Features
Leptospirosis – no longer the rural farmer’s disease
Making a breakthrough in the study of leptospirosis, a bacterial infection transmitted from animals, a team of Sri Lankan researchers in a collaborative endeavour has discovered six new genotypes of this largely undermined tropical disease. In an exclusive interview with the Sunday Island, they throw light on the findings of their research which are now in international literature enabling new knowledge on the world’s commonest zoonotic disease.
by Randima Attygalle
No longer considered the ‘rural farmer’s disease’, leptospirosis, commonly called rat fever or mee una in Sinhala, is changing its dynamics, urging clinicians, health policy-makers and the public to revisit this common tropical disease of both humans and animals. The bacterium that causes leptospirosis is spread through the urine of infected animals, which can get into water or soil and can survive there for weeks or months. Many different kinds of wild and domestic animals carry the bacterium including cattle, pigs, rodents, dogs, horses and wild animals.
Humans can become infected with the bacterium either through contact with urine of an infected animal or with water or soil contaminated with the urine of infected animals. The bacteria can enter the body through skin, eyes, nose or mouth. Outbreaks of leptospirosis are usually caused by exposure to contaminated water, such as floodwaters. It is a serious occupational hazard for those working outdoors such as farmers, miners etc. and professionals such as veterinarians in close contact with animals. According to global research findings, around one million cases of leptospirosis and 58,900 deaths are estimated to occur worldwide each year. More than 70% of the deaths are reported from the tropical, poorest regions of the world.
A re-merging disease here at home, leptospirosis has gained much attention since the large outbreak in 2008. “The annual incidence of leptospirosis that had required hospitalization from 2008 to 2015 was 52.1 per 100,000 people, with an estimated case fatality rate of 7.0% according to National Health Bulletin data. In 2018 there was another resurgence in numbers. The disease is no more a ‘seasonal’ one as it was conventionally known to be, resulting in multiple outbreaks per year, notably during rainy seasons. Manifestations of the disease have also changed, with a wide array of new clinical entities such as pulmonary haemorrhage (bleeding into the lungs), pancreatitis, and myocarditis coupled with high case fatality. These shifts in the disease call for new strategies, new interventions and the need to reorganize ourselves as the health care sector,” says Dr. Panduka Karunanayake, Senior Lecturer from the Department of Clinical Medicine, University of Colombo.
The purpose of this research project between researchers from several local institutions (Medical Research Institute and Base Hospital Elpitiya under the Ministry of Health, and University of Peradeniya and University of Colombo) and Japan (National Institute of Infectious Diseases in Tokyo, and Graduate School of Infectious Diseases and Institute of Genetic Medicine of Hokkaido University) had been to identify the serogroups and genetic groups of Leptospira organisms that are found here at home. “This knowledge is important to better understand the new clinical manifestations for their early diagnosis and treatment, and to know the carrier animal for specific control measures, as this disease is carried by animals,” explains Dr. Karunanayake.
A laborious process, first, the organisms need to be ‘isolated’ (grown) in artificial culture, and thereafter artificially ‘maintained’ (kept alive) in culture media. This needs specialized laboratories with biosafety measures. The National Reference Laboratory (NRL) for Leptospirosis at the MRI offers this service to hospitals routinely. “Organisms were isolated from blood of patients affected by the 2015-2017 leptospirosis outbreak from the Base Hospital in Elpitiya and animal kidney tissue from Kandy. Once they were successfully grown and maintained in culture, they were sent to Japan for the genetic characterization which was done for us by the Japanese collaborator (Dr. Nobuo Koizumi, National Institute of Infectious Diseases (NIID), Japan),” says Dr Karunanayake.
The genetic characterization and serogroup analyses were done in NIID, Japan which demonstrated that these strains belonged to three genetically-defined species. “When their genotypic strains were analyzed, it was found that the isolates belong to 15 different strains, of which six were not described before in the world literature, hence treated as ‘novel genotypes’. Of these, three were from patients treated at the Base Hospital in Elpitiya. They were causing multiple complications such as kidney, liver, heart and lung involvement and septic shock. However, all of these patients survived,” says Dr. Karunanayake.
Although leptospirosis had been prevalent in our country since the 1950s, it has been changing its nature in the last decade. “While the number of cases are increasing alarmingly, the clinical picture too is changing, with the identification of new and troublesome complications including pulmonary haemorrhage, pancreatic involvement, heart involvement, community-acquired sepsis, etc.” he said. The disease is also affecting a wider group of people, such as those living in urban areas and people exposed only briefly to stagnant waters or floods.
“After 40 years since Dr. K. Nityananda’s work in the 1960s and 1970s at the NRL, we have been able to introduce new strains for the first time to the world literature on leptospirosis, again from the NRL,” observes Dr. Lilani Karunanayake, Consultant Clinical Microbiologist and Head/National Reference Laboratory for Leptospirosis at the Medical Research Institute. The emergence of new genotypes, as she points out, imply the importance of strict quarantine of imported cattle as well as other imported domestic animals that are potential reservoirs of leptospirosis. “Unintentional introduction of rodent reservoirs through improper garbage disposal and the existence of unidentified reservoir animals in the country also call for attention,” says the senior microbiologist who further says that new knowledge from this study will be valuable in future research for patient management and specifically-targeted control approaches for reservoir hosts in the prevention and control of leptospirosis in Sri Lanka. She extended her thanks to the clinicians from various hospitals who sent in samples, which enabled these discoveries in the best interest of people.
The National Reference Laboratory (NRL) for Leptospirosis at the MRI which serves as the central referral laboratory in the country performs certain specific leptospirosis tests, samples for which are sent from hospitals island-wide. “Although certain tests could be performed at peripheral levels, some of the advanced cases need to be referred to the central lab,” notes Dr. Karunanayake, adding that the Teaching Hospitals at regional level should be strengthened with testing facilities for early detection.
Non-specific features of the patients such as fever, headaches, body aches, diarrhea which could mimic other conditions such as dengue has rendered early detection of leptospirosis very challenging, says Dr. Sajiv De Silva, Consultant Physician, Base Hospital, Balapitiya. “Hence kidney complications and the lung involvement are two specific features we give attention to in our investigations which often require intensive care. We also take serious account of the patient’s exposure to paddy fields and muddy water. In the Elpitiya patient cluster which we took as our research sample, the kidney complications and pulmonary haemorrhage were very severe which enabled us to add the new genotypes from this cluster to the world literature on leptospirosis.” He further remarks that these genotypes are more virulent than those found in the Western Province. Similar to the cluster in Elpitiya, more recent samples from patients in Galle, Balapitiya and Udugama in the Southern Province have reflected more severe complications, particularly lung and kidney complications which trigger rapid deterioration of the patient.
Patient demographic changes are also significant as the research reveals, points out Dr. De Silva. “Apart from farmers and miners who were traditionally identified as the most vulnerable to the disease, today we find a considerable percentage of young patients who had contacted it by merely visiting a paddy field or bathing in a river.” Diagnosing leptospirosis has become a “dilemma” for the physicians at the peripheral level, observes the Consultant who adds that, blurring lines between dengue and leptospirosis makes it more challenging. “In both situations platelets will drop. However in the treatment of dengue, while fluids need to be administered proportionate to the urine output, in the case of leptospirosis, fluids cannot be administered to mitigate pulmonary hemorrhage.”
Reiterating on the urgency of seeking early hospital care, the physician notes, “the earlier they come, faster the laboratory diagnosis would be.” Although clinical diagnosis of leptospirosis was not possible in the first few days of symptoms, today the availability of the PCR test (free in the state health sector) makes this possible, he adds. The toll the disease takes on families and the national health budget cannot be undermined. In a bid to create awareness on prevention of it by promoting safety footwear and early detection among the communities at rural level, a programme is now in place facilitated by the MOHs and PHIs says Dr. De Silva.
The breakthrough research is also a reflection of the validity of the ‘One Health’ concept where collaborative health efforts of multiple disciplines working nationally and globally can attain optimal health for people, animals and the environment, observes Dr. Chandika Gamage, Veterinarian and Senior Lecturer from the Department of Microbiology, Faculty of Medicine, University of Peradeniya. “Pathogens isolated from rats and humans in a molecular study during the research had revealed same genetic strain types which have enabled us to enlarge our knowledge on leptospirosis,” explains Dr. Gamage.
Although traditionally leptospirosis had been considered a disease spread by rats (‘natural reservoirs’), it is now becoming clear that there are other animals, such as cattle, that harbour the bacteria and spread it, points out Dr. Gamage. The research had further thrown light on dairy cattle as a potent reservoir of the disease. They are often grazed on grassland infected with rat urine and can can set off a vicious cycle, says the Veterinarian. “One excretion of cattle urine can be an amplifier pathogen of leptospirosis.”
Concurrent studies in humans, animals and environmental sampling can determine how these interact to bring about disease in humans which validates the One Health approach, says the Veterinarian. Furthermore, diverse sero groups were found in this study to cause both human disease and that present in animals like cattle and buffalo, pointing towards the need for new preventive strategies to control human leptospirosis in Sri Lanka, he says. Research will also be extended to the study of domestic animals such as dogs and cats as potential carriers of the disease.
“It is imperative that we contribute to the control of leptospirosis through One Health perspective through preventive measures such as safe garbage disposal which would otherwise become breeding grounds for rats, vaccination of cats and dogs, use of preventive footwear in agrarian and other outdoor pursuits. While a patient infected with the disease may be treated, unless we adopt a holistic approach towards prevention, the environment around us could still be a catalyst of the disease hindering the control or even elimination of the disease.”
by Dr Gotabhya Ranasinghe
Senior Consultant Cardiologist
National Hospital Sri Lanka
When we sought a meeting with Hon Dr. Ramesh Pathirana, Minister of Health, he graciously cleared his busy schedule to accommodate us. Renowned for his attentive listening and deep understanding, Minister Pathirana is dedicated to advancing the health sector. His openness and transparency exemplify the qualities of an exemplary politician and minister.
Dr. Palitha Mahipala, the current Health Secretary, demonstrates both commendable enthusiasm and unwavering support. This combination of attributes makes him a highly compatible colleague for the esteemed Minister of Health.
Our discussion centered on a project that has been in the works for the past 30 years, one that no other minister had managed to advance.
Minister Pathirana, however, recognized the project’s significance and its potential to revolutionize care for heart patients.
The project involves the construction of a state-of-the-art facility at the premises of the National Hospital Colombo. The project’s location within the premises of the National Hospital underscores its importance and relevance to the healthcare infrastructure of the nation.
This facility will include a cardiology building and a tertiary care center, equipped with the latest technology to handle and treat all types of heart-related conditions and surgeries.
Securing funding was a major milestone for this initiative. Minister Pathirana successfully obtained approval for a $40 billion loan from the Asian Development Bank. With the funding in place, the foundation stone is scheduled to be laid in September this year, and construction will begin in January 2025.
This project guarantees a consistent and uninterrupted supply of stents and related medications for heart patients. As a result, patients will have timely access to essential medical supplies during their treatment and recovery. By securing these critical resources, the project aims to enhance patient outcomes, minimize treatment delays, and maintain the highest standards of cardiac care.
Upon its fruition, this monumental building will serve as a beacon of hope and healing, symbolizing the unwavering dedication to improving patient outcomes and fostering a healthier society.We anticipate a future marked by significant progress and positive outcomes in Sri Lanka’s cardiovascular treatment landscape within the foreseeable timeframe.
by Fr. Emmanuel Fernando, OMI
Jesuit Fr. Aloysius Pieris (affectionately called Fr. Aloy) celebrated his 90th birthday on April 9, 2024 and I, as the editor of our Oblate Journal, THE MISSIONARY OBLATE had gone to press by that time. Immediately I decided to publish an article, appreciating the untiring selfless services he continues to offer for inter-Faith dialogue, the renewal of the Catholic Church, his concern for the poor and the suffering Sri Lankan masses and to me, the present writer.
It was in 1988, when I was appointed Director of the Oblate Scholastics at Ampitiya by the then Oblate Provincial Fr. Anselm Silva, that I came to know Fr. Aloy more closely. Knowing well his expertise in matters spiritual, theological, Indological and pastoral, and with the collaborative spirit of my companion-formators, our Oblate Scholastics were sent to Tulana, the Research and Encounter Centre, Kelaniya, of which he is the Founder-Director, for ‘exposure-programmes’ on matters spiritual, biblical, theological and pastoral. Some of these dimensions according to my view and that of my companion-formators, were not available at the National Seminary, Ampitiya.
Ever since that time, our Oblate formators/ accompaniers at the Oblate Scholasticate, Ampitiya , have continued to send our Oblate Scholastics to Tulana Centre for deepening their insights and convictions regarding matters needed to serve the people in today’s context. Fr. Aloy also had tried very enthusiastically with the Oblate team headed by Frs. Oswald Firth and Clement Waidyasekara to begin a Theologate, directed by the Religious Congregations in Sri Lanka, for the contextual formation/ accompaniment of their members. It should very well be a desired goal of the Leaders / Provincials of the Religious Congregations.
Besides being a formator/accompanier at the Oblate Scholasticate, I was entrusted also with the task of editing and publishing our Oblate journal, ‘The Missionary Oblate’. To maintain the quality of the journal I continue to depend on Fr. Aloy for his thought-provoking and stimulating articles on Biblical Spirituality, Biblical Theology and Ecclesiology. I am very grateful to him for his generous assistance. Of late, his writings on renewal of the Church, initiated by Pope St. John XX111 and continued by Pope Francis through the Synodal path, published in our Oblate journal, enable our readers to focus their attention also on the needed renewal in the Catholic Church in Sri Lanka. Fr. Aloy appreciated very much the Synodal path adopted by the Jesuit Pope Francis for the renewal of the Church, rooted very much on prayerful discernment. In my Religious and presbyteral life, Fr.Aloy continues to be my spiritual animator / guide and ongoing formator / acccompanier.
Fr. Aloysius Pieris, BA Hons (Lond), LPh (SHC, India), STL (PFT, Naples), PhD (SLU/VC), ThD (Tilburg), D.Ltt (KU), has been one of the eminent Asian theologians well recognized internationally and one who has lectured and held visiting chairs in many universities both in the West and in the East. Many members of Religious Congregations from Asian countries have benefited from his lectures and guidance in the East Asian Pastoral Institute (EAPI) in Manila, Philippines. He had been a Theologian consulted by the Federation of Asian Bishops’ Conferences for many years. During his professorship at the Gregorian University in Rome, he was called to be a member of a special group of advisers on other religions consulted by Pope Paul VI.
Fr. Aloy is the author of more than 30 books and well over 500 Research Papers. Some of his books and articles have been translated and published in several countries. Among those books, one can find the following: 1) The Genesis of an Asian Theology of Liberation (An Autobiographical Excursus on the Art of Theologising in Asia, 2) An Asian Theology of Liberation, 3) Providential Timeliness of Vatican 11 (a long-overdue halt to a scandalous millennium, 4) Give Vatican 11 a chance, 5) Leadership in the Church, 6) Relishing our faith in working for justice (Themes for study and discussion), 7) A Message meant mainly, not exclusively for Jesuits (Background information necessary for helping Francis renew the Church), 8) Lent in Lanka (Reflections and Resolutions, 9) Love meets wisdom (A Christian Experience of Buddhism, 10) Fire and Water 11) God’s Reign for God’s poor, 12) Our Unhiddden Agenda (How we Jesuits work, pray and form our men). He is also the Editor of two journals, Vagdevi, Journal of Religious Reflection and Dialogue, New Series.
Fr. Aloy has a BA in Pali and Sanskrit from the University of London and a Ph.D in Buddhist Philosophy from the University of Sri Lankan, Vidyodaya Campus. On Nov. 23, 2019, he was awarded the prestigious honorary Doctorate of Literature (D.Litt) by the Chancellor of the University of Kelaniya, the Most Venerable Welamitiyawe Dharmakirthi Sri Kusala Dhamma Thera.
Fr. Aloy continues to be a promoter of Gospel values and virtues. Justice as a constitutive dimension of love and social concern for the downtrodden masses are very much noted in his life and work. He had very much appreciated the commitment of the late Fr. Joseph (Joe) Fernando, the National Director of the Social and Economic Centre (SEDEC) for the poor.
In Sri Lanka, a few religious Congregations – the Good Shepherd Sisters, the Christian Brothers, the Marist Brothers and the Oblates – have invited him to animate their members especially during their Provincial Congresses, Chapters and International Conferences. The mainline Christian Churches also have sought his advice and followed his seminars. I, for one, regret very much, that the Sri Lankan authorities of the Catholic Church –today’s Hierarchy—- have not sought Fr.
Aloy’s expertise for the renewal of the Catholic Church in Sri Lanka and thus have not benefited from the immense store of wisdom and insight that he can offer to our local Church while the Sri Lankan bishops who governed the Catholic church in the immediate aftermath of the Second Vatican Council (Edmund Fernando OMI, Anthony de Saram, Leo Nanayakkara OSB, Frank Marcus Fernando, Paul Perera,) visited him and consulted him on many matters. Among the Tamil Bishops, Bishop Rayappu Joseph was keeping close contact with him and Bishop J. Deogupillai hosted him and his team visiting him after the horrible Black July massacre of Tamils.
Sri Lanka-Singapore Free Trade Agreement
By Gomi Senadhira
senadhiragomi@gmail.com
“You might tell fairy tales, but the progress of a country cannot be achieved through such narratives. A country cannot be developed by making false promises. The country moved backward because of the electoral promises made by political parties throughout time. We have witnessed that the ultimate result of this is the country becoming bankrupt. Unfortunately, many segments of the population have not come to realize this yet.” – President Ranil Wickremesinghe, 2024 Budget speech
Any Sri Lankan would agree with the above words of President Wickremesinghe on the false promises our politicians and officials make and the fairy tales they narrate which bankrupted this country. So, to understand this, let’s look at one such fairy tale with lots of false promises; Ranil Wickremesinghe’s greatest achievement in the area of international trade and investment promotion during the Yahapalana period, Sri Lanka-Singapore Free Trade Agreement (SLSFTA).
It is appropriate and timely to do it now as Finance Minister Wickremesinghe has just presented to parliament a bill on the National Policy on Economic Transformation which includes the establishment of an Office for International Trade and the Sri Lanka Institute of Economics and International Trade.
Was SLSFTA a “Cleverly negotiated Free Trade Agreement” as stated by the (former) Minister of Development Strategies and International Trade Malik Samarawickrama during the Parliamentary Debate on the SLSFTA in July 2018, or a colossal blunder covered up with lies, false promises, and fairy tales? After SLSFTA was signed there were a number of fairy tales published on this agreement by the Ministry of Development Strategies and International, Institute of Policy Studies, and others.
However, for this article, I would like to limit my comments to the speech by Minister Samarawickrama during the Parliamentary Debate, and the two most important areas in the agreement which were covered up with lies, fairy tales, and false promises, namely: revenue loss for Sri Lanka and Investment from Singapore. On the other important area, “Waste products dumping” I do not want to comment here as I have written extensively on the issue.
1. The revenue loss
During the Parliamentary Debate in July 2018, Minister Samarawickrama stated “…. let me reiterate that this FTA with Singapore has been very cleverly negotiated by us…. The liberalisation programme under this FTA has been carefully designed to have the least impact on domestic industry and revenue collection. We have included all revenue sensitive items in the negative list of items which will not be subject to removal of tariff. Therefore, 97.8% revenue from Customs duty is protected. Our tariff liberalisation will take place over a period of 12-15 years! In fact, the revenue earned through tariffs on goods imported from Singapore last year was Rs. 35 billion.
The revenue loss for over the next 15 years due to the FTA is only Rs. 733 million– which when annualised, on average, is just Rs. 51 million. That is just 0.14% per year! So anyone who claims the Singapore FTA causes revenue loss to the Government cannot do basic arithmetic! Mr. Speaker, in conclusion, I call on my fellow members of this House – don’t mislead the public with baseless criticism that is not grounded in facts. Don’t look at petty politics and use these issues for your own political survival.”
I was surprised to read the minister’s speech because an article published in January 2018 in “The Straits Times“, based on information released by the Singaporean Negotiators stated, “…. With the FTA, tariff savings for Singapore exports are estimated to hit $10 million annually“.
As the annual tariff savings (that is the revenue loss for Sri Lanka) calculated by the Singaporean Negotiators, Singaporean $ 10 million (Sri Lankan rupees 1,200 million in 2018) was way above the rupees’ 733 million revenue loss for 15 years estimated by the Sri Lankan negotiators, it was clear to any observer that one of the parties to the agreement had not done the basic arithmetic!
Six years later, according to a report published by “The Morning” newspaper, speaking at the Committee on Public Finance (COPF) on 7th May 2024, Mr Samarawickrama’s chief trade negotiator K.J. Weerasinghehad had admitted “…. that forecasted revenue loss for the Government of Sri Lanka through the Singapore FTA is Rs. 450 million in 2023 and Rs. 1.3 billion in 2024.”
If these numbers are correct, as tariff liberalisation under the SLSFTA has just started, we will pass Rs 2 billion very soon. Then, the question is how Sri Lanka’s trade negotiators made such a colossal blunder. Didn’t they do their basic arithmetic? If they didn’t know how to do basic arithmetic they should have at least done their basic readings. For example, the headline of the article published in The Straits Times in January 2018 was “Singapore, Sri Lanka sign FTA, annual savings of $10m expected”.
Anyway, as Sri Lanka’s chief negotiator reiterated at the COPF meeting that “…. since 99% of the tariffs in Singapore have zero rates of duty, Sri Lanka has agreed on 80% tariff liberalisation over a period of 15 years while expecting Singapore investments to address the imbalance in trade,” let’s turn towards investment.
Investment from Singapore
In July 2018, speaking during the Parliamentary Debate on the FTA this is what Minister Malik Samarawickrama stated on investment from Singapore, “Already, thanks to this FTA, in just the past two-and-a-half months since the agreement came into effect we have received a proposal from Singapore for investment amounting to $ 14.8 billion in an oil refinery for export of petroleum products. In addition, we have proposals for a steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million), sugar refinery ($ 200 million). This adds up to more than $ 16.05 billion in the pipeline on these projects alone.
And all of these projects will create thousands of more jobs for our people. In principle approval has already been granted by the BOI and the investors are awaiting the release of land the environmental approvals to commence the project.
I request the Opposition and those with vested interests to change their narrow-minded thinking and join us to develop our country. We must always look at what is best for the whole community, not just the few who may oppose. We owe it to our people to courageously take decisions that will change their lives for the better.”
According to the media report I quoted earlier, speaking at the Committee on Public Finance (COPF) Chief Negotiator Weerasinghe has admitted that Sri Lanka was not happy with overall Singapore investments that have come in the past few years in return for the trade liberalisation under the Singapore-Sri Lanka Free Trade Agreement. He has added that between 2021 and 2023 the total investment from Singapore had been around $162 million!
What happened to those projects worth $16 billion negotiated, thanks to the SLSFTA, in just the two-and-a-half months after the agreement came into effect and approved by the BOI? I do not know about the steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million) and sugar refinery ($ 200 million).
However, story of the multibillion-dollar investment in the Petroleum Refinery unfolded in a manner that would qualify it as the best fairy tale with false promises presented by our politicians and the officials, prior to 2019 elections.
Though many Sri Lankans got to know, through the media which repeatedly highlighted a plethora of issues surrounding the project and the questionable credentials of the Singaporean investor, the construction work on the Mirrijiwela Oil Refinery along with the cement factory began on the24th of March 2019 with a bang and Minister Ranil Wickremesinghe and his ministers along with the foreign and local dignitaries laid the foundation stones.
That was few months before the 2019 Presidential elections. Inaugurating the construction work Prime Minister Ranil Wickremesinghe said the projects will create thousands of job opportunities in the area and surrounding districts.
The oil refinery, which was to be built over 200 acres of land, with the capacity to refine 200,000 barrels of crude oil per day, was to generate US$7 billion of exports and create 1,500 direct and 3,000 indirect jobs. The construction of the refinery was to be completed in 44 months. Four years later, in August 2023 the Cabinet of Ministers approved the proposal presented by President Ranil Wickremesinghe to cancel the agreement with the investors of the refinery as the project has not been implemented! Can they explain to the country how much money was wasted to produce that fairy tale?
It is obvious that the President, ministers, and officials had made huge blunders and had deliberately misled the public and the parliament on the revenue loss and potential investment from SLSFTA with fairy tales and false promises.
As the president himself said, a country cannot be developed by making false promises or with fairy tales and these false promises and fairy tales had bankrupted the country. “Unfortunately, many segments of the population have not come to realize this yet”.
(The writer, a specialist and an activist on trade and development issues . )
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