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SLMA News Editorial Committee-2015Editor-In-Chief: Prof. Sharmini Gunawardena

Committee:

Dr. Amaya EllawalaDr. Iyanthi AbeyewickremeProf. Deepika FernandoDr. Sarath Gamini De Silva

December 2015, Volume 8, issue 12

NEWSSLMATHE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION

Page No.

CONTENTS

Cover Story

NewsPresident's Message 02

Sri Lanka Medical Association (SLMA)

Strategic Plan 2015 – 2020 02, 03

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

Who is a Medical Specialist? 10, 12

Malaria Count 2015 12

Leishmaniasis: Are we ready to combat 14, 16, 18, 20, 21

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This Source (Pvt.) Ltd,Suncity Towers, Mezzanine Floor,18 St. Anthony's Mawatha, Colombo 03.Tele: +94 117 600 500 Ext 3521Email: [email protected]

Official Newsletter of The Sri Lanka Medical Association.Tele: +94 112 693324 E mail: [email protected]

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.

The Sri Lanka Medical Association Dance 2015 08, 09, 10

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December 2015 SLMANEWSPRESIDENT’S MESSAGE

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“Greatness is not where we stand, but in what direction we are moving”

SLMA is an organization with a long history and is the oldest running Professional

College in Sri Lanka. However, there was no concrete Plan of Ac-tion to direct its activities for the fu-ture. Although a Strategic Plan had been developed in the past, it had not been revised and updated.

Therefore, the SLMA commit-tee under the leadership of the President, decided to embark on the path to develop a new Strate-gic Plan for the future. This initia-tive was supported by a Consultant who introduced the concept of stra-tegic 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 well-being of all Sri Lankans, through Advocacy, Leadership and Multi-Sector Collaboration, while achiev-ing the highest standard of medical professionalism and ethical con-duct as the apex medical profes-sional organization in Sri Lanka with a global reach.

SRI LANKA MEDICAL ASSOCIATION (SLMA) STRATEGIC PLAN 2015 – 2020

Oliver Wendell Homes

Contd. on page 03

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 develop-ment. In keeping with the theme for the year, “Connect, communicate, collaborate for improved health and healthcare” SLMA took part in numer-ous 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 re-quired collaborative partnerships and dialogue with sectors within and out-side the healthcare sector.

The last Council Meeting was held on the 5th of December and a sum-mary of activities was presented to facilitate continuity of activities initi-ated 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 grate-ful 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 sad-ness or pain to anyone during my nu-merous 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 Abey-wickrama 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 appre-ciation for the invaluable support I re-ceived from the Executive Committee, the Council, members of our associa-tion 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 coun-try. It was a matter of pride to recog-nize first hand that when the SLMA speaks on any issue related to health or health policy, it is considered seri-ously. It is important for future custo-dians 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 cur-rent 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

Dear friends and colleagues,

SLMANEWS December 2015

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The Vision;

To halt the rise of Non Communi-cable 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, Col-laboration, Diversity, Integrity, Leader-ship and Social Responsibility.

The main objectives listed are;

1. To advocate the reorientation of the health sector towards health promo-tion with a life cycle approach.

2. To engage the non-health sector in taking on equal responsibility in pre-venting and reducing health inequi-ties.

3. To promote healthy lifestyle and ad-dress major causative factors for NCDs and diabetes among vulnerable populations through a health promo-tion approach.

The first three objectives relate to halt-ing the rise of Non Communicable Diseases (NCD) with a special em-phasis on diabetes.

4. To enhance the capacity of medical professionals

This relates to SLMA’s key role in

developing medical professionals’ knowledge and skills through Con-tinuous Professional Development (CPD) Programmes

5. To play an advocacy role towards a comprehensive curative and preven-tive healthcare for the community

The last objective focuses on the significant role SLMA plays in advocat-ing for a healthier nation through pub-lic 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.

SLMA Strategic Plan...Contd. from page 02

By Dr. Shamini Prathapan (Assistant Secretary, SLMA)

The 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 fol-lowed by the guest speaker Dr. Lucian Jayasuriya.

The President of the Puttalam Clini-cal Society, Dr. M. Sugunadevan, wel-comed the gathering and delivered the welcome speech. Prof. Jennifer

Perera, President of the SLMA also addressed the gathering.

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 Ra-jiv 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 dis-turbances in July 1983 when he was Director of General Hospital, Colom-bo. He concluded by again emphasiz-ing that the lessons learnt were the 4’C’s – Competence, Commitment, Communication and Common sense.

ANNUAL SCIENTIFIC SESSIONS OF THE PUTTALAM CLINICAL SOCIETY AND THE SLMA

Contd. on page 04

December 2015 SLMANEWS

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Annual Scientific...Contd. from page 03

Contd. on page 06

The guest lecture was followed by the 1st session which was chaired by Prof. J. Perera and Dr. D. Dissanay-ake. The panel of speakers consisted of Dr. N. Rajasekara, Consultant Pae-diatrician from Puttalam Base Hos-pital, Dr. P. Manivannan, Consultant Physician from Puttalam Base Hospi-tal and Dr. Navodha Attapattu, Consul-tant Paediatric Endocrinologist from Lady Ridgeway Hospital, Colombo.

Dr. N. Rajasekara, initiated the ses-sion with a comprehensive presen-tation on “Childhood Obesity”. The lecture commenced by highlighting the fact that obesity is one of the ma-jor health challenges of the 21st Cen-tury 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 cy-cle of obesity. The genetic causes of obesity such as the Prader Willi Syn-drome, Bardet-Biedl Syndrome, con-genital leptin deficiency and the leptin receptor insensitivity disease were ex-plained in detail. She finally concluded by explaining the methods of prevent-ing childhood obesity.

Dr. Navodha Attapattu continued this discussion with her lecture on “Endocrine aspects of obesity in chil-dren”. She described the endocrine disorders associated with obesity such as growth hormone deficiencies,

hypothyroidism, pseudohypoparathy-roidism, 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 insu-lin resistance where the clinical mark-er is acanthosis, metabolic syndrome etc.

Dr. P. Manivannan, then delivered a comprehensive lecture on “Meta-bolic syndrome of obesity”. He began with a clinical discussion followed by a description of the history of meta-bolic 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 defi-nition and criteria for the diagnosis of metabolic syndrome was proposed by the International Diabetic Federation (IDF). He described the pathophysiol-ogy of metabolic syndrome of obesity and its components: abdominal obesi-ty, atherogenic dyslipidemia, elevated BP, insulin resistance, hypercoagula-ble state, pro-inflammatory state and chronic hyper secretion of stress me-diators. He completed his lecture with a discussion of the related manage-ment and life style interventions.

The second session commenced af-ter tea and was chaired by Dr. Shami-ni Prathapan and Dr. S. Jeewatharan. The panel of speakers consisted of Dr. L. Rajapakse, Consultant Obste-trician, Dr. R. A. Y. Rupasinghe, Con-sultant Surgeon, Dr. M. Sugunade-van, Consultant Anaesthetist, all from Puttalam Base Hospital and Dr. Ranil Jayawardena Clinical Nutritionist from Nawaloka Hospital.

Dr. L. Rajapakse, started the 2nd ses-sion 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 obe-sity 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 in-creased by 87%. He ultimately point-ed out that there are also anaesthetic complications as well.

Dr. R. A. Y. Rupasinghe, Consultant Surgeon, spoke about the surgical techniques available for the manage-ment of obesity in his lecture titled “Surgical options for obesity”. He de-scribed 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 “An-aesthetic challenges in obesity”. He focused on the difficult airway with a short neck, increased bulk of tis-sues 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 ventila-tion 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.


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Annual Scientific...Contd. from page 04

He stressed the need and the rea-sons for a good pre-operative assess-ment, intraoperative management and post-operative care.

After this brain storming session, Dr. Ranil Jayawardena delivered his lecture on “Nutrition concept and con-troversies 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 discus-sion.

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. Jaya-kody, Consultant Radiologist at Put-talam Base Hospital. A large number of Medical Officers and Consultants participated in this much awaited pro-gramme.

The quiz programme was followed

by two lectures delivered by Dr. W. Jayasinghe, Consultant ENT Sur-geon, and Dr. V. G. Abeywicrema, Consultant Dermatologist, both from the Puttalam Base Hospital.

Dr. W. Jayasinghe, in his lecture on “Obstructive sleep apnoea” de-tailed the triad of Sleeping Disordered Breathing consisting of obstruction, apnoea / hypopnea and Respira-tory Event Related Arousal (RERA). The most severe form could lead to obstructive sleep apnoea with many sequelae such as impaired cogni-tion, decreased attentiveness, being prone to accidents, insulin resistance, pulmonary hypertension, cor pulmo-nale 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 “Obe-sity and skin” where he described the manifestations of obesity in the skin such as acanthosis nigricans, acro-chodons, keratosis pilaris, striae dis-tensae 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.

Prof. Ajantha S. Dharmasiri Director and the Chairman of the Board of Management, Postgraduate Institute of Management, University of Sri Jayewardenepura, Sri Lanka [email protected]

This concept paper attempts to offer thoughts on academ-ics as thought leaders, in critically evaluating their con-

tribution. Blending with the personal experiences of the author, triple roles of academics are proposed as knowl-edge capturing, knowledge communi-cating and knowledge creating. The need to move from a vicious cycle to a virtuous cycle in knowledge champi-oning is emphasized in the paper for the purpose of socio-economic uplift-ment.

1. IntroductionAcademics engage in scholarly ac-

tivities. They deal with knowledge in playing multiple roles. They have to think and act as knowledge creators as well as knowledge sharers. Aca-demics influence the attitudes and aptitudes of student community (Dear-love, 2002). This is where the “thought leadership” comes into the forefront. Superiority in scientific thinking, blend-ed with socio-cultural realities is what an academic should smartly possess. It qualifies them to join the constella-tion of thought leaders.

In fact, leadership is not about posi-tions and titles but decisions and ac-tions. It refers to a mindset of influenc-ing, inspiring and instructing. Leaders as opposed to laggards, deliver re-sults. As it has been observed, leader-

ship is a vastly explored but least un-derstood 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 intrinsi-cally-driven motivation is the need of the hour.

2. Triple roles for academicsThe way I see it, academics have

triple roles to play. These can be de-picted as a knowledge pyramid of aca-demics. Figure 1 depicts the details.

A REFLECTION ON ACADEMICS AS THOUGHT LEADERS

Contd. on page 07


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Source: Dharmasiri (2015a)

3. Academics as Knowledge Capturers

The bottom of the knowledge pyra-mid contains the role of knowledge capturer. This includes the learning dimension of an academic. We learn from the womb to the tomb, as life-long 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 rap-idly getting obsolete (Senge, 1990). Particularly, in the areas of Informa-tion, 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 re-minds me of a story that I heard about an elderly professor. He was serving in a residential campus in an Europe-an 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 stu-dents, 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

re-cycled knowledge over and over again to cater for ever-increasing lecture demand. Hence, the knowl-edge capturing dimension suffers and opportunity to review and re-new oneself gets neglected.

4. Academics as Knowledge Communicators

The middle part of the knowl-edge pyramid is all about sharing knowledge. It highlights the tradi-

tional role of teaching. Communicat-ing knowledge does not necessarily mean lecturing. We at the Postgradu-ate 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 docu-mentaries, movie extracts, video re-cordings, 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 op-posed 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 tech-nique” 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 bi-ased here in basing on mostly post-graduate teaching experience. Yet, ir-respective 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 academ-ics should reach the pinnacle of knowl-edge 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 con-tributes 2.3%, South Korea, 2.9% and China, 1.3% from their GDP for research. A recent report published by the Ministry of Technology & Re-search 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 devel-oped 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 alarm-ing situation is that it is getting worse in recent years. For example, in 1996 Sri Lanka had 6000 full time research-ers 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 commend-able. 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 pyra-mid, 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.

A Reflection on Academics...Contd. from page 06

Figure 1. Triple roles for academics

Contd. on page 08


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A Reflection on Academics...Contd. from page 07

Source: Dharmasiri (2015a)

As figure 2 depicts, the bottom is the vicious cycle where an academic gets stranded in capturing, collect-ing, contemplating and continuing of knowledge. In other words, one gets engrossed in sharing same knowl-edge over and over without review-ing, reflecting and renewing. I refrain from giving Sri Lankan examples, but I know many among us who experi-ence this situation either knowingly or unknowingly.

The break though occurs when one moves from the vicious cycle to the vir-tuous cycle. Instead of moving beyond knowledge contemplating to knowl-edge 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 ex-ample. When I started teaching Human Resource Management, I diligently adhered to the text-book models, in sharing my ex-perience through them. I could even remember the entire lec-ture 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 need-ed to move beyond.

When I started challenging the ap-propriateness of some of the teach-ing models to our socio-cultural con-text, the move from viscous cycle to virtuous cycle began. My research on Strategic Human Resource Manage-ment (SHRM) shed new insights to the way we approach people particu-larly in the humanly rich South Asian context (Dharmasiri, 2015b). It gave me more confidence to blend western models with regional and local reali-ties, rather than blindly sharing what the books say.

7. Conclusion This paper attempted to reflect on

academics as thought leaders. Essen-tially, 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 per-haps overdoing.

ReferencesBass, 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 uni-versities 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/Academ-ics-as-thought-leaders--Promises-and-pitfalls.

Dharmasiri, A. S. (2015b), HRM for man-agers: A learning guide, Colombo: Post-graduate 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-in-university.html

Senge, P. M. (2006). The fifth discipline: The art and practice of the learning or-ganization, London: Broadway Business.

Figure 2. Vicious Cycle to Virtuous Cycle

THE SRI LANKA MEDICAL ASSOCIATION DANCE 2015Held at the Waters Edge Hotel on the 12th of December 2015


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SLMA Dance 2015...Contd. from page 08

Contd. on page 10


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SLMA Dance 2015...Contd. from page 09

A panel discussion on the above topic was held on 12th October 2015 at the SLMA Lionel Me-

morial Auditorium, to raise the aware-ness and create a dialogue among the medical community on this inter-esting and much debated topic. The event was organised by the SLMA Ex-pert Committee in Medical Education and chaired by Dr. Palitha Abeykoon (Chairperson, SLMA Expert Commit-tee in Medical Education).

The panel consisted of eminent speakers representing different dis-ciplines of medicine. Dr. Lalantha Ranasinghe, Professor Senaka Ra-japakse, 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 repre-sented the SLMC (Sri Lanka Medical

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 docu-ment to govern a medical professional as a “Medical Specialist” in the country and therefore the need of a medical registry to benchmark a medical spe-cialist. He described the endeavors of the SLMC in amending the medical ordinance to govern medical special-ists and the progress in implementing a registry for medical specialists.

He further stated that the influx of for-eign 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, repre-senting the PGIM (Postgraduate Insti-tute 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 sys-tem of board certification.

The document of board certification is currently the standard document which recognises a medical special-ist in the country and the Ministry of Health only recruits medical special-ists with board certification. He further mentioned that the PGIM is working towards accreditation of its board cer-tification by the international medical community and also described the ne-cessity of establishing a mechanism for mutual recognition of properly trained and accredited medical spe-cialists from foreign countries.

“WHO IS A MEDICAL SPECIALIST?”SLMA Expert Committee in Medical Education

Contd. on page 12


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Who is a ...Contd. from page 10

Professor Jennifer Perera, Dean, Faculty of Medicine, Uni-versity 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 fol-lowing four to six years of train-ing. However she emphasised the importance of continued training and the necessity to introduce a system of recertification to main-tain 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 coun-tries. Furthermore the need to de-velop 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, repre-senting the GMOA (Government Medical Officers Association), provided a detailed description of the activities undertaken by the or-ganisation 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 pro-fessionals, 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 certi-fied by the PGIM. Dr. Padeniya described the steps initiated by the GMOA to develop a proce-dure to evaluate foreign doctors. He stated that these activities are

detailed in the book published by the GMOA titled, ‘Establishment of ‘Specialist Registry’ & Introduc-tion of an Evaluation Procedure for Foreign Medical Specialists’.

Dr. Padeniya described the re-newed 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 can-not be implemented due to certain legal constraints.

He assured however that in-terim measures have been taken and a procedure of registering for-eign specialists has been imple-mented. Dr. Padeniya concluded by emphasising the role of the SLMC in implementing a special-ist 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 spe-cialists within the context of gen-eral practice. She talked about the two groups of family physicians practicing in the country; board certified Consultant Family Physi-cians 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 clini-cal specialists and elaborated on the necessity of determining the appropriateness in terms of quali-fications, of ‘specialists’ to whom patients are referred. He high-lighted 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 special-ists. He added that a procedure of regular ac-creditation should also be developed, with the provision of adequate facilities for continuous professional development.

The presentations by panelists were fol-lowed by a discussion, where the exclusive role of the PGIM in providing postgraduate medical training in the country and the ques-tion of considering PhDs as a specialist qualifi-cation, were discussed. During the discussion, the role of professional colleges in recertifica-tion of specialists was emphasised.


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Excerpts of the symposium jointly or-ganized by the Expert Committee on Communicable Diseases of the SLMA & Centre for Diagnosis, Research & Train-ing of Leishmaniasis, Department of Parasitology, Faculty of Medicine, Uni-versity of Colombo, held on the 12th of November 2015 from 11.30am - 1.30pm at the Auditorium of the Sri Lanka Medi-cal Association.

Overview of leishmaniasis in Sri Lanka, case detection and laboratory

diagnosisDr. Yamuna Siriwardana, Senior Lecturer, Department of Parasitology, Faculty of Medicine, University of Colombo

Disease leishmaniasisLeishmaniasis is a vector borne proto-

zoan infection. Clinical disease is known to manifest in 3 main forms, i.e. cutane-ous (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 mani-festations 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 hepatospleno-megaly. 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 elimi-nation 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 leish-maniasis in the Indian subcontinent. In Sri Lanka, L. donovani that causes vis-ceral 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 LankaIn 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 cam-paigns carried out in northern and south-ern Sri Lanka following this resulted in continued case reporting in large num-bers 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 wid-ening of case distribution in the coun-try to include almost all the districts by year 2008. A wide age range, includ-ing 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 atypi-cal manifestations are also reported. In the recent part, clinical aspects have be-come 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. Further-more, 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.

“LEISHMANIASIS: ARE WE READY TO COMBAT?”

Contd. on page 16

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Leishmaniasis...Contd. from page 14

L. donovani is transmitted by its sandfly vector (“Hohaputuwa” in the lo-cal language - Sinhala). Sandflies are widely prevalent in Sri Lanka. Baseline evidence for zoonotic transmission in the Northern and peri-domestic trans-mission 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 main-tained solely in humans. Humans were the only known reservoir for L. don-ovani. However preliminary research has provided evidence for possible ani-mal involvement in Sri Lanka.

The way forward Leishmaniasis sets a typical example

of a disease in which characteristics tend to differ considerably between en-demic settings or causative species.

Cutaneous leishmaniasis caused by a visceralizing parasite is a rare situa-tion in global literature and available in-formation 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 informa-tion will lead to many clinico-epidemio-logical implications on case manage-ment and disease control.

Case detection and laboratory confir-mation

The mainstay of L. donovani control is considered as case detection and prop-er 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 with-in endemic communities are the three main strategies highlighted by the WHO for elimination of VL.

Pre-treatment confirmation is advis-able prior to treatment as there are no pathognomonic clinical features in leish-maniasis, clinical patterns are diverse and late lesions or treated lesions have a greater chance of producing false neg-ative results.

Clinical markers for screening have been recently described. Coupling up clinical and laboratory tools can en-hance case detection (5). Light micros-copy (LM) carried out on skin lesion aspirates, scrapings or biopsies in CL and MCL and on bone marrow aspi-rates 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, parasitologi-cal 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 de-layed self referrals. True disease burden may be much higher than reported. En-hanced clinical suspicion, coupled with proper methods for confirmation are necessary. Skin lesions of traditional cu-taneous forms of parasites in other en-demic settings are known to completely heal spontaneously or with treatment and 1% of the cases tend to recur after cure. Dissemination requiring proper an-ti-leishmanial treatment is a possibility in immune compromised individuals. In Sri Lanka, however, the dangerous possi-bility 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 improve-ment, parasite clearance, recurrences after cure and visceralization are known possibilities. The treatment outcome of a disease caused by a genetically dis-tinct and an understudied parasite vari-ant in Sri Lanka can be different from that of known parasites. Unnecessary administration of costly and toxic anti-leishmanials that require hospitalization and close monitoring should be avoided. Specific anti-leishmanials are used to treat all 3 forms in Sri Lanka (6). Man-aging 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 pre-vent development of host immunity. De-lay in cure creates a window for infection transmission. The question then arises with regard to the appropriate drug/s and protocol selection. However, the fi-nal answer should be evidence based.

Contd. on page 18


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Achieving a parasitological cure af-ter treatment may be difficult in some leishmanial infections and the remain-ing 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 un-der 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 estab-lished. Early treatment will help to reduce parasite reservoirs. With the emergence of MCL, VL and diversity in CL manifes-tations, the disease may be considered in the dermatological, general medical, dental and ENT surgical settings as well. Differences in transmission characteris-tics may pose difficulties in prescribing a homogenous control programme for the island. Evidence based use of insecti-cides and other vector control measures would be necessary.

References1. Accelerated work to overcome the impact of neglect-

ed 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 cu-taneous leishmaniasis in Sri Lanka, a wolf in sheep’s clothing? Trends Parasitol. 2009; 25: 458–463.

4. Faculty of Medicine, University of Colombo, Sri Lan-ka: National action plan for leishmaniasis control in Sri Lanka. In first international colloquium on leish-maniasis, Colombo, Sri Lanka. Abstracts and action plan. 2009.

5. H. V. Y. D. Siriwardana, U. Senarath, P. H. Chan-drawansa, N. D. Karunaweera. Use of a clinical tool for screening and diagnosis of cutaneous leish-maniasis in Sri Lanka. Pathogens and Global Health 2015:109 (4);174-183.

6. Karunaweera ND, Siriwardana HVYD, Karunanay-ake 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 grow-ing 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 oc-cur at the site of the inoculation and are usually asymptomatic. The initial lesion is an erythematous papule which gradu-ally 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 photoder-matitis can be seen in cutaneous leish-maniasis. Leishmaniasis recidivans is a chronic form and is resistant to treat-ment.

Typical lesions can easily be diag-nosed clinically, however it is recom-mended to carry out laboratory investi-gations.

A few cases of muco-cutaneous and visceral leishmaniasis have been report-ed in Sri Lanka.

We have analyzed demographic and clinical data in patients with leishmani-asis 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 treat-ment is important to prevent and to mini-mize the disfiguring scars particularly the facial lesions, to avoid the second-ary infections and to control the spread of the disease in the population.

Contd. on page 20



The most common methods used in Sri Lanka are sodium stibogluconate and cryotherapy. Sodium stibogluconate can be given intralesionally, intramuscu-larly 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 stibo-gluconate as the only treatment modal-ity and the emerging drug resistance.

Therefore alternative therapies to treat patients are required. Alternative treat-ment methods such as hypertonic sa-line, metronidazole and thermotherapy have been used with variable success in Sri Lanka. Other alternative treatments include paromomycin, miltefosine, keto-conazole, itraconazole, fluconazole and amphotericin B.

It is important to be familiar with the ef-fectiveness, 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 resis-tance.

Challenges in prevention and controlDr. Paba Palihawadana, Chief Epidemiologist, Epidemiology Unit, Ministry of Health

Historical OverviewLeismaniasis 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 iden-tified as a parasite independently by Cunningham, Broosky, Leishmann and Donovann.

WHO has estimated that each year nearly two million people are affected by

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 coun-try free from leishmaniasis till early nine-ties. First local case of CL was reported from Ambalantota Medical Officer of Health area from the Hambantota dis-trict, 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 sys-tem, CL case reporting has gradually increased after being made a notifiable disease. The first locally acquired VL pa-tient presented from North Central prov-ince in 2006 (5).

Disease EpidemiologyThe disease has a wide spectrum of

manifestations ranging from self-limiting skin lesions to disseminated disease af-fecting the entire reticuloendothelial sys-tem. Visceral leishmaniasis (VL), mu-cocutaneous 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 charac-terized 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, farm-ers and armed personnel were the high-est. Exposed body areas such as limbs, head and neck, chest and face were affected more frequently than non ex-posed areas. The lesions were mainly papular, nodular or ulcerative lesions.

Disease SurveillanceLeishmaniasis has been a notifiable

disease in Sri Lanka since 2008. Ac-cordingly 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 hav-ing leishmaniasis mainly at dermatol-ogy clinics are notified to the respec-tive 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 Na-tional Surveillance Unit at the Epidemi-ology Unit, Ministry of Health.

Contd. on page 21

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Challenges in Prevention and Control

Epidemiological evidence demon-strates that geographical spread of CL is gradually expanding in the country. Despite CL being established as an endemic disease, the disease epidemi-ology 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 pa-tients prompted by benign nature of the disease with its non itchy, non tender le-sions and the ability to self heal facilitate disease transmission in the local con-text.

Poor compliance of patients due to the long treatment regime and socio eco-nomic factors also promotes susceptibil-ity 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 dis-ease 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 dis-ease surveillance activities specially the routine reporting of the disease by the private health institutions.

Reference1. WHO 2010. Technical Report Series. Control of the

Leishmaniasis, Geneva, Switzerland.

2. WHO 2012. Accelerating work to overcome the glob-al 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 Cuta-neous Leishmaniasis in Sri Lanka. Tropical Medicine and Hygine 95(6) 432-3.

4. Rajapaksha, U.S., Ihlamulla,R.L., Udagedara, C.,Karunaweera,N.D.,2007. Cutaneous leishmanaia-sis 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 Defini-tion for Notifiable Diseases in Sri Lanka. 2nd ed Sri Lanka.

7. Karunaweera, N.D., Rajapaksha, U.S.,2009. Is leis-manaisis 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 leishmani-asis (PKDL), a dermatosis generally ob-served in patients with a previous history of kala-azar (KA) or visceral leishmani-asis (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 Ben-gal, 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 leish-manoid” to describe the condition, as Leishman-Donovan (LD) bodies were observed in lesional smears. Eventu-ally, following further studies by Shortt and Brahmachari, Acton and Napier, Knowles and Das Gupta, and other workers at the Calcutta School of Tropi-cal Medicine, the disease was renamed as post-kala-azar dermal leishmaniasis.

Post kala-azar dermal leishmaniasis (PKDL) is reported mainly from two re-gions, 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, transmis-sion 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 Leishmani-asis from South Asia.

The campaign to eliminate visceral leishmaniasis by 2015 has been under-way since 2005, when the health min-isters of Bangladesh, India and Nepal signed a Memorandum of Understand-ing 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 inci-dence 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 de-oxycholate: 1mg/kg over 4 months 60-80 doses, [as per WHO guidelines on diagnosis and management of PKDL, 2012]. As humans are the only reservoir, and with the recent advances in diagno-sis and management of Leishmaniasis, the target appears feasible. In the initial phase of the elimination programme, passive case detection of PKDL was be-ing undertaken.

However, being a chronic dermato-sis 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 detec-tion 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 Ben-gal is well on its way to achieve its target of elimination of VL/PKDL.


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