Is Sri Lanka showing symptoms of a third wave?

PCR testing, machine malfunctions and less surveillance

Even though vaccination drives have begun to immunise healthcare workers against COVID-19, the general public is yet to receive their doses. While the World Health Organisation and Sri Lanka’s allies have promised to donate more vaccines when people would have access to these vaccine remains a doubt. On the other hand the number of positive cases are once again on the rise and the number of deaths too has been significant over the past few days. Although we have now learned that controlling a pandemic is no easy task, many wonder how the situation worsened from a properly controlled first wave at the onset of the pandemic last year. 

"Vaccination will not have an immediate impact as it would take 2-3 weeks after the second dose is given for the vaccine to be fully effective"

Machine malfunctions and pandemic mafia 

“There has to be public and social measures to control COVID-19, but the Government doesn’t seem to be doing any of them as of late,” opined All Ceylon Medical Officers Association Secretary Dr. Jayantha Bandara. “One of the first steps is to have border control. PCR tests should be done on all passengers who arrive in the country and they should be sent in for a two weeks quarantine period. But this didn’t happen during the past few months and we saw how the Ukrainian tourists were touring the country. The second step is to do mass scale PCR testing within the country. We have to accept the fact that we are now at the community transmission stage even though the Ministry of Health and the Epidemiology Unit keep on denying it. How can we do PCR testing when the machines are not functioning properly, we are short of reagent supply and laboratory facilities?,” he questioned.
“As per the Government statistics less than 1000 positive cases are being reported daily. But we do not know if these are actual figures. Even to do surveillance, we are lacking human and physical resources. Another concern is the ICU bed capacity. When positive cases are admitted to hospital they have to wait in line because the bed capacity is full. The government doesn’t seem to be having any plans to expand these facilities,” he added. 
Speaking about social measures Dr. Bandara further said that people need to continue with adhering to safety precautions. “If the police see people standing less than one metre apart people will be fined, but is there a mechanism for social distancing in buses and trains? Fining is easy, but necessary infrastructure needs to be in place if people are to follow safety precautions,” he said.

"Several of the vaccines also are not recommended for people who have serious illnesses"

Dr. Bandara further said that people should ignore myths that are being spread about various COVID cures. “A pandemic is a socio-economic and political issue. Many countries that have followed scientific approaches are controlling the pandemic well when opposed to countries that are promoting myths. The pandemic also made many businessmen richer as they have found a market for Rapid Antigen Kits, PCR Kits, masks, hand sanitizers and other essentials people need on a daily basis. They have in fact created a mafia out of the pandemic. The ACMOA has repeatedly said that we need to eliminate COVID-19 and to do that the Government should arrange the funds to achieve this goal.” said Dr. Bandara. 

"Nurses don’t have a break and the authorities are facing a situation where their services are required 24/7"

No break for nurses

“Healthcare workers are at risk and even though we have made several requests the authorities have turned a blind eye to them,” said Public Service United Nurses Union President Ven. Muruthettuwe Ananda Thera. “The virus seems to be spreading fast and many people are testing positive. Nurses don’t have a break and we are facing a situation where their services are required 24/7. But if the authorities don’t pay attention to our requests we would have to opt for trade union action.” said Ven. Ananda. 

"Since all PHIs have been deployed for COVID Control they are unable to attend other duties"

Heavy workload of PHIs

“The virus has not been controlled and cases are being reported from the community,” opined Public Health Inspectors (PHI) Union President, Upul Rohana. “There have also been instances when PCR reports have been delayed and misplaced. When patients are being discharged after quarantining there’s no proper mechanism to send them home. Many return home by bus and PHIs have been asked to arrange transport facilities as well.” said Rohana.

But since all PHIs have been deployed for COVID Control they are unable to attend to other duties.  They are working day and night and haven’t even been paid for working overtime. We also have a limited cadre and have made formal requests to increase it by another 1000 PHIs. But we are awaiting a response from authorities,” he added. 

"The bed capacity is also full, but what are the alternatives?"

Priorities neglected 

Although Sri Lanka controlled the pandemic outbreak during its first wave to a greater extent the onset of the second wave posed bigger challenges. “The government is trying to show that it has controlled the second wave because it has started vaccinating people,” opined Government Medical Laboratory Technologists Association President Ravi Kumudesh. “But in reality, PCR tests that were carried out at government institutions have been neglected. Some machines are not working. There are three extraction machines at the Bandaranaike International Airport, but there are no reagents to carry out testing. So the samples taken from passengers go to a different lab and samples from people in Galle, Badulla and other areas come to the lab at the BIA.” said Kumudesh. 

“The number of people testing positive is greater than the number of people recovering. The PCR testing network doesn’t function properly. There are more cases in the community. I believe that we controlled the virus when we had limited facilities. The bed capacity is also full, but what are the alternatives? However, they are trying to show that the situation is under control,” he added. 

“ Death usually occurs 2-3 weeks after infection, so it would take much longer for this to show up in deaths. The percentage of the elderly population who are most at risk of death who have been vaccinated so far is very small anyway. Vaccinating critically ill patients with COVID is useless”
- Director at Institute of Health Policy, Dr. Ravindra Rannan-Eliya

Voicing his concerns on the vaccine and its registration process, Kumudesh further said that it would take at least another two years to vaccinate all people. “Although the World Health Organisation claims that the Pfizer vaccine is the best option, why did the National Medicines Regulatory Authority (NMRA) register the COVISHIELD vaccine? If the WHO is going to donate 50 million COVAX vaccines why are they claiming that it’s going to be expensive? It is a donation after all! So we observe a double standard in the registration process as well. On the other hand the validation and verification actually means checking on the labels and expiry date. Therefore they are not really testing the contents in the vaccine,” he explained.

Kumudesh further said that right now the vaccine is only being administered to healthcare workers. “There’s a speed at which the vaccine will be manufactured. One must also keep in mind that healthcare workers would be immunised only when they receive the second dose. For that it would take another six months or so. The airport is also open and tourists are arriving. This means there will be new strains. When we ask MOH for a Next-Generation Sequencing machine they said it’s not necessary. The virologists themselves are not interested in bringing down a new technology and speeding up PCR testing. There are experts in molecular biology who’s knowledge could be utilised at this moment, but that too is not being done. Scientists in medical labs are not given the authority to take charge of the situation. With these kinds of agendas, we will soon be welcoming a third wave,” he warned. 

" Some institutions have also started their routine investigations apart from PCR testing and therefore the PCR testing rate has reduced. 
-State Minister Dr. Sudarshani Fernandopulle"

AstraZeneca vaccine not good enough to achieve herd immunity 

“Vaccination will not have an immediate impact as it would take 2-3 weeks after the second dose is given for the vaccine to be fully effective,” said international medical researcher and Director at Institute of Health Policy, Dr. Ravindra Rannan-Eliya. “Death usually occurs 2-3 weeks after infection, so it would take much longer for this to show up in deaths. The percentage of the elderly population who are most at risk of death who have been vaccinated so far is very small anyway. Vaccinating critically ill patients with COVID is useless - vaccines only prevent infection, after you have been infected it is too late. I also doubt that the vaccines have been cleared for people critically ill with other disease - the clinical trials were done only on small numbers of mostly health people. Several of the vaccines also are not recommended for people who have serious illnesses. Even if we vaccinate 100% of people, some people will still die since the vaccine is not 100% effective (70% in case of COVISHIELD), and since transmission will increase if we relax restrictions after we vaccinate, unless we can get to zero cases.” Dr. Rannan-Eliya said. 

He further said that right now the best vaccines are Pfizer (95% efficacy in preventing the illness), Moderna (94%) and Gamaleya Sputnik (92%). “These are the only vaccines currently able to achieve herd immunity if Sri Lanka imports one of the new more infectious variants, such as the B117 variant that an English cricketer had. AstraZeneca is not good enough to achieve herd immunity, plus it also performs worse than the other three against some other variants. The AZ conclusion that it is not good enough to achieve herd immunity with B117 or other new variants has also been made independently by all the expert groups in the UK plus the UK Government’s Scientific Advisor, so this is not just my conclusion.

“ The second step is to do mass scale PCR testing within the country. We have to accept the fact that we are now at the community transmission stage even though the Ministry of Health and the Epidemiology Unit keep on denying it”
All Ceylon Medical Officers Association Secretary 
Dr. Jayantha Bandara"

“If I were the Government and want to relax borders I would obtain either Pfizer, Moderna or Gamaleya. AZ/Sinovac are not good enough. Pfizer/Moderna are more expensive than Gamaleya and need ultra-cold storage. So if I was the Government, I would purchase Gamaleya for 70% of the population to supplement the AZ supplies from COVAX. Only after vaccinating everyone would I open borders - this is the strategy also in countries that have the best COVID response such as Australia, Taiwan, etc.” said Dr.Rannan-Eliya. 

“However, good our treatment is, the reality is that two to six persons out of every 1,000 infected with the virus will die. Please note that the number infected is much greater than the number of reported cases, since not all infections are detected. The only way to prevent anybody dying is to kill the virus completely. That means going for zero local cases as we had for several months after May. This is how Australia, New Zealand, China, Taiwan, Vietnam, Cambodia, Thailand, Singapore are all avoiding deaths. Zero cases means ‘Elimination’. The official National COVID Strategy still says Elimination is the goal, and the President’s vision is to prevent outbreaks. So to ensure everyone’s safety, our leaders need to exercise leadership by ensuring that all parts of government implement the President’s Strategy and Vision on COVID.

 
To do that the one thing that needs to be addressed is the level of PCR testing, which is too low to bring this outbreak under control. As our research team has shown, the key intervention that explains why some countries succeeded is testing. As long as our testing remains inadequate more people will die every day. To stop this outbreak, we need to be doing 50-70,000 tests a day, or 4-5 times current rates,” he advised. 

“There have also been instances when PCR reports have been delayed and misplaced. When patients are being discharged after quarantining there’s no proper mechanism to send them home. Many return home by bus”
-Public Health Inspectors (PHI) Union President, Upul Rohana

Matters to be rectified soon

When contacted State Minister of Primary Healthcare Services, Pandemics and COVID Prevention Dr. Sudarshani Fernandopulle said that the PCR testing lab at BIA has been temporarily closed after six staff members tested positive for COVID-19. “They were doing a great service and even went out of the way to deliver test results,” she said.  She also said that there’s a slight reduction in PCR testing since machines have been working continuously. “Some institutions have also started their routine investigations apart from PCR testing and therefore the PCR testing rate has reduced,’’ said Dr.Fernandopulle. Approximately 15,000 PCR tests are being done daily in the government sector and around 3,500 tests are done by the private sector. A new lab was opened in Kegalle yesterday. 

Following a discussion, private laboratories have been advised to streamline their services in terms of improving quality so as to avoid pooling of samples.
Responding to a query on bed capacity, Dr. Fernandopulle further said that the situation is manageable as people are being discharged daily. “The discharge criterion was reduced to 10 days for asymptomatic people.”
When asked why only the AstraZeneca vaccine has been registered so far she said that only the AstraZeneca vaccine has met NMRA’s documentation criteria. “Thereafter the NMRA registered the vaccine for emergency purposes. The documentation process is the only issue. If the other two vaccines also produced all documentation then they too will be registered.” she said. 

COVID-19 vaccine given to military personnel. Pic - Kithsiri De Mel