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Background Chemoprophylaxis is an effective tool for individuals to minimize their risk of contracting malaria and serves an important public health role in preventing imported malaria. Yet, it is only effective if the traveller is fully compliant with the prescribed regimen. For many destinations, a choice of prophylactic agents is available, so historical compliance data can be helpful for both physicians and travellers to make an informed decision. Methods We analyzed the historical self-reported compliance data for six chemoprophylactic agents currently recommended by CDC for primary malaria chemoprophylaxis by searching PubMed, Embase, CINAHL, Web of Science, and Scopus for observational studies reporting on travelers within the last 25 years. The quality of data was graded as “good” or “poor” using the NIH quality assessment tool for cohort and cross-sectional studies. Cumulative compliance data were compiled for all studies (gross compliance) and the subgroup of studies with “good” quality evidence (refined compliance). Subgroup analyses were performed for weekly vs daily administered regimens, between military and civilian travelers, and across each prophylactic agent. Results Twenty-four eligible studies assessed compliance for mefloquine (n=20), atovaquone-proguanil (n=11), doxycycline (n=13), and chloroquine (n=3). No studies were found for primaquine or tafenoquine. Both gross and refined compliance were significantly better for weekly regimens than daily regimens (P

In 2017, a dengue epidemic of unexpected magnitude occurred in Sri Lanka. A total of 186,101 suspected cases and 440 dengue-related deaths occurred. We conducted a comprehensive analysis of this epidemic by comparing national surveillance data for 2017 with data from the preceding 5 years. In all Sri Lanka districts, dengue incidence in 2017 increased significantly over incidence during the previous 5 years. Older schoolchildren and young adults were more clinically symptomatic than those at extremes of age. Limited virologic surveillance showed the dominant circulating variant was dengue virus type 2 cosmopolitan genotype in the most affected district. One quarter of total annual cases were reported 5 weeks after the southwest monsoon started. Changes in vector abundance were not predictive of the increased incidence. Direct government expenditures on dengue control activities in 2017 were US $12.7 million. The lessons learned from this outbreak are useful for other tropical nations facing increasing dengue incidence.

Background Carica papaya (CP) extract is becoming popular as an unlicensed herbal remedy purported to hasten recovery in dengue infection, mostly based on observations that it may increase platelet counts. This systematic review and meta-analysis aims to critically analyze the evidence from controlled clinical trials on the efficacy and safety of CP extract in the treatment of dengue infection. Methods PubMed, LILACS and Google Scholar were searched for randomized or non-randomized trials enrolling patients with suspected or confirmed dengue where CP extract was compared, as a treatment measure, against standard treatment. Recovery of platelet counts as well as other clinical indicators of favourable outcome (duration of hospital stay, prevention of plasma leakage, life threatening complications, and mortality) were assessed. Results Nine studies (India-6, Pakistan-1, Indonesia-1, Malaysia-1) met the inclusion criteria. Seven studies showed an increase in platelet counts in patients receiving CP extract, while one study showed no significant difference between the two groups, and direct comparison was not possible in the remaining study. Serious adverse events were not reported. CP extract may reduce the duration of hospital stay (mean difference − 1.98 days, 95% confidence interval − 1.83 to − 2.12, 3 studies, 580 participants, low quality evidence), and cause improvement in mean platelet counts between the first and fifth day of treatment (mean difference 35.45, 95% confidence interval 23.74 to 47.15, 3 studies, 129 participants, low quality evidence). No evidence was available regarding other clinical outcomes. Conclusions The clinical value of improvement in platelet count or early discharge is unclear in the absence of more robust indicators of favourable clinical outcome. Current evidence is insufficient to comment on the role of CP extract in dengue. There is a need for further well designed clinical trials examining the effect of CP on platelet counts, plasma leakage, other serious manifestations of dengue, and mortality, with clearly defined outcome measures.

Background A major challenge in dengue management in resource limited settings is the confirmation of diagnosis. Clinical features of dengue often overlap with other infections and molecular diagnostic tools are not readily accessible to clinicians at hospitals. In addition, the prediction of plasma leakage in dengue is also difficult. Hematocrit level and ultrasound scans (combined with clinical parameters) are helpful to detect plasma leakage once it has happened, not before. Methods Colombo Dengue Study (CDS) is a prospective cohort study of clinically suspected adult dengue patients recruited from the National hospital of Sri Lanka (within the first 3 days of fever) that aimed to a) identify clinical and basic laboratory test parameters to differentiate dengue from non-dengue fever, b) evaluate the comparative efficacy of loop-mediated isothermal amplification (LAMP) for dengue diagnosis (vs. NS1 antigen test and RT-qPCR) and c) identify early associations that are predictive of plasma leakage or severe dengue. The basic laboratory tests considered here included hematological parameters, serum biochemistry and inflammatory markers. Results Only 70% of clinically suspected patients were confirmed as having dengue by either the NS1 antigen test or RT-qPCR. On a Bayesian latent class model which assumes no “gold standard”, LAMP performed equally or better than RT-qPCR and NS1 antigen test respectively. When confirmed dengue patients were compared with others, the earlier group had significantly lower lymphocyte counts and higher aspartate aminotransferase levels (AST) within the first 3 days of fever. Confirmed dengue patients with plasma leakage had a lower mean age and a higher median baseline AST level compared to those without plasma leakage (p

Primaquine was the only licenced antimalarial hypnozoiticidal drug available until recently. Now there is a newly approved alternative: tafenoquine. This review explores the efficacy of tafenoquine as a primary and terminal prophylactic agent in malaria. Multiple databases (Cochrane Central Register of Controlled Trials [CENTRAL], MEDLINE [PubMed], Embase [Ovid], Scopus, CINAHL [EBSCOhost] and LILACS) were searched for clinical randomised controlled trials that had used tafenoquine for prophylaxis without language or time restrictions. The last date of searching was 13 August 2018. For primary prophylaxis, tafenoquine reduced episodes of malaria compared with placebo, at a dose range from 50 mg weekly to 400 mg monthly in three trials conducted in Ghana, Kenya and Thailand. Two trials compared tafenoquine vs mefloquine, but malaria episodes were too few to reach a conclusion. For terminal prophylaxis, evidence from two trials suggest that tafenoquine may have equal or better efficacy compared with primaquine. All trials excluded pregnant participants or those with G6PD deficiency. Tafenoquine is effective for both primary and terminal prophylaxis. If used for primary prophylaxis it may continue to offer protection against vivax relapses after exposure has ended (as terminal prophylaxis).

Objectives To compare the traditional hematocrit-based criteria (>20% rise above baseline) with ultrasonography for diagnosing plasma leakage in dengue fever and to identify clinical indicators for triaging patients in resource-limited settings when the demand for ultrasonography is high. Methods The Colombo Dengue Study is a prospective observational cohort study recruiting dengue patients in the first three days of dengue fever, before plasma leakage. Serial hematocrit assessments and ultrasonography were performed in patients recruited from October 2017 to February 2020. Clinical signs/symptoms and laboratory investigation results independently associated with ultrasound detected plasma leakage were identified with a derivation cohort and confirmed in a validation cohort. Results 129 of 426 patients had ultrasonography-confirmed plasma leakage while 146 had a hematocrit rise >20%. Those positive on ultrasonography were also likely to fulfill the hematocrit-based criteria (OR: 4.42, 95% CI: 2.85 - 6.86), but the two groups did not overlap fully. In the derivation cohort (n-317), platelet count 51 IU/L and having abdominal pain in the first three days of fever were independent predictors of ultrasound-detected plasma leakage. In the validation cohort (n-109), the combination of low platelet count and high aminotransferase level had better predictive capacity in terms of sensitivity and specificity. Conclusion Dengue patients should be monitored with both serial hematocrit and ultrasonography whenever possible and plasma leakage should be diagnosed by either one of these criteria. If accessibility to scans is limited, platelet count, serum transaminase levels and presence of abdominal pain are useful to triage patients.

Background Previous studies on post-infection fatigue in dengue are few but suggest that up to 25% of dengue patients may suffer from fatigue. This study aimed to evaluate the prevalence and associations of post-infection fatigue in dengue patients compared with non-dengue fever patients. Methods Post-infection fatigue and its demographic and clinical associations were assessed in adult dengue and non-dengue fever patients 2 months after the acute infection in a prospective cohort study in Sri Lanka. Fatigue at 2 months (primary endpoint) was assessed with the fatigue questionnaire as a dichotomous outcome based on a pre-recommended cut-off (score ≥4) and as the total score from the questionnaire (higher score indicates more fatigue). Results Of 260 patients, 158 had dengue and, of these, 51 (32%) had fatigue at 2 months. Risk was higher in dengue patients (vs non-dengue; relative risk [RR] 4.93 [95% confidence interval {CI} 2.3 to 10.4]) and more so in female dengue patients (vs male dengue patients; RR 2.45 [95% CI 1.24 to 4.86]). Severe dengue patients had a higher mean fatigue score (p=0.024). Conclusions Post-infection fatigue is an underappreciated burden of this widely prevalent infection. Our findings are useful to triage patients at risk of fatigue for follow-up.

Background Plasmodium vivax malaria has a persistent liver stage that causes relapse of the disease and continued P vivax transmission. Primaquine (PQ) is used to clear the liver stage of the parasite, but treatment is required for 14 days. Primaquine also causes haemolysis in people with glucose‐6‐phosphate dehydrogenase (G6PD) deficiency. Tafenoquine (TQ) is a new alternative to PQ with a longer half‐life and can be used as a single‐dose treatment. Objectives To assess the effects of tafenoquine 300 mg (single dose) on preventing P vivax relapse. Search methods We searched the following up to 3 June 2020: the Cochrane Infectious Diseases Group Specialized Register; CENTRAL; MEDLINE; Embase; and three other databases. We also searched the WHO International Clinical Trial Registry Platform and the metaRegister of Controlled Trials for ongoing trials using "tafenoquine" and "malaria" as search terms up to 3 June 2020. Selection criteria Randomized controlled trials (RCTs) that gave TQ to prevent relapse in people with P vivax malaria. We planned to include trials irrespective of whether participants had been screened for G6PD enzyme deficiency. Data collection and analysis All review authors independently extracted data and assessed risk of bias. As true relapse and reinfection are difficult to differentiate in people living in endemic areas, studies report "recurrences" of infection as a proxy for relapse. We carried out meta‐analysis where appropriate, and gave estimates as risk ratios (RR) with 95% confidence intervals (CI). We assessed the certainty of the evidence using the GRADE approach. Main results Three individually randomized RCTs met our inclusion criteria, all in endemic areas, and thus reporting recurrence. Trials compared TQ with PQ or placebo, and all participants received chloroquine (CQ) to treat the asexual infection). In all trials, pregnant and G6PD‐deficient people were excluded. Tafenoquine 300 mg single dose versus no treatment for relapse prevention Two trials assessed this comparison. TQ 300 mg single dose reduces P vivax recurrences compared to no antihypnozoite treatment during a six‐month follow‐up, but there is moderate uncertainty around effect size (RR 0.32, 95% CI 0.12 to 0.88; 2 trials, 504 participants; moderate‐certainty evidence). In people with normal G6PD status, there is probably little or no difference in any type of adverse events (2 trials, 504 participants; moderate‐certainty evidence). However, we are uncertain if TQ causes more serious adverse events (2 trials, 504 participants; very low‐certainty evidence). Both RCTs reported a total of 23 serious adverse events in TQ groups (One RCT reported 21 events) and a majority (15 events) were a drop in haemoglobin level by > 3g/dl (or >30% reduction from baseline). Tafenoquine 300 mg single dose versus primaquine 15 mg/day for 14 days for relapse prevention Three trials assessed this comparison. There is probably little or no difference between TQ and PQ in preventing recurrences (proxy measure for relapse) up to six months of follow‐up (RR 1.04, 95% CI 0.8 to 1.34; 3 trials, 747 participants; moderate‐certainty evidence). In people with normal G6PD status, there is probably little or no difference in any type of adverse events (3 trials, 747 participants; moderate‐certainty evidence). We are uncertain if TQ can cause more serious adverse events compared to PQ (3 trials, 747 participants; very low‐certainty evidence). Two trials had higher point estimates against TQ while the other showed the reverse. Most commonly reported serious adverse event in TQ group was a decline in haemoglobin level (19 out of 29 events). Some other serious adverse events, though observed in the TQ group, are unlikely to be caused by it (Hepatitis E infection, limb abscess, pneumonia, menorrhagia). Authors' conclusions TQ 300 mg single dose prevents relapses after clinically parasitologically confirmed P vivax malaria compared to no antihypnozoite treatment, and with no difference detected in studies comparing it to PQ to date. However, the inability to differentiate a true relapse from a recurrence in the available studies may affect these estimates. The drug is untested in children and in people with G6PD deficiency. Single‐dose treatment is an important practical advantage compared to using PQ for the same purpose without an overall increase in adverse events in non‐pregnant, non‐G6PD‐deficient adults., Plain language summary Tafenoquine for preventing relapse in people with vivax malaria What was the aim of this review? The aim of this review was to see if tafenoquine could prevent relapses of vivax infections and if this effect is equivalent to that of standard‐dose primaquine. Standard‐dose primaquine is defined as 15 mg/day for 14 days for adults. Key messages Tafenoquine prevents vivax malaria relapses (measured as recurrences of infection in all studies as it is not possible to differentiate a true relapse from a reinfection) in adults compared to no relapse prevention treatment (placebo). There is also probably little or no difference between tafenoquine and primaquine in preventing relapses. The evidence was of moderate certainty due to the low number of studies and few data. There is probably little or no difference in the overall adverse events with tafenoquine compared to placebo or primaquine. However, we are uncertain if tafenoquine causes more serious adverse events such as a drop in blood haemoglobin. What was studied in this review? Vivax malaria is caused by the parasite Plasmodium vivax. The disease includes a dormant (inactive) stage of liver infection and this can cause relapse (worsening) unless it is treated. The most frequently used medicine for relapse prevention until recently was primaquine, but now there is a new alternative named tafenoquine. The US agency responsible for protecting public health, the Food and Drug Administration (FDA), recommends tafenoquine for relapse prevention at a single 300 mg dose. Compared to primaquine, which is usually given daily for 14 days, single‐day dosing provides a significant advantage. However, both primaquine and tafenoquine can cause rupture or destruction of red blood cells (called haemolysis) in people with a hereditary condition called glucose‐6‐phosphate dehydrogenase (G6PD) enzyme deficiency. We conducted a Cochrane Review on the effect of tafenoquine on clearing the dormant P vivax parasites in infected people to prevent a relapse. However, it is difficult to differentiate between a true relapse and a new infection in the same individual unless the person was removed from a malaria‐endemic area after initial treatment. All trials included in this review did not do that and have actually measured recurrences as a proxy measure to infer on relapses. While acknowledging this limitation, in giving recommendations and results in this review we used the word 'relapse' as preventing relapses is the intention for using tafenoquine as a single dose in these trials. What are the main results of the review? We examined the research published up to 3 June 2020. We identified three trials conducted in nine countries in 747 adults with confirmed P vivax malaria. All adults received chloroquine (to clear the parasites from the blood) and some groups received either tafenoquine in a single dose of 300 mg, primaquine or placebo (an inactive tablet matched for the duration of primaquine). All were observed for recurrences of P vivax malaria (up to six months) and all trials tested people for G6PD activity and excluded people who were deficient. Pregnant women and children were also excluded. Adults receiving tafenoquine 300 mg had fewer relapses (inferred from the lower number of recurrences of infection) than adults who had placebo (moderate‐certainty evidence). There was probably little or no difference between Tafenoquine 300 mg and primaquine for relapse prevention (moderate‐certainty evidence). There is probably little or no difference in overall side effects between tafenoquine and primaquine (moderate‐certainty evidence). We are uncertain though if tafenoquine causes more serious adverse events compared to placebo or premaquine (for example, haemolysis; very low‐certainty evidence).

Background Repurposing hydroxychloroquine (HCQ) and chloroquine (CQ) as antiviral agents is a re-emerging topic with the advent of new viral epidemics. Aims To summarize evidence from human clinical studies for using HCQ or CQ as antiviral agents for any viral infection. Sources PubMed, EMBASE, Scopus, Web of Science for published studies without time or language restrictions; Cochrane Clinical Trial Registry and Chinese Clinical Trials Registry for trials registered after 2015; MedRxiv for preprints within the last 12 months. Content Study eligibility criteria were interventional and prospective observational studies (with or without a control group). Participants were adults and children with a confirmed viral infection. Interventions included the use of CQ or HCQ as antiviral agent in one or more groups of the study. Two authors independently screened abstracts, and all authors agreed on eligible studies. A meta-analysis was planned if studies were available which were similar in terms of participants, intervention, comparator and outcomes. Nineteen studies (including two preprints) were eligible (HIV 8, HCV 2, dengue 2, chikungunya 1, COVID-19 6). Nine and ten studies assessed CQ and HCQ respectively. Benefits of either drug for viral load suppression in HIV are inconsistent. CQ is ineffective in curing dengue (high-certainty evidence) and may have little or no benefit in curing chikungunya (low-certainty evidence). The evidence for COVID-19 infection is rapidly evolving but at this stage we are unsure whether either CQ or HCQ has any benefit in clearing viraemia (very-low-certainty evidence). Implications Using HCQ or CQ for HIV/HCV infections is now clinically irrelevant as other effective antivirals are available for viral load suppression (HIV) and cure (HCV). There is no benefit of CQ in dengue, and the same conclusion is likely for chikungunya. More evidence is needed to confirm whether either HCQ or CQ is beneficial in COVID-19 infection.

Dengue infection classically presents with fever, thrombocytopaenia, and varying degrees of plasma leakage, giving rise to shock. However, a myriad of other manifestations, involving the cardiovascular system, the nervous system, the liver, the kidneys, the gut and the haematological system have been reported in dengue. This review summarizes these varied presentations.

The utility of CareStart(TM) Malaria Pf/PAN (HRP2/pLDH) Ag Combo Test, in detecting non-endemic clinical malaria cases was evaluated in Sri Lanka, a country in prevention of re-establishment of malaria following elimination. RDT, microscopy and nested PCR were performed for 350 suspected malaria patients recruited prospectively. There were 173 PCR confirmed malaria patients and 177 PCR negative subjects. Plasmodium falciparum amounted to 48% of infections with 44% P. vivax, 6% P. ovale and 2% P. malariae. Performance characteristics of RDTs and microscopy were compared with nested PCR. Sensitivity and specificity of RDT with 95% confidence intervals (CI) were as follows: any malaria infection 95.95% (CI = 91.84–98.36) and 94.92% (CI = 90.57–97.65); P. falciparum 100% (CI = 95.65–100) and 97.00% (CI = 94.18–98.70) and other species 92.22% (CI = 84.63–96.82) and 99.62% (97.88–99.99) respectively. A significant difference between sensitivities of HRP2 (100%, CI = 95.65–100) and pan pLDH line (68.67%, CI = 57.56–78.41) was seen for P. falciparum, parasite densities less than 1000 parasites/microliter being detected only by HRP2. Sensitivity and specificity of microscopy with 95% CI were as follows: any malaria infection, 94.22% (CI = 89.63–97.19) and 99.44% (CI = 96.89–99.99); P. falciparum 89.16% (CI = 80.40–94.90) and 99.63% (CI = 97.94–99.99); other species 98.89% (CI = 93.96–99.97) and 100% (CI = 98.59–100) respectively. The low sensitivity of pan specific pLDH for P. falciparum, P. ovale and P. malariae should be taken in to consideration when using this RDT as a point of care test when and wherever microscopy facilities are not readily available. Considering the low sensitivity of microscopy for P. falciparum, it is preferable to perform both tests, when malaria is highly suspected.

Toxoplasmosis is an infection caused by the intracellular protozoan parasite Toxoplasma gondii, and is associated with clinically significant infection in immunocompromised individuals. Vertical transmission during pregnancy can manifest as congenital toxoplasmosis in the neonate, and can have serious consequences. This review aims to describe the modalities for prophylaxis of toxoplasmosis in susceptible populations, and focuses on the following: (1) prophylaxis of congenital toxoplasmosis; (2) prophylaxis of toxoplasmosis in patients with HIV/AIDS; and (3) prophylaxis of toxoplasmosis in transplant recipients.

The mite-borne rickettsial zoonosis scrub typhus is widely prevalent in parts of Southeast and Far East Asia, and northern Australia. The disease is an acute febrile illness, associated with rash and often an eschar, which responds dramatically to treatment with antibiotics. In some cases it results in a serious illness leading to multiple organ involvement and death. The disease manifestations are thought to result from a systemic vasculitis, caused by both direct effects of the organisms as well as an exaggerated immune response, although little is understood about its pathogenesis. A wide spectrum of clinical manifestations, affecting nearly every organ system, have been described with scrub typhus. Some of these manifestations are serious and life threatening. In this systematic review, we summarise the typical and atypical manifestations of scrub typhus reported in the literature. Awareness of these unusual manifestations will hopefully guide clinicians towards diagnosing the condition early, and initiating early appropriate antibiotics and other supportive measures.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: 1. To assess the effectiveness of primaquine and tafenoquine for primary prophylaxis againstPlasmodium vivax andPlasmodium falciparum infections. 2. To assess the effectiveness of tafenoquine for terminal prophylaxis of vivax malaria. 3. To compare the safety profile and compliance rates of tafenoquine and primaquine when used for primary (P. vivax and P. falciparum infections) and terminal (P. vivax infections) prophylaxis.

Leptospirosis is a disease of epidemic proportions in Sri Lanka. There is paucity of data on the determinants of mortality and impact of therapy in patients with leptospirosis admitted to critical care settings in endemic territories.This retrospective cross-sectional study was performed in patients with serologically confirmed leptospirosis admitted to the intensive care unit of the General Hospital, Kalutara from January 2011 to April 2014. Associations between socio-epidemiological, clinical and laboratory parameters and patient mortality were examined.Forty-five patients were included. The mean age was 49.11(SD = 16.95) and majority (92%) were male. Percentage mortality was 44.4%. Patient mortality was associated with age40 (p = 0.012), symptoms of uremia (p = 0.017), evidence of CNS involvement (p = 0.039), presence of oliguria (p = 0.002) and anuria (p = 0.014), presence of multi-organ dysfunction syndrome (MODS) (p0.001), CRP96 (p = 0.036), platelet count20,000 (p = 0.045), Potassium5.0 (p = 0.05), metabolic acidosis with pH7.2 (p = 0.03), INR2 (p = 0.037) and requirement of mechanical ventilation (p0.001). Cox regression analysis revealed MODS and potassium5 to be independently associated with mortality.A high mortality rate is noted. The presence of MODS and serum potassium concentration5.0 was independently associated with mortality in this retrospective study of patients with confirmed leptospirosis in a critical care setting.

INTRODUCTION Sri Lanka has eliminated local transmission of malaria. Assessing physician preparedness for early case detection is important, in order to prevent re-establishment of local transmission. METHODS Adherence to malaria screening practices in patients admitted with fever to 12 hospitals in a previously malaria endemic district was evaluated using a cross sectional survey. In addition, knowledge and attitudes among doctors on current malaria surveillance practices and treatment recommendations was assessed. RESULTS Of 403 fever patients, 150 warranted screening for malaria under the criteria defined by the Anti Malaria Campaign (AMC), with 93 of them having fever for over 7 days. Of these eligible patients, 12.6% (19/150) were investigated by doctors (including 3 persons with fever over 7 days), 14.6% (22/150) by laboratory staff and 72.6% (109/150) by the research team. The majority of doctors were not familiar with the treatment guidelines for malaria (76.5%, 75/98). CONCLUSIONS Mandatory continuous medical education programmes need to continue to ensure that malaria remains on the differential diagnosis of a fever patient, especially in patients with fever over 7 days. It is essential to publicize the availability of free-of-charge malaria diagnostic facilities, and to ensure that proper notification procedures are followed when a malaria patient is diagnosed.

Objectives The annual incidence of dengue has been increasing over the last few years in Sri Lanka with seasonal epidemics. Biological control of the vector has not been part of the integrated vector control implemented by the public health authorities of Sri Lanka so far. This pilot study assessed the effectiveness of using Bacillus thuringiensis israelensis (Bti) spray to control the Aedes mosquito vector population density. Methods Prospective controlled effectiveness study in three administrative divisions of Colombo. Study areas were selected from urban, semiurban and rural administrative divisions within the district, and they were compared with two matching controls from the same division. Test areas received three cycles of Bti spraying 1 month apart. Control areas were not sprayed with Bti. Ovitrap and larval indices were calculated at baseline and 2 weeks after each spray cycle. Results There was a significant improvement in the adult vector population (ovitrap index) in the test areas after three spray cycles, but this effect had disappeared after 8 weeks (no residual effect). There was no consistent positive impact on larval indices (premise, container and Breteau indices) after each spray cycle. Conclusion Bti might have a moderate impact on adult vector populations mediated via transient reductions in larval populations. However, this effect is not sustained probably due to rapid re-infestation. Bti spray, if implemented, can only play a supplementary role to other vector control methods.

Objective The objectives of this study were to; (a) evaluate the current practices of peer assisted learning among second year and final year medical students of Faculty of Medicine, University of Colombo, Sri Lanka; (b) identify reasons for engaging in peer assisted learning; (c) identify perceived weaknesses in current learning activities; and (d) determine student characteristics associated with engaging in peer assisted learning. Results This cross sectional study interviewed two hundred and eighty-four eligible students. Average number of hours spent on peer assisted learning during a week was significantly greater among second year students compared to final year students (15.1 vs. 7.1 h, p

The global incidence of dengue has increased sevenfold between 1990 and 2013. Despite a low case fatality rate (

OBJECTIVES To evaluate the evidence for use of different formulations of amphotericin B (AmB), minimum effective dose for each formulation and its comparative efficacy against other drugs in achieving definitive cure of visceral leishmaniasis. METHODS This systematic review and meta-analysis included following data sources: PubMed, Embase, Scopus, Web of Science and CINAHL. Controlled prospective clinical trials (randomized or nonrandomized, including dose-ranging studies) conducted between 1996 and 2017 with at least one treatment group receiving AmB were included (published data only). The primary outcome was definitive cure at 6 months. Adverse events and mortality were assessed as secondary outcomes. The PROSPERO registration number for this review is CRD42017067488. RESULTS Thirty-one studies (26 from India) that enrolled 6903 patients into 84 study groups met the selection criteria. In India, liposomal AmB was not inferior to AmB deoxycholate (relative risk 1.00, 95% confidence interval (CI) 0.96-1.03, two randomized controlled trials (RCTs), 514 participants, high-quality evidence), and a single dose of the earlier formulation as low as 3.75 mg/kg achieved a cure rate of over 89% (95% CI 70.6-97.2). AmB deoxycholate was as effective as miltefosine (relative risk 0.99, 95% CI 0.95-1.03, two trials, 523 participants, high-quality evidence) and may be better than paromomycin (relative risk 1.04, 95% CI 1.02-1.07, one trial, 667 participants, low-quality evidence) in achieving definitive cure. CONCLUSIONS AmB is an efficacious drug in the Indian subcontinent. Further evidence is needed from prospective clinical trials in other endemic geographical regions.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the efficacy of vector control measures against Ae. albopictus and Ae. aegypti in reducing the incidence of viral infections spread by these mosquito species.

Background Sri Lanka has been free from indigenous malaria since November 2012 and received the WHO certificate for malaria-free status in September 2016. Due to increased global travel, imported malaria cases continue to be reported in the country. Military personnel returning home from international peace-keeping missions in malaria endemic countries represent a key risk group in terms of imported malaria. The present study intended to characterize the potential causes of a malaria outbreak among the Sri Lankan security forces personnel deployed in the Central African Republic (CAR). Methods Data were collected from a cross-sectional survey distributed among Sri Lankan Air Force personnel who had returned from United Nations peace-keeping missions in the CAR region. A pre-tested questionnaire was used for the data collection, and focus group discussions were also conducted. Results One hundred twenty male Air Force personnel were interviewed (out of a group of 122 officers and airmen). All participants were deployed in the CAR for 14 months and were aware of the existence of chemoprophylaxis against malaria. The majority of the subjects (92.5%, 111/120) also knew that prophylaxis should be started prior to departure. However, the regular use of chemoprophylaxis was reported by only 61.7% (74/120) of the sample. Overall, 30.8% of the participants (37/120) had 44 symptomatic episodes of malaria during deployment, and one person succumbed to severe malaria. All cases were associated with noncompliance with chemoprophylaxis. Conclusion Better coordination with overseas healthcare services and the establishment of directly observed chemoprophylaxis may help to avoid similar outbreaks in the future.

Objective To discuss epidemiological aspects of imported malaria and the potential impact of imported malaria cases reported in Sri Lanka 2008–2011 in terms of a possible resurgence of the disease. Methods The national malaria database was used to assess details regarding country where the infection was possibly acquired, species of Plasmodium, number of days lapsed between disembarkation in Sri Lanka and diagnosis, compliance with national treatment guidelines including percentage of patients followed up as per the national guidelines. Results After the strengthening of malaria surveillance, during the 4-year period, 152 imported malaria cases were recorded: an increase of 176% in the number of cases. Most of the imported malaria infections were acquired by Sri Lankan Nationals mainly from South Asia, especially India. Plasmodium vivax accounted for 64% of the infections. Approximately 50% of the cases were diagnosed in the Western Province. The average period from disembarkation in Sri Lanka to malaria diagnosis was 3.6 days. Patients were managed and treated according to the national guidelines. 82% of the patients were followed up for 28 days to ensure parasite clearance. Conclusions There is a possible increasing risk of re-introduction of malaria to the country from imported cases. Enhanced surveillance activities and the increase in international travel have contributed to an increase in recorded case numbers. There is a need to further strengthen surveillance, especially for monitoring and timely addressing of imported malaria, if the country is to prevent the re-establishment of transmission within. The importance of having an efficient response mechanism to deal with imported malaria is also highlighted. Objectif Discuter des aspects epidemiologiques du paludisme importe et l'impact potentiel des cas de paludisme importe signales au Sri Lanka entre 2008 et 2011, en termes d'une resurgence possible de la maladie. Methodes La base de donnees nationale de lutte antipaludique a ete utilisee pour evaluer les details concernant le pays ou l'infection a probablement ete acquise, les especes de Plasmodium, le nombre de jours ecoules entre l'arrivee au Sri Lanka et le diagnostic, le respect des directives nationales de traitement, y compris le pourcentage de patients suivis selon les directives nationales. Resultats Apres le renforcement de la surveillance du paludisme au cours de la periode de quatre ans, 152 cas importes de paludisme ont ete enregistres, soit une augmentation de 176% du nombre de cas. La plupart des cas de paludisme importes ont ete acquis par des ressortissants sri-lankais, principalement de l'Asie du Sud, notamment en Inde. Plasmodium vivax representait 64% des infections. Environ 50% des cas ont ete diagnostiques dans la province de l'Ouest. Le delai moyen entre l'arrivee au Sri Lanka et le diagnostic du paludisme etait de 3,6 jours. Les patients ont ete pris en charge et traites selon les directives nationales. 82% des patients ont ete suivis pendant 28 jours afin de s'assurer de l’elimination des parasites. Conclusions Il existe un risque possible croissant de la reintroduction du paludisme dans le pays a partir de cas importes. Des activites de surveillance accrue et l'augmentation des voyages internationaux ont contribue a une augmentation du nombre de cas enregistres. Il est necessaire de renforcer la surveillance, en particulier dans la reponse au paludisme importe par le suivi et en temps opportun, si le pays veut empecher le retablissement de la transmission a l'interieur. L'importance d'avoir un mecanisme de reponse efficace pour traiter le paludisme d'importation est egalement soulignee. Objetivo Discutir aspectos epidemiologicos de la malaria importada y el impacto potencial de los casos de malaria importada reportada en Sri Lanka entre el 2008–2011 en terminos del posible resurgir de la enfermedad. Metodos La base de datos nacional para malaria se utilizo para evaluar los detalles con respecto al pais en el que posiblemente se habia adquirido la infeccion, las especies de Plasmodium, el numero de dias que pasaron desde el desembarco en Sri Lanka y el diagnostico, cumplimiento con las guias nacionales de tratamiento incluyendo el porcentaje de pacientes con seguimiento segun las guias nacionales. Resultados Despues de fortalecer la vigilancia de malaria, se registraron 152 casos de malaria importada durante un periodo de cuatro: un aumento del 176% en el numero de casos. La mayoria de las infecciones importadas fueron adquiridas por nacionales de Sri Lanka principalmente en Sud Asia, y especialmente en India. Plasmodium vivax era responsable del 64% de las infecciones. Aproximadamente un 50% de los casos fueron diagnosticados en la Provincia del Oeste. El periodo medio entre el desembarco en Sri Lanka y el diagnostico de malaria era de 3.6 dias. Los pacientes fueron manejados y tratados segun las guias nacionales. Un 82% de los pacientes fueron seguidos durante 28 dias para asegurar la limpieza de parasitos. Conclusiones Hay un posible aumento en el riesgo de reintroduccion de la malaria en el pais debido a los casos importados. Una mejora en las actividades de vigilancia y el aumento de viajes internacionales han contribuido a un aumento en el numero de casos registrados. Es necesario reforzar la vigilancia, especialmente para monitorizar y ocuparse a tiempo de la malaria importada, si el pais ha de prevenir el reestablecimiento de la transmision interna. Se enfatiza la importancia de tener un mecanismo de respuesta eficiente para manejar la malaria importada.

Background: With Sri Lanka aiming towards malaria elimination by 2015, the National Anti Malaria Campaign has stressed on the importance of identification of the species of Plasmodium either by examination of stained blood smears for malaria parasites or by Rapid Diagnostic Tests for malaria antigens before the initiation of treatment. This study aims at confirmation of the accuracy of clinical and/or microscopical malaria diagnosis using serology. Materials and Methods: Study population comprised 51 individuals diagnosed with malaria either microscopically or clinically during the first half of 2011. ELISA for detection of the two significant blood antigens (AMA-1 and MSP1-19) was carried out in these individuals, 14-28 days after being diagnosed as being positive for malaria microscopically. Results: ELISA confirmed the microscopic diagnosis in all 47 of the patients including two mixed infections which flagged positive for both parasite antigens. However, four individuals diagnosed clinically as being positive for P. vivax by Health Care Providers were negative for malaria antibodies by ELISA. Conclusions: With 175 cases of malaria reported in 2011, a formidable challenge exists to diagnose malaria positive blood smears due to the large number of negative blood smears being seen daily. After routine cross checking of positive slides, it is heartening to note that there were no false positives detected through serological assays amongst patients who were diagnosed as malaria positive by microscopy. Presumptive treatment of febrile patients with anti-malarials can lead to waste of resources and adversely impact the condition of the patient if the fever is not due to malaria.

Background Sri Lanka is a malaria-free country. However it remains surrounded by countries with endemic malaria transmission. Since the last indigenous case of malaria was reported in October 2012, only imported malaria cases have been diagnosed with 36 cases detected in 2015, which includes 17 cases each of Plasmodium vivax and Plasmodium falciparum and two cases of Plasmodium ovale. Methods This study investigated the knowledge and practices regarding malaria chemoprophylaxis among all the Sri Lankan security forces personnel returning from peacekeeping missions in malaria endemic countries over a 7 month period. Adherence to other malaria prevention measures, occurrence of adverse events and incident cases of malaria were also recorded maintaining the anonymity of the respondents. Potential associations for non-compliance were studied. Results Interviews were carried out with 559 security forces personnel returning home from foreign deployments in malaria-endemic regions (males: 550, 98.4 %). The majority (553, 98.9 %) was well aware of the need for chemoprophylaxis during the overseas stay and its regular use as prescribed. The overall adherence to chemoprophylaxis was good with 78.7 % (440/559) reporting regular, as prescribed, use. Having better educational qualifications, being female, being prescribed mefloquine, having fever during deployment and belonging to a security force other than the army were significantly associated with poor compliance (p

Uncontrolled studies suggest that magnesium sulphate controls spasms in patients with established tetanus. We performed a meta-analysis of controlled trials that compared magnesium sulphate with placebo or diazepam for the treatment of patients with tetanus. We searched PubMed, Scopus, Embase and the Cochrane clinical trials registry. Three studies met the inclusion criteria, containing 275 participants (199 male patients, 72.4%). Magnesium sulphate did not reduce mortality, relative risk (95% CI): vs placebo, 0.80 (0.41-1.58); vs diazepam, 1.11 (0.70-1.75). The data on duration of total intensive care unit stay, total hospital stay and the need for ventilatory support were conflicting and pooling of results could not be done due to methodological differences of individual trials. More controlled trials are needed to assess the effect of magnesium sulphate on reducing autonomic instability, spasms, duration of intensive care and hospital stays and the need for mechanical ventilation.

Climate change is defined as a statistically significant variation in either the mean state of the climate or in its variability, persisting for an extended period—typically decades or longer—that may be attributed to natural internal processes, external forcing, or persistent anthropogenic changes in the composition of the atmosphere or in land use. Malaria, the world’s most important and deadly tropical mosquito-borne parasitic disease, kills approximately 1 million people and afflicts as many as 1 billion people in 109 countries throughout Africa, Asia, and Latin America. Reducing the impact of malaria will significantly enhance the efforts to achieve the Millennium Development Goals, agreed upon by every United Nations Member State. Variation in climatic conditions, such as temperature, rainfall patterns, and humidity, has a profound effect on the longevity of the mosquito and on the development of malaria parasites in the mosquito and, subsequently, on malaria transmission.

Les changements climatiques designent une variation statistiquement significative de l’etat moyen du climat ou de sa variabilite qui persiste pendant de longues periodes (generalement pendant des decennies ou plus) pouvant etre dus a des processus internes naturels, a des forcages externes ou a des changements anthropiques persistants de la composition de l’atmosphere ou de l’affectation des terres.

This review concentrates on different aspects of malaria chemoprophylaxis, namely drug combinations, resistance, impact of malaria prevention in pregnancy and cost effectiveness. A MEDLINE search was performed for all articles with the key word ‘Malaria’ in the title field and ‘Prophylaxis’ in any field. The search was restricted to articles published in English within the last decade (1999–2009). Data sources included review articles published in core clinical journals, cohort studies, interventional studies, case control studies and cross sectional analyses. The mechanism of action, trial evidence of efficacy, side effects and geographical distribution of resistance is discussed for each prophylactic drug regimen. Impact of prophylaxis in pregnancy and the cost considerations are discussed under two separate sub topics.

Objective: This study was designed to compare diagnosis of trichomoniasis by culture, wet smear examination, and Giemsa stain. A modified technique was used to transport and prepare the specimen to ensure parasite viability prior to Giemsa staining. Materials and Methods: A clinic-based prospective study was carried out in association with the National STD/AIDS Control Programme over a period of 18 months. Three swabs were collected from the posterior fornix of 346 newly registered female patients for diagnosis of trichomoniasis. A wet smear was prepared using the first swab. The second swab was placed in 5 mL of 0.9% saline with three drops of 5% glucose at room temperature and centrifuged twice at a low speed prior to preparation of a Giemsa stained smear. The third swab was for culture. The three tests were performed independently. The specificity and sensitivity of the wet smear and Giemsa stain were compared to culture. Results: With culture, the prevalence of trichomoniasis was 6.9% (95% CI: 4.1-9.3%). The Giemsa-stained smear was found to be highly sensitive (100%, 95% CI: 86.2-100%) and specific (99.69%, 95% CI: 98.26-99.95%) compared to culture. The wet smear was less sensitive (95.83%, 95% CI: 79.76-99.26%) but equally specific (100%, 95% CI: 98.82-100%). Conclusion: In developing countries, facilities for using culture are limited and wet smear examination in the field is also difficult due to the immediate need for laboratory facilities. Our study demonstrated that, in this setting, using a transport medium prior to Giemsa staining is a feasible alternative, with a high-diagnostic yield.

Many trials have explored the efficacy of individual drugs and drug combinations to treat bancroftian filariasis. This narrative review summarizes the current evidence for drug management of bancroftian filariasis. Diethylcarbamazine (DEC) remains the prime antifilarial agent with a well-established microfilaricidal and some macrofilaricidal effects. Ivermectin (IVM) is highly microfilaricidal but minimally macrofilaricidal. The role of albendazole (ALB) in treatment regimens is not well established though the drug has a microfilaricidal effect. The combination of DEC+ALB has a better long-term impact than IVM+ALB. Recent trials have shown that doxycycline therapy againstWolbachia, an endosymbiotic bacterium of the parasite, is capable of reducing microfilaria rates and adult worm activity. Followup studies on mass drug administration (MDA) are yet to show a complete interruption of transmission, though the infection rates are reduced to a very low level.

Human cutaneous leishmaniasis (CL) caused by Leishmania donovani, a pathogen more usually associated with visceral leishmaniasis, is now endemic in Sri Lanka. This report details the characteristics of 200 patients with locally acquired CL, who were recruited prospectively for an ongoing study into the genetic susceptibility to CL in Sri Lanka. In each case, the CL was confirmed by the demonstration of amastigotes in a direct smear and/or promastigotes in a culture. Although only 82% of the Sri Lankan population is Sinhalese, all 200 patients belonged to this ethnic group. The patients had a median age of 32 years (range=4-80 years). Most of them each had a single, non-tender, non-itching and dry lesion which had started as a papule and then gradually enlarged and ulcerated, with changes in the surrounding skin. None of the patients had any signs of systemic disease. Eleven (5.5%) each had at least one other affected family member. Patients with multiple lesions were most likely to be found in families with more than one affected member (P=0.002) but multiple lesions were not associated with diabetes mellitus (P>0.05). Although the results of passive detection under-estimate the true occurrence of a disease, the present data point towards enhanced susceptibility to CL among the Sinhalese and/or certain individuals, possibly determined by genetic factors.

Leptospirosis is an illness with a wide spectrum of clinical manifestations and severe illness affects nearly all organ systems. Serious and potentially life-threatening clinical manifestations of acute leptospirosis are caused by both direct tissue invasion by spirochaetes and by the host immune responses. In its severe form, leptospirosis can cause multi-organ dysfunction and death in a matter of days. Therefore it is critical to suspect and recognize the disease early, in order to initiate timely treatment. While the classical presentation of the disease is easily recognized by experienced clinicians practising in endemic regions, rarer manifestations can be easily missed. In this systematic review, we summarize the atypical manifestations reported in literature in patients with confirmed leptospirosis. Awareness of these unusual manifestations would hopefully guide clinicians towards early diagnosis.

Background Migration of medical professionals is a long recognized problem in Sri Lanka, but it has not been studied in depth. Undergraduate and postgraduate medical education in Sri Lanka is state sponsored, and loss of trained personnel is a loss of investment. This study assessed the intention to migrate among medical students and newly passed out graduates from the largest medical school in Sri Lanka. Methods A cross sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo in September 2013 with the participation of first and fourth year medical students and pre-intern medical graduates. Data was collected using a self administered, pre-tested questionnaire that collected data on socio-demographic details, intention to migrate and factors influencing a decision for or against migration. Results There were 374 respondents, 162 from first year (females; 104, 64.2%), 159 from fourth year (females; 85, 53.5%) and 53 pre interns (females; 22, 41.5%). Of the entire sample, 89 (23.8%) had already decided to migrate while another 121 (32.3%) were not sure of their decision. The most cited reasons for migration were a perceived better quality of life, better earnings and more training opportunities in the host country. There were no socio-demographic characteristics that had a significant association with the intention to migrate, indicating that it is a highly individualized decision. Conclusions The rate of intention to migrate in this sample is low when compared to international studies from Africa and South Asia, but is still significant. The core reasons which prompt doctors to migrate should be addressed by a multipronged approach to prevent brain drain.

BACKGROUND The security forces are a high risk group for malaria transmission in Sri Lanka. Interrupting transmission and maintaining surveillance in this group is an important component of elimination efforts. The objective of the study was to develop a prototype educational programme on malaria for security forces serving in endemic areas. METHODS An interactive seminar was designed to deliver the required knowledge. The content was on current status, transmission, signs and symptoms and the role of security personnel in identification and prevention of malaria. Each seminar was preceded by a pre-test and followed by a post test to assess the improvement of knowledge. RESULTS Fifty seminars were held in eight districts over 2 months with 2301 security forces personnel participating. Pre seminar knowledge on malaria was significantly better in the medical corps, those who had completed secondary education and in the Army compared to other security forces (p

Background With the aim of eliminating malaria from Sri Lanka by 2014, the Anti-Malaria Campaign of Sri Lanka (AMC) sought the support of Tropical and Environmental Disease and Health Associates Private Limited (TEDHA), a private sector organization. In 2009, TEDHA was assigned 43 government hospitals in the district of Mannar in the Northern Province and in districts of Trincomalee, Batticaloa and Ampara in the Eastern Province to carry out malaria surveillance to complement the surveillance activities of the AMC. Passive case detection (PCD), activated passive case detection (APCD) and active case detection (ACD) for malaria have been routinely carried out in Sri Lanka. Methods The active case detection programme of TEDHA involves screening of populations irrespective of the presence of fever or any other signs or symptoms of malaria to detect infections and residual parasite carriers. ACD is done by TEDHA in a) high risk populations through mobile malaria clinics including armed forces personnel and b) pregnant females who visit antenatal clinics for asymptomatic malaria infections during the first trimester of pregnancy. Populations are selected in consultation with the Regional Malaria Officer of the AMC thus avoiding any overlap with the population screened by the government. Results TEDHA screened 387,309 individuals in the four districts for malaria by ACD including high risk groups and pregnant women between January 2010 and December 2012. During this period seven individuals were diagnosed with Plasmodium vivax infections and one individual was detected with a mixed infection of P. vivax and Plasmodium falciparum. All eight cases were detected by ACD carried out by mobile malaria clinics among high risk groups in the Mannar district. Conclusion The progress made by Sri Lanka in the malaria elimination drive is largely due to increased surveillance and judicious use of control methods which has resulted in zero indigenous malaria cases being reported since October 2012. ACD played a major role in interrupting malaria transmission in the country.

Background Individuals with fever are screened for malaria in specially-established malaria diagnostic laboratories set up in rural hospitals in the Northern and Eastern Provinces of Sri Lanka. Large numbers of blood smears negative for malaria parasites are being screened daily. Good quality smears are essential to maintain a high diagnostic competency among the technical staff. The modifications made to the World Health Organization (WHO) standard operating procedures to improve the quality of smears have been studied. Methods A blinded, controlled, interventional study was conducted in 22 intervention and 21 control malaria diagnostic laboratories. Changes were made to the WHO standard operating procedure protocols to prepare, stain and examine blood smears for malaria parasite detection which were implemented in intervention laboratories. These included wipe-cleaning slides, preparing both thick and thin smears on the same slide, reversing the order of collecting blood for thick and thin smears, dry fixing thick smear for 20–25 minutes under table lamp, polishing the edge of spreader slide with sand paper and fixing the thin smear with methanol if not stained within four hours. Parameters with respect to quality of the smear as per WHO criteria were studied using randomly selected slides, and time taken for the report to be issued was recorded in both groups before and after the intervention. Results There were no significant differences observed in the parameters studied at baseline between the two groups or pre and post intervention in the control group. In the intervention group streak formation in thin smears was reduced from 29.4% to 5.0%. The average fixing time of thick smears was reduced from 2.4 hours to 20 minutes. Inappropriate thickness of thick smears reduced from 18.3% to 1.5%. Overall quality of thick smears and thin smears increased from 76.1% to 98.0% and 81.7% to 87.0%, respectively. The quality of slides bearing both thick and thin smears increased from 60.0% to 87.0%. Conclusions New protocols with amendments to the WHO standard technical procedures ensure that good quality blood smears are prepared rapidly to diagnose malaria and the time required to issue the reports was reduced.

Over 1800 clinically suspected cases of cutaneous leishmaniasis have been referred to the Department of Parasitology, Faculty of Medicine, Colombo, Sri Lanka for investigation since 2001. This study analyses some sociological aspects of 120 patients with laboratory confirmed cutaneous leishmaniasis. This information is important to design and implement control programmes. The disease was predominant among males. In females lesions occurred mainly on the face, while in men they were seen mainly on the limbs. Immediate medical advice was sought by 13% of the population; the others sought treatment when the skin lesion grew or failed to heal. Females delayed seeking treatment as they probably misinterpreted the lesion as a pimple. Only 39% were referred to a Consultant Dermatologist by a medical officer during the first visit. The mean duration of time from the detection of the lesion to referral was approximately eight months. Psychologically, the presence of the lesion affected less than 20% of individuals. Costs related to treatment were relatively low in Sri Lanka. Late presentation and diagnostic delay was related to lack of awareness. Educational programmes should be carried out, aimed both at health care workers and the community to ensure early diagnosis and treatment for cutaneous leishmaniasis.

This study determines whether 72 health care providers in a previously conflict-affected district in Sri Lanka adhere to the recommendations of the Anti Malaria Campaign with regard to diagnosis, prescribing antimalarials and reporting of a positive case. All patients suspected of clinically having malaria are being referred for laboratory confirmation, indicating that presumptive treatment is not practiced. The knowledge amongst health care providers regarding accurate management and reporting of a malaria positive case needs to be improved. © 2012 Royal Society of Tropical Medicine and Hygiene.

The efficacy of different treatment regimens in clinical syndromes of toxoplasmosis were assessed by conducting a systematic review of published randomized clinical trials through extensive searches in MEDLINE, EMBASE, and SCOPUS with no date limits, as well as manual review of journals. Outcome measures varied depending on the clinical entity of toxoplasmosis. Risk of bias was evaluated and quality of evidence was graded. Fourteen randomized trials were included of which one was a non-comparative study. One well-designed trial showed that trimethoprim-sulphamethoxazole was more effective than placebo for clinical recovery of toxoplasmic lymphadenopathy in immunocompetent hosts. For toxoplasmic encephalopathy, efficacy of pyrimethamine+sulphadiazine and trimethoprim+sulphamethoxazole were similar, whereas pyrimethamine+sulphadiazine versus pyrimathamine+clindamycin showed no difference, irrespective of the outcome. Intravitreal clindamycin+dexamethasone and conventional treatment with oral pyrimethamine+sulphadiazine had similar efficacy with regard to all outcome measures in ocular toxoplasmosis, and intravitreal therapy was found to be safe. Adverse effects seemed more common with pyrimethamine+sulphadiazine. Most trials for encephalitis and ocular manifestations had a high risk of bias and were of poor methodological quality. There were no trials evaluating drugs for toxoplasmosis in pregnancy, or for congenital toxoplasmosis. Pyrimethamine+sulphadiazine is an effective therapy for treatment of toxoplasmic encephalitis; trimethoprim+sulphamethoxazole and pyrimethamine+clindamycin are possible alternatives. Treatment with either oral or intravitreal antibiotics seems reasonable for ocular toxoplasmosis. Overall, trial evidence for the efficacy of these drugs for toxoplasmosis is poor, and further well-designed trials are needed.

Diagnostic confusion may occur between dengue and malaria when febrile patients with thrombocytopenia return from travel to previous malaria endemic areas. Laboratory tests should include blood smear examination for malaria parasites even though current malaria endemicity in Sri Lanka is low.

Background Tuberculosis. toxocariasis and toxoplasmosis are among the common infectious causes of lymphadenitis in children. Cases of Toxoplasma gondii and Toxocara spp co-infection have been reported. Case Presentation This case report describes a co-infection of Toxoplasma gondii, Toxocara spp and tuberculosis in a child with chronic lymphadenopathy and eosinophilia. Conclusion The case report highlights two important points. First is the diagnostic challenges that are encountered by clinicians in tropical countries such as Sri Lanka, where lymphadenopathy and eosinophilia with a positive serology commonly point towards a parasitic infection. Secondly the importance of proper history taking and performing the Mantoux test as a first line investigation in a country where the incidence of tuberculosis is low, even in the absence of a positive contact history.