Lak Kumar

Dr. Lak Kumar is pioneering the treatment for dengue fever (DF) and dengue hemorrhagic fever (DHF). His novel approach to treatment has reduced the number of deaths attributable to the disease by half in Sri Lanka. This distinct model has caused revision of the guidelines for dengue fever treatment in Sri Lanka and abroad.

Dr. Kumar’s work is motivated by his belief that dengue fever is a predictable and treatable disease, and therefore conventional methods of treatment can and should be improved upon. His work has also helped to dispel public fear and common misconceptions surrounding dengue fever, and his new approach to treatment has shown that dengue fever infection does not have to result in patient death.

Dr. Kumar’s new approach to treating dengue fever is the result of a close analysis of dengue fever death in Sri Lanka. In 2009, Dr. Kumar studied all 64 child deaths due to dengue fever at Ragama Hospital, where he was posted as a pediatrician. His work went beyond merely studying patient records; Dr. Kumar visited the homes of each of the deceased in order to analyze the patient’s complete medical condition. During his analysis, he spent time in Thailand with a team of doctors who worked in regions with high incidences of dengue fever. With Thailand-based Professor Suchitra Nimmannitya, Kumar discussed his findings. Nimmannitya’s team believed that fluid management was the most important part of reducing dengue fever mortality. Dr. Kumar realized that successful treatment of dengue fever in Sri Lanka, and all over the world, was more about proper doctor training and less about a lack of medical resources. Upon returning to Sri Lanka, Dr. Kumar discovered that standards for fluid management in dengue patients were not uniform in Sri Lanka or globally, leading to many unnecessary and treatable deaths from the disease.

In addition to championing the standardization of fluid management therapy for dengue fever treatment, Dr. Kumar has also established a fully equipped Dengue High Dependency Unit (DHDU) in Sri Lanka that encompasses a national hotline, a 24-hour doctor information service, and a new round-the-clock blood monitor system. As a result, Ragama Hospital has had zero deaths due to dengue fever.

Dengue is caused by four closely related viruses transmitted by Aedes aegypti mosquitoes. Dengue is a worldwide epidemic, persisting in over 100 countries, and is found primarily in urban settings in the tropics. Between 50 and 100 million cases of dengue are reported around the world each year and over 2.5 billion people are at risk of infection. Several hundred thousand dengue cases each year result in dengue hemorrhagic fever, which usually affects children under 15 years of age. The average fatality rate with dengue hemorrhagic fever is 5 percent.

The majority of people infected with dengue develop DF, which is a “flu-like” illness that is not life threatening. However, some infected people develop a severe life threatening form of the disease known as DHF. Typically, less than 5 percent of people infected with dengue viruses develop DHF, but the fatality rate of such DHF cases can be very high (30 to 40 percent in Sri Lanka prior to the implementation of Dr. Kumar’s methodology). Although scientists are still far from understanding why only some dengue infections lead to hemorrhagic disease, it is clear that factors such as age and previous exposure to dengue infections increase the risk of severe disease. Of more than 70 countries with dengue as a serious public health problem, only two (Cuba and Singapore) have succeeded in controlling dengue by reducing mosquitoes. Even in these two countries, the mosquito has not been completely eliminated, and dengue epidemics have returned in recent years.

Dengue patients in critical condition should be treated in Intensive Care Units, but such facilities are in limited supply in many countries. In Sri Lanka, only a few government hospitals have such units and, even where they exist, spare beds are rare. Moreover, the blood transfusion and platelet transfusion services sometimes needed for critically ill dengue patients are not available in most hospitals. In 1989 clinicians started to observe more cases of DHF in Sri Lanka. Initially, most of the cases were reported from the capital city of Colombo and the southwestern coastal belt. After 2000, the magnitude of dengue epidemics increased and the virus spread to other parts of the country. DHF is reported from almost all districts in the island nation. The years 2004 and 2009 recorded over 15,000 and 35,000 cases of suspected dengue respectively. Between 2009 and mid-September 2010, dengue fever infected over 65,000 people in Sri Lanka and caused 563 deaths. An island-wide outbreak of dengue fever in Sri Lanka in the last three years has underlined the steady deterioration of public healthcare and preventative measures to contain the disease. The largest caseload was reported in 2009, which had 346 deaths and over 35,000 infections.

The prevalence of dengue is steadily increasing in Sri Lanka and around the world, continuing a decades-long trend. With global temperatures warming, it is expected to become a pandemic in countries that never had dengue before.

After completing his initial analysis of the causes of dengue fever and death, Dr. Kumar worked on revising standards and creating a comprehensive guideline to change conventional treatment. His revisions focus more on fluid management in order to minimize dengue fever mortality. However, the medical community did not easily accept his recommendations. Dr. Kumar’s methods require doctors to overcome their own misconceptions about dengue and confront the fact that their previous mistreatment may have led to many more patient deaths. Some medical doctors feared that they could be accused of medical malpractice for prior treatments. Dr. Kumar has also had to overcome the challenge of his junior status in a hierarchical field in order to get his methodology implemented by the medical establishment. In 2010, Dr. Kumar established a DHDU—a semi-intensive care unit focused exclusively on dengue treatment—and began managing difficult dengue patients with specially trained staff in his base hospital. He introduced the revised fluid management method with a 24-hour monitoring system that was initially linked to his mobile phone. The success of his unit captured the attention of the national government, and many serious DHF cases were transferred to his hospital from government and private hospitals. Dr. Kumar began an extensive educational process that trained clinicians on his methods throughout Sri Lanka. He has conducted over 100 training sessions for doctors from hospitals all over the country. He trains whole teams of physicians, nurses, and medical staff to implement his methodology. In an effort to codify his knowledge, Dr. Kumar is building a training unit with the Negombo Hospital, his home hospital since February of 2012. The unit will have the largest DHDU.

Dr. Kumar has also successfully communicated his strategy across borders. In Pakistan, he found a more receptive audience than he initially faced in Sri Lanka, mainly due to the unfortunate circumstances of his arrival. Following a second year of catastrophic floods in Pakistan in the fall of 2011, an estimated 100,000 people contracted dengue fever. This event was possibly the largest single epidemic of dengue in history. Dr. Kumar and his team trained over one thousand Pakistani doctors on the clinical management of dengue fever by providing the tools and knowledge to establish a similar model of treatment to the one he pioneered. With the Pakistani doctors, Dr. Kumar began a supervised group: the Dengue Expert Advisory Unit, and he believes they will be able to take charge of future dengue outbreaks in Pakistan.

In addition to his work with Pakistan, Dr. Kumar has been able to change World Health Organization (WHO) guidelines on dengue. Initially, WHO dengue strategy focused on developing a vaccine by 2017. Dr. Kumar argued that the vaccine could not control all dengue infection and death, namely due to the many strains of dengue that infect patients. Successful inoculation would require at least four separate vaccines. In 2012, Dr. Kumar co-authored a dengue treatment method that was incorporated into the WHO National Guidelines on Management of Dengue Fever and Dengue Hemorrhagic Fever.

Dr. Kumar was a student of Professor Harendra de Silva, Sri Lanka’s first Ashoka Senior Fellow. He considers Professor Harendra his mentor and credits him as his inspiration to make changes in the delivery of free healthcare services to children. He established his first children’s clinic in the Ragama General Hospital. Today, this ward is distinguished as a model ward for its child-friendly services and clean environment. In Ragama Hospital and Negombo Hospital, Dr. Kumar renovated abandoned buildings to create break rooms and office spaces for his colleagues to incentivize doctors to spend more time working in the hospital. The break rooms were also set up as spaces where doctors could share their learnings and request assistance on tough cases. Dr. Lak established his first DHDU at Ragama Hospital in an effort to give preference to deprived children who had been infected by dengue. Dr. Kumar has dedicated his life to providing maximum healthcare services to children and to help his colleagues around Sri Lanka and elsewhere deliver effective service. Over the past three years, he has reduced the child fatality rate to less than 1 percent, and aims to decrease the child fatality rate to below 0.2 percent within the next five years. Dr. Kumar continues to innovate in his field and improve the way free health service is delivered in Sri Lanka and other parts of the world.