Sri Lanka’s move to eliminating Malaria

Dr. Kamini Mendis writes

The incidence in Sri Lanka was already decreasing by the time the roll back malaria initiative was launched by WHO in 1998, after which the global spotlight was on malaria, and a great deal of political will and support was garnered, and increased funds became available.

Sri Lanka received two major grants from the Global Fund of about 7 and 3.5 million USD, and these would have helped. There are probably several reasons that could account for the decrease in malaria in Sri Lanka this time round, including technical and administrative reasons that malaria control operations were more efficient, to the malaria professionals having a stronger research background and therefore being more evidence based in their operations, decentralisation of the health systems, greater stability in the regions.

But other reasons are also likely: the life-styles of people living in endemic areas have improved considerably, improved housing - where in the 1980’s when I started working in the deep south of malaria country, in places where we had to trek in bush country with nothing but mud huts miles apart, now stand houses comparable with anything in Colombo, and motorable road systems. People’s lifestyles and expectations have changed with it.

Mosquito repellents are used. Equally important might be natural factors - the global environmental changes to which malaria transmission is extremely sensitive, - the climate which reduces the life span of the mosquito by one day could wipe out malaria in some situations. Anopheles culicifacies is not one species but a complex - some members of this complex are good vectors of malaria and others are not.

Could, for some reason, the former type have taken over the latter? Any and all of these could have been the reasons for this decline in malaria.

And more importantly can and should we now go the next step and eliminate malaria from Sri Lanka?

Elimination as we have defined in WHO, is the interruption of local mosquito-borne transmission in a defined geographical area such as a country, which means zero incidence of locally acquired cases - imported cases can still occur but they will not spread the disease further. Eradication is the permanent reduction to zero of the worldwide incidence of infection. So when we talk of Sri Lanka, to be technically precise, it is the elimination of malaria that is being referred to, eradication is a global objective.

Getting to this level is a major achievement, but not unexpected, given the tools that are available today, and the good health infrastructure and antimalarial campaign we have in Sri Lanka. But elimination - or the interruption of transmission is quite another story. To understand the complexities of malaria control and elimination, one has to have even a glimpse of what lies behind the spread of malaria.

The biology underlying malaria and strategies for elimination

The number of cases a single malaria patient will generate over its entire duration, is called the basic reproduction rate. For malaria to be eliminated this Zo has to be less than one.

Zo is expressed mathematically as follows:

Zo = b. C/r

r is the daily loss of human infectivity, and earlier and more effectively patients are treated this will increase and Zo will decrease. C is an extremely important entity almost entirely relating to the mosquito vector, called the vectorial capacity and is determined by how many mosquitoes there are, how often they feed on humans, and how long they live. They are all reduced by both preventive measures which are used - house-spraying and use be insecticide treated nets. We do not have an intervention against this.

An important aspect about malaria however, is that the disease is not uniformly distributed in a locality or in people. For example, in a given area like this, if there are say a 1000 infections, 700 of them might be in just these 4 houses - some places, some households, and some individuals have more malaria than others because the contact between humans and mosquitoes is heterogenous, resulting in a small proportion of people receiving a large proportion of parasite inoculations, and only some of those who get inoculated become infected because humans differ in their susceptibility to malaria.

This lack of uniformity confers a high degree of resilience to the cycle of malaria transmission - makes it difficult to break. As a result, when there is a lot of malaria, the application of interventions through a blanket approach - basically giving them to everyone in the area will have a big impact on malaria transmission, but, when it comes to low numbers as we have now in Sri Lanka, interrupting the cycle will require a very focused approach.

Every individual who gets malaria will now have to be known and treated very quickly and its origin traced, and focal mosquito control measures have to be applied to foci of transmission to prevent the onward spread of the disease.

It is for this reason that the move from malaria control to elimination requires a significant change in strategy: from population-wide coverage to one based on a sophisticated surveillance system to detect every case of malaria in real time and act rapidly.

The question now

But the question now, is can we sustain this achievement? When the incidence of a disease has dropped to being sporadic at best, it is difficult to sustain large budgets in the face of other more demanding health problems.

Clinicians and technicians tend to lose their diagnostic skills when cases are rare - we saw this in eastern Europe. It is said that the malaria eradication programme of the 1950’s eradicated more malariologists than malaria itself.

Unwarranted prescription of expensive drugs

Prof. Herbert A. Aponso

How many poor people are compelled to beg and borrow, and perhaps forego the essential family needs such as adequate food and clothes for the rest of the family, because doctors have not cared to give a thought for the high cost of medical care, resulting from unwarranted prescription of expensive drugs (not only in the private sector, but in the State sector as well, where poor patients are asked to buy expensive drugs - also expensive investigations), when equally effective drugs may be available at a cheaper price. A former President of the Sri Lanka Medical Association of the recent past called upon all doctors to refrain from advertising any brand drugs at their workplaces.

However, we regret to observe that some popular brands are being advertised all over the country on the name boards of several private hospitals dispensaries and surgeries, pharmacies, and even boutiques.

It is unfortunate that there are some doctors who do not know or do not care to find out the cost of the medicines that they prescribe. They ‘remember’ only the ‘catchy’ and expensive brand names of drugs.

Some members of the ignorant public are also made to think so. Patients (or their parents) go to a doctor trusting him/ her to do the best for them. Does a doctor think that prescribing an expensive drug is a hallmark of a competent doctor and that those who continue to prescribe the generic or less expensive drugs are perhaps lagging behind the latest developments? Nothing can be further from the truth.

At present there are well over 100 brands of amoxillin the cost ranging from about Rs. two to about three times that amount. A common drug prescribed for severe pain and/or high fever is diclofenac. The price of a 50mg tablet varies from 60 cents to ten times that amount. And so it is for many many drugs. Patients have the right to find out from the doctor whether a less expensive, but reliable.

Sri Lanka - Our perspective of Down’s syndrome?

I recently took a seven-year old shopping to a fair held at the BMICH grounds. She chose and bought herself a pink watch and a matching pink mobile phone.

She couldn’t quite make me understand what she wanted to buy her teenager brother, but was determinedly un-persuaded as the shop assistants and I tried to cajole her into buying various caps and other trinkets for her brother.

She suddenly said ‘aiya!’ and darted off spotting what she had been looking for, she headed straight for the Parker pen stall and said, “Present for aiya, at last! A pen in a box! Aunty Iante, my money please”. Who do you see painted in this word picture - a child or Down’s syndrome?

Medical classifications are helpful

Medical Classifications are helpful and necessary in order for families, doctors, therapists, teachers and all other related persons to understand and work together to overcome difficulties faced, and also, to learn acceptance of a person who is facing special challenges in living and learning due to a particular condition.

However classifications such as “Down’s syndrome” should never be used to de-value a person born with such a condition and persuade families that nothing can be done for their child or adult family member. It should also be always used responsibly within the community, to provide and promote understanding and acceptance ,and never to promote discriminatory attitudes and alienation of the person and family.

Understanding Down’s Syndrome

When a child is born with Down’s Syndrome, the medical classification enables all involved, family and professionals, to better understand the strengths of the child, and also, to evaluate difficulties and where extra supports are necessary for the child, family and the professionals, in order to enable the child to reach his or her potential developmental milestones.

Children with Down’s Syndrom can face many challenges in reaching their developmental milestones. These difficulties will be mountain-like difficulties at times, to both the family and the professionals involved. However early diagnosis, intervention and consistent, hard work on the parts of the family and the professionals working together as a team, will most often produce positive results, as has been proved in Sri Lanka.

Down’s Syndrome and Schooling

Children with Down’s syndrome can and need to go to school in Sri Lanka Adults with Down’s syndrome provided the proper vocational training and acceptance within a work place, can do a job to provide some income to the family or at least to provide some service to the community.

However, one of the greatest challenges we face in Sri Lanka at present, is that the opportunity and proper facilities for children with Down’s syndrome to have access to properly planned models of schooling are yet limited.

Adolescents and adults with Down’s syndrome, face difficulties in gaining access to usefully targeted vocational training that provides job opportunities within the modern day job market in Sri Lanka. Combating discriminatory attitudes and persuading employers to employ a person with Down’s Syndrome is yet another challenge being overcome too slowly. In fact the above-mentioned faces are true for all children and adults with special needs due to Down’s syndrome or other conditions living in Sri Lanka today.

Solving this problem

One of the main ways to solve this would be by attitude changes within us all. This change should first make us understand how Down’s syndrome or other conditions affect a person and secondly to stand together to make a change in Sri Lanka.

Offer your friendship and support to a person with Down’s syndrome. Learn from each other on an equal basis. Do not do it from the perspective of providing charity, it would only de-value your effort. Do it from the aspect of making a friend for equal opportunity of shared lives and experiences.

Opening your pre-school for these children

Decide to work towards opening your pre-school or secondary school to a few children with special needs. Do not do it out of charity, but because it is these children’s right to have education.

If every school in Sri Lanka, worked to accept a few children with special needs and to develop and provide well planned, individualised, educational models for them, it will strengthen the entire Sri Lanka an education system by establishing ‘a respect for individuality and a culture of collaboration that encourages and supports problem solving.

Such cultures are likely to facilitate the learning of all pupils, and alongside them, the professional learning of all teachers... increasing equity is the key to improvements in schooling for all.” Mel Ainscow, p25, “Special Needs in the classroom,” 2004, Unesco publishing.

Opening your place of employment.

Decide to work towards opening your place of employment to a few persons with special needs. ‘A respect for individuality and culture of collaboration that encourages and supports problem solving...’ as mentioned in the above quote are buzzwords in the modern workplace.

If you need help in conceptualizing a project such as this, there are professionals in Sri Lanka who would support you. Attitude changes and new perspectives in thinking patterns would be the most important first step.

One message never be forgotten

As we all work together to enable children, adolescents and adults with Down’s syndrome in Sri Lanka to access their rights for education, employment and acceptance as individuals in society who are treated with respect, there is one message that should never be forgotten by family members, professionals and all persons in the community.

Training of a child, adolescent and adult starting early and being consistently applied as they grow is of utmost importance and is the only way to achieve success. However you are not training a robot. A child or adult with Down’s syndrome is above all human.

This child or adult will have normal human tendencies of good and bad traits, good and bad days, normal human needs of having specific tastes, the need of freedom to make choices, the need to learn to cope with success and disappointment, the need to learn what is right and wrong, the need to be given a chance to pursue talents that they have and would like to pursue, the desire for friendships of their choice and acceptance within the community they live in, at home, community events, school or work. Allow them the opportunities to learn but also the freedom to grow as individuals.

They will in turn give us a new freedom in thinking and refreshing opportunities to learn and grow as individuals too.

Ianthe Perera Speech and Language Therapist, University of Colombo Diploma in Speech and

Language Therapy, DSU, Ragama Medical Faculty, University of Kelaniya.

Unwelcome news to some elderly doctors

Since 1970, doctors who are over 65 years residing in the UK or elsewhere, and registered with the General Medical Council (GMC) UK, need not pay an annual retention fee to maintain their names in the register. In future, says the GMC, doctors who want to remain on the register and practice medicine in the UK will have to pay the fee, which currently stand at 390 Sterling pounds a year for those residing in the UK, and some what less to those staying overseas.

The GMC says that this is necessary to avoid contravening the law made in 2006 for a qualification body (this includes registration, and thus includes GMC) to discriminate on grounds of age. The decision taken by the Council, has not been universally well received, nor does it seem to make any sense.

The Health Editor of the TIMES paper in UK, writing to the British Medical Journal (BMJ July 19,2008) questions this decision. He writes, “old age” said the Chinese sage Confucius,” is a good and pleasant thing. It is true you are gently shouldered off the stage, but then given such a comfortable front row stall as a spectator.

” Not if the GMC has its way! The GMC may be helping to make old age less good for some, but since a key objective of modern medicine and public health is that more of us should reach old age, we should do all we can to make it as good as possible. At a time when life is full of examples where elderly people are given privileges: rail fare concessions, but passes, prescription fees, higher bank interests, and others, the decision made by GMC is paradoxical, in that it is using legislation designed to prevent discrimination against elderly people - the Employment Equality (age) Regulation 2006 - to justify the change.

One thing for sure is that the British parliament had no intention of forcing a lot of older doctors to pay retention fees. That was never the purpose of the legislation and if it is accepted without demur it could have knock-on effects in many other areas of life.

The British Medical Association, therefore, has decided to judicially review this decision by the Council to withdraw the age exemption for payment of the annual retention fee for doctors who are 65 and over. The GMC has now written to the doctors concerned (myself included), that it has put on hold all steps to implement the decision of the Council in this regard until the substantial hearing, and judgement has been given.

Dr. Terence Perera

Stress relief strategies to ease allergy symptoms

Dr. Kelum Pelpola

If you suffer with allergy symptoms, you know all about the stress of having a chronic condition. Some people have to go through these troublesome symptoms throughout their whole life. Not only it is difficult to breathe with allergy symptoms, but poor sleep can lead to fatigue and problems in concentrating. On the other hand, allergy medication may cause appetite changes, low energy, and even irritability. All you want is relief: from the stress, the symptoms, all of it.

What causes allergies?

Allergy symptoms are an example of an overreaction by the immune system to otherwise harmless substances. If you have allergies, you might blame the allergens — the pollen in the air, your best friend’s cat — for your symptoms. But actually, most allergens are themselves harmless innocents. What really causes allergic reactions is your own immune system. It mistakes these innocuous allergens for a serious threat and attacks them. The symptoms of an allergy are the result of your body’s misguided assault.

Understanding the mechanisms of allergy is recent — just over the past 35 to 40 years, says Gailen D. Marshall, MD, PhD, who is the director of the division of Clinical Immunology and Allergy at the University of Mississippi Medical Center. While allergic diseases have both genetic and environmental components there’s still so much about allergy we don’t know.

It begins with exposure. Even if you’ve inhaled an allergen (this is a substance your body perceives as harmful, triggering an allergic reaction). many times before without trouble, at some point, for some reason, your body flags it as an invader. During this particular exposure, the immune system studies the allergen. It readies itself for the next exposure by developing antibodies, special cells designed to detect it. You are now “sensitized” to the allergen.

Then, the next time you’re exposed to the allergen, your immune system kicks into action. The antibodies recognize it. That triggers the activation of special cells called mast cells. These cells are responsible for allergy symptoms in the lungs, skin, and lining of the nose and intestinal tract.

The mast cells burst open, flooding your system with chemicals such as histamine. Chemicals such as histamine are what cause allergy symptoms, like swelling. Swelling in your nasal passages might cause a runny nose. Swelling in your airways could cause asthma symptoms.

Keep in mind that the amount of exposure matters. If you’re allergic to strawberries, maybe eating one or two never causes any symptoms. But once you eat three or four, you may suddenly break out in hives (an allergic reaction of the skin). There’s a tipping point — or threshold — for people with allergies.

You can handle some exposure, but if it gets to be too much, your immune system is triggered to attack. “In the late 1960s, we’d ask people how many had allergies and an estimated 1 in 10 people reported some form of allergy,” Marshall says. “Now compare that with 1 in 3 people in 2000 having some form of allergy.”

So, what’s changed? While genes don’t change that fast, probably our environment has. Probably more air pollution, along with a “squeaky clean society,” each play a role in increasing allergies.

How Is stress related to allergy symptoms?

Stress is your body’s response to situations, inside and out, which interfere with the normal balance in your life. Virtually all of the body’s systems — digestive, cardiovascular, immune, and nervous system — make adjustments in response to stress. When you’re all stressed out, your body releases hormones and other chemicals, including histamine, the powerful chemical that leads to allergy symptoms.

While stress doesn’t actually cause allergies, it can make an allergic reaction worse by increasing the histamine in your bloodstream. Unfortunately, stress and allergies go hand in hand, says Los Angeles-based ENT doctor, Murray Grossan, MD.

Once the allergy season is full-blown, the combination of miserable allergy symptoms, nights of fitful sleep, and fatigue, definitely leave you in need of stress relief.

To be continued

Fusion of Gametes

Dr. Madara S. B. Ralapanawa (MD) Master in Clinical Embryology (Australia) will make a presentation on ‘Fusion of Gametes’ at the opening of Apollo Fertility Centre at the Apollo Hospital Colombo on September 28 at 6 p.m.

Healthwatch Medical Crossword Draw No. 33

At this draw which will be held at 10.30 a.m. at the Colombo Apollo Hospital auditorium the following special invitees from the Apollo Hospital will be present; besides Pramod de Silva, Editor, Daily News.

1. Ajith Jayaratne (Chairman)

2. Lakith Pieris (CEO)

3. Dr. Irevan (Asst. General Manager)

4. Dr. Sevwandi Thilakawardhana (DMS)

5. Randika Perera (Head of Business Development)

6. Aruna Jayakodi (Dep. General Manager).

(The crossword is sponsored by Nestle Healthcare Nutrition).