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Elders need special protection – SLAGM
Let us save our parents and grandparents from the coronavirus infection, stressed the President of the Sri Lanka Association of Geriatric Medicine, Dr. Padma Gunaratne, pointing out that the safety of our seniors is our responsibility.
“We appeal to all sons and daughters to keep their parents separate and isolated if they are more than 60 years of age,” she says.
Dr.Padma Gunaratne
Taking a close look at COVID-19 worldwide, she points out that as per the available statistics, the death rates are especially high among older adults. The analysis of data from affected countries has revealed age as an important risk factor for poor outcome and higher fatality.
While the affected people above the age of 80 years carry a 15% risk of fatality, people between 70-79 years have an 8% risk of dying from this illness. There is 0.2-0.4% risk of fatality reported for patients below the age of 40 years. As smoking and the presence of co-morbidities such as heart diseases, diabetes and cancers are other known risk factors for poor outcome, the elderly with co-morbidities are likely to suffer severe disease with pneumonia and multi-organ dysfunction, cautions Dr. Gunaratne.
She says: “Sri Lanka has the fastest ageing population in Southeast Asia and according to the last census (2012), 12% of the population is in the elderly category and are more than 60 years of age. As such, it is the duty of all Sri Lankans to ensure that the elderly are not exposed to the COVID-19 infection.”
How do we protect elders from this disease? Here is the SLAGM’s simple advice.
Stay at home as much as possible. Don’t go out during this period when the virus is spreading.
Try to self-isolate yourself from others as you are more vulnerable.
Try to avoid regular clinics, replenish your medication by sending another to the closest pharmacy and take your medications without fail.
Wash your hands frequently for 20 seconds with soap and water especially after touching money and going out of home.
Keep a distance of at least 3 feet when talking to another person.
Avoid touching, kissing or hugging your children, grandchildren or others.
Cover your mouth and nose with the crook of your elbow when you cough.
Discourage other people from visiting your home and avoid gatherings.
If you have to go out for an unavoidable reason use a face mask in crowded places.
Drink warm water and avoid cold beverages.
Eat a healthy diet, practise meditation, read books and sleep well.
| Garbage bags as protective gowns for health staff  Some protective gowns manufactured to the designs of Dr. Udaya de Silva being handed over by the Army and the Air Force to Health Ministry Secretary Bhadrani Jayawardena, while GMOA President Dr. Anuruddha Padeniya looks on. Necessity is the mother of invention, it is said and that is what happened at the Anuradhapura Teaching Hospital which has led not only to the designing of Personal Protective Equipment (PPE) for large-scale production but also simple ones that can be made at home. The raw material is the jumbo garbage bags and some cellotape for the home product, the Sunday Times learns. It is the Anuradhapura Hospital’s Consultant Paediatrician, Dr. Udaya de Silva, and his team of junior doctors and nurses who came up with this innovative idea, making blocks and attempting different designs in the ward. “We did the research and innovation, while large-scale manufacturing has been undertaken by the factories of the Air Force at the Katunayake and Anuradhapura airbases and the army’s Yakkala apparel (ranaviru) centre, while in the private sector, Brandix, Hirdaramani and MAS Holdings have begun production,” says Dr. de Silva. He believes that already around 10,000 such protective kits have been produced. It all began when a baby with pneumonia was admitted to Dr. de Silva’s ward and on being asked about the travel history, it was found that the family had returned from Italy, a high-risk country for COVID-19. Dr. de Silva and his staff immediately moved the child to an isolation room and wore the PPE during examination of the patient. Later the baby tested negative for the new coronavirus. A PPE is very expensive and can only be used once. If there is a COVID-19 patient, the staff will need at least 10-20 PPE each day, he said. Doing a check on the internet and consulting microbiologists, Dr. de Silva and his team hit upon the idea of using the garbage bags the hospital had for waste collection and designed one to cover the body, along with a face-shield and a standard N-95 mask. “Nikamata haduwa,” he laughs, explaining that they tried those on dolls. The sealing techniques they used for these polythene gowns included conventional polythene sealer, aluminium foil with cloth iron and teflon sheets with soldering iron.  Dr. Udaya de Silva “What is being produced industrially is our 23rd model but we are now having the 27th which can be made at home, using extra-large polythene garbage bags sealed with cellotape,” he says. It was the President’s Additional Secretary Mrs. Indika Wijegoonewardene who made the whole thing a reality when she arranged a meeting for him with President’s Secretary Dr. P.B. Jayasundera who also cottoned onto the idea of Sri Lanka exporting these products someday. The Government Medical Officers’ Association (GMOA) too got involved with its President Dr. Anuruddha Padeniya bringing Health Services Director-General, Dr. Anil Jasinghe into the loop with the army apparel (ranaviru) section’s Major General Manjula Manatunge and Air Force’s Air Vice Marshal Andrew Wijesuriya and Air Vice Marshal Lalith Jayaweera of the Engineering Division coming on board. Now Dr. de Silva and his team are looking at producing face shields from overhead projector (OHP) sheets and shoe coverings and also fine-tuning a disinfection process to kill the virus using steam from a hair-dryer. He has been requested to collaborate with the research and development (R&D) team at the National Operations Centre for the Prevention of COVID-19; the subcommittee of the Sri Lanka College of Paediatricians; and the Institution of Engineers Sri Lanka.
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| Private hospitals are working The emergency services and other outpatient and inpatient clinical facilities are functioning at private hospitals, thereby reducing the burden on the government health sector, which is now focused on mobilizing facilities to take on COVID-19 infected patients, said the President of the Association of Private Hospitals and Nursing Homes (APHNH), Dr. Lakith Peiris when contacted by the Sunday Times. He said that the private hospitals around the country have urgently responded to the COVID-19 pandemic situation, having taken stringent steps to manage the flow of patients in their hospitals. Fundamental to this has been their priority in triaging patients and visitors – the process of rapid identification of COVID-19 suspected patients – and directing them to assigned government hospitals, provision of PPE including masks to suspect patients and staff, adherence to stringent infection control protocols and guidelines to ensure safety of all patients, visitors, staff and the community. Highlighting the importance of aggressive COVID-19 PCR testing to either reverse the outbreak we expect in the future in Sri Lanka, to slow it down or keep infected cases at a low level, Dr. Peiris said that testing should be made a priority. These are lessons we can learn from other countries such as Singapore, Hong Kong, Korea, Taiwan, China and even Germany which ramped up testing capacity very early during the outbreak and were able to contain COVID-19. AMS seeks strong clinical input in any action on COVID-19 Appreciating the positive steps taken with regard to combating COVID-19, the Association of Medical Specialists (AMS) has also expressed extreme concern about what it has observed – “many delays and lapses in some of the steps” – in the past few days. “We note with sadness the inadequate interactions the committees set up to battle COVID-19 have had with clinicians involved with patient care at hospital level,” says the AMS, pointing out that there have been many instances where hospital administrators were not receptive to suggestions and requests of clinicians at institutional level which has become an obstacle to design a proper clinical plan. The AMS, which has sent its concerns and recommendations to President Gotabaya Rajapaksa, reiterates that since it is directly them and their teams who have to manage cases very much more than those ‘decision makers’, “we collectively decided to place before you a plan we believe should be implemented without delay for the sake of saving lives and containing the virus without it exploding into the catastrophic situation experienced in some countries”. The AMS points out that the way each country’s decision-makers or advisors to the governments handled the epidemic has been responsible for varying case fatality rates in those countries, for eg. 0.22% in Germany vs 8% in Italy vs 2.5% in the United Kingdom. “A well-represented Task Force from different sectors should be entrusted the duty of finding ways to ‘implement’ scientifically useful preventive and treatment strategies. We believe the delay that did not prevent the imported cases through air travel especially from Italy and Europe was a result of the defect we had in this arrangement at the beginning,” it states. According to the AMS the use of various treatment options with emerging evidence should have repeated reviews and be considered by a well-represented medical panel selected on their known technical capabilities and expertise than through ad hoc means. The proposals of the AMS which suggest changes to clinical practice (for a temporary period) have been guided by three main overarching principles – clinical urgency; patient and healthcare worker protection; and conservation of healthcare resources. The AMS suggestions include: Stopping and curtailing all routine and non-emergency hospital visits by restricting routine clinics. Methods to minimize inconvenience could be brought in such as giving drugs from clinics for three months and setting up telephone consultation methods to provide essential advice to patients. Cancel all routine non-urgent surgeries until further notice. Re-organize/arrange doctors and other healthcare staff in hospitals into 3 to 4 small groups to continuously work for 10-14 days on rosters, keeping the rest at home to be called in whenever there is a need to self-quarantine the ‘on-duty’ team in the event of a suspected exposure to a COVID-19 patient. Other staff who is not on duty but on standby in their homes should have strict instructions to stay at home to avoid community acquired COVID-19 infection. The Health Ministry should develop a system to deal with staff who signs daily attendance registers. Small units can be amalgamated to run essential services. The remaining staff can be temporarily transferred to needed units or institutions. It is mandatory to ensure the safety and wellbeing of staff assigned to corona-dedicated hospitals, with an adequate number of masks and PPE and other measures to minimize the risk of exposure. They should also be divided into groups that work for 10-14 days continuously with food and accommodation provided during this period, but should ideally have essential quarantine for 14 days following their duty period before they reunite with their families. For this, it is best to identify accommodation in a hotel or other building with arrangements being made to provide their daily needs. Government should consider establishing dedicated telephone hotlines for each hospital, so that patients can obtain advice especially before coming to hospital whenever possible. All hospitals should be advised to set up admission criteria for all wards for ‘any illness’ enabling screening of all patients with a set of questions to avoid a possible corona patient/highly suspicious contact getting admitted with an unrelated medical or surgical problem, risking the staff and other patients. Essential facilities have to be set up in the ‘isolation wards’ to look after such patients until COVID-19 is excluded by doing a specific test. All countries which have shown better success have facilitated ‘more testing’ and Sri Lanka should not impose unfair restrictions for testing. We like to draw the attention of decision-makers about the ‘difficulty’ that the first physician who got infected had in getting the test done for the index patient he had seen whose positive results led to the discovery of the physician contracting disease. All healthcare workers should have easy access to testing whenever the need arises. A’pura Hospital sets up 22-room isolation centre It was the same incident in which a baby who had returned from Italy and sought treatment at the Anuradhapura Teaching Hospital, which is the designated hospital for the district, which galvanised the doctors to set up a compact isolation unit, across the road from the main building.
Several rounds of discussions were held with the participation of the Director Dr. Dulan Samaraweera, GMOA’s Secretary Dr. Shashika Vithanage, clinicians including Dr. Damith Chandraratne, says Emergency Medicine Specialist, Dr. Kanishka Seneviratne. Initially, it was just an idea and when that baby came in the need for isolation rooms stared us in the face and we identified the gaps, he says, explaining that the components needed were: How to triage a patient at first contact in the OPD or emergency and direct such a suspected case to a buffer zone for swabs etc., to be taken for testing An isolation area Discussions resulted in identifying the 22-room Methsiri Sewana, which had been set up for CKDu patients. There are attached toilets and it was ideal, with the armed forces doing a “marvellous” job, getting the building ready in 24 hours, with the hospital’s Professorial Unit, headed by Dr. Hemal Senanayake, providing the guidelines and protocols to run it. “It has been functioning for two weeks now. We have kept three suspected cases from the Wanni quarantine centre here and when tested positive sent them onto to the National Institute for Infectious Diseases (NIID), Angoda, and the Welikanda Hospital for treatment,” says Dr. Seneviratne adding that the dedication of Consultant Intensivist Dr. Razil Bandara in developing critical care support was invaluable. While commending the armed forces for also helping in the current process of constructing a six-bed ICU, he was also appreciative of the support extended by the nursing staff, junior staff, Public Health Inspectors (PHIs) and ambulance service. “The Anuradhapura Hospital is very active and providing wider care for patients including the psychological aspects. We are trying to set in motion a video conferencing facility for patients, while at present they have wi-fi in the isolation unit,” he added.
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With the hospital’s Clinical Virologist Dr. Saranga Sumathipala conducting the test for COVID-19, there was a need to keep any suspected cases in isolation.