News
Experts detail staggered exit strategy to open up SL & control COVID-19
To lift or not to lift the lockdown, especially in the high-risk districts including Colombo, is the critical question Sri Lanka is facing.
“We should not be in a hurry, as haste to ease the strict measures could result in an adverse situation for the country,” said a health expert, with many others agreeing, while hailing the action taken so far to curb the spread of the virus.
A well-thought out staggered ‘exit’ strategy is vital, many said, conceding that they understood the major impact on the economy. However, they argued that if a second wave of COVID-19 infections came, it would be a severe challenge for Sri Lanka on every front, including the economy.
The important measures taken so far are the closure of the country’s entry points including the main airport, imposition of curfew, quarantining returnees from other countries, tracing and quarantining contacts of confirmed ‘positive’ cases and hospitalizing COVID-19 positive patients.
The high-risk districts in which the curfew has not been lifted are Colombo, Kalutara, Gampaha, Puttalam, Kandy and Jaffna, with several other smaller areas being sealed off to halt movement.
A senior medical specialist pointed out that many of those who have tested positive for COVID-19 do not have symptoms (asymptomatic) and there may also be others who are asymptomatic or pre-symptomatic who may spread the disease, while another said that the entry-points were closed to prevent a large number of infected people from coming into the country.
This was while curfew and quarantining helped to prevent asymptomatic infected people from giving the disease to others, the source stressed, adding that all these actions stopped an explosion of the new coronavirus.
“Let’s not irrevocably undo all this good work and plunge the country into crisis,” was the plea of many.
Here are a few strategies being put forward to keep Sri Lanka safe from COVID-19:
- Prevent re-introduction of the disease by those who come into the country by allowing incoming passenger traffic only through the main Bandaranaike International Airport (BIA), Katunayake. A sophisticated laboratory should be set up at the BIA and all these passengers tested and the results obtained before they leave the airport. Then the passengers can be sent into home-quarantine if the test is negative or to hospital if it is positive.
- Easing the lockdown in stages to make sure that one infected person does not visit a public place resulting in a massive outbreak. Such easing of the lockdown could be staggered with government and economic activities begun in early May, schools and universities after a lapse of some weeks and social activity after a lapse of more time.
College of Community Physicians
Reiterating that the challenge is to ensure a “balance” between epidemic prevention and returning to normalcy in public life, the College of Community Physicians of Sri Lanka (CCPSL) has said that an exit strategy is not a one-time approach. It should be implemented in a “staggered” manner taking into consideration the evolving dynamics of the epidemic.
“Ending the curfew too soon could lead to a second outbreak, while enforcing it for too long could further cripple the economy and public morale. When to end the current phase must be decided at national level by an expert panel comprising health and non-health authorities with close monitoring of area-specific virus caseloads,” the CCPSL cautions.
There should also be a phasing out approach: Phase I – Stringent restrictions in high-risk areas; Phase II – Moderate restrictions in moderate-risk areas; and Phase III – Relaxed restrictions in low-risk areas.
“A careful analysis of the interventions already adopted should be carried out and decisions made on what aspects need to be removed or gradually scaled down. This should be done under the guidance, coordination and supervision of the National Operation Centre for Prevention of COVID-19 Outbreak,” the CCPSL states, adding that it is vital to learn from other countries, where new waves of infection in several of them have prompted policy reversals with further lockdowns.
Before easing the lockdown, the CCPSL suggests that it is important to determine the stage of the epidemic – is it the post-peak stages with sporadic cases; the second wave; or the community transmission stage in each geographical area termed ‘high risk’, ‘moderate risk’ or ‘low risk’? Such determination would come through:
- Passive surveillance of suspected patients fulfilling the case definition of COVID-19
- Active surveillance through targeted high-risk testing among all three tiers of close contacts and quarantined persons and health facility testing of close contacts
- Sentinel surveillance of patients in sentinel centres fulfilling the criteria of Severe Acute Respiratory Infection (SARI) and Influenza Like Illness (ILI).
- Antibody testing among those providing frontline essential services (oncology, obstetrics and ICU staff) and those negative for RT-PCR, two weeks after recovery.
Urging that a blanket exit strategy should not be applicable across the country, the CCPSL recommends ‘targeted’ strategies at area and district level, categorized according to the caseload based on: the number of cases reported in the last 28 days; extent of primary/secondary contact load in the last 28 days; geographical scattering of households/families; judgment on the compliance of the resident population with epidemic control measures.
Decisions on the transportation of goods and people between high-risk and low-risk areas, alternative methods of continuing school education and maintaining physical distancing in set-ups such as economic centres should be worked out by multi-sectoral teams, the CCPSL adds.
| Exit plans should be based on surgical theatre model: GMOA & ICTA | |
| Sri Lanka’s exit strategy should be based on a common structure similar to a surgical theatre – a ‘sterile’ area in a ‘contaminated’ environment.This is the model being suggested by the Government Medical Officers’ Association (GMOA) and the Information and Communication Technology Agency (ICTA).As disease elimination and eradication is not possible to-date, the GMOA-ICTA combine recommends the ‘Hammer and Dance’ Theory in which COVID-19 is aggressively controlled (hammer) followed by strategies to ensure a good control (dance).Their model is that Sri Lanka should be categorized into three – Sterile Zone; Contaminated Zone; and the in-between Buffer Zone, with thwe aim being to expand the Sterile Zone and shrink the Contaminated Zone.· The Divisional Secretariat level should be the smallest zone, since it is represented by 81 officials from various ministries facilitating its ability to function independently in administrative, health (with more than one hospital or medical facility) and financial (with more than one banking facility) facets, with directives from the relevant national-level authorities. There are 331 Divisional Secretariats in the country and a survey should be conducted in each to cover: the health status (COVID-19 confirmed/suspected cases, other health conditions & health resources); work & occupation (within or outside the zone); distribution of households; economic potential (banks/factories); and self-sufficiency (agricultural opportunities/fisheries/poultry/ production of goods). The decision whether the zone is sterile or contaminated should be based on this survey. The proposed criteria for the Sterile Zone would be having no confirmed COVID-19 cases for 28 days prior to declaration and having no suspects or contacts of COVID-19 patien ts for 28 days. If the presence of even one case or suspect is found, the zone would fall under the contaminated category. The proposed criteria for the Contaminated Zone would be having at least one confirmed case of COVID-19 within the 28 days prior to declaration and the presence of suspects or contacts of COVID-19 patients who would be tested immediately. If the number of cases or suspects becomes zero for 28 days, the zone would fall under the sterile category. The proposed criteria for the Buffer Zone would be a sterile area having no confirmed cases, no suspects or contacts for 28 days but being situated between a Sterile Zone and a Contaminated Zone. Such a Buffer Zone may even be between two districts. The GMOA-ICTA also propose a detailed governance strategy (corona and non-corona related) for each zone. With regard to the Contaminated Zone, the non-corona related governance includes essential food, medicines and goods being supplied through systematic delivery to the doorstep, extra support for families and individuals as a larger part of the country would have been opened up, only those involved in essential services being allowed to travel for work and within the zone only and border crossings being prohibited. For the Contaminated Zones, the corona-related governance would include curfew, home and institutional quarantine and prohibition of total movement within the zone. According to the GMOA-ICTA, the Contaminated Zones may be as large as a district such as Colombo or a smaller administrative area. Extensive surveillance involving contact tracing, testing, isolation on confirmation, quarantining, social distancing, hand hygiene and using face-masks would help ‘shrink’ these areas gradually. “Through this exit strategy, only the affected areas would be locked down, while other areas would function normally,” the GMOA-ICTA add. |
Powerful SLMA Inter-Collegiate Committee formed to face COVID-19 threat
Prof. Indika Karunathilake
Specialist doctors drawn from different fields have formed a powerful alliance to give evidence-based advice on how to safeguard the country, while gradually easing the restrictions.
Formed under the umbrella of the Sri Lanka Medical Association (SLMA), the ‘Inter-Collegiate Committee’ comprises all professional colleges and associations of medical practitioners.
SLMA President Prof. Indika Karunathilake is the Chairperson, the Ceylon College of Physicians President Dr. Ananda Wijewickrama the Convener; and SLMA Secretary Dr. Sumithra Tissera the Secretary of the committee.
Dr. Ananda Wijewickrama
“The reality is such that we will have to co-exist with the new coronavirus and gear ourselves to be vigilant,” said Prof. Karunathilake, explaining that the relaxation of restrictions placed to curb the spread of COVID-19 should be based on strong epidemiological data and community participation in which hand-hygiene and social distancing are very much a part of the lifestyle of the people.
This is important considering the current situation faced by many countries after the relaxation of control measures. Singapore which relaxed its restrictions recently is now facing a second wave of infections, he said.
The SLMA Inter-Collegiate Committee aims to provide a common platform for all professional bodies to have a candid dialogue and establish national-level consensus among all medical professional bodies with regard to national-level guidance and recommendations now and in the future.
| SLMA’s mathematical model for COVID-19 | |
 A mathematical prediction model for COVID-19 has been developed under the auspices of the SLMA, based on national data, epidemiological characteristics in Sri Lanka and international trends.The model has predicted three different scenarios based on adherence to strict controls. They are:
“As a nation, we are now at a ‘testing’ time for our resilience, courage and patience,” says Prof. Indika Karunathilake. The model has been developed by Prof. Manuj Weerasinghe, Professor in Community Medicine, Faculty of Medicine, and Dr. Nishantha Perera of the Department of Mathematics, University of Colombo. The Health Ministry’s Epidemiology Unit and the World Health Organization’s Country Office had contributed to this model in terms of technical support. |
Need for more RT-PCR testing
With much concern about a shortage of swabs needed for the RT-PCR (Reverse Transcription-Polymerase Chain Reaction) tests last week, the Sunday Times learns that the issue has been overcome with a stock of swabs and viral transport media (VTM) for 11,000 tests being purchased from abroad.
This is while 1,000 swabs have been produced by the Sri Lanka Institute of Nanotechnology (SLINTEC), with assurances that it has the capability of producing 3,000 swabs a day. These swabs are being validated, it is learnt.
Moves are also underway to increase the RT-PCR testing capacity to about 2,000 tests a day, across all institutions carrying out these tests. The centres where this gold-standard test is carried out are the Medical Research Institute (MRI), the National Institute of Infectious Diseases (NIID); the National Hospital of Sri Lanka; the Kandy National Hospital; the Colombo North (Ragama), Anuradhapura, Karapitiya, Jaffna, Batticaloa & Kotelawala Defence University Teaching Hospitals; the National Cancer Institute; the Ratnapura Hospital; and the Sri Jayewardenepura University.
Some experts have suggested as part of the exit strategy, it would be crucial to establish RT-PCR testing for the community. Pic by Lahiru Harshana
The Sunday Times understands that VTM is being produced by the MRI, which has this week been instructed by Health Ministry Secretary Bhadrani Jayawardena to produce adequate stocks for 50,000 tests.
It is also reported that Sri Lanka received 20,000 PCR test-kits from the Alibaba Group based in China and another 20,000 from China.
Some experts have suggested that as part of the exit strategy, it would be crucial to establish RT-PCR testing for the community.
This is justified by the strong argument that the “only” test with which a person infected with COVID-19 who can spread the disease in the community, can be confirmed is the RT PCR test.
However, the RT-PCR test is only 60% sensitive and whether it becomes positive is dependent on the viral load at the time of sampling, where the sample was taken from and the skill of the person taking the sample, one expert explained.
A person without symptoms may have to be tested repeatedly to find out whether he/she is infected or not, ideally on three occasions at 7-day intervals, especially if there is a history of contact with a COVID-19 PCR positive person. This is why it is important to establish RT-PCR testing services for the community, the source said.
Others cite Taiwan as a successful model where, as of April 13, 47,215 tests (around 2,042 tests per million population) were carried out in which 393 patients were detected. In comparison, Sri Lanka, has carried out only 4,525 tests up to that time (around 217 tests per million population) and detected 217 patients.
Therefore, there is an urgent need to increase Sri Lanka’s testing capacity by 10-fold or more, they state, explaining that while the existing hospital-based laboratories cater to hospitalized patients, it is necessary to establish a laboratory for the community.
They suggest that it could be done by consolidating the unutilized laboratory equipment available in hospitals and universities and mobilizing scientists and laboratory technicians in hospitals and university laboratories into one laboratory. Thereafter, walk-in or drive-through sample collection centres could be set up in the community.