as a species complex consisting of species B and E, while An. subpictus exists as a complex of species A-D. The freshwater breeding habit of An. culicifacies is well established. In order to further characterize the breeding sites of the major malaria vectors in Sri Lanka, a limited larval survey was carried out at a site in the Eastern province that was affected by the 2004 Asian tsunami., Methods: Anopheline larvae were collected fortnightly for six months from a brackish water body near Batticaloa town using dippers. Collected larvae were reared in the laboratory and the emerged adults were identified using standard keys. Sibling species status was established based on Y-chromosome morphology for An. culicifacies larvae and morphometric characteristics for An. subpictus larvae and adults. Salinity, dissolved oxygen and pH were determined at the larval collection site., Results: During a six month study covering dry and wet seasons, a total of 935 anopheline larvae were collected from this site that had salinity levels up to 4 parts per thousand at different times. Among the emerged adult mosquitoes, 661 were identified as An. culicifacies s.l. and 58 as An. subpictus s.l. Metaphase karyotyping of male larvae showed the presence of species E of the Culicifacies complex, and adult morphometric analysis the presence of species B of the Subpictus complex. Both species were able to breed in water with salinity levels up to 4 ppt., Conclusions: The study demonstrates the ability of An. culicifacies species E, the major vector of falciparum and vivax malaria in Sri Lanka, to oviposit and breed in brackish water. The sibling species B in the An. subpictus complex, a well-known salt water breeder and a secondary malaria vector in the country, was also detected at the same site. Since global warming and the rise in sea levels will further increase of inland brackish water bodies, the findings have significant implications for the control of malaria in Sri Lanka and elsewhere.

The authors conducted a cross-sectional comparative prevalence study to evaluate the effect of pollution on individuals who lived in an industrial zone in Sri Lanka. In this study, 81 male and female children who were 1-12 yr of age and 158 adults (51 males, 107 females) in the industrial zone were matched with 73 children (32 males, 41 females) and 146 adults (58 males, 88 females), respectively, who lived in a nonindustrialized area and whose ages were similar to those of the exposed individuals. The authors used a pretested questionnaire and a detailed clinical examination, including peak expiratory flow rate measurements, to assess the prevalence of illness. Children in the industrial area were 2.3 times more likely to have unexplained episodic cough (95% confidence interval [CI] = 0.98, 10.3) and 2.8 times more likely to have rhinitis (95% CI = 1.1, 7.1). The adult population was 2.1 times more likely to have unexplained episodic cough (95% CI = 1.13, 7.09), 3.7 times more likely to have unexplained headaches (95% CI = 2.2, 6.3), and adults had a significantly greater reduction in expiratory flow (peak expiratory flow rate = 446 - 92x [industrial area] + 91x [male] - 0.8x [years lived in the area]).