Respect!

People wearing protective masks are seen inside an overcrowded bus after the government announced curfew over the weekend, as the number of people tested positive for COVID-19 in the country increases in Colombo, Sri Lanka. (Reuters)

Let us start respecting the virus at least now. Boastful statements and media circuses will not get rid of it. No country has been spared. Bigger and more powerful countries than us have been brought to their knees by it. The countries and States that were held as lighthouses of COVID-19 control had to eat humble-pie within months.  

 
Swift and decisive action taken by the President, the Armed Forces, the Public Health and Hospital staff from March to June protected us. We should ensure that the economic hit that we have taken so far should not be in vain. What can we learn from the current outbreak and what should we do? Did it leak from the airport? Faulty quarantine? Introduced purposefully? Or is there a less dramatic, but a more concerning explanation?   

Looking at what happened elsewhere in the world can give us insights. In the initial stage, around March and April this year, there was an explosion of cases and deaths in many countries in Europe and in the US. Evidence is now accumulating that this virus started circulating in these countries three or more months before this happened. Even in initially successful countries such as Australia, New Zealand and Vietnam (including Sri Lanka), mostly unexplained eruptions of cases occurred after 2-3 months of no indigenous cases being reported.   

A conclusion that can be drawn from this is that the virus can circulate in the population causing no symptoms or causing minimal symptoms that people ignore for some time. This is borne out even in Sri Lanka where the vast majority of those diagnosed as harbouring the virus having no symptoms or minimal symptoms. Going by news reports, even though over 1,000 workers were infected in the factory at the epicenter of the current outbreak, only a proportion of them displayed symptoms, and only a handful needed hospital admission before it was diagnosed as COVID-19. 

When a sufficiently large number say 100,000 in a population is infected, everyone begins to see that it is here. When it reaches such a figure, even if only 1% need intensive care, there will be around a thousand in ICUs. If the mortality even as low as 0.1% (one in one thousand), one hundred people would have died. These figures are just for illustrative purposes and there are many technical aspects to consider and formulae to be used in such estimations. Mind you, official figures will not show the hundred thousand, because all of them wouldn’t have been tested.   For the virus to appear out of nowhere, the virus needs to be circulating in groups that will not show much symptoms, mainly in the younger and fitter people. When it reaches vulnerable groups, such as very old people or those with other conditions, we see hospitalizations. This is assuming that it is suspected and diagnosed in hospitals. We may have been very lax during the previous three months even on this. In some hospitals even sending a routine PCR sample for surveillance purposes created a major stir, which discouraged the process.   
A place where people work in relatively close quarters, regularly, for very long hours and then live in very close quarters in hostels, is an environment where respiratory viruses thrive. Overworked, tired and stressed employees who presumably posses less immunity would also make the virus very happy.   

Since we have not been shown of a convincing explanation on how this started, we should not be blind to other other possibilities. If it cannot be proved that the virus was not imported directly to the factory which is at the epicenter of the current outbreak, we have to consider if it was circulating in a small scale outside and suddenly found the ideal nesting ground. It is a very concerning possibility that we should look at carefully.   
However, we should also bear in mind that these conditions are ideal even for an accidental leak to this factory from faulty quarantine or any other way. This write-up is not intended to shift the culpability of what happened from anyone. It intends to look at other possibilities that we should guard against. 

  "Although there were no reported cases of non-imported COVID-19 in Sri Lanka for a relatively long period of time, there is the theoretical possibility that there could have been low-grade, asymptomatic or mildly symptomatic, and undetected chains of infection during this time."

If this outbreak originated at this premises, we are on much better grounds to control it than in the case of it coming inside from an active asymptomatic chain in the community. Although there were no reported cases of non-imported COVID-19 in Sri Lanka for a relatively long period of time, there is the theoretical possibility that there could have been low-grade, asymptomatic or mildly symptomatic, and undetected chains of infection during this time. The real-world sensitivity of the RT-PCR test for detecting the virus is 70-80%. It is much higher in controlled conditions.This means that it can identify 70-80 persons out of 100 persons that are actually having the virus in routine testing.   

So, for every 100 tested we will miss around 20. This is a crude generalization for explanatory purposes. The real technical aspect of this is more complex and nuanced and there are approaches to minimize this. Though a person is even tested three times, there is a statistical possibility of missing positive cases. Compounding this is the behaviour of the virus – the vast majority of those infected and capable of spreading it does not even know that they are infected.   
By mid July, the country started working as before, public events were in full swing, and the usual unacceptable overcrowding of public transport and public offices became the norm again. Mask-wearers were rare as wings upon cats. Shows and religious gatherings were the norm rather than the exception. Amidst this, the Kandakdu outbreak occurred in early July. By the second week of July, the election campaigns were in full swing. This was in the backdrop of infections linked to the Kanakadu cluster being identified in many parts of the country.   

If there were a few low-grade chains of infections around, however small and remote, the election campaigns (of all the political parties) would have been ideal foil for amplifying the spread. The campaigning in earnest began around July 20 or just before. Large public gatherings with minimal precautions were seen throughout the country. This sense of normality was broadcast unfettered in the media adding to the complacency.   
The Ministry of Health has gone on record that the symptoms began to appear in the affected factory around the September 20. The virus would have been in circulation in the factory since early September at least, for symptoms to appear by then. Early September is around 6 weeks (three incubation periods) from mid July. Theoretically, if the amplification of the spread occurred during the campaign period, this time line fits for an eruption to occur.   

Let us hope that this is not what really happened. If it is true, there can be many other yet-unseen, low-grade chains of the virus spreading without being detected. One more reason to wish that this is not the case is that permission was given quite recklessly to conduct the Book Fair. This attracted tens of thousands of people daily to gather in a relatively small area from September 18 to 27. All this time, the Minuwangoda cluster was raging undetected and infecting thousands. Many young people from all parts of the county mingled there daily and went back to their homes and hostels. There could have been many with the virus there, not knowing they had it. One can argue that the elections gatherings were local affairs, and if any chains were active these would be limited to their localities. This does not hold true for the Book Fair.   

If another amplification happened there, we will only see the results in mid to late November or early December. Hopefully if any chains were started or amplified during this period they will be detected through intensified surveillance that will follow because of current outbreak. Such chains will appear as unrelated, unexplained clusters, which we may be seeing even now.   

So what can be done now apart from the standard advise given to the public?   
First, we should start respecting the virus and bring down our ego several notches. Respect does not mean fear, spinelessness or subjugation.We have accepted that we were lax, which is an excellent start. We should also immediately start assuming that community spread has begun. This is the only way to prevent community spread if it is not taking place, or controlling it if it is occurring.   
Most importantly, we should demystify and de-stigmatize the illness. Those infected with the virus are not to blame. Those who had infected others at workplaces and weddings have done so unknowingly. They are victims. Victims of those responsible for controlling the virus, who took their eyes off the ball. Victims of lobby groups that kept pushing for loosening restrictions to keep profiteering as before.   

Public support will continue to dwindle if high-handed, uncaring and insensitive action continue to take place “against” such victims who are infected, and those who were exposed.   
If the economy is to be protected, we should not allow events or activities that can amplify the spread without giving much economic benefits. Some examples are sports, concerts, events such as weddings, parties and funerals, religious gatherings, university and other higher education activities, tuition classes, continued operations of saloons, spas etc. Each day that we procrastinate, is a day of joy to the virus. 

 
We should also seriously consider shutting down the entire epicenter area. There are thousands of more factories and millions of jobs outside this zone. We should not jeopardize all these by obstinately continuing as before within this zone, for a few to profit at the expense of many. Short term pain is much more preferable to long-term agony.   
We can minimize crowding in public transport as we did earlier. All institutions should have a business continuity plan – making sure all employees are not exposed at once to any person or group with the virus. Public and private institutions should not have to involuntarily cut down their activities due to unforeseen exposure of staff. It will be much graver than a controlled slowing down according to a plan, operating with minimum staff and dividing staff into groups. This is nothing new. We did all of this only a few months ago.   
There is more action that can be taken, although it may not be politically palatable or acceptable to businesses. The businesses that have made huge profits in the past, but refuse to pay their employees and pretend that they will collapse if closed for two weeks. 

 
We should also realize the less effective action. For example, most of the infected do not show symptoms. Therefore, checking temperatures (even correctly) has only a small protective value although it has a large symbolic value.   
Through all this, we have been shown very clearly that people should be treated as people. Not “human resources”. Resources are there for exploitation for profit. This is exactly what seems to have happened at the epicenter. It may still be happening. If the workers were treated as humans, this outbreak would have been detected much earlier. Things would have been back to normal by now.