By Kalani Kumarasinghe

The leaders of Sri Lanka's battle against Covid-19 came together for a panel discussion at Wijerama House, headquarters of Sri Lanka Medical Association to review Sri Lanka’s journey in containing the coronavirus outbreak. Head of the National Operation Centre for Prevention of COVID-19 Outbreak (NOCPCO), Army Commander Lieutenant General Shavendra Silva, Director General Health Services Dr. Anil Jasinghe and Chief Physician at the National Infectious Diseases Institute Dr. Ananda Wijewickrama discussed Sri Lanka’s unique approach to tackling the disease and made important notes on challenges ahead. Moderated by Prof. Indika Karunathilake, President of the Sri Lanka Medical Association, the discussion was a part of the Asia-Pacific Academic Consortium for Public Health international webinar on Covid-19. Exceprts: 

Two-thirds of all Covid-19 patients in Sri Lanka show no symptoms

With the combining work of the Ministry of health, tri-forces, the police and other administrative structures, Sri Lanka has been able to control the spread of the illness to a reasonable extent, Dr. Ananda Wijewickrema who has been on the clinical frontline battling this pandemic said. “We are going at a flattened curve. At present, the Health Ministry's policy is to admit all the positive cases irrespective of their symptomatology (Symptoms characteristic of a medical condition exhibited by a patient) We can do that at the moment because we only have close to 700 patients in the country. That is an incidence of about 3 per 100,000,” he calculated. 

With over 20,000 Polymerase Chain Reaction (PCR) tests carried out and the number of tests being increased and widely carried out across the country, whoever tests positive for the virus, they are admitted to five specialized hospitals where positive cases are being treated. According to Dr. Wijewickrama, this is due to two reasons. 

“One is to monitor if they are developing symptoms and to detect early if these patients are getting any complications. The second reason is to isolate them and prevent them from spreading the disease,” he explained. “Because of the limited numbers at present we are continuing to do this,” However if the numbers increase, this strategy would have to be revised, he stressed. 

Interestingly, Dr. Wijewickrama noted that out of all the Covid-19 positive patients, two-thirds were asymptomatic, meaning that these patients have shown no symptoms of the disease. “We have a large number of asymptomatic patients. Maybe this is because of the higher number of testing we do in relation to the population numbers and maybe it is because of the quarantine facilities, as well as the contact tracing,” he ventured. 

Out of the symptomatic patients or patients who show symptoms, only 16 had been in critical condition. “Out of these, seven patients died. One patient died at the time of admission and another one couple of hours later,” he said. Meanwhile, the other five patients who were in critical condition were given intensive care treatment but unfortunately succumbed to the disease.

Hydroxychloroquine used for treatment

Dr. Wijewickrama said that Covid-19 positive patients in Sri Lanka are currently being treated with Hydroxychloroquine, a drug used in the successful treatment of malaria among other diseases. 
“When we started, we went through the available evidence. With the limited available evidence, the experts decided to give hydroxychloroquine to patients,” he said. “I know the evidence is very limited and other available evidence says there is no definite effect of this compared to other drugs, but still we continue to give that. In fact, we are in the process of analysing the response of the patients, the physical symptoms as well as the viral clearance of the patients who were given this drug,” the experienced physician said. 

In three severe instances, patients have been treated with convalescent plasma. “Health authorities are meanwhile in the process of collecting convalescent plasma and checking antibodies for future use if required,” Dr. Wijewickrema said. He was referring to a medical procedure used by doctors treating the novel disease worldwide

At least eight clusters reported in Sri Lanka

Dr. Anil Jasinghe, Director General of Health Services in Sri Lanka said that while most countries, especially in the West, approached the disease by aiming to control it, Sri Lanka tackled the outbreak in its own manner. “The main approach of many western countries was detection and treatment. All these countries in the East, even if you take Singapore or China, they attempted to do the same. In Sri Lanka, based on our strong public health system, we were able to harness the inert strengths,” he noted.  

Dr. Jasinghe said that there have been at least eight clusters reported in Sri Lanka since the outbreak of the disease. “We have had at least eight recognized clusters, and we have been able to sort of ‘finish-off’ those clusters. There were two very bad clusters among them, especially in urban areas. These were the clusters linked to the drug addicts etc. But even with those clusters, I believe we have been able to achieve success at least 90 to 95 per cent. Some of these clusters we have officially closed. They have a normal life going on in those areas,” he added. 

Dr. Jasinghe although was not willing to detail the intensive care capacities of Sri Lanka’s hospitals, assured that there were no issues in managing this outbreak. “We have no issue whatsoever with our treatment capacities. We have been incrementally strengthening capacities. We don't want to say how many ICU beds or how many hospitals are available, but I assure you we are ready for any number of cases,” he asserted. 

Dr. Jasinghe stressed that Sri Lankan health authorities’ objective is primarily to minimize the number of patients at the onset itself, instead of allowing the disease to progress and having to treat patients at hospitals. “We have been able to minimize the number of patients and even with the present-day clusters, we believe that with our strong public health system, we will soon be able to curtail the numbers.” Dr. Jasinghe attributes the success of Sri Lanka’s Covid-19 management in the public healthcare system’s ability to have overcome and wiped out several diseases in the past. 

Drug addicts, lumpens and beggars

The expert panel were in agreement when discussing the complexities of dealing with the population of various socio-economic levels in Sri Lanka. “With drug addicts or lumpens as we sometimes call them, our approach was different when it came to these groups. It's not discrimination but one has to detect and identify the problems of these various segments of society. This is where the army was very supportive,” Dr. Jasinghe said. 

“If you have a well-designed house, quarantine is possible at home. But we have areas where shanties with very poor socio-economic conditions. Dr. Jasinghe said that one particularly bad experience the authorities had to deal with was when Covid-19 positive cases were identified from two different slum areas nearby. “Even during the curfew people have been visiting each other as it is an enclosed area. On the other hand, they were different shanty outfits,” he recalled. 

Dr. Jasinghe said the authorities have taken measures to relocate beggars as a part of the country’s pandemic management efforts. “Beggars have also been taken to certain residential facilities where they are taken care of. Notwithstanding the socio-economic level, I think they have been treated well and they are given clothes and meals, their requirements have been well looked after. Even the special segments of society are well looked after,” he said. 

50 quarantine centres and over 50,000 in isolation

Head of the National Operation Centre for Prevention of COVID-19 Outbreak (NOCPCO), Army Commander Lieutenant General Shavendra Silva said the overall goal since the establishment of the task force in Sri Lanka was to prevent further spread and to contain the virus. “The tri-forces established more than 50 quarantine centres in Sri Lanka,” he said. 
 
However, this establishment has not been short of challenges. Lt. General Silva said the most challenging aspect of this process was to carry out contact tracing of Covid-19 positive cases. “We have extensively used the intelligence services to collaborate with the health and public administration services. Some people argued and questioned as to how the military can do this, but it was on the job training for us,” he said. 
 
“Contact tracing of the affected personnel remains the most important factor for containment. The intelligence services of the armed forces and the Police, with health authorities, were tasked to conduct contact tracing in to first, second and third tiers of the confirmed, suspected and exposed cases. Therefore, the quarantine process and the conduct of PCR testing were followed up as and when required,” he said explaining the unique approach taken by Sri Lanka to involve the military in efforts to contain the virus. 
 
According to the NOCPCO chief 51 quarantine centres have been established since the disease outbreak in Sri Lanka. “The uniqueness was that there was not a single spread from A to B within a quarantine centre,” he claimed. “More than 3900 were in quarantine centres as of yesterday and approximately about 58,000 were isolated in their houses through contact tracing,” he said.