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The ‘soldiers’ at the medical front battling COVID-19
Senior citizens wearing nasks arrive at a bank in Puttalam to collect their pensions. Pic by Hiran Priyankara
The battle against the tiny new coronavirus is being waged by ‘soldiers’ on different fronts.
At hospital level, especially in those treating COVID-19, the arms-bearers, nay the stethoscope, thermometer and medicine wielders include the senior doctors, medical officers, nurses and minor staff.
The hospitals treating COVID-19 are the Infectious Diseases Hospital (now called the National Institute of Infectious Diseases), Angoda, where a majority of patients are; the Welikanda Base Hospital; the Colombo East (Mulleriyawa) Hospital where the mother with COVID-19 and her baby are being managed; and the newly set up Iranawila Hospital; and also the Homagama Hospital looking after highly-suspect cases.
A different fight is being fought at ground-level by the medical officers of health and the public health staff.
“This is a multidisciplinary effort involving many people,” a senior doctor told the Sunday Times listing all those involved on the medical side as the Epidemiologists, the Internal Medicine Specialists, the Virologists, the Respiratory Physicians, the Anaesthetists, the Emergency Medicine Physicians and junior doctors.
This pandemic is the clinically most challenging issue the world including Sri Lanka has faced, where the disease is highly infectious with no definitive treatment, the doctor said, explaining that in the COVID-19 crisis, Internal Medicine Specialists have been active at national and public level.
“We have been engaging in discussions with the Health Ministry and providing input on the clinical management of patients with the new coronavirus and also discussing the requirements of the staff. We urged that hospitals treating COVID-19 should be provided adequate personal protective equipment (PPE) and that these hospitals also should have proper isolation units,” said the doctor, adding that they have also carried out public awareness campaigns on the disease by distributing leaflets and circulating videos on social media.
Ministering angels
They are the ministering angels for all those whose bodies are wracked by the new coronavirus.
“We are like one family, be it the doctors, nurses or minor staff and we keep working for the benefit of the people,” said the Matron of the Infectious Diseases Hospital (IDH), Geethani Udugamakorala who heads the 130 nursing officers.
The dedication is such that most of them do not go home anymore. They have sent their families to relatives’ homes and taken up temporary residence in houses close to the hospital, while some live in the quarters provided, the Sunday Times understands.
Explaining that they take all the precautions stipulated including the use of hand sanitizer, face-masks and PPE, Matron Udugamakorala says that before the COVID-19 outbreak, the hospital had a cleaning service but now the minor staff has voluntarily taken on this task.
Even though the nursing staff has leave, no one utilizes a single day. She sometimes tells her nurses, “Meh sumane onanan nivaduwak ganna” (Take leave this week), but they refuse with the reply, “Api meh vede ivarakaralama gamuko” (Let’s finish this job first).
Simple rewards are forthcoming…..“people bring us food, tell us to use their homes to stay after work and supermarkets donate dry rations. There are also those who come in and say they are not in a position to do anything, but offer prayers for us”.
“The patient-patient relationship is growing,” she smiles, adding how they are also very fond of the nurses and try to prevent them from catching the disease by keeping them from coming into contact with their cutlery and crockery.
Describing the IDH as their home, Matron Udugamakorala says that their only wish is to save all those lives under their care.
| Masks unmasked! | |
| The people are confused. Should they wear a face-mask or shouldn’t they, is on their minds. Simple cloth face-coverings slow the spread of the virus, advises the Centers for Disease Control (CDC) of the United States of America and recommends this measure in areas of significant community-based transmission. These coverings also prevent people who may have the virus and do not know it, from transmitting it to others. This is slightly in contrast to the World Health Organization (WHO) guidelines which state that if “you are healthy, you only need to wear a mask if you are taking care of a person with suspected COVID-19. Wear a mask if you are coughing or sneezing”. Of course, masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water, many experts said. In Sri Lanka, the College of Community Physicians of Sri Lanka (CCPSL) has sought “clear” guidance on wearing masks. Giving the view that it should be emphasized as an additional voluntary public health measure, the CCPSL adds that the evidence available on non-surgical masks and guidelines provided should be reviewed and recommendations made that are favourable in the local context, rather than having a rigid approach.
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| Not letters but medicines | |
| The ring of the postman’s bell these days at some people’s gates will not be the harbinger of letters but medicines. Postmen are delivering packages of medicines, said Postmaster General Ranjith Ariyaratne when contacted by the Sunday Times, explaining that just as patients who go to a government hospital clinic have a record book, these hospitals maintain a record of their patients. “The hospitals know how long a patient’s prescription is filled and whether that patient requires a stock of medicine. When a patient does require medicine, the hospital will put the package together, label it meticulously with the name of the patient, clinic number, contact details and address and send it to the Postal Department for delivery,” he said, pointing out that medicines are being distributed at no charge. All those who are not under a clinic but are in urgent need of medicines can Whatsapp or Viber their prescriptions to any of the 40 Osu Sala outlets under the State Pharmaceutical Corporation and those outlets will fill the prescription and handover the packages to be delivered by the Postal Department for a nominal fee, Mr. Ariyaratne added.
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Senior medical specialists from varying fields show the scientific way to beat the virus
A detailed plan to keep the new coronavirus at bay has been put forward by a team of senior medical specialists to President Gotabaya Rajapaksa.
The team highlighted that adequate testing of suspected cases and contacts is a key strategy in overcoming the challenge posed by COVID-19.
“We recommend testing of all suspected cases of COVID and all their contacts. The contacts should be tested with PCR on Day 7, Day 14 and on Day 21 and again with an antibody test on Day 28 so that it would be possible to detect all cases of that cluster and also make sure infection may not be spreading in that cluster anymore,” they have pointed out.
The medical specialists who have made this strong plea are Dr. Vajira Senaratne (cardiology), Prof. Ranjani Gamage (neurology), Prasad Katulanda (endocrinology), Prof. Saroj Jayasinghe (medicine), Prof. Neelika Malavige (microbiology), Prof. Arjuna De Silva (gastroenterology), Prof. Vajira Dissanayake (genetics), Dr. Kumudini Ranatunga (anaesthesia), Dr. Amitha Fernando (respiratory) and Dr. Indika de Lanerolle (emergency medicine).
The others who provided their expertise are Dr. Ananda Wijewickrama (The National Institute of Infectious Disease), Prof. Manuj Weerasinghe (community medicine) and Dr. Jude Jayamaha (Medical Research Institute).
The specialists have stressed that PCR testing of nose/throat secretions are required in hospitals, in primary contacts (those in quarantine centres) and ideally in secondary contacts (those in areas where patients/contacts were found). The testing should be freely available in all the areas where mini-epidemics are seen.
“The antibody test would have a place under specific situations (for community screening). Such tests (preferably SARS-CoV2 specific IgG ELISA) can be used in combination with the PCR in identifying contacts of positive patients with no contact history with a positive patient and also to screen for high risk groups,” they state.
They add: “There is a long supply chain of equipment and personnel. Swabs to take the sample, protective equipment for the person who takes it, mediums to carry it, boxes that are safe to carry, protective equipment to the person who carries it, trained staff to do the tests and disposal. Each of this is essential before the machines are used.”
At the stage of opening offices, factories and schools, meanwhile, we will require large-scale testing of thousands, decentralized and available at these sites. Pooled testing by PCR or rapid tests/IgG ELISA could be used. This is while a fast-track method to evaluate and register diagnostic kits is set in place.
The other measures suggested are:
Local production of ventilators and other necessary equipment –
Several groups are repairing and producing ventilators such as the Universities of Moratuwa and Peradeniya. A fast-track method to evaluate and register these products involving the College of Anaesthetists and Intensivists is required. The regulations used at the National Medicines Regulatory Authority (NMRA) need to be amended to facilitate the registration of medical devices.
Personnel Protection Equipment (PPE) and masks –
All healthcare workers attending to COVID-19 patients or suspected patients must be provided the appropriate PPE.
A clear message must be communicated regarding the use of masks: N95 for aerosol generating procedures; surgical masks for healthcare workers, patients and carers of patients; washable cloth masks for all other healthy people.
The PPE and masks of adequate quality can be produced by different groups such as the Tri Forces, MAS, Brandix, Hayleys and Ansel, while a fast-track mechanism to assess quality before release to the health sector has to be established. The possible evaluators could be SLINTEC, the nano-tech institute and the Health Ministry’s MRI.
Infrastructure –
The designated hospitals and potential COVID-19 hospitals should have a pre-fabricated room or similar facility in all emergency treatment units/preliminary care units/emergency departments to manage patients suspected to be having the infection, presenting with respiratory symptoms and presenting with other illnesses. These are urgently required within one to two weeks.
This allows health workers to speak, examine and treat patients in a protected environment, for example, transparent partitions, negative pressure areas, seating at a distance, a clear patient pathway, areas to keep the PPE, areas to wash and change.
Each hospital should have an operational cell to coordinate these actions. A separate respiratory triage as appropriate for clinical presentation. Most COVID patients will present with respiratory symptoms and managing these patients in designated clinical settings will help identify COVID suspects and prevent the exposure of staff and other patients.
To ensure the institution has an agreed plan to meet infrastructural, material, laboratory, radiology, pharmacy, infection control, transport and human resource needs in the likelihood of a surge of COVID patients.
Intensive care and ventilators –
Identified ICUs for COVID should be staffed, equipped and ready to accept patients. At present 5 ICUs have been identified in the Western Province. We suggest selecting one ICU each from other provinces too. An already functioning ICU with best facilities is suitable rather than makeshift ICUs to treat these patients who have a high mortality rate.
A national network that monitors and coordinates ICU bed availability has been developed by the College of Anaesthesiologists & Intensivists with the Health Ministry. It is doing trial runs at present and we recommend it to be implemented. Immediate modifications to be made to all ICUs (especially those in affected areas) to reduce aerosol/droplet exposure during high-risk procedures
The Security Forces could help build these pre-fabricated cubicles according to specifications and instal them where feasible.
COVID-19 testing: RT-PCR is the gold standard
Testing for COVID-19 came under the spotlight this week as many health experts reiterated that the RT PCR is the ‘gold standard’, while a few attempted to push for rapid antibody testing.
For diagnosis, RT-PCR (Reverse Transcription-Polymerase Chain Reaction) is still the best option, reiterated SARS-buster and Professor of Virology at the School of Public Health, Hong Kong University, Prof. Malik Peiris, when the Sunday Times contacted him.
He said that the Hong Kong University has developed its own antibody tests but they are laboratory-based assays. “With these, we have shown that antibody tests are not very sensitive in the early days of illness. That is the time you need to make the diagnosis,” he said, explaining that there are also many suppliers of these so-called rapid tests and some of them are “really” bad.
Categorical that “it is not a path I would recommend”, Prof. Peiris goes on to explain that there are two ways to make a diagnosis of an acute COVID-19 case. They are:
- Detect the virus in the nose, throat or sputum of a patient.
- Detect an antibody response to the infection in the blood of the patient. By definition, this takes some time after the onset of infection.
“By ‘rapid test’ what most people are talking about is a blood test. So by definition, the likelihood of this being positive early in the infection is not so high. Later in the infection, yes. But ideally we want to diagnose patients early,” added Prof. Peiris.
The Director-General of Health Services, Dr. Anil Jasinghe, meanwhile, said that the number of tests being carried out to identify those affected by COVID-19 was being increased, though he did not mention a figure.
“But the number of cases has not gone up with the increased testing, which is a positive trend. Testing will be increased among certain identified categories of people,” he added.
RT-PCR tests are now being done at the Medical Research Institute (MRI), Colombo; the Kandy National Hospital; the Anuradhapura, Karapitiya & Ragama Teaching Hospitals; the National Institute of Infectious Diseases (NIID), Angoda; the National Cancer Institute, Maharagama; the Ratnapura Hospital; the Teaching Hospital of the Kotelawala Defence University, Werahera; and the Sri Jayewardenepura University.
In a technically-strong statement issued this week, the Presidents of the Sri Lanka Medical Association (SLMA), the Ceylon College of Physicians (CCP) and the Sri Lanka College of Microbiologists have urged that in this current stage of the epidemic the authorities should increase the RT-PCR testing capacity to 1,500 tests per day and conduct community surveillance in hotspots.
“According to the Epidemiology Unit, currently there are 2,000 first-level contacts of COVID-19 confirmed cases in Sri Lanka. If these first level contacts can be covered through risk stratified/pooled sampling, it will provide the evidence-base on how the next level of contacts should be screened and address current concerns and uncertainty regarding the number of asymptomatic patients,” they say, emphasizing that any shift in the current testing policy for COVID-19 should be considered within the border framework of the present successful public health response and not as an isolated technical matter.
Citing the recommendation of the World Health Organization (WHO) that confirmation of cases of COVID-19 should be by nucleic acid amplification tests (NAAT) such as RT-PCR, Prof. Indika Karunathilake, Dr. Ananda Wijewickrama and Dr. Shirani Chandrasiri point out that the primary strength of molecular tests is that they directly detect the gene sequences of the virus in the early stages of infection when the patient is infectious.
They add: “Thus, detection of COVID-19 by RT-PCR can be done from five days prior to the onset of symptoms to several days after symptoms have waned. The test to detect IgM/IgG antibodies to diagnose COVID-19 infection cannot replace the value of the RT-PCR test, as this rapid test relies on the detection of antibodies made by the patient which may take up to 7 to 12 days to produce antibodies. As such, patients in the early stages of the disease will be missed and it will lead to more spreading within the community due to a false assurance depending on a negative antibody test result.”
Adding their voice, six senior professors from different universities pushed for an increase in testing capacity so that all those with contact with COVID-19 positive persons could be tested and not just those with symptoms, with the clear proviso that in this regard the advice of virologists need to be sought on the most appropriate test for use in specific scenarios, followed by stocking up on supplies. Harness capacity in the private health sector, under stringent regulatory control, for testing and patient care if the need arises.
| WHO’s ‘Solidarity’ to pursue effective treatment for COVID-19 | |
| The World Health Organization (WHO) and several partners have launched ‘Solidarity’, an international clinical trial to help find an effective treatment for COVID-19. The Solidarity trial will compare four treatment options against standard of care, to assess their relative effectiveness against COVID-19. By enrolling patients in multiple countries, the trial aims to rapidly discover whether any of the drugs slow disease progression or improve survival. While providing simplified procedures to enable even overloaded hospitals to participate with no paperwork required, as of March 27, more than 40 countries including Argentina, Bahrain, Canada, France, India, Iran, Malaysia, Norway, South Africa, Spain, Switzerland and Thailand had confirmed their participation. The four treatment options selected are:
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