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CONTENTS
Page No.
Cover Story
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
The Sri Lanka Medical Association Dance 2015
08, 09, 10
December 2015, Volume 8, issue 12
SLMA News Editorial Committee-2015 Editor-In-Chief: Prof. Sharmini Gunawardena
News
Committee:
President's Message
02
Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
Sri Lanka Medical Association (SLMA) Strategic Plan 2015 – 2020
02, 03
Our Advertisers
Annual Scientific Sessions of the Puttalam Clinical Society and the SLMA
03, 04, 06
A Reflection on Academics as Thought Leaders
06, 07, 08
The Sri Lanka Medical Association Dance 2015
08, 09, 10
Glaxosmithkline Pharmaceuticals Ltd. Union Assurance PLC. Douglas & Sons (Pvt) Ltd. Western Hospital. Elcardo Industries (Pvt) Ltd. eChannelling PLC.
Who is a Medical Specialist?
10, 12
Tokyo Cement Company (Lanka) Plc. The Central Hospital.
Malaria Count 2015
12
Durdans Hospital. Emerchemie NB (Ceylon) Ltd.
Leishmaniasis: Are we ready to combat
14, 16, 18, 20, 21
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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December 2015
PRESIDENT’S MESSAGE
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Dear friends and colleagues,
I
am sending the last message to the newsletter as the President. I am confident that you enjoyed and gained much by reading this regular newsletter. The year was filled with many activities, and priority was given to continuous professional development. In keeping with the theme for the year, “Connect, communicate, collaborate for improved health and healthcare” SLMA took part in numerous activities with a diverse group of stakeholders to improve its advocacy role in issues related to the profession as well as to health in general. This required collaborative partnerships and dialogue with sectors within and outside the healthcare sector.
The last Council Meeting was held on the 5th of December and a summary of activities was presented to facilitate continuity of activities initiated by the outgoing Council. I believe we delivered a diverse and beneficial programme of activities, to cater to the multiplicity of academic and social in-
terests of our membership. I am grateful for all the constructive feedback received during my office which was a very valuable learning experience for me personally. Please accept my sincere apologies if I caused any sadness or pain to anyone during my numerous interactions. The Medical Dance was held on 12th December at the Waters Edge and the Annual General Meeting of the SLMA was held on 17th December, at which a new Council was elected. The incoming President Dr. Iyanthi Abeywickrama has planned the Induction Ceremony for the 16th of January 2016 and I wish her a very enjoyable and productive year of office. First and foremost I want to take this opportunity to place on record my deepest thanks and sincere appreciation for the invaluable support I received from the Executive Committee, the Council, members of our association and many others. This made my
tenure of office as President a most enjoyable period of my life. During my association with the SLMA over the past years I have been aware of the potential of the SLMA as well as its responsibility in contributing to improving healthcare of this country. It was a matter of pride to recognize first hand that when the SLMA speaks on any issue related to health or health policy, it is considered seriously. It is important for future custodians of this hallowed organization to leverage this potential to improve the healthcare and social standards of this country. The collective efforts of all should be geared towards making a difference through addressing current needs of our society be it health or otherwise. Finally let me wish each and every one of you the Compliments of the Season, a Blessed Christmas and a Peaceful New Year! Professor Jennifer Perera
SRI LANKA MEDICAL ASSOCIATION (SLMA) STRATEGIC PLAN 2015 – 2020
“Greatness is not where we stand, but in what direction we are moving”
S
Oliver Wendell Homes
LMA is an organization with a long history and is the oldest running Professional College in Sri Lanka. However, there was no concrete Plan of Action to direct its activities for the future. Although a Strategic Plan had been developed in the past, it had not been revised and updated.
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Therefore, the SLMA committee under the leadership of the President, decided to embark on the path to develop a new Strategic Plan for the future. This initiative was supported by a Consultant who introduced the concept of strategic planning to the members. The end product that is now available in print is the sole effort of the SLMA committee. The Mission; To improve the health and wellbeing of all Sri Lankans, through Advocacy, Leadership and MultiSector Collaboration, while achieving the highest standard of medical professionalism and ethical conduct as the apex medical professional organization in Sri Lanka with a global reach.
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SLMA Strategic Plan... The Vision; To halt the rise of Non Communicable Diseases with an emphasis on diabetes. To be the strongest and most respected voice on advocacy for health. To be the leader in ethics and continuous professional development in healthcare. It was identified that SLMA’s work revolved around seven core values, namely Accountability, Advocacy, Collaboration, Diversity, Integrity, Leadership and Social Responsibility. The main objectives listed are; 1. To advocate the reorientation of the health sector towards health promotion with a life cycle approach.
2. To engage the non-health sector in taking on equal responsibility in preventing and reducing health inequities.
developing medical professionals’ knowledge and skills through Continuous Professional Development (CPD) Programmes
3. To promote healthy lifestyle and address major causative factors for NCDs and diabetes among vulnerable populations through a health promotion approach.
5. To play an advocacy role towards a comprehensive curative and preventive healthcare for the community
The first three objectives relate to halting the rise of Non Communicable Diseases (NCD) with a special emphasis on diabetes. 4. To enhance the capacity of medical professionals This relates to SLMA’s key role in
The last objective focuses on the significant role SLMA plays in advocating for a healthier nation through public friendly policies and programmes. Several activities are outlined under each objective with identified means of progress and responsible persons, in order to track the progress of the SLMA in achieving its mission by 2020.
ANNUAL SCIENTIFIC SESSIONS OF THE PUTTALAM CLINICAL SOCIETY AND THE SLMA By Dr. Shamini Prathapan (Assistant Secretary, SLMA)
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Perera, President of the SLMA also addressed the gathering.
he Annual Scientific Sessions of the Puttalam Clinical Society in collaboration with the SLMA was held on the 21st of October 2015 at the Auditorium of the Puttalam Base Hospital (PBH). The Council of the Puttalam Clinical Society led the ceremonial procession with the SLMA council members followed by the guest speaker Dr. Lucian Jayasuriya.
The President of the Puttalam Clinical Society, Dr. M. Sugunadevan, welcomed the gathering and delivered the welcome speech. Prof. Jennifer
The sessions commenced with Dr. Lucian Jayasuriya delivering his guest lecture on “Some experiences of a medical administrator: lessons for management”. He spoke about lessons learnt since 1975, when he was at the Galle General Hospital. The lessons leant 40 years ago were to analyze the problem, find the root cause, know the environment, respect persons, commitment, communication and competency. He gave examples such as the difficulty he had as Direc-
tor General of Teaching Hospitals in giving medical cover for the late Rajiv Gandhi when he came to sign the Indo-Sri Lanka pact in 1987, in which the lessons learnt were commitment and personal communication; of the 1989 JVP insurrection, and of the disturbances in July 1983 when he was Director of General Hospital, Colombo. He concluded by again emphasizing that the lessons learnt were the 4’C’s – Competence, Commitment, Communication and Common sense.
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Annual Scientific... The guest lecture was followed by the 1st session which was chaired by Prof. J. Perera and Dr. D. Dissanayake. The panel of speakers consisted of Dr. N. Rajasekara, Consultant Paediatrician from Puttalam Base Hospital, Dr. P. Manivannan, Consultant Physician from Puttalam Base Hospital and Dr. Navodha Attapattu, Consultant Paediatric Endocrinologist from Lady Ridgeway Hospital, Colombo.
Dr. N. Rajasekara, initiated the session with a comprehensive presentation on “Childhood Obesity”. The lecture commenced by highlighting the fact that obesity is one of the major health challenges of the 21st Century and its spread at an alarming rate across the globe now affecting low and middle income countries as well. She discussed causes and complications of obesity, and showed the vicious cycle of obesity. The genetic causes of obesity such as the Prader Willi Syndrome, Bardet-Biedl Syndrome, congenital leptin deficiency and the leptin receptor insensitivity disease were explained in detail. She finally concluded by explaining the methods of preventing childhood obesity.
Dr. Navodha Attapattu continued this discussion with her lecture on “Endocrine aspects of obesity in children”. She described the endocrine disorders associated with obesity such as growth hormone deficiencies,
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hypothyroidism, pseudohypoparathyroidism, leptin deficiency or resistance to leptin action, glucocorticoid excess (Cushing syndrome), precocious puberty, polycystic ovary syndrome (PCOS) and the prolactin-secreting tumors. She explained in depth the clinical clues for pathological obesity and went on to discuss the endocrine complications of obesity such as insulin resistance where the clinical marker is acanthosis, metabolic syndrome etc. Dr. P. Manivannan, then delivered a comprehensive lecture on “Metabolic syndrome of obesity”. He began with a clinical discussion followed by a description of the history of metabolic syndrome dating back to 1920, when Kylin, a Swedish physician demonstrated the association of high blood pressure, hyperglycaemia and gout. He stated that the current definition and criteria for the diagnosis of metabolic syndrome was proposed by the International Diabetic Federation (IDF). He described the pathophysiology of metabolic syndrome of obesity and its components: abdominal obesity, atherogenic dyslipidemia, elevated BP, insulin resistance, hypercoagulable state, pro-inflammatory state and chronic hyper secretion of stress mediators. He completed his lecture with a discussion of the related management and life style interventions. The second session commenced after tea and was chaired by Dr. Shamini Prathapan and Dr. S. Jeewatharan. The panel of speakers consisted of Dr. L. Rajapakse, Consultant Obstetrician, Dr. R. A. Y. Rupasinghe, Consultant Surgeon, Dr. M. Sugunadevan, Consultant Anaesthetist, all from Puttalam Base Hospital and Dr. Ranil Jayawardena Clinical Nutritionist from Nawaloka Hospital. Dr. L. Rajapakse, started the 2nd session with a detailed presentation on “Obesity in pregnancy”. He stated that obesity is a commonly occurring risk
factor in Obstetrics and in pregnancy is defined as a BMI of 30kg/m² or more at the first antenatal consultation. He discussed the effects of maternal obesity in pregnancy with regards to the mother and foetus. He detailed the associated serious adverse outcomes and went on to describe the related pre-pregnancy, antenatal, natal and postnatal care. He emphasized the risks of inter-pregnancy weight gain in a woman who has gained three or more units of BMI during an average two year period where the risk of a large-for-gestational-age birth is increased by 87%. He ultimately pointed out that there are also anaesthetic complications as well.
Dr. R. A. Y. Rupasinghe, Consultant Surgeon, spoke about the surgical techniques available for the management of obesity in his lecture titled “Surgical options for obesity”. He described the laparoscopic techniques available and the opened methods as well. He emphasised the advantages of the laparoscopic techniques and also mentioned about banding and its limitations. Dr. M. Sugunadevan continued the discussion with his lecture on “Anaesthetic challenges in obesity”. He focused on the difficult airway with a short neck, increased bulk of tissues in the upper airway, limited neck movements, decreased cervical and mandibular mobility, being prone for obstruction with loss of consciousness together with difficulty in mask ventilation and laryngoscopy and anticipation of a difficult airway. He also described the related respiratory, cardiovascular, gastrointestinal and endocrine effects, thromboembolism risks and ultimately the pharmacological effects. Contd. on page 06
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Annual Scientific... He stressed the need and the reasons for a good pre-operative assessment, intraoperative management and post-operative care. After this brain storming session, Dr. Ranil Jayawardena delivered his lecture on “Nutrition concept and controversies in obesity”. He stressed the need of losing calories that should be equal to the intake. This lecture was followed by several questions from the audience and ended in a lively discussion. The session after lunch was chaired by Dr. C. Samarasinghe and Dr. H. Salih. The session began with a quiz programme conducted by Dr. U. Jayakody, Consultant Radiologist at Puttalam Base Hospital. A large number of Medical Officers and Consultants participated in this much awaited programme. The quiz programme was followed
by two lectures delivered by Dr. W. Jayasinghe, Consultant ENT Surgeon, and Dr. V. G. Abeywicrema, Consultant Dermatologist, both from the Puttalam Base Hospital. Dr. W. Jayasinghe, in his lecture on “Obstructive sleep apnoea” detailed the triad of Sleeping Disordered Breathing consisting of obstruction, apnoea / hypopnea and Respiratory Event Related Arousal (RERA). The most severe form could lead to obstructive sleep apnoea with many sequelae such as impaired cognition, decreased attentiveness, being prone to accidents, insulin resistance, pulmonary hypertension, cor pulmonale etc. He described the tests used for detection of the condition such as Epworth Sleepiness Score, Multiple Sleep Latency Test and sleep studies of which polysomnography is the gold standard.
The session concluded with Dr. V. G. Abeywicrema speaking on “Obesity and skin” where he described the manifestations of obesity in the skin such as acanthosis nigricans, acrochodons, keratosis pilaris, striae distensae and adiposis dolorosa. Each of these conditions was illustrated with pictures. It was further explained that hyperandrogenism and hirsuitism, PCOS, adiposis dolorosa and many more were consequences of obesity. The vote of thanks was given by Dr. B. Branavan, Secretary, Puttalam Clinical Society. This was followed by a fellowship tea.
A REFLECTION ON ACADEMICS AS THOUGHT LEADERS Prof. Ajantha S. Dharmasiri Director and the Chairman of the Board of Management, Postgraduate Institute of Management, University of Sri Jayewardenepura, Sri Lanka director@pim.lk
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his concept paper attempts to offer thoughts on academics as thought leaders, in critically evaluating their contribution. Blending with the personal experiences of the author, triple roles of academics are proposed as knowledge capturing, knowledge communicating and knowledge creating. The need to move from a vicious cycle to a virtuous cycle in knowledge championing is emphasized in the paper for the purpose of socio-economic upliftment.
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1. Introduction Academics engage in scholarly activities. They deal with knowledge in playing multiple roles. They have to think and act as knowledge creators as well as knowledge sharers. Academics influence the attitudes and aptitudes of student community (Dearlove, 2002). This is where the “thought leadership” comes into the forefront. Superiority in scientific thinking, blended with socio-cultural realities is what an academic should smartly possess. It qualifies them to join the constellation of thought leaders. In fact, leadership is not about positions and titles but decisions and actions. It refers to a mindset of influencing, inspiring and instructing. Leaders as opposed to laggards, deliver results. As it has been observed, leader-
ship is a vastly explored but least understood phenomena on earth (Bass and Stogdill, 1990). Many definitions of leadership in the limelight portray its multi-dimensional nature. Academics should shift from their perennial plight of “publishing or perishing” to a new paradigm of thought leadership. Such a transformation requires vision and passion. Overcoming socio-economic as well as religio-cultural barriers in moving ahead with a strong intrinsically-driven motivation is the need of the hour.
2. Triple roles for academics The way I see it, academics have triple roles to play. These can be depicted as a knowledge pyramid of academics. Figure 1 depicts the details. Contd. on page 07
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Contd. from page 06
A Reflection on Academics... Figure 1. Triple roles for academics
re-cycled knowledge over and over again to cater for ever-increasing lecture demand. Hence, the knowledge capturing dimension suffers and opportunity to review and renew oneself gets neglected.
4. Academics as Knowledge Communicators
Source: Dharmasiri (2015a)
3. Academics as Knowledge Capturers The bottom of the knowledge pyramid contains the role of knowledge capturer. This includes the learning dimension of an academic. We learn from the womb to the tomb, as lifelong learners. I prefer to be called as a management learner than an “expert”. This is more relevant in the context of change, where knowledge is rapidly getting obsolete (Senge, 1990). Particularly, in the areas of Information, Communication and Technology (ICT), the rate of knowledge updating seems more rapid. This is where the academics have to explore new knowledge. They should have the mindset of exploration. It reminds me of a story that I heard about an elderly professor. He was serving in a residential campus in an European city, staying in the upper-most floor of the building complex. His room was well lit early morning and the students could see him reading. Among the students, they were discussing as to why this veteran still suffers in getting up so early to read. One student had the guts to go and ask from him, as to why he is doing so. The professor gave a profound answer. “I would rather you drink from a flowing fountain than from a stale pond” (author unknown). Upon reflecting, I was wondering whether we Sri Lankan academics are more “flowing fountains” or “stale ponds”. We might be hurriedly offering
The middle part of the knowledge pyramid is all about sharing knowledge. It highlights the traditional role of teaching. Communicating knowledge does not necessarily mean lecturing. We at the Postgraduate Institute of Management (PIM), have been practicing, what we call four modes of teaching. They refer to “tell, ask, show and do”. Telling means the typical lecturing. Asking means to engage the learning community by raising questions expecting answers from them. Showing refers to audio – visual interventions such as documentaries, movie extracts, video recordings, internet-based resources such as You tube etc. Doing means to get the student community to engage in group discussions. In a typical three hour “session” (we prefer this as opposed to a lecture), roughly one third would be telling. I see clear issues among us, Sri Lankan academics in this respect. Are we loading students with knowledge through one-way communication in making them mere receivers? They would easily resort to “parrot technique” in memorizing everything and reproducing at the exam with spelling and grammar errors. Are we being challenged by the student community sufficiently, in leading to a meaningful interactive discussion? I might be biased here in basing on mostly postgraduate teaching experience. Yet, irrespective of what level an academic has to tackle, an appropriate adaption is always possible. We need to begin with the end in mind (Covey, 1989)
5. Academics as Knowledge Creators This is where the research comes into the limelight. Sri Lankan academics should reach the pinnacle of knowledge pyramid in becoming knowledge creators. Relevant research with rigor and results is the need of the hour. Pinikahana (2011) observed the need to focus on for private sector to collaborate in university research. He shared some revealing statistics about local research. “Sri Lanka contributes only 0.17% from GDP whereas Singapore contributes 2.3%, South Korea, 2.9% and China, 1.3% from their GDP for research. A recent report published by the Ministry of Technology & Research in Sri Lanka revealed that Sri Lanka has only 287 researchers per million which is less than the world average of 894. The average number of researchers per million in the developed world and the developing world is 3272 and 374 respectively. It is clear from these statistics that Sri Lankan situation is worse than the average third world situation. The most alarming situation is that it is getting worse in recent years. For example, in 1996 Sri Lanka had 6000 full time researchers including university researchers but by 2006 this number declined to 4200 (Pinikahana, 2011)”. In such a context, any move to strengthen the research rigor, particularly among the University community is commendable. As I observe, there is a clear need to create better awareness on the importance of research. This I see acutely in the field of management.
6. Moving from a Vicious Cycle to a Virtuous Cycle In moving up in the knowledge pyramid, academics need to move from a viscous cycle to a virtuous cycle. I have attempted to capture both the cycles as depicted in figure 2. Contd. on page 08
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A Reflection on Academics... Figure 2. Vicious Cycle to Virtuous Cycle
Source: Dharmasiri (2015a)
As figure 2 depicts, the bottom is the vicious cycle where an academic gets stranded in capturing, collecting, contemplating and continuing of knowledge. In other words, one gets engrossed in sharing same knowledge over and over without reviewing, reflecting and renewing. I refrain from giving Sri Lankan examples, but I know many among us who experience this situation either knowingly or unknowingly. The break though occurs when one moves from the vicious cycle to the virtuous cycle. Instead of moving beyond knowledge contemplating to knowledge continuing, the cycle should break with knowledge challenging. That’s the entry to the passage of knowledge creating and knowledge
championing. Let me explain this much needed move through an example. When I started teaching Human Resource Management, I diligently adhered to the textbook models, in sharing my experience through them. I could even remember the entire lecture or even several lectures by heart. I was essentially, recycling same knowledge, of course with delivery effort sans intellectual stimulation for me. I realized it is just tutoring and not teaching. I needed to move beyond. When I started challenging the appropriateness of some of the teaching models to our socio-cultural context, the move from viscous cycle to virtuous cycle began. My research on Strategic Human Resource Management (SHRM) shed new insights to the way we approach people particularly in the humanly rich South Asian context (Dharmasiri, 2015b). It gave me more confidence to blend western models with regional and local realities, rather than blindly sharing what the books say.
7. Conclusion This paper attempted to reflect on academics as thought leaders. Essentially, it is an invitation to review and renew oneself. Also one may argue of
the need to have a conducive climate with right remuneration. Perhaps, we do more than double the amount of teaching than our western colleagues as academics, and less than half the amount of researching compared to them. I am simply inviting to have a fresh look at what we are doing or perhaps overdoing.
References Bass, B. M., & Stogdill, R. M. (1990). Handbook of leadership (Vol. 11), New York: Free Press. Covey, S. R. (1989), The seven habits of highly effective people, New York: Simon Schuster. Dearlove, J. (2002). “A continuing role for academics: The governance of UK universities in the post-Dearing era”, Higher Education Quarterly, 56(3): 257-275. Dharmasiri A.S. (2015a), Academics as thought leaders: Promises and pitfalls, http://www.ft.lk/article/490579/Academics-as-thought-leaders--Promises-andpitfalls. Dharmasiri, A. S. (2015b), HRM for managers: A learning guide, Colombo: Postgraduate Institute of Management. Pinikahana, J. (2011), The role of the private sector in university research in Sri Lanka, http://www.srilankaguardian. org/2011/02/role-of-private-sector-inuniversity.html Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization, London: Broadway Business.
THE SRI LANKA MEDICAL ASSOCIATION DANCE 2015 Held at the Waters Edge Hotel on the 12th of December 2015
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SLMA Dance 2015...
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SLMA Dance 2015...
“WHO IS A MEDICAL SPECIALIST?” SLMA Expert Committee in Medical Education
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panel discussion on the above topic was held on 12th October 2015 at the SLMA Lionel Memorial Auditorium, to raise the awareness and create a dialogue among the medical community on this interesting and much debated topic. The event was organised by the SLMA Expert Committee in Medical Education and chaired by Dr. Palitha Abeykoon (Chairperson, SLMA Expert Committee in Medical Education). The panel consisted of eminent speakers representing different disciplines of medicine. Dr. Lalantha Ranasinghe, Professor Senaka Rajapakse, Professor Jennifer Perera, Professor Antoinette Perera and Dr. Sarath Gamini de Silva enlightened the gathering with a very informative dialogue on the topic. Dr. Lalantha Ranasinghe represented the SLMC (Sri Lanka Medical
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Council) and AMS (Association for Medical Specialists) and emphasised that both organisations shared the same views regarding the concept of a “Medical Specialist”. In his speech he highlighted the absence of a document to govern a medical professional as a “Medical Specialist” in the country and therefore the need of a medical registry to benchmark a medical specialist. He described the endeavors of the SLMC in amending the medical ordinance to govern medical specialists and the progress in implementing a registry for medical specialists. He further stated that the influx of foreign medical specialists to the country and their absorption into many private sector clinical settings has made it necessary to expedite this process. Professor Senaka Rajapakse, representing the PGIM (Postgraduate Institute of Medicine), also highlighted the
absence of a specialist registry in the country and the necessity for such. He stated that the PGIM, as an institution under the purview of the University of Colombo, has the authority to provide accreditation as a medical specialist in a specified discipline through a system of board certification. The document of board certification is currently the standard document which recognises a medical specialist in the country and the Ministry of Health only recruits medical specialists with board certification. He further mentioned that the PGIM is working towards accreditation of its board certification by the international medical community and also described the necessity of establishing a mechanism for mutual recognition of properly trained and accredited medical specialists from foreign countries. Contd. on page 12
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Who is a ... Professor Jennifer Perera, Dean, Faculty of Medicine, University of Colombo expressing her views on the topic portrayed a medical specialist as a “medical professional who has completed advance education and training in a specific area of medicine”. She stated as per the local context the training of a medical specialist ends with board certification following four to six years of training. However she emphasised the importance of continued training and the necessity to introduce a system of recertification to maintain the specialist status. She also called attention to the necessity to provide opportunities for sub specialties to develop and expand their boundaries to be on par with the developments of other countries. Furthermore the need to develop other skills in addition to the discipline specific knowledge and skills, i.e. communication skills, empathy, decision making, team work, ability to handle pressure etc. was also highlighted in her speech. Dr. Anuruddha Padeniya, representing the GMOA (Government Medical Officers Association), provided a detailed description of the activities undertaken by the organisation in relation to the topic. He identified the main problem to be the lack of a proper definition of a specialist and a method of evaluation of foreign medical professionals, and emphasised the need of a specialist registry. He further stressed that this problem is applicable mainly to the private sector, as the government sector has a streamlined procedure of recruiting specialists board certified by the PGIM. Dr. Padeniya described the steps initiated by the GMOA to develop a procedure to evaluate foreign doctors. He stated that these activities are
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detailed in the book published by the GMOA titled, ‘Establishment of ‘Specialist Registry’ & Introduction of an Evaluation Procedure for Foreign Medical Specialists’. Dr. Padeniya described the renewed interest in this topic with the implementation of CEPA and SATIS, heightening the need for a reinforcement of the regulatory framework. He stated that though the groundwork had been laid, the suggested specialist registry cannot be implemented due to certain legal constraints. He assured however that interim measures have been taken and a procedure of registering foreign specialists has been implemented. Dr. Padeniya concluded by emphasising the role of the SLMC in implementing a specialist register. Prof. Antoinette Perera, as the President of the Sri Lanka College of General Practitioners (SLCGP), provided a fresh perspective to the topic by focusing on medical specialists within the context of general practice. She talked about the two groups of family physicians practicing in the country; board certified Consultant Family Physicians and General Practitioners (GP) with some (eg.:- Diploma in Family Medicine) or no special qualifications. She concluded by stating that the SLCGP planned to initiate a separate register for General Practitioners and ensure that all GP’s undergo a certain level of specialist training. Dr. Sarath Gamini de Silva, acted as representative of clinical specialists and elaborated on the necessity of determining the appropriateness in terms of qualifications, of ‘specialists’ to whom patients are referred. He highlighted that the lack of a proper referral system, at times resulted
in patients seeking specialist treatment from those poorly qualified to offer such care. Dr. de Silva further emphasised the need for adding the quantum of experience to the definition of a specialist. He also questioned where the line is drawn between the boundaries of specialty knowledge and if a specialist in one area could also be considered as a specialist outside of his area of expertise. Dr. de Silva agreed with the previous speakers regarding the need for a process of certifying and regulating specialists. He added that a procedure of regular accreditation should also be developed, with the provision of adequate facilities for continuous professional development. The presentations by panelists were followed by a discussion, where the exclusive role of the PGIM in providing postgraduate medical training in the country and the question of considering PhDs as a specialist qualification, were discussed. During the discussion, the role of professional colleges in recertification of specialists was emphasised.
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“LEISHMANIASIS: ARE WE READY TO COMBAT?” Excerpts of the symposium jointly organized by the Expert Committee on Communicable Diseases of the SLMA & Centre for Diagnosis, Research & Training of Leishmaniasis, Department of Parasitology, Faculty of Medicine, University of Colombo, held on the 12th of November 2015 from 11.30am - 1.30pm at the Auditorium of the Sri Lanka Medical Association.
Overview of leishmaniasis in Sri Lanka, case detection and laboratory diagnosis Dr. Yamuna Siriwardana, Senior Lecturer, Department of Parasitology, Faculty of Medicine, University of Colombo
Disease leishmaniasis Leishmaniasis is a vector borne protozoan infection. Clinical disease is known to manifest in 3 main forms, i.e. cutaneous (CL), muco-cutaneous (MCL) and visceral leishmaniasis (VL) in humans. Final clinical outcome is multi-factorial, infecting Leishmania species being the main determining factor. Cutaneous leishmaniasis results in a range of manifestations from tiny papules to large ulcerative and destructive lesions over exposed body areas. Lesions occur in the naso-pharyngeal region involving buccal or tongue mucosae, soft palate and nose in mucosal leishmaniasis. Visceral infection involves spleen, liver and bone marrow infection and presents with PUO, anaemia and hepatosplenomegaly. VL is usually fatal if not detected
and treated properly. Human leishmaniasis results in a huge global burden and is listed as one of the eight major neglected tropical parasitic diseases (1). The World Health Organization (WHO) has targeted elimination of its most virulent form, VL, from the Indian subcontinent by year 2020. In spite of these attempts, the number of leishmaniasis endemic sites is ever expanding with new foci and new sites being continuously reported at a global scale. Sri Lanka is a new focus of leishmaniasis in the Indian subcontinent. In Sri Lanka, L. donovani that causes visceral leishmaniasis in other endemic settings results in CL in a clear majority with few MCL and VL infections reported so far (2).
History and onset in Sri Lanka In the 1990’s the disease was limited to few imported cases among overseas employees returning to the country and remained sporadic in nature. The first
locally acquired infection from southern Sri Lanka was reported in 1992. A case from northern Sri Lanka was detected in year 2001. A series of awareness campaigns carried out in northern and southern Sri Lanka following this resulted in continued case reporting in large numbers from both areas. Since then, over 2500 clinically suspected cases have been referred to our institution alone for disease confirmation.
Current status, what is known so far? Clinical profile and the parasite Several clinical studies carried out at different occasions highlighted a widening of case distribution in the country to include almost all the districts by year 2008. A wide age range, including both males and females, is affected and CL remains the main clinical form up to date. Clinical manifestations of CL however, are diverse, a range of atypical manifestations are also reported. In the recent part, clinical aspects have become more complex with the report of few cases of MCL and VL. L. donovani is generally known to cause deadly VL, except for a few CL, and MCL reports in the world. Furthermore, local L. donovani is genetically different from members of the same species complex found in previously identified endemic settings (2).
Vectors, reservoirs, risk factors and transmission In leishmaniasis, transmission can be either peri-domestic or zoonotic. Contd. on page 16
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December 2015 Contd. from page 14
Leishmaniasis... Case detection and laboratory confirmation
L. donovani is transmitted by its sandfly vector (“Hohaputuwa� in the local language - Sinhala). Sandflies are widely prevalent in Sri Lanka. Baseline evidence for zoonotic transmission in the Northern and peri-domestic transmission in the coastal plain in Southern Sri Lanka has been observed indicating a possible regional variation in disease transmission patterns. Animals such as domestic dogs and rats are known to act as animal reservoirs in some forms while some parasite species are maintained solely in humans. Humans were the only known reservoir for L. donovani. However preliminary research has provided evidence for possible animal involvement in Sri Lanka.
The way forward Leishmaniasis sets a typical example of a disease in which characteristics tend to differ considerably between endemic settings or causative species. Cutaneous leishmaniasis caused by a visceralizing parasite is a rare situation in global literature and available information is also very limited. The need for an evidence based approach in case management, prevention and control strategies has been highlighted (3). A considerable amount of information is available through research. The disease has been made notifiable since 2008 and a national action plan has been developed for leishmaniasis control (4). The accumulation of scientific information will lead to many clinico-epidemiological implications on case management and disease control.
The mainstay of L. donovani control is considered as case detection and proper management, due to the absence of animal reservoirs. Early case detection and treatment, vector control (managing the sandflies that transmit the parasite) and communication and education within endemic communities are the three main strategies highlighted by the WHO for elimination of VL. Pre-treatment confirmation is advisable prior to treatment as there are no pathognomonic clinical features in leishmaniasis, clinical patterns are diverse and late lesions or treated lesions have a greater chance of producing false negative results. Clinical markers for screening have been recently described. Coupling up clinical and laboratory tools can enhance case detection (5). Light microscopy (LM) carried out on skin lesion aspirates, scrapings or biopsies in CL and MCL and on bone marrow aspirates in VL is the first line laboratory tool. Sensitivity of LM highly depends on the parasite load and it is technically demanding. Parasite in-vitro isolation and PCR methods are used as second line investigations. These are limited to a few laboratories within the island. rK 39 dipstick assay is used for serological diagnosis of VL. However, parasitological techniques may often be necessary for confirmation. In Sri Lanka, passive case detection is still the main mode of case detection. Diagnosis is still established on clinical grounds in a proportion of cases due to logistical reasons. The non disturbing nature of initial skin infections, lack of awareness and asymptomatic nature of
almost all VL infections may lead to delayed self referrals. True disease burden may be much higher than reported. Enhanced clinical suspicion, coupled with proper methods for confirmation are necessary. Skin lesions of traditional cutaneous forms of parasites in other endemic settings are known to completely heal spontaneously or with treatment and 1% of the cases tend to recur after cure. Dissemination requiring proper anti-leishmanial treatment is a possibility in immune compromised individuals. In Sri Lanka, however, the dangerous possibility of visceralization of the cutaneous variant of a visceralizing species cannot be disregarded. Recent reports of VL and MCL in the country already points towards this possibility. Treat or leave to self-heal?
Visceral infections with L. donovani always require treatment with specific anti-leishmanials while self- limiting forms of CL could be left to self cure. Response of dermotropic L. donovani to standard antileishmanial therapy has shown great variability. Clinical improvement, parasite clearance, recurrences after cure and visceralization are known possibilities. The treatment outcome of a disease caused by a genetically distinct and an understudied parasite variant in Sri Lanka can be different from that of known parasites. Unnecessary administration of costly and toxic antileishmanials that require hospitalization and close monitoring should be avoided. Specific anti-leishmanials are used to treat all 3 forms in Sri Lanka (6). Managing different clinical forms caused by a new parasite variant is not straight forward and should be undertaken with utmost caution. Inappropriate use of drugs and substandard formulations can result in drug resistance and prevent development of host immunity. Delay in cure creates a window for infection transmission. The question then arises with regard to the appropriate drug/s and protocol selection. However, the final answer should be evidence based. Contd. on page 18
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SLMANEWS
December 2015 Contd. from page 16
Leishmaniasis... Achieving a parasitological cure after treatment may be difficult in some leishmanial infections and the remaining parasites may stay dormant. Correct selection of a drug, complete treatment and adequate follow up together with appropriate advice to patients appear to be essential.
Towards disease control, gaps in knowledge and future needs Increase in parasite virulence and the non-immune status of the indigenous population with increased vulnerability may help quick establishment of MCL and VL causing variants. The number of VL and MCL cases may be grossly under diagnosed in Sri Lanka, due to low transmission levels of VL, asymptomatic nature, and lack of clinical suspicion. It is a timely need to identify and adopt correct preventive and control strategies for Sri Lanka sooner rather than later, before more virulent strains are established. Early treatment will help to reduce parasite reservoirs. With the emergence of MCL, VL and diversity in CL manifestations, the disease may be considered in the dermatological, general medical, dental and ENT surgical settings as well. Differences in transmission characteristics may pose difficulties in prescribing a homogenous control programme for the island. Evidence based use of insecticides and other vector control measures would be necessary.
References
1. Accelerated work to overcome the impact of neglected tropical diseases. A roadmap for implementation. WHO (2012). Geneva, Switzerland. Accessed on line at http://whqlibdoc.who.int/hq/2012/WHO_HTM_ NTD_2012.1_eng.pdf (2012.04.20) 2. Siriwardana HV, Noyes HA, Beeching NJ, Chance ML, Karunaweera ND and Bates PA. Leishmania donovani and cutaneous leishmaniasis, Sri Lanka. Emerg Infect Dis 2007; 13(3):476-8. doi:10.3201/ eid1303.060242 3. Karunaweera, N. D. Leishmania donovani causing cutaneous leishmaniasis in Sri Lanka, a wolf in sheep’s clothing? Trends Parasitol. 2009; 25: 458–463.
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4. Faculty of Medicine, University of Colombo, Sri Lanka: National action plan for leishmaniasis control in Sri Lanka. In first international colloquium on leishmaniasis, Colombo, Sri Lanka. Abstracts and action plan. 2009. 5. H. V. Y. D. Siriwardana, U. Senarath, P. H. Chandrawansa, N. D. Karunaweera. Use of a clinical tool for screening and diagnosis of cutaneous leishmaniasis in Sri Lanka. Pathogens and Global Health 2015:109 (4);174-183. 6. Karunaweera ND, Siriwardana HVYD, Karunanayake PH. Management of leishmaniasis. Sri Lanka Prescriber.2013. 21 (2): 1-5.
Clinical presentations and challenges in patient management Dr. Sanjeewa Hulangamuwa, Consultant Dermatologist, Base Hospital, Chilaw
Leishmaniasis has become a growing health problem in Sri Lanka. Major forms of leishmaniasis are cutaneous, muco-cutaneous and visceral and the cutaneous form is now an established disease in Sri Lanka. Clinical presentation of cutaneous leishmaniasis can be variable and can simulate various other skin conditions. Incubation period ranges from a few days to several months. Skin lesions occur at the site of the inoculation and are usually asymptomatic. The initial lesion is an erythematous papule which gradually increases in size. Then it forms a central crust giving a characteristic vol-
cano like appearance. The skin lesion usually heals with a scar. A hypopigmented halo around the lesion, satellite lesions and photodermatitis can be seen in cutaneous leishmaniasis. Leishmaniasis recidivans is a chronic form and is resistant to treatment. Typical lesions can easily be diagnosed clinically, however it is recommended to carry out laboratory investigations. A few cases of muco-cutaneous and visceral leishmaniasis have been reported in Sri Lanka. We have analyzed demographic and clinical data in patients with leishmaniasis who presented to the skin clinic, Teaching Hospital Anuradhapura from July 2007 to July 2011. Treatment of cutaneous leishmaniasis will depend on several factors such as the site of the lesion, size of the lesion and the number of lesions. Early treatment is important to prevent and to minimize the disfiguring scars particularly the facial lesions, to avoid the secondary infections and to control the spread of the disease in the population. Contd. on page 20
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December 2015 Contd. from page 18
Leishmaniasis... The most common methods used in Sri Lanka are sodium stibogluconate and cryotherapy. Sodium stibogluconate can be given intralesionally, intramuscularly or intravenously depending on the clinical setting. Now treatment failures to the most widely used sodium stibogluconate are more frequently seen, due to possible causes such as, intrinsic difference in species sensitivity, administering sub therapeutic doses, using sodium stibogluconate as the only treatment modality and the emerging drug resistance. Therefore alternative therapies to treat patients are required. Alternative treatment methods such as hypertonic saline, metronidazole and thermotherapy have been used with variable success in Sri Lanka. Other alternative treatments include paromomycin, miltefosine, ketoconazole, itraconazole, fluconazole and amphotericin B. It is important to be familiar with the effectiveness, limitations and the adverse effects of these therapeutic modalities in treating patients. The current challenges we face in managing patients are the increasing disease burden, rising trend of atypical cases, treatment failures and drug resistance.
Challenges in prevention and control Dr. Paba Palihawadana, Chief Epidemiologist, Epidemiology Unit, Ministry of Health
Historical Overview Leismaniasis is an ancient disease with evidence of its existence since 650 BC. The causative agent of the disease was first described by Sergeant Major David Cunningham of India in 1885. The causative agent was correctly identified as a parasite independently by Cunningham, Broosky, Leishmann and Donovann. WHO has estimated that each year nearly two million people are affected by
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the disease out of which 1.5 million are infected with CL. The annual incidence of leishmaniasis is about two million (1). Further the disease has been listed as one of the eight major neglected tropical parasitic diseases (2). Sri Lanka was considered as a country free from leishmaniasis till early nineties. First local case of CL was reported from Ambalantota Medical Officer of Health area from the Hambantota district, in 1992 (3). Eventually CL has been established as an endemic disease in Sri Lanka (4). Leishmaniasis was made a notifiable disease in 2008. According to the routine disease surveillance system, CL case reporting has gradually increased after being made a notifiable disease. The first locally acquired VL patient presented from North Central province in 2006 (5).
Disease Epidemiology The disease has a wide spectrum of manifestations ranging from self-limiting skin lesions to disseminated disease affecting the entire reticuloendothelial system. Visceral leishmaniasis (VL), mucocutaneous leishmaniasis (MCL) and cutaneous leishmaniasis (CL) are the main clinical manifestations. CL is a benign, self limiting illness with a long incubation period. It is characterized by painless and non itchy skin lesions. When considering the geospatial spread of CL, in 2015 only few districts
were spared of reporting the disease. Anuradhapura, Hambantota, Matara, Kurunegala and Polonnaruwa are the highest reporting districts in the country. According to the special surveillance data, the highest numbers of patients were from the age group between 10 to 60 years, while those from all age groups including infants and adults over 80 years, were affected. There is an obvious male preponderance among the patients probably due to the higher exposure to the vector. Among the most affected occupational categories, farmers and armed personnel were the highest. Exposed body areas such as limbs, head and neck, chest and face were affected more frequently than non exposed areas. The lesions were mainly papular, nodular or ulcerative lesions.
Disease Surveillance Leishmaniasis has been a notifiable disease in Sri Lanka since 2008. Accordingly all medical practitioners who attend to a patient suspected of having leishmaniasis should immediately notify the area Medical Officer of Health (6). Presently patients suspected as having leishmaniasis mainly at dermatology clinics are notified to the respective Medical Officer of Health. Each confirmed leishmaniasis case should be further investigated through special surveillance by the respective Medical Officer of Health and reported to the National Surveillance Unit at the Epidemiology Unit, Ministry of Health. Contd. on page 21
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December 2015
Contd. from page 20
Leishmaniasis... Challenges in Prevention and Control Epidemiological evidence demonstrates that geographical spread of CL is gradually expanding in the country. Despite CL being established as an endemic disease, the disease epidemiology is inadequately studied and the knowledge on vector bionomics is still limited. Most of the studies on CL have mainly focused on parasitological and clinical aspects of the disease (7). Poor health seeking behaviour of patients prompted by benign nature of the disease with its non itchy, non tender lesions and the ability to self heal facilitate disease transmission in the local context. Poor compliance of patients due to the long treatment regime and socio economic factors also promotes susceptibility in the community hence the spread of the disease. To allocate resources for disease control and prevention against the competing priorities both in the field of communicable and non- communicable diseases is also a challenge, when disease control is considered. It has also been evident that the awareness of the disease among both health personnel and general public is still poor. As there are many stakeholders within the health sector, proper intra-sectoral collaboration has to be established and strengthened to tackle this scourging disease. It is important to strengthen the disease surveillance activities specially the routine reporting of the disease by the private health institutions.
Reference 1. WHO 2010. Technical Report Series. Control of the Leishmaniasis, Geneva, Switzerland. 2. WHO 2012. Accelerating work to overcome the global impact of neglected tropical diseases a roadmap for implementation 2012WHO Geneva, Switzerland WHO/HTM/NTD/2012.1 Full version. 3. Athukorala, D. N., Senevirathne, J. K., Ihalamulla, R. L., Premarthne, U. N. 1992. Locally acquired Cutaneous Leishmaniasis in Sri Lanka. Tropical Medicine and Hygine 95(6) 432-3.
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4. Rajapaksha, U.S., Ihlamulla,R.L., Udagedara, C.,Karunaweera,N.D.,2007. Cutaneous leishmanaiasis in Southern Sri Lanka. Royal Society of Tropical Medicine and Hygine.101 p799-803. 5. Abeygunasekara, P.H., Costa, Y.J., Seneviratne, N., Ranatunga, N., Wijesundara, M.D.S., 2007. Locally acquired visceral leishmanaisis in Sri Lanka. Ceylon Medical Journal.52 (1) p 30-31. 6. Ministry of Health, 2011. Surveillance Case Definition for Notifiable Diseases in Sri Lanka. 2nd ed Sri Lanka. 7. Karunaweera, N.D., Rajapaksha, U.S.,2009. Is leismanaisis in Sri Lanka benign and be ignored. Journal of Vector Borne Disease, 46:13-17.
Elimination of leishmaniasis in South Asia; myth or reality? Mitali Chatterjee, MD PhD FNAsc FAScT MAMS, Professor, Department of Pharmacology, Institute of Postgraduate Medical Education & Research, Kolkata, India
Post kala-azar dermal leishmaniasis (PKDL), a dermatosis generally observed in patients with a previous history of kala-azar (KA) or visceral leishmaniasis (VL), was first described in 1922 by the eminent Indian physician-scientist, Sir U. N. Brahmachari (1873-1946). At a meeting of the Asiatic Society of Bengal, he presented four cases with unique dermal involvement, all of whom had been successfully treated for kala-azar, time interval varying from 6 months to 5 years. He advocated the term “dermal leishmanoid� to describe the condition, as Leishman-Donovan (LD) bodies were observed in lesional smears. Eventually, following further studies by Shortt and Brahmachari, Acton and Napier, Knowles and Das Gupta, and other workers at the Calcutta School of Tropical Medicine, the disease was renamed as post-kala-azar dermal leishmaniasis. Post kala-azar dermal leishmaniasis (PKDL) is reported mainly from two regions, Sudan in Eastern Africa and South Asia (India, Nepal, Bangladesh and Bhutan) with incidences of 50-60% and 5-10% respectively. Unlike in Africa where speculation continues to be rife on whether transmission of kala-azar
is anthroponotic or zoonotic, transmission in South Asia is anthroponotic, with Leishmania parasites surviving and propagating intra-dermally in patients with PKDL. Therefore, patients with PKDL have immense epidemiological significance emphasizing the relevance of its identification as also treatment for the successful elimination of Leishmaniasis from South Asia. The campaign to eliminate visceral leishmaniasis by 2015 has been underway since 2005, when the health ministers of Bangladesh, India and Nepal signed a Memorandum of Understanding for joint efforts to eliminate this deadly disease. The National Health Policy-2002 set the goal of Kala-azar elimination in India by the year 2010 which was revised to 2015, wherein the target was to reduce the annual incidence of kala azar to less than one per 10 000 at the district or sub district level by 2015, now extended to 2017. PKDL patients are to be treated with (i) Liposomal amphotericin B: 5mg/kg per day by infusion two times per week for 3 weeks for a total dose of 30mg/kg, or (ii) Miltefosine: 100mg orally per day for 12 weeks, or (iii) Amphotericin B deoxycholate: 1mg/kg over 4 months 6080 doses, [as per WHO guidelines on diagnosis and management of PKDL, 2012]. As humans are the only reservoir, and with the recent advances in diagnosis and management of Leishmaniasis, the target appears feasible. In the initial phase of the elimination programme, passive case detection of PKDL was being undertaken.
However, being a chronic dermatosis with low morbidity and no mortality, passive case detection was found to be the tip of the iceberg. Accordingly, the approach now is for active case detection which has dramatically increased the number of cases of PKDL in West Bengal. With the availability of improved DNA based methods to detect PKDL, the elimination programme in West Bengal is well on its way to achieve its target of elimination of VL/PKDL.
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