• Accurate tracing and data collection needed: GMOA

By Sarah Hannan  Sri Lanka is riding its most aggressive wave of Covid-19 infections with last week’s numbers climbing by nearly 3,000 cases; the number of positive cases reported on 22 October stood at 6,287, and by last Wednesday (28), it stood at 9,205.  The Government is continuously reassuring the public that there will not be an islandwide lockdown at this point, stating that while only selected areas would be isolated, some areas would allow restricted travel whilst quarantine curfew over the weekend will be implemented in other areas.  With the bulk of the cases reported within the week being from in and around the Western Province, after the Peliyagoda Fish Market cluster was detected, quarantine curfew was imposed in the Western Province from midnight last Thursday (29), and will continue until 5 a.m. tomorrow (2). 

Home quarantine and halfway centres alternatives? 

Ministry of Health Chief Epidemiologist Dr. Sudath Samaraweera, speaking to The Sunday Morning, stated that considering the rising numbers, the placing of first contacts of persons who tested positive for the virus had to be reconsidered.  “We are understanding the shortcomings of sending all the people to quarantine centres after the recent clusters and subclusters were detected. A more community medicine-based approach needs to be looked at rather than a military method,” Dr. Samaraweera explained.  While asking persons to quarantine at home could work, there are also instances where those asked to quarantine at home might not be able to follow the set guidelines; meanwhile, some might not have the means to home quarantine either. To address such instances, Dr. Samaraweera suggested establishing a halfway centre that can hold persons under observation before they are sent to quarantine centres or referred for immediate medical attention to state or private hospitals, so as to reduce the risk of healthy persons getting exposed to carriers of the virus.  “The situation was overwhelming over the past two weeks, as the health services were stretched thin, given the limited workforce and equipment made available. The health of several hospital staff and frontline support staff was compromised and they were sent to be quarantined or were admitted to hospitals after they either tested positive or were exposed to a high-risk group,” Dr. Samaraweera added.  While dwindling bed capacities can become an issue, halfway centres will reduce the overcrowding as even asymptomatic persons can be monitored throughout, which would reduce the virus from spreading further, he said.  “Not all are in critical stages, and if we place everyone in the same building, regardless of whether they are identified as low or high risk, we are compromising the health of those who could recover within a shorter period of time.  “Categorisations based on the severity of the virus should also be taken into consideration going forward, so that those who are in critical condition and in need of special care can be referred to the relevant institutions without delay, and in turn, the necessary beds can remain vacant at Intensive Care Units (ICUs) that are equipped with all the gear needed to treat their conditions,” Dr. Samaraweera noted. 

Accurate surveillance needed 

Information is not being communicated clearly and accurately by the local authorities, with instances where a statement issued one day, is corrected or amended the next.  It would seem the administrative mechanisms and operations of the country are once again readjusting to restricted movement and increased levels of social distancing.  Added to that, state and private institutions, including those running state hospitals and quarantine centres, seem to be clambering to ensure adequate bed capacities and room availability in their bid to manage space constraints.  As the severity of the pandemic in Sri Lanka is increasing, having spread to over 20 districts, the Government Medical Officers’ Association (GMOA) last week noted that case mapping was being done inaccurately, as every detection was filed under the cluster name.  Meanwhile, the GMOA also shared some suggestions with Minster of Health Pavithra Wanniarachchi, the Secretary to the Minister of Health, the President’s Secretary, and the Director General of Health Services, whilst also writing to the World Health Organisation (WHO) Country Representative for Sri Lanka to collaborate with them and provide technical guidance to design and introduce a well-established data surveillance system to prevent the spread of the disease.  GMOA Secretary Dr. Senal Fernando noted: “We are extremely disappointed to note that patient mapping is not performed up to expected standards, especially due to the failure of the Epidemiology Unit to share the necessary data with relevant parties.  “We have therefore developed a digital surveillance platform that will include GPS mapping of patients and contacts under GN (grama niladhari) divisions, real-time PCR-positive data from all government and private laboratories, and details of close contacts.” 

GMOA’s methodology on quarantine and zonal lockdowns 

The GMOA also made recommendations on the quarantine process, which is currently outsourced to the military and operating under the technical guidance of the health sector.  “Considering the current trend of increasing numbers of people detected and sent for quarantine, with the majority being identified as asymptomatic, and the development of more case detection and exclusion facilities, we suggest redesigning the quarantine policy to optimise the available resources,” Dr. Fernando elaborated.  He added: “Exploring all types of case detection facilities to diagnose as well as to exclude Covid-19-safe persons is vital; with a criterion to be followed for selecting individuals for quarantine facilities.”  Following are the GMOA’s recommendations:  Individuals can be selected for quarantine as follows: 

• Based on age/exposure level/disease conditions/symptoms/risk factors/social background/foreign immigrant status/PCR test result/first or second contacts 
• Classification of quarantine facilities based on location, individuals admitted to each centre, and presence and absence of facilities 

Centres to be classified as: 

• Level I:  Institutional quarantine – hotels, camps, rehabilitation centres 
• Level II: Home quarantine under strict supervision 
• Level III: Home quarantine which is less stringent 

He stated that treatment should be based on guidelines according to patient risk categories, symptoms, risk factors and comorbidities, complications, and in keeping with proposed treatment facilities (Level I, Level II, Level III).  Criteria for selecting individuals for treatment facilities are as follows: 

• Based on age/exposure level/disease conditions/symptoms/risk factors/social background/foreign immigrants/PCR test result/first or second contacts 
• Classification of treatment facilities to correspond to the risk levels 

The following actions could be carried out in each zone (red/yellow/green) based on governance, maintenance of the supply chain, and plan of implementation: 

• Zonal lockdown 
• Zonal governance and maintenance 
• Zonal exit (moving from a red zone to green) 

The GMOA hopes this new methodology will facilitate the ongoing Covid-19 prevention operation to effectively face the new challenges posed during the recent past in Sri Lanka.  It also added that the current mechanism of contact tracing, testing, and awareness should be carried out more efficiently and systematically based on scientific evidence with a multi-sectorial approach.