REGISTERED AT THE DEPARTMENT OF POST QD/27/NEWS/2015
April 2015, VOLUME 08, ISSUE 04
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
Cover Story...
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SCAN THIS CODE TO READ ONLINE Childhood injury prevention
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Women's day activities
Private practice
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CONTENTS Page No.
Cover Story
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
April 2015, Volume 8, issue 04
SLMA History of Medicine Lecture: The Evolution of Mental Health
SLMA News Editorial Committee-2015
News
Editor-In-Chief: Prof. Sharmini Gunawardena
President's message
02
SLMA History of Medicine Lecture: The Evolution of Mental Health
02-07
Childhood Injury Prevention
07-08
Reducing Cardiovascular Disease Risk
10-12
What has Private Practice Done to Us?
14-16
Emerging and Re-emerging Infections
16-20
Summary of the International Women's Day Celebrations 2015
20-21
The Bliss of Alcohol
22
Committee: Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
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Official Newsletter of The Sri Lanka Medical Association. Tele: +94 112 693324 E mail: office@slma.lk Professor Jennifer Perera MBBS, MD (Col), MBA(Wales), PgDip MedEd (Dundee), PgDip Women’s Studies(Col). President, Sri Lanka Medical Association, No 6, Wijerama Mawatha, Colombo 7, Sri Lanka.
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April 2015
PRESIDENT'S MESSAGE
SLMANEWS
Dear Members,
W
e have had another busy month at the SLMA. As usual we had several guest lectures and symposiums organized by the expert committees and professional colleges. The attendance at these events has been very satisfactory. A novel type of activity was conducted for International Women’s Day celebrations where several short video clips captured and filmed by the media industry were made use of to educate all categories of healthcare personnel and media groups regarding women’s role in society. It was most educative, enlightening and entertaining to all those who were present at the Lady Ridgeway Hospital Auditorium. This activity was conducted in collaboration with the Women and Media Collective, a non-governmental organization, and we are thankful for their immense contribution to this event. As the roof is still being repaired most of the activities were conducted at venues away from the SLMA auditorium. The roof repair of Wijerama
House has become a costly affair amounting up to seven million. If there are any benefactors who would like to contribute for the roof repair it would be most welcome and appreciated by all. As you may well be aware, there is pollution of well water with oil effluent from power plants in the Jaffna Chunakkam area. SLMA received several requests from both doctors and lay organisations to initiate a dialogue with relevant groups. Members of the SLMA visited the affected site and held a very interactive meeting with all stakeholders including the Ministry of Health, Representatives of the Jaffna Medical Association, WHO, UNICEF, Faculty of Medicine Jaffna, Water Resources and Water Supply Drainage Boards, Central Environmental Authority, Sri Lanka Engineers Institute, Ceylon Electricity Board and the reputed Chemists. The final draft report has been circulated with short term and long term recommendations to all stake holder groups and will be posted on the SLMA website very soon.
The expert committees of the SLMA are working through their planned agenda for the year in keeping with the mission and vision of the SLMA. SLMA has met with relevant stakeholders with regard to the corporate plan and mission of the SLMA and is having discussions on finalizing the strategic objectives with an implementation plan and we hope to keep you updated on these developments. In the meantime the preparations for the 128th Annual Scientific Congress and Annual National Health Walk and Run are being made and I would like to invite all members to participate and assist us in making these events a success. If there are volunteers who would like to be part of the Health Walk and Run organizing committee please drop an email to office@slma.lk. An association can make an impact only if there is high level of participation of its membership in activities. Thus I extend a warm invitation to all to be part of this exciting programme organized from 28th June to 8th July 2015. Professor Jennifer Perera
The Evolution of Mental Health in Sri Lanka from Providing Care for People with Lunacy to Promotion of Mental Health Summary of the SLMA History of Medicine Lecture delivered by Professor Nalaka Mendis, Emeritus Professor of Psychiatry, University of Colombo
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n this presentation I plan to focus on significant developments in mental health in Sri Lanka initiated in the last two hundred years. These developments could be divided into four periods. In each period; (asylum, mental hospital, general hospital and community) there were specific initiatives to introduce contemporary practices to improve the lives of people with mental illness in Sri Lanka. These initiatives were introduced by individuals who creatively used their positions
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to introduce far reaching changes to develop mental health. The sustainability and success of these initiatives depended on prevailing professional, bureaucratic, social, political and economic influences. The Asylum period: In the early nineteen hundreds, on the understanding that insanity was the result of brain dysfunction, the aim was to provide humane care in a place of safety to prevent harm to self or to the community.
Contd. on page 03
SLMANEWS
April 2015
Contd. from page 02
The Evolution of... The task of care was undertaken on behalf of the state by law enforcement and medical institutions. Modern mental health care was introduced to Sri Lanka with the steps taken by Governor S. McKenzie when he recognised the need to find alternative care for lunatics languishing in jails. His initiatives led to the Lunacy Ordinance in 1839 which was amended the following year and again later. This legislation mandated the Governor to establish Asylums, laid down the procedures of admission and discharge of those who were identified as insane vagrants and paupers. The courts were given the responsibility of diagnosing insanity and subsequent commitment to an asylum, and at the time the Hendala Leprosy Hospital was used for the purpose. Dr. George Davey was responsible for the establishment of the asylum in Borella to which 58 patients were transferred from Hendala Hospital in 1847. The first Ceylonese superintendent of the asylum Dr. J. Wambeek built on the earlier achievements and established humane care of high quality during his eleven year tenure as the first Ceylonese Superintendent. Moral care included humane treatment which was complimented with good food, healthy environment, employment therapy, leisure activities and recreation. Since then all Superintendents were Ceylonese until the arrival of Dr. J. Plaxton from England in 1876. With the overcrowding of the Borella asylum the need for a bigger asylum was accepted by the Governors W. Gregory and J. R. Longdon. Due to disagreements on the site, design, number of beds and funding there was a delay in completing the buildings and finally in 1988 the new Colombo Asylum with four hundred beds located at a site fourteen acres in extent at the south eastern edge of cinnamon gardens accommodated all patients transferred from Borella. Within ten years of completion, the
Colombo Asylum was over crowded and there were serious management problems due to lack of staff, funds and other services. In 1911 a decision was made to build a new asylum with 1800 beds in a one hundred acre site at Angoda and all patients from the Colombo asylum were transferred to the new asylum in 1926. Even this new large asylum was inadequate to meet the increasing demand and soon there was severe overcrowding, understaffing and inadequate funding resulting in very poor, unhygienic conditions with degrading standards of care. The Mental Hospital era: In 1938 with the understanding that insanity is the result of mental disease and that early treatment helps the insane to recover, steps were taken to transfer the legal, administrative and care to health authorities. Thus the “asylum” was renamed the “mental hospital”. At the time, with the deteriorating situation at Angoda the State Council requested Professor E. Mapother, an eminent academic from England, to recommend ways to improve mental health services. He provided ten recommendations which laid the foundations for the establishment of a modern psychiatric service. Although some of the recommendations were accepted by the government, the intervening Second World War delayed their implementation. In 1943 in order to provide early treatment for the mentally ill, a clinic was opened at the General Hospital Colombo. Dr.C. Amarasinghe provided services for adults. Dr. I. Senanayake while providing adult services later established clinics for children and prisoners. Later more general and special clinics were established including clinics for psychotherapy, neuropsychiatry and child guidance. In 1944 the Pelawatta hospital was established in a five hundred acre site for rehabilitation. A new psychopathic hospital was established in 1949 at a
one hundred and fifty acre site at Mulleriyawa, with a house of observation and an early treatment facility. In the 1940’s and 1950’s new cadres were created, appointments were made and overseas training was given to psychiatrists, male nurses, social workers, occupational therapists and psychologists to strengthen the mental health service. Modern treatments consisting of convulsive therapy, insulin coma therapy, drug therapy and psychosurgery was introduced in the mid-forties. Occupational therapy was expanded to outdoors and many social welfare programmes were initiated later. Since mid 1950’s with the continuing overcrowding and inadequate resources and loss of assets mental hospitals deteriorated further. The General Hospital period: The need to decentralise mental hospital services has been recommended for decades. Contd. on page 04
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SLMANEWS
April 2015 Contd. from page 03
The Evolution of... Since the early 1960’s with the realization that psychiatry is another medical specialty, health planners contemplated integrating psychiatry to general medical care and general hospitals. A committee chaired by Dr. W. G. Wickremasinghe appointed by the government in 1966, identified provincial hospitals to locate psychiatry units and reiterated the need to implement most recommendations by Mapother made in 1938, in addition to proposing a series of new recommendations. Accordingly Drs. A. Rodrigo, T. Arulampalam and C. Wijesighe opened GH units in Kandy, Point Pedro and Colombo in 1966, 1968 and 1970 respectively, but unfortunately this development could not be sustained due to the migration of many psychiatrists in the 1970’s. Amendment of the lunacy ordinance in 1956 facilitated voluntary referrals thus increasing the inpatient and outpatient load in the newly established GH units. In 1967 a cadre position was created to appoint a Superintendent of Mental Health Services to coordinate mental health services. Initiatives to establish academic psychiatry, a long standing recommendation, was fulfilled when University of Colombo established the Department of Psychiatry in 1968. Dr. C. Wijesinghe was made the head and later the Professor of the new Department. Later a chair was created in the Peradeniya University to which was appointed Dr. A. Rodrigo. Integration of psychiatry into general health was initiated when psychiatry was introduced to the medical curriculum in 1968 by the Colombo Faculty and later in Peradeniya. Psychiatry was introduced to nurses training in 1962 by the school of nursing established in Mulleriyawa. The Mental Health Association, formed in 1959 later became the Psychiatric Association. Since the mid-1950’s the World Health Organisation provided technical support to build the capacity of the mental health system.
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The Community period: In the 1970’s with the realization that the mental health problems, their determinants, the care and the necessary resources for care are located in the community, the mental health activities gradually shifted from a general hospital approach to the community. This necessitated the development of new attitudes, structures, personnel and competencies in the mental health system. Towards the end of the 1970’s the few remaining psychiatrists, the much stigmatized mental hospital and the GH units were clearly incapable of responding to such demands. In the early 1980’s the new generation of psychiatrists with a community orientation undertook the challenge and the first development was the project undertaken by the author to establish the National Council for Mental Health in 1982. This organization established the first Community Mental Health Centre (Sahanaya) in Sri Lanka in 1983 with the participation of the community to provide and catalyse community mental health activities. The services included public education, training of mental health professionals, promoting self-help and care groups, provision of services to people with emerging mental health problems. Sahanaya also initiated the development of partnerships with public agencies. Since then many such community organizations have been established to provide valuable services. During this period existing community services were expanded and new community organizations were established to focus on people with psychosocial problems including battered women, people having problems related to trauma, alcohol, drugs and suicidal ideas. In the 1980’s and 1990’s the government introduced new legislation to establish institutions with the responsibility of coordinating psychosocial work of children, elderly, women, the disabled, drug addicts,
alcohol dependents and other categories. Most of the above services are community oriented and accessible to communities through local centres such as District Secretariats. Academic positions created in child psychiatry, community psychiatry, clinical social sciences and ethics by University of Colombo since the 1970’s and those appointed were expected to generate new knowledge and develop services. In order to improve the competencies of graduates, the University of Colombo in 1994 gave more exposure and weightage to psychiatry by making it a separate subject at the final MBBS examination. Similarly, the mental health component was expanded in all health and social care programmes including those in primary care. The health promotion movement since the 1980’s integrated mental health programmes carried out by public health practitioners in schools, work places and in the communities with the aim of promoting mental health in populations. Contd. on page 07
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SLMANEWS
April 2015
Contd. from page 04
The Evolution of... Universities and other institutions established courses in psychology and clinical psychology during this period. In the eighties the then government initiated a series of activities to improve access to services. The manpower shortage was gradually overcome with the increasing number of psychiatrists graduating from the MD programme established in 1980, Medical Officers of Mental Health completing the training programme initiated by Sahanaya in 1999, those completing a
Diploma programme conducted by the Postgraduate Institute of Medicine in 2000 and medical graduates emerging from new medical schools with mental health competencies. The shortage of facilities was overcome by renovating unused buildings with funds from public and other funding agencies. Since the early eighties the establishment of new inpatient units, new rehabilitation units, outpatient and outreach clinics facilitated the development of basic psychiatric services at district or the provincial level.
Conclusion: Care has moved from the prison to asylum, mental hospital, general hospital and finally to the community. Today we speak of the care of mentally ill, prevention of mental illness and the promotion of mental health in individuals and communities. Sri Lanka has taken very important steps to introduce contemporary developments to improve the care of those with mental health problems. However difficulties related to implementation and sustainability of the initiatives has prevented the realization of their full potential.
Childhood Injury Prevention through Maternal and Child Health Networks Dr. Kapila Jayaratne MBBS, DCH, MSc, MD Consultant Community Physician Chairperson – Expert Committee on Ergonomics – SLMA and National Program Manager on Maternal and Child Morbidity & Mortality Surveillance, Family Health Bureau, Ministry of Health.
I
n Sri Lanka, each year hundreds of children die from injury related causes. Injuries have been ranked among the first five leading causes of death among this age group. One fifth of annual hospital admissions are due to injuries. Apart from the acute morbidity, injured children suffer from long term disability and chronic pain that limit their ability to perform age-appropriate everyday activities over their lifetime. A majority of these mortalities and morbidities are preventable. Data sources on child injuries in Sri Lanka show that around 600 children under 16 years die each year due to injury-related causes. This is 10% of total deaths of the same age group. Aspiration, transport accidents, drowning, poisoning and animal bites are leading causes. Apart from this, every year 206,000 under 16 children are admitted to hospitals
due to injuries. This is one fifth of all admissions of the same age group. A majority (54%) of cases are due to external injuries which includes motor traffic causes. It is reported that every year nearly 18000 children sustain fractures or dislocations. Other major causes of hospital admissions are animal bites, poisoning, asphyxiation and burns. The approximate lower margin of the cost of hospital care amounts to Rs. 900 million per year. Many options are available to prevent these injuries and injury-related deaths. The three ‘E’s in the prevention of childhood injuries are: Education, Enforcement (law regulations) and Engineering (physical environment modifications). The Family Health Bureau (FHB) and the SLMA Expert Committee on Ergonomics (SLMA – ECE) conducted several activities with the objective of childhood injury prevention through maternal and child health networks over the last few months.
Child Injury Poster A poster on childhood injury prevention was developed as a collaborative project by FHB, SLMA – ECE and UNICEF. The poster was designed to suit Sri Lankan contexts in order to
raise awareness among all relevant parties. The poster shows vulnerabilities of different age groups for injuries and the advice and prevention options available in a graphical framework. A total of 15,000 posters were printed in both the Sinhala and English languages and are ready for distribution to all public health midwives, Medical Officer of Health offices, health care institutions, general practitioners and other first contact physicians. Contd. on page 08
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SLMANEWS
April 2015 Contd. from page 07
Childhood Injury ... SLMA – ECE has received funds from UNICEF to telecast the above videos in premier television channels.
Media Activities Several articles were published in leading newspapers about child injury prevention for awareness among the general public regarding the gravity of preventable injuries in the Sri Lankan context and the options in prevention of such.
The poster was presented to the Hon. Minister of Health Dr. Rajitha Senaratne and DGHS Dr. Palitha Maheepala at a function held at FHB recently.
alert the community level stakeholders to identify other children at risk for injury. Child injury death reviews are conducted as a comprehensive, multidisciplinary review of child deaths, to better understand how and why children die, and use the findings to take action that can prevent further deaths and improve the health and safety of children. The Family Health Bureau is planning to introduce Community Child Injury Death Reviews as a pilot project in three selected districts – Gampaha, Kalutara and Kegalle. A consultative meeting was held in March 2015 to work out a mechanism for the death review process and to develop data formats.
Childhood Injury prevention video The video “Imagine” developed with SafeKids Worldwide on prevention of child injuries in Sri Lanka was translated in to Sinhala. Both English and Sinhalese versions were shared with the electronic media and social networks. Link: https://www.youtube. com/watch?v=fTsA_eFI5qQ
Way forward
Child Injury Death Reviews The death of a child is a community responsibility and such a death due to injury is a sentinel event that should
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Further strengthening of domiciliary MCH networks with the aim of childhood injury prevention including promotion of safe home concept, parent awareness, safe schools, multi-stakeholder activities, improved hospital care and injury surveillance mechanisms are few of the activities in the agenda.
SLMANEWS
April 2015
Reducing Cardiovascular Disease Risk: A Challenge Beyond 2015 Dr. Upul Senarath MBBS, MSc., MD Specialist in Community Medicine Senior Lecturer, Faculty of Medicine, University of Colombo
Cardiovascular disease burden Cardiovascular disease (CVD) is the leading cause of mortality, causing 17 million deaths each year worldwide [1] . The problem is on the increase in Sri Lanka, particularly over the last 2 decades. In Sri Lanka, the hospital admissions due to ischaemic heart disease have risen from 163 to 476 per 100,000 population, with its mortality from 15 to 25 per 100,000 population between 1990 and 2010 [2] . Similarly, there has been a rapid increase in hospitalization due to hypertension (201 to 481 per 100,000) and diabetes (88 to 360 per 100,000) [2] . Several community-based surveys indicated that the prevalence of CVD is higher in urban and semi-urban settings than rural areas [3-5]. According to the Ragama Health Study, the prevalence of diabetes among adults aged 35-64 years was 23.7%, hypertension 44.9%, and dyslipidaemia 51.6%. A substantial proportion of healthy individuals acquired diabetes (19.1%), hypertension (24.8%) and dyslipidaemia (61.8%) over a 3-year follow up period [6]. Sri Lanka is facing a rapidly ageing population because of reduced fertility and an increase in life expectancy. The proportion of persons above 60 years will be 25% by 2040, and this will increase the burden of CVD [7]. The increased burden due to CVD affects individuals, families and community in-terms of premature mortality, loss of productive life years, costs to the patient, health services, and to the state, and in turn the national development. Changes in lifestyle and
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dietary practices associated with rapid urbanization and socio-economic development will further increase the risk for chronic non-communicable diseases, resulting in higher incidence of cardio-vascular disease events in the population [3-6]. A study in the Colombo district highlighted that more than 80 percent of the adult population aged 16-64 years eat an inappropriate diet without the recommended serving of fruits and vegetables and almost 33 percent of women and 19 percent of men were physically inactive [8]. Increased energy intake among adults has become a key issue leading to obesity [9].
Cardiovascular disease risk Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low consumption of fruits and vegetables, alcohol, and physical inactivity account for most of the CVD risk worldwide [10]. The cardiovascular risk is amplified when several risk factors are present in combination. Considering multiple risk factors, an individual’s CVD risk can be predicted, for example the Framingham calculation for 10-year myocardial infarction risk takes into account selected risk factors such as age, sex, smoking status, systolic blood pressure, total and HDL cholesterol [11]. Adopting a total cardiovascular risk approach using World Health Organization and International Society of Hypertension (WHO/ISH) risk prediction chart has been recommended for resource poor settings [12] . According to WHO/ISH chart, the prevalence of 10-year cardiovascular risk above 20-percent threshold was 8.1%, and above 10-percent threshold was 17.1% among adults enrolled in the Ragama Health Study [6].
Risk reduction by nutrition and lifestyle interventions Although drug treatment, such as lipid-lowering with statins, may be appropriate among individuals at high risk of CVD, adoption of a healthy diet is preferable to long-term medication in the general population in order to prevent or delay the onset of disease and to reduce the burden on health services [10]. A recent Cochrane review provides evidence that dietary advice is effective in bringing about modest beneficial changes in diet and cardiovascular risk factors, over approximately 12 months [13]. Dietary advice reduced total serum cholesterol, LDL cholesterol, blood pressure and cardiovascular events (OR=0.59) after 3 to 24 months. Lifestyle interventions too have shown substantial reduction in CVD risk. A clinical trial conducted in USA revealed that lifestyle recommendations for blood pressure control significantly lowered the estimated 10-year CVD risk by 12% to 14% relative to a control condition [14]. It is believed that multicomponent behavioral interventions incorporating diet and lifestyle recommendations would result in substantial reductions, and if achieved, should have important public health benefits.
Public health response to address the problem The government of Sri Lanka has given high priority to address the problem of CVD in the national health agenda, through establishment of a Directorate for prevention and control of non-communicable disease, and endorsement of national policy and strategic framework for prevention and control of chronic non-communicable diseases in 2009. Contd. on page 12
SLMANEWS
April 2015 Contd. from page 10
Reducing Cardiovascular... The National Diabetic Prevention Task Force of the Sri Lanka Medical Association launched NIROGI Lanka (National Initiative to Reinforce and Organize General Diabetes Care In Sri Lanka) to stimulate and support the adoption of effective measures for prevention and control of Diabetes Mellitus linked with prevention of cardiovascular disease. Further, educational programmes and material for risk factor modification, for example dietary and healthy lifestyles are being implemented through mass population strategies. Non-communicable disease prevention clinics are conducted at community level though Medical Officers of Health. However, the current preventive programmes need further strengthening and modifications in order to achieve an impact on the community. More personalized communication strategies for risk modification would be essential in the existing health system.
Conclusion The increasing burden due to CVD affects the country in-terms of premature mortality, loss of productive life years, costs to the patient, health services, and to the state, and in turn the national development. A gap in knowledge exists with respect to evidence on effective interventions that would address dietary and lifestyle causes, and thereby reduce cardiovascular risk specially focused on individuals in the community. More concerted efforts and multi-disciplinary approaches are needed to reduce disease burden due to cardiovascular events, and thereby achieve economic benefits due to reduced health expenditure, premature deaths and disability-adjusted life years.
References 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet
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Confession of a Physician
2013;380:2095-128. 2. Ministry of Health. Indoor morbidity and mortality reports. In. Colombo: Medical Statistics Unit; 2012. 3. Arambepola C, Allender S, Ekanayake R, Fernando D. Urban living and obesity: is it independent of its population and lifestyle characteristics? Tropical medicine & international health 2008;13:448-57. 4. Katulanda P, Constantine GR, Mahesh JG, et al. Prevalence and projections of diabetes and pre-diabetes in adults in Sri Lanka-Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabet Med 2008;25:1062-9. 5. Wijewardene K, Mohideen MR, Mendis S, et al. Prevalence of hypertension, diabetes and obesity: baseline findings of a population based survey in four provinces in Sri Lanka. Ceylon Medical Journal 2005;50:62-70. 6. University of Kelaniya Faculty of Medicine. In-depth analysis of Ragama Health Study. Colombo; 2012. 7. De Silva WI. Population Projections for Sri Lanka: 1991-2041: Institute of Policy Studies; 1997. 8. Arambepola C. Abdominal obesity and its association with selected risk factors of coronary heart disease in an adult population in the district of Colombo: Post Graduate of Medicine (PGIM), University of Colombo, Sri Lanka; 2004. 9. Jayawardena R, Byrne NM, Soares MJ, Katulanda P, Hills AP. Food consumption of Sri Lankan adults: an appraisal of serving characteristics. Public Health Nutr;16:653-8. 10.Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): casecontrol study. Lancet 2004;364:937-52. 11.Risk assessment tool for estimating your 10year risk of having a heart attack. Ministry of Health and Human Services, USA. (Accessed 2014, at http://cvdrisk.nhlbi.nih.gov/.) 12.Mendis S, Lindholm LH, Anderson SG, et al. Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings. Journal of Clinical Epidemiology 2011;64:1451-62. 13.Rees K, Dyakova M, Ward K, Thorogood M, Brunner E. Dietary advice for reducing cardiovascular risk. The Cochrane Library 2013:1-88. 14.Maruthur NM, Wang N-Y, Appel LJ. Lifestyle Interventions Reduce Coronary Heart Disease Risk: Results From the PREMIER Trial. Circulation 2009;119:2026-31.
I kept saying I was not old Now I realize I was too bold Truth was clear as the story unfold Arteries blocked, my feet got cold.
Cholesterol was high four years ago Needed more tests, but didn't undergo. Too busy for that, always on the go Didn't want to be sick, bad for my ego.
A scar on the leg, and one on the chest Wounds have healed, they didn't fest After many years, an enforced rest Now I am ok, feeling at my best
So much trouble could have been avoided What I advised others, if I simply abided Priorities in life now I have amended Wiser in the future, it's firmly decided
Had a narrow escape without going yonder Got a lease of life, I have service to render Just a word of warning to my opposite gender My heart is now throbbing, ten years younger!
Friends and colleagues who visited me Sent cards, flowers and prayed for me Knowing you care was comforting to me From the bottom of my heart, I thank thee
Written while convalescing after coronary bypass surgery in April 1998 Dr. Sarath Gamini de Silva
SLMANEWS
April 2015
What has private practice done to us? Dr. Panduka Karunanayake Senior Lecturer and Consultant Physician, Department of Clinical Medicine, Faculty of Medicine, University of Colombo
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octors’ private practice has gone through some change during our country’s recent history. In the pro-socialist early-1970s, private practice for state sector doctors was banned, and doctors desiring to do private practice were required to resign from the state service and engage in private practice full-time. After market liberalization in 1977, private practice after duty hours was again allowed for state sector doctors – this marked the beginning of ‘channel practice.’ With this change, did the medical profession also change? Let me examine this issue – with as much malice and culpability towards me as to any other. The benefits of the post-1977 change are many. These include increased income for doctors (and reduced clamor to governments to increase doctors’ salaries), reduced brain drain, meeting the demand for private sector healthcare from the upper- and middle-classes, and expansion of the healthcare private sector (which today has become the healthcare innovator in the country, a role that the state sector exclusively played in the pre-1977 era). In addition, the ‘off-loading’ of upper- and middleclass demand on the state healthcare service very likely has eased its burden immensely, allowing it to serve the poor better than otherwise. But private practice has also had deleterious effects, some anticipated and others not. There has been a reduction of doctors’ and consultants’ interest in the welfare and care of state sector patients, sometimes even discriminating against those who have not ‘channeled’ them. Patients often say that they channeled the consultant before getting admitted to his or her ward (“loku dostharawa allala thamayi
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giye”), because they perceive that it will lead to better care or attention. During my internship, senior nurses recounted to me how consultants used to do regular night ward rounds – and how hospital DMOs, MSs and directors did hospital night rounds – before private practice came in. Although initially the private practice income was supposed to supplement the state salary, it soon superseded the latter, and most personal decisions came to be made on the basis of the former. What specialty shall I choose? Which specialty has more private practice? Which allows faster board certification, hence earlier commencement of private practice? Which postgraduate trainer allows me to do private practice (or turns a blind eye to it) during my registrar or SR training? Which station has more private practice (or less competition)? Which station is situated in an area where private patients are richer, or private labs or nursing homes better? Eventually, even the subjects we choose to study and the skills we choose to acquire become investment decisions, not academic, intellectual or service decisions. In order to ‘reach out to the market,’ consultants and doctors often befriend media personnel and get themselves ‘invited’ to day-time television talk-shows ardently watched by housewives, ostensibly giving ‘health education’ – a phenomenon known in economics as creating supplier-driven demand. Are we still the same kind of doctor? Private practice has blurred boundaries between specialties and created new ways of dealing with colleagues. In the state sector you are unhappy with the colleague who refers patients to you, but in the private sector you like him. In the private sector, specialists treat patients outside one’s area of specialty, but in the state sector such patients are promptly referred to the relevant specialists, who are even blamed if the patients are not promptly ‘taken over’ to their wards. Patients
are sometimes prematurely discharged from state hospital wards to ‘clear the crowd,’ incompletely investigated or partly treated, but are kept back and fully managed in the private sector. The consultant is not the same person in the state and private sectors – he is a devil from 8 to 4 and an angel from 4 to 8. But even the angel from 4 to 8 is not very divine. Some consultants see over 100 patients in a day, and naturally this attracts comment by the laity. Patients not only ‘take a number,’ but they also find a friend or relative with a house close to the channel center, where they ‘park’ and watch television, have dinner and stay in comfort until their number ‘gets near’ close to midnight. There are incidents when a patient took two numbers when channeling a consultant, in the hope that the patient will get a little more time! The over-numbering naturally leads to less time, less diagnosis, more tests and more medications per patient. In the long cases in undergraduate and postgraduate exams, we learn how to incorporate all the symptoms into a single composite diagnosis, but in the private sector we simply prescribe one drug per symptom and one test per symptom or sign. It is alleged that some consultants keep several patients in the consultation room simultaneously: one on the chair, one undressed and on the couch waiting to be examined, and one getting dressed ready to leave. Some consultants have no compunction about employing pre-interns to take the history, do the examination and write the diagnosis for them: they merely write the prescription, or sometimes only put the signature to the prescription decided and printed out by the pre-intern. It is not only the clinicians who have changed their ways. During my internship I heard about a forensic specialist who was infamous for giving false evidence in courts as his ‘private practice.’ Some community physicians do private practice, which they are supposed not to, and pose off as general physicians. Contd. on page 16
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April 2015 Contd. from page 14
What has Private... Stories are abound in the laboratory specialties about ‘territorial disputes’ – this lab is mine, don’t come to it! But it is not only with regard to our careers and practices that we have undergone change. It has sunk deeper. Recently, a senior consultant physician retired after decades of illustrious service, teaching countless undergraduates and training many postgraduates. When he went back to his home town to recommence his private practice, some of the physicians in that area prevented the channel centers from accommodating him, by threatening to pull out of those centers. Not only the doctorpatient and the doctor-doctor relationships, but even the teacher-student or trainer-trainee relationships have now changed. I wonder what will change next. Retired senior consultants have told me stories of the pre-private practice days, when they used to spend
more time with family, friends and colleagues. They also had time for games, to read or have hobbies. A retired consultant psychiatrist, one of my teachers, recently proudly recounted to me the many stories of the days when he, as a practicing psychiatrist, also played the cello in the symphony orchestra. How has private practice enriched us, for the impoverishments that are upon us? One of my contemporaries put it succinctly when he compared his life to a loaf of bread: there is quantity, but not quality.
8.00 am – 4.00 pm
4.00 pm – 8.00 am
It is about 40 years, a mere two generations, since private practice started. Already, it has changed the landscape, the profession and the individual so much. What is in store for us in the next one or two generations? What has private practice done to us?
Emerging and Re-emerging Infections: a challenge to human progress and survival Dr. Hasini Banneheke, Convener of the SLMA Expert Committee on Communicable Diseases and Senior Lecturer in Parasitology, Faculty of Medical Sciences, Sri Jayewardenepura University
Introduction The world is the home for a variety of micro-organisms and multiple hosts. Many interactions are taking place among them resulting in both favourable and unfavourable outcomes. Generally those adverse outcomes are caused by pathogenic micro-organisms. There are more than 1400 recognized pathogens in the world with over 12% of them being novel pathogens. With the increase of these novel pathogens or known pathogens, health professional and authorities identified the need for particular attention and intervention. Thus the term ‘emerging and reemerging diseases’ was introduced to highlight and warn the world about the impending threat
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from epidemics caused by these new pathogens. World Health Organization (WHO) has defined an emerging disease as “one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range”. For example Middle East Respiratory Syndrome Corona virus (MERS-CoV) which is sweeping the Arabic peninsula currently is a new pathogen. During the last decade, human plague has re-emerged (India – 1994/2002, Indonesia – 1997, Algeria – 2003), after a silent period of about 30-50 years.
Who is cleverer, man or microbe? WHO along with other stake holders in health in the USA and worldwide, devised rapid response systems to monitor and contain disease outbreaks and to develop new weapons against microbes. This system assesses risks and existing systems
and prioritizes public health problems to develop strategic plans which are executed with ongoing monitoring to evaluate the impact and outcome. These mechanisms were tested by severe acute respiratory syndrome in 2003 and a series of practical and conceptual inadequacies in preparedness were revealed.
Why should we be worried? What is the impact on us? Emerging infections are a challenge to human progress and survival and are a leading cause of death and disability worldwide. An infectious disease in one country is a threat to the rest of the world through air travel. They magnify the global burden of infections and cause a major negative impact on economy and well being of the society. Inappropriate and intentional use of biological agents poses a threat to national security in addition to health implications. Contd. on page 18
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Emerging and... Recent media news from countries affected by the Ebola outbreak reporting parliament order of detention of Ebola coordinator, sacking of the national security head, probe into mishandling of funds, closing down of schools, quarantining of hospitals, business bankruptcy due to contact history with Ebola patients, occupational health related lawsuits against working places etc. are a few examples of the chaos caused by emerging infections.
Increased tuberculosis and influenza transmission contracting cholera during pilgrimage Acquiring dengue during travel "Airport" malaria
• Globalization of food supplies
- Difference in quality & expectancy of life
• Modern mass production
- Uneven global access to wealth, water, sanitation and public health services
- Increases the chances of accidental contamination
• War and famine • Occupational exposure (Eg: Ebola) • Lack of political will and support
There are many factors that lead to the emergence of infectious diseases. These are related to the human host, human behaviour, pathogen, environment, industry and technology.
Pathogen related factors
• ‘Aging planet’-increasing elderly population (Median age has risen to 29.2 with 11.7% being over 60 year of age) • Human susceptibility to infection has increased due to reasons such as infections (Eg: Human Immuno-Deficiency Virus -HIV), chronic illnesses and medications As a result people live longer but have weaker immune systems. Human demographics and behaviour related factors • Inflation of population size - Insufficient infrastructures
• Intent to harm using biological agent (Eg: posting powder form anthrax spores in letter through US postal mail in 2001) There are certain microbial adaptations and changes that support disease emergence. • Jumping species - from animals to humans (More than 60% of the emerging diseases are zoonoses. Of these, more than 70% of pathogens have originated from wild animals.) • Pathogens continue to evolve with enhanced virulence (Eg: toxin-producing Staphylococcus aureus causing Toxic Shock Syndrome) • Development of antibiotic resistance (eg: multidrugresistant Mycobacterium tuberculosis) Environment related factors Ecological and environmental changes and agricultural development have assisted infectious agents in many ways.
- Inadequate sanitation & access to clean water
• Global warming effect on vectors increasing the abundance and distribution.
• Urbanization/migration
• Higher ocean temperature
- More people are concentrated in cities
• Elevated rainfall creating new breeding habitats for mosquitoes and other vectors
- Increased population density • Breakdown of public health measures can contribute too. - Decrease in chlorine quantity in water supplies (Eg: rapid spread of cholera in South America 1991-1992) - Inadequate vaccination (Diphtheria epidemic in former USSR in the 1990s)
• Deforestation and land clearance lead to - Habitat encroachment (Eg: rainforest, wetlands) - People placed in contact with unfamiliar but already present natural reservoir or host (animal, arthropod) - Large dams cause ecological changes that encourage (or discourage) vector breeding
- Ecological diversity
Technology and industry related factors
- Rapid transport of infected fresh products & livestock
• Uneven global access to information such as HIV innovations in treatment, preparedness plans for pan-
• Travel with expanded distance & speed
demics and natural disasters, new or existing medical knowledge and new technologies such as Geographic Information System which is useful for planning of control programmes, results in the increased suffering of underprivileged nations while not so needy developed nations enjoythe facilities.
• Poverty and social inequality
What are the triggering factors causing infectious agents to emerge or re-emerge?
Human related factors
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Eg.
- Amplifies consequences of the contamination • Excessive antimicrobial usage on livestock farming. (In USA, out of the total antibiotic usage, more than 70% is used on animals for non-therapeutic purposes) • New or improved diagnostic technology and research advances - Reveal of new basis of infectious disease (Eg: role of Wolbachia bacteria in the pathogenesis of lymphatic filariasis) - Identification of previously unknown microbes for known diseases (eg. H. pylori - peptic ulcer) - Detection of new pathogens (Eg: Severe acute respiratory syndrome SARS-CoV, West Nile virus) • Blood & organ transplantation transmitted infections (Eg: HIV, Hepatitis B) Global situation updates Emerging and re-emerging infections have been classified in different ways by each institution or country. For example, the National Institute of Allergy & Infectious Disease (NIAID) categorizes based on the pathogens, namely pathogens newly recognized in the past two decades (group I), re-emerging pathogens (group II) and agents with bioterrorism potential (group III-category A, B, C). WHO has a separate scope of work aiming to combat the international spread of outbreaks, provide technical assistance to affected countries or communities rapidly and maintain preparedness. Thus WHO alerts the rest of the world in relation to any emergence of infectious disease outbreak. Such diseases reported by ‘Global Alert and Response Network’ of WHO in 2014 were Ebola (West Africa), Marburg (Uganda), MERS-CoV (Arabic peninsula),Polio (Central Africa, and Madagascar), human infection with avian influenza (China/Hong Kong), Legionnaires' Disease (Portugal)and West Nile virus (Brazil). Contd. on page 19
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Emerging and... In 2015 (up to 20th March) Ebola (West Africa), MERS-CoV (Arabic peninsula), human infection with avian influenza (China/Hong Kong) have continued to exist, while Measles (The Americas and WHO European region), Meningococcal disease (Nigeria) and Typhoid Fever (Uganda) have cropped up. Ebola There are five Ebola virus species, four of which cause disease in humans. It is a virus from the filovirus family. The natural reservoir host of Ebola virus is not known yet but is believed to be bat based on the evidence and the nature of similar viruses. The infection has caused a total of 24701 cases and 10194 deaths by 15th March 2015. Sierra Leon, Liberia and Guinea are the countries affected with intense transmission with frequency of occurrence in descending order. Human infection with avian influenza (H7N9) Avian influenza A (H7N9) was detected for the first time in March 2013 in China. Until that time it had not been recovered either from animals or humans. According to WHO, there have been 571 confirmed human cases of avian influenza A(H7N9) mainly (552 cases)from China with 212 deaths by 23rd February 2015. The animal reservoir, main exposures and routes of transmission to human and virus prevalence among animals and humans are not known. Canada and Malaysia have had few travel associated infections but so far international spread has not occurred. Therefore WHO does not recommend any travel restrictions or screenings to prevent human infection with avian influenza. Middle East Respiratory Syndrome Corona virus (MERS-CoV) This is a new viral respiratory illness which was first reported in Saudi Arabia in Sept 2012. Later retrospective assessments revealed that the 1st case had been found in Jordan in April 2012. As of 5th February 2015, there have been 971 laboratory confirmed cases with 356 deaths. Most (63.5%) of the affected patients are males and
the median age is 48 years ranging from 9 months to 99 years. Countries in or near the Arabian peninsula with cases include, • Saudi Arabia • United Arab Emirates (UAE) • Qatar • Oman • Jordan • Kuwait • Yemen • Lebanon • Iran Countries with travel-associated cases include United Kingdom (UK), France, Tunisia, Italy, Malaysia, Philippines, Greece, Egypt, United States of America (USA), Netherlands, Algeria, Austria and Turkey. Every year an estimated population of 1.4 million travels to Saudi Arabia for Hajj and no cases had been detected among pilgrims returning. So far no cases have been reported from Sri Lanka, nevertheless surveillance is ongoing. People are at higher risk if they have a history of, • Recent travel to the Arabic peninsula • Contact with suspected/confirmed case in the community/healthcare environment • Exposure to camels (preceding 14 days) • Pre-existing co-morbidities (Eg: diabetes, cancer and chronic lung, heart, and kidney diseases) • Being healthcare workers To reduce the risk of infection, health advices such as avoidance of contact with camels, drinking raw camel milk or raw camel urine and eating undercooked meat, particularly camel meat should be followed. Sri Lankan situation updates The Epidemiology Unit carries out disease surveillance mainly on the diseases listed in the notifiable register. Dengue is the most important vector borne disease at present with an increasing trend from 32063 in 2013 to 47246 in 2014. When comparing the data of the first two months of the preceding years (7131 in 2012, 6720 in 2013, 5621 in 2014) with 2015 data
(9950), the incidence has clearly risen irrespective of the intense control activities. Further, the Epidemiology Unit has also reported increasing trends in Measles and Leptospirosis during 2013. Emergence of Visceral Leishmaniasis in Sri Lanka during the last decade has been notified by the researchers. Brugian Filariasis which was once thought eliminated seems to have appeared again with cases being detected in both endemic and non-endemic areas. Preventive strategies There are a variety of approaches to counteract the threats imposed by emerging infectious diseases. 1. Surveillance and response • Strengthen disease surveillance nationwide • Improve methods for gathering and evaluating surveillance data • Ensure the use of surveillance data to improve public health practice and medical treatment • Strengthen global capacity to monitor and respond to emerging infectious diseases 2. Applied research • Develop tools for identifying and understanding emerging infections • Identify risk factors • Conduct research to develop and evaluate control strategies 3. Infrastructure and training • Enhance epidemiologic and laboratory capacity • Improve communication with local health departments, health-care professionals, and others • Enhance capacity to respond to outbreaks • Provide training opportunities to relevant personnel 4. Prevention and control • Implement, support, and evaluate control programmes. • Promotion of safe behaviours that reduce disease transmission • Support and promote disease control and prevention internationally Conclusion Emerging infections is a challenge imposed by the micro-organism on the health and safety of mankind.
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April 2015 Contd. from page 19
Emerging and... There are many host, pathogen and environment related triggering factors that cause infectious agents to emerge and create out breaks. Development of effective control strategies, vigilance and preparedness will be essential to face future global outbreaks and epidemics caused by emerging and re-emerging diseases. Summary An emerging disease is one that has appeared in a population for the first time or that may have existed previously but is rapidly increasing in incidence or geographic range (WHO definition). It is a challenge to human progress and survival contributing as a leading cause of death and disability worldwide. It also magnifies the global burden of infections and causes major negative impact on economy and well being of the society. An infectious disease in one country is a threat to the rest of the world especially due to the possibility of international spread through air travel. There are many human, pathogen, environment, societal/human behaviour related and technology or industry related fac-
tors that lead to the emergence of infectious diseases. Rapid population growth, increasing poverty, increasing urban migration, more frequent movement across international boundaries by tourists, workers, immigrants, and refugees, alterations in the habitats of animals and arthropods that transmit disease, increasing numbers of persons with impaired host defenses and changes in the way that food is processed and distributed are some such contributing factors. Majority (>60%) of emerging diseases are zoonoses. Of these, more than 70% of pathogens have originated from wild animals. The Global Alert and Response Network of World Health Organization has reported Ebola (West Africa), Marburg (Uganda), MERS-CoV (Arabic Peninsula), Polio (Central Africa, and Madagascar), Human infection with avian influenza (China, Hong Kong mainly), Legionnaires' Disease (Portugal), West Nile virus (Brazil) outbreaks during 2014. Dengue is the most important communicable disease in Sri Lanka at present. The Epidemiology Unit of Sri Lanka has reported an increased in-
cidence than in the previous year in Dengue during 2014 and Leptospirosis and Measles cases during 2013. Regular systematic surveillance and rapid response, infrastructure development and training, applied research, preventive and control measures are the control strategies that are useful to counteract the threats imposed by emerging infectious diseases. References Frank M. Snowden Emerging and reemerging diseases: a historical perspective Immunological Reviews Special Issue: Immunology of Emerging Infections, 2008, 225 (1): 9–26 Morens D.M. & Fauci A.S. Emerging Infectious Diseases: Threats to Human Health and Global Stability. PLoS Pathog 2013, 9(7): e1003467. doi:10.1371/journal.ppat.1003467 Samarasekara S.D. Lymphatic filariasis in Sri Lanka; what have we done? Where are we now? Symposium on moving towards filariasis free Sri Lanka organized by the Expert Committee on Communicable Diseases of Sri Lanka Medical Association March 2015 Siriwardana H.V.Y.D., Chandrawansa P.H., Sirimanna G. & Karunaweera N.D. Leishmaniasis in Sri Lanka: a decade old story Sri Lankan Journal of Infectious Disease 2012, 2(2):2-12 World Health Organization Global alert and response 2015; http:// www.who.int/ Annual Health Bulletin 2012; Ministry of Health, Sri Lanka Epidemiology unit Disease surveillance 2015; Ministry of Health, Sri Lanka
Summary of the International Women’s Day Celebrations 2015 By Dr. Nadeeka Chandraratne, Secretary, SLMA Expert Committee on Women's Health
I
n the wake of International Women’s Day 2015, the Expert Committee on Women’s Health (WHC) of the Sri Lanka Medical Association, together with Women and Media Collective (WMC) and the Family Planning Association (FPA) Sri Lanka, organized a short film screening and a discussion on issues of gender and sexual health at the Auditorium, Lady Ridgeway Hospital, on 3 March 2015. The WMC is a group of Sri Lankan ladies who have been actively engaged in bringing about a fair society that does not discriminate women based on gender.
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Discussion with (left to right) Prof. Shalini Sri Ranganathan, Dr. Mahesh Rajasuriya, Dr. Sepali Kottegoda (WMC), Mr. Thisun Chandrasiri (short film winner) and Ms. J.P.K. Jayaweera (short film winner)
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Summary of the... The FPA of Sri Lanka which is one of the most expansive and well known NGO's in the country that focuses on family planning, sexual and reproductive health and welfare of families was the other partner of this activity and was also the sponsor of this event. The main aim of this session was to enlighten the audience on issues related to gender and sexual health, thereby promoting them to be gender equitable in their day to day life and in work life. Another reason behind selecting this session was to motivate health professionals to promote visual media in delivering health messages. It is a known fact that Sri Lanka has not made full use of the influence of media on health, especially the modern forms of web based visual media, in spite of ample evidence that exposure to media has a significant impact on individual and population health behaviours.
2 Demonstrated how women had overcome such situations on their own 3 A few scenarios where men show empathy in roles of women and contribute to overcome gender discriminations The session was well attended by both medical and paramedical staff including students from the Nurses Training School who participated as special invitees for this occasion.
Watching the 2014 winning short film, ‘Wegawath Gahaniya’ by Ms. J.P.K. Jayaweera
The audience
Prof Jennifer Perera, the President of SLMA, a past chairperson and a long standing member of the WHC made an interesting introductory remark on how women were treated and supposed to be treated equally giving examples from the Old Testament of the Gospel. Ten short films from WMC’s short film competitions, which have been held over the years, were shown at this session. The screening of the films were followed by a lively discussion moderated by Dr. Sepali Kottegoda, the Executive Director of WMC, Dr. Mahesh Rajasuriya, Senior Lecturer in Psychiatry and Prof. Shalini Sri Ranganathan, Professor in Pharmacology of the University of Colombo and a member of the WHC. Several of the winning short film producers were also invited to share their stories behind the films created. The main critique highlighted that the films depicted 1 Common situations in the country where the woman is discriminated based on gender
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April 2015
The Bliss of Alcohol - Personal Views Reproduced from an email conversation between Dr. Malik Fernando and Prof. Diyanath Samarasinghe Prof. Diyanath: Alcohol is such a bore is it not, and meant primarily for people who want to demonstrate to themselves that they are having a good life? The ‘foreign hard liquor’ must be really helpful, for the more we pay per molecule of ethyl alcohol the stronger their action on the brain’s pleasure receptors; Quite unlike the boring molecules of C2H5OH in the local stuff. Dr. Malik: Oh! Diyanath Wish I can get you to enjoy a glass of single malt scotch, relaxing on a haansi putuwa, with Beethoven’s 9th symphony playing. Sheer heaven! But you probably do not believe in that? Prof. Diyanath: Well, well Malik, So easily spotted was your impish intent. “No I shall not rise to this bait” I thought. But alas, you’ve won, clever ruse too strong to resist. This heaven you paint is not unfamiliar. Nor am I averse to such conditioning. But Beethoven would’ve been upset had he known that one Diyanath needed a scotch to enhance the 9th. He may even have left it unfinished.
But I don’t feel here either the need to bluff myself
When next you lie back, malt scotch in hand, to really get into the 9th,
with wonderful imagery and words.
look carefully at when the alcohol kicks in,
Let’s learn to let alcohol
having reached threshold needed to work:
stand on its own,
the symphony by then would be long gone.
speak for itself. And enjoy watching it falter.
But that does not stop symbol from casting heavenly spell. (On second thoughts: maybe better not peer too closely. Would be a pity to spoil the magic painstakingly nurtured over years). Many others down their drink with strong conviction
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I know too well you’re not one hemmed-in, unable with no drink to tune in to birds and bees or music on chaise-lounge. So your urge to boost drink with irrelevant embroidery
that it lubricates interaction.
is strange.
And I’ve been there as well. I’d still gladly consume to humour and help those who feel constrained without it.
Leave that to sad souls who cannot enjoy even intercourse without thanking malt scotch for the bliss.
SLMANEWS THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
If undelivered return to : Sri Lanka Medical Association. No. 6, Wijerama Mawatha, Colombo 7 Registered at the Department of Post Under No: QD/27/NEWS/2015