When asked by the Sunday Times about various allegations of corruption being made against the Health Ministry, Dr. Hemantha Herath said that the accusers should come forward with evidence, so that action could be taken against whoever was corrupt.

It would, however, be very unfair to make baseless allegations when the ministry is battling a major health crisis faced by the country, he added

The deaths at home

With many expressing concern over COVID-19 deaths of several people while at home, Chief Epidemiologist Dr. Sudath Samaraweera said that some of them were in self-quarantine.

The others were not in self-quarantine owing to the huge number of cases that have been reported, he said, explaining that this is due to this wave being triggered by a different strain to what has been circulating earlier. The transmissibility of the virus from person to person is very high, the viral load is high and there are different complications arising in the infected.

“Due to the high number of people infected, there is a possibility of some cases not getting detected on time. In these instances, they may test positive for COVID-19 after death,” said Dr. Samaraweera.

Health personnel capacity

Conceding that health personnel are “definitely” overwhelmed and they are working round-the-clock, he said that it is still manageable.

He added: “On Thursday, we performed testing in the Colombo Municipal Council (CMC) area and most cases are popping up from there. This is due to the congested housing environment, making transmission fast. When we detect cases we put them under quarantine. But some of the cases were not detected on time because people in this area have other illnesses as well.”

Referring to health personnel who have contracted the virus, Dr. Samaraweera said that almost all of them are linked to either the Peliyagoda fish market or a positive contact from the current clusters and not due to their work in the healthcare setting.

According to the Government Medical Officers’ Association (GMOA) 50 healthcare personnel have been hit by the virus.

Advice to the public

“Even when the curfew is lifted, stay home as much as possible. Come out of your homes only if there is an urgent need or if you have to go to work. Do everything that can be done remotely or online,” said the Chief Epidemiologist, urging especially the elderly and those having chronic diseases to stay at home and manage their diseases well.

If you leave your home, maintain social distance, carry out hand-hygiene, wear the face-mask and don’t touch your eyes, nose or mouth, he said, adding that this is the only way to stop the transmission of the virus.

Blood clots triggering heart  attacks: New complication seen in SL

The different complications manifesting this time round in COVID-19 patients are what the Sunday Times discussed with Consultant Physician Dr. Eranga Narangoda attached to the Homagama Base Hospital.

“Cardiac deaths (through heart attacks) are being seen in this second wave that we did not experience in the first wave,” he said, pointing out that even though blood-clot problems were recorded in other countries earlier, Sri Lanka did not have such issues then.

Comparing the deaths in the two waves, he said that in the first wave there was just 1 death due to a heart attack out of 13 deaths, while in the second wave there have been 5 deaths due to heart attacks out of 17 deaths.

This Physician who is treating COVID-19 patients said that the majority of deaths in the first wave occurred due to bad COVID pneumonia.

But with a new strain of the virus in the second wave, more people are being hit by vascular complications – clots forming in the arteries and veins. When these clots affect the coronary arteries (the vessels taking blood to the heart muscle), they get heart attacks, sometimes even before they get COVID-19 symptoms and complications such as pneumonia.

“Therefore, we need to watch out for other complications such as strokes (clots affecting the brain) and clots in the legs (deep vein thrombosis or DVT),” he pointed out.

Dr. Narangoda urged people to get themselves tested through an RT-PCR test if they have had contact or been exposed to a possible COVID-19 infected person. The test would be vital if there is fever, dry cough, sore-throat or shortness of breath.

NMRA registration of rapid antigen test kits

The National Medicines Regulatory Authority (NMRA), after following due processes including technical evaluations, has registered two rapid antigen test kits in the past few weeks, the Sunday Times learns.

This comes on the heels of a decision by the Health Ministry that rapid antigen test kits have a role to play in the screening, contact tracing and surveillance efforts linked to the COVID-19 crisis, an NMRA source said, explaining that the gold standard for diagnosis of COVID-19 is RT-PCR testing.

Both the rapid antigen test kitsare pre-qualified by the World Health Organization (WHO). The agent in Sri Lanka for both these kits is the same pharmaceutical company. Of the two varieties of rapid antigen test kits, one is being manufactured by the US company Abbott Diagnostics and the other by SD Diagnostics in South Korea, it is learnt.

The Sunday Times understands that the WHO has secured 120 million rapid antigen test kits for distribution among low and middle income countries. Sri Lanka is due to get the first donation of 100,000 kits (of 500,000 kits) of the South Korean variety tomorrow (Monday).

“These tests provide reliable results in about 15-30 minutes rather than hours or days, at a lower price with less sophisticated equipment,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus has said.

Children are not being kept alone

As Sri Lanka faced the second wave, the Sunday Times looked at ground-level logistics in taking positive people to either hospitals or intermediate care centres.

Many distraught people feared that children would be separated from their parents especially their mothers, while others were concerned that they would be taken far away from home.

Several Medical Officers of Health (MOHs) assured that mothers would be given the option of taking small children with them. The system was for each MOH area to await the list of positive people in their areas, telephone each person and tell him/her to be ready with a bag packed to be taken to these institutions. Thereafter, an ambulance would go around picking them up.

Some MOHs conceded that depending on the number of positive people in their areas, the ambulance could get late and sometimes arrive at homes in the night.

“There may have been some issues earlier, but we are trying to correct these,” one MOH said. Gradually, the processes were being ironed out, the Sunday Times learnt, with many who were in intermediate care centres confirming that they were comfortable and had adequate food and facilities.

“Our first RT-PCR tests were taken on October 5 and we were asked to go home. Then on the same day we were asked to be ready and I was taken to a Galle quarantine centre by the police and the army, while my family was taken to one in Matara,” said Deepika Ranasinghe (39), an employee of the Brandix apparel factory in Minuwangoda, who lives in Marapola with her 40-year-old husband and four children – three sons and a daughter aged 19,11, 9 and 15 respectively.

Things happened quickly thereafter – the Marapola Public Health Inspector (PHI) had called her on the night of October 7 to inform her that she was positive and to tell the army that.

In the quarantine centre, there were three others who were also Brandix employees. When Deepika tested positive, she was isolated from the others. Around 12.30 p.m. on October 8, she was taken to the Neville Fernando Hospital with seven other patients, treated and discharged from there on October 25, after which she went home.

“Army eka apita hondata salakuwa. Kisi prashnayak  thibbeh na,”she said, explaining that the army treated them well.

Her nine-year-old son who was in quarantine tested positive on October 28, even though his first test was negative, and was sent to the Minuwangoda Hospital so that she could stay with him.

“On November 1, a vehicle was sent to take me to the hospital accompanied by two PHIs, while my son was transferred from Matara to Minuwangoda by the army,” she says.

Deepika says that although they have no physical contact at the hospital as they are being kept in isolation, her son has the comfort of having her close by.

The other members of her family are now at home having completed quarantine at Matara but are in home quarantine till November 15.

(See the statement of the Human Rights Commission of Sri Lanka on the quarantining process)

Don’t forget the Ruweenas, Fathimas, Parameshwaris….  in our midst

The new normal set off by the COVID-19 pandemic has wrought drastic changes in the lives of many, especially pushing daily wage earners further into abject poverty.

S. Parameshweri and her family

The Sunday Times looked at the hardships faced by hundreds of daily domestic workers who usually fan out from the numerous wattes dotting the city, to toil in the homes of the affluent and get back home to feed their families with the wages they earn.

Living a hand-to-mouth existence, these domestic helpers, mostly women, are unable to earn a living not only due to the curfew but also due to fears of their employers that they would bring the virus into their homes.

Ruwani (35) who lives in the shanties off Torrington Avenue has been home without work since the beginning of October. She has three teenage children and her husband who is a trishaw driver has been off work, having fallen off a tree and injuring his back.

During the first wave she was stuck at home, as unlike many others she does not own a mobile phone and her employer in Kohuwela had not been able to contact her. Many a day, the family would have plain tea as starvation took over their routine.

The tales of these women living in penury being similar do not take away their heartrending tragedy.

Still recovering from the first lockdown, Fathima Zulfika who lives in the Lakhiru Sewana flats, Maligawatte, was struggling to pay her electricity and water bill arrears of Rs. 59,000 little by little, when the second wave and its consequences hit.

Some of her neighbours have had their water and electricity disconnected and Fathima who had been working as a maid in several households fears a similar fate along with having no food on the table.

Ruweena and her granddaughters

The family is in dire straits. Her husband Jiffry who is over 60 has been chucked out of his job by his employer on account of his age and her eldest son, a trishaw driver, is now sitting idle at home.

“My youngest son who is 17 is looking for a job but there is no work,” says Fathima who is also looking after her eldest son’s wife and child.

Desperate, Fathima prepared food and sold it to her neighbours but more and more people requested food on credit and she has not been able to continue even this business.

For a very long time, she and her family have not had three meals a day and whenever they do get some food they share it with the neighbours as they cannot bear to see the next-door children starve.

Those four little girls, aged nine, seven, six and three, are being looked after by their grandmother Ruweena, while their mother, a divorcee is the sole breadwinner, earning just Rs. 250 per day, pasting paper bags. Now she too is unable to sell those paper bags.

“We can barely give the children anything to eat and sometimes we starve,” says Ruweena, hoping against hope that someone would drop by to give them even basic essentials such as rice and dhal.

S. Parameshwari, a seamstress at a small tailoring shop, also faces the same plight. Her home down Arunodhaya Mawatha, Rajagiriya, is shared not only with her husband but also her elderly mother, daughter, son-in-law and grandchild.

Caught in the vice-like grip of paying interest on loans she took during the earlier lockdown, now she is looking into an abyss of more debt and starvation.

Parameshwari’s husband who worked part-time at a factory is out of a job now and her son-in-law who was employed at an educational institute also has no work.

“It is a constant struggle to make ends meet,” she sighs.

For Ravi, living in the Kirullapone slums, who goes from home to home to clean them from top to bottom, there has been no work since the Minuwangoda cluster began.

His wife is ill and so is his mother and he is close to tears when he says that he has come to the end of his tether.

Just a few tales of sorrow and starvation, representing many more.

“Being at CT Level 3 along with the current virus mutation strain D614G which has a high viral load and high transmissibility is extremely worrisome,” he says, stressing that the outcome could be more deaths in the coming two weeks.

Dr. Haniffa reiterates that the health authorities should have been looking for what was there and not what they wanted to be there. They should have told the decision-makers what has to be told and not what the decision-makers wanted to hear.

His suggestions are:

• The whole campaign against COVID-19 should be more health-centric with other stakeholders being called in when and where necessary.
• Testing needs to be ramped up even now, as it is inadequate to perform only opportunistic testing.
• There should be real-time updates on where the cases are. This information should be shared with the public so that people can take their own precautions of not visiting the affected areas.
• The whole country should not be shut down but depending on the threat posed by the virus, local shutdowns should be carried out.

According to the WHO, the CT classification is now divided into four levels – from low incidence (CT1) to very high incidence (CT4). The classification is:

• No (active) cases Imported/sporadic cases
• Clusters of cases
• CT1: Low incidence of locally-acquired widely-dispersed cases detected in the past 14 days
• CT2: Moderate incidence of locally-acquired widely-dispersed cases detected in the past 14 days
• CT3: High incidence of locally-acquired widely-dispersed cases in the past 14 days
• CT4: Very high incidence of locally-acquired widely-dispersed cases in the past 14 days

Meanwhile, adding his voice to the clamour for more testing, Dr Ravi Rannan-Eliya of the Institute for Health Policy said that increasing RT-PCR testing reduces COVID-19 transmission.

“In combination with contact tracing and isolation it is probably the most effective intervention we have to control the virus…..the most important gap in our current strategy that we need to fix, remains PCR testing,” he said, adding that the increasing numbers of deaths in the past few days is a sign that the outbreak may be larger than our current constrained PCR testing is able to track. “As many of us warned six months ago, we needed to ramp up PCR testing capacity and routine testing to keep the virus at bay and prevent future outbreaks,” he said.

The global COVID-19 pandemic has caused a catastrophe to mankind, both economically and biologically. When looking at every confirmed 100 cases there is a 2.6-person risk of death. However, the Infection Fatality Ratio (the mortality rate in all infected including symptomless cases) ranges from 0.2% to 0.7%. As such, for every 1,000 who get infected, there is a chance of 2 to 7 people dying.

In Sri Lanka, at the time of writing, there were 8,413 confirmed cases inclusive of symptomless people, with 16 deaths. This gives a mortality rate of 0.1%. Therefore, when looking at the statistics analytically, Sri Lanka’s Infection Fatality Rate approximates other countries.

Sri Lanka’s main strategy-focus is to keep the country free of the dreaded community spread. The state has taken the responsibility of isolating and supporting the total mass of contacts – RT-PCR positive symptomless people, people with mild disease and people who need clinical care.

This objective calls for zero probability of human error. This task requires a foolproof methodology that should be sustained for the entire span of the global epidemic, which is expected to run for at least two years. However, the lack of a herd immune response may delay it even to 4 or 5 years. The closure of borders for such a long time calls for economic independence and strength. The nation should be able to self-sustain its economy, society and COVID-19 management strategy isolated from the rest of the world for such a period.

What Sri Lanka has left out of its strategy are the concepts of risk management and resource management. It is a theoretical probability that the state could chase all the contacts and cases for such a long time with 100% efficiency. But the sustenance of such a system needs total isolation of the country to keep the work at a manageable level. Then it would be counter-intuitive to reboot the economy.

With these firm views, the system seems to have forgotten how it should adapt if and when community spread occurs. When looking at resource management, it is obvious that the isolation camps have exceeded capacity and the hospitals are full. The decision to begin home quarantine of first contacts following such saturation suggests that the state has not thought ahead of events. The next point of saturation would be sending RT-PCR positive but symptomless people home, leaving room only for symptomatic people.

However, commencing such programmes without forethought would create issues. The country has not devised a system for home quarantine. Home isolation calls for the requirement of protection of the risk population. According to the numbers seen so far, many people will not even notice that they have the disease.

But when the virus sweeps through the population, it will cause the death of people in high-risk categories. Therefore, it is this ‘risk population’ that needs strong attention at this moment.

The country has a social and administrative framework, with management cells at the grassroots to devise an excellent system.

This system is to have COVID-19 preventive and management cells, comprising the area’s GramaSevaka, Medical Officer of Health (MOH), police and low-risk volunteers, at the level of the GramaSeva units. These units could be linked to a central control mechanism to ensure a coordinated strategy.

Preventing economic death

The popular method of preventing death in the COVID-19 pandemic is the imposition of quarantining and lockdown. However, this paves the way for recession and economic death.

Sri Lanka is facing imminent economic collapse due to an almost 100% debt to GDP ratio. Sri Lanka essentially needs a functioning economy in the face of shrinking foreign currency reserves.

The most rational way of preventing economic death is to balance the killer effects of the virus through controlled and graded quarantine while running the economy, similar to the western approach.

The slowing or shutting down of the whole of society ‘unselectively’ based only on the burden of the epidemic may be an illogical way of handling the outbreak. This approach is based on the hope that the world would find a treatment or effective vaccine shortly.  The most obvious driving force for such an approach, however, is the individual emotional response towards the deaths. Realistically, there would be some inevitable mortality in a natural phenomenon like a pandemic and the need would be to achieve the least mortality.

The risk of death & reverse quarantine

Global responders have forgotten the scientific evidence and the concept of a risk population. Currently, evidence shows that the majority of the deaths occurs in this population.

Therefore, a rational approach would be ‘reverse quarantine’ under which only the risk population, which is a minority of the total, would be quarantined when they do not have the disease. This risk population needs to be quarantined at domestic and social levels and when there is a requirement in isolation facilities.

The risk population should be educated and trained in the methods of prevention of the disease. There should be well-defined control measures designed for them. These protocols should include measures to be adopted at the domestic/individual domains as well as at the levels of the village, town, workplace and nation.

This would be the most effective way of saving people from death, while allowing others to carry out the usual functions of the society and economy.

However, it is vital not to undermine the importance of conventional control methods to keep infection rates among the non-risk population at a manageable level. Otherwise, it would have drastic effects like in Italy and Spain.

Epidemiological surveillance should be active all the time and total lockdowns should be implemented only when there is rapid spread.

Surveillance and resource management

As science cannot predict all risk factors for mortality, more research is needed to expand the predictive ability of the mortality risk. The surveillance of the non-risk population should be vigorous to identify the risk factors. It is also important to detect those who would need treatment as well.

In a pandemic of this magnitude, resource management is very important. The system cannot get overwhelmed by not having a focus on providing services. If the capability of the health system and economic powers is exhausted keeping non-risk people monitored and isolated from economic functions, what would follow is catastrophe. The state cannot exhaust its economy by feeding the non-risk adult workforce at isolation camps.

When the dynamics of the epidemic are set in society, mass isolation efforts would exhaust resources and inevitably lead to chaos. In such a scenario, the people at risk could fall through the system which could lead to uncontrolled mortality.

The surveillance of the epidemic pattern is important in predicting and detecting genetic mutations of the virus. In the 1918 influenza pandemic, the world saw a massive and lethal second wave which had completely different characteristics to the usual influenza. This is thought to be due to a genetic mutation. Such mutations could make non-risk groups slide into risk populations. Hence, continuous monitoring is essential to detect such patterns along with strategy revisions.

Numbers do not lie. The statistics of the current and 1918 pandemics show that deaths occur in a defined population.

Human civilization is a dynamic organism. It needs the economic lifeline to be alive. Individual emotional responses and poor resource and risk management can only do more harm than good to human civilization.