Preparing for an exit strategy

PCR tests being conducted on vendors at Peliyagoda fish market

• In COVID-19 there can be three states-pre-symptomatic, symptomatic, or asymptomatic
• Those categorized as asymptomatic could truly be pre-symptomatic
• Follow all safety methods at once, all the time
• Don’t discriminate people based on religion or age 
• People still don’t adhere to basic safety measures

As people continue to be testing positive for COVID-19 health officials are keeping a close watch on the numbers. The number of PCR tests has been increased and random testing has begun.  However, identifying asymptomatic persons is a crucial step during this period because they are people who don’t develop any symptoms associated with the virus. Sometimes they could easily have symptoms that they would ignore.

It was also reported that those who returned from quarantine centres too have developed symptoms. As the government is preparing for an exit strategy, medics believe that adhering to safety measures is a matter that shouldn’t be taken lightly anymore. 

Identifying asymptomatic persons

“The meaning of the word “asymptomatic” is that a person is without symptoms that can be attributed for that particular disease, in this instance COVID 19,” explained Dr Neranjan Dissanayake, Consultant Pulmonologist at the Ratnapura Teaching Hospital.

“Let me elaborate it a bit. As we know, any disease manifests as changes in the normal physiology causing abnormal physiological presentations. With regards to COVID 19, the major symptoms (i.e.: abnormal physiological manifestations) are fever, cough, sore throat and shortness of breath, among many others.
“In COVID 19, unlike in a majority of other diseases, there can be three states, depending on whether he can transmit the disease, while having symptoms (symptomatic transmission), before the onset of symptoms (pre-symptomatic transmission), or without developing symptoms whatsoever (asymptomatic transmission).

Symptomatic transmission: Most epidemiological and virology studies show that COVID 19 is transmitted by persons with symptoms, to people who are in close contact with them through respiratory droplets, contact with contaminated objects/surfaces or by direct contact.

Repeated testing of biological samples from confirmed patients has shown that it is in the early course of the disease that the shedding of the virus is highest, mainly from the nose and throat. This usually happens within the first three days of onset of symptoms. Hence, patients will be more contagious around the time of symptom onset than later in the disease process.

"The WHO, reports only of a very few cases of asymptomatic transmission, mainly among close contacts, but various scientific publications, gives a wide range, from 5% to 80% of the total COVID 19 patients
- Dr. Neranjan  Dissanayake"

Pre-Symptomatic transmission: Usually it takes about 5 to 6 days to develop symptoms after you are exposed to the SARS-Co V 2 virus, which causes COVID 2019; i.e. the incubation period. But in some people, the onset of symptoms can be delayed to up to 14 days. Of those with this delayed incubation period, some can shed the virus and can become positive for COVID 19 before any symptom occurs, usually 1 to 3 days before symptom onset. Hence, they can be infective before the onset of symptoms, but they will be symptomatic eventually.

Asymptomatic transmission: In theory, an asymptomatic transmission is the transmission of the disease from a person who does not have or does not develop any symptoms attributed to COVID 19 at any point in time. 
“The WHO, reports only of a very few cases of asymptomatic transmission, mainly among close contacts, but various scientific publications, gives a wide range, from 5% to 80% of the total COVID 19 patients,” he said.
“The disparity might be due to several reasons, one major factor maybe that most- who are categorized as asymptomatic- can be truly pre-symptomatic. The other might be that some of these people will have atypical symptoms for COVID 19, such as lack of smell and taste. People having very mild symptoms that they usually neglect, is another possibility. But still, a sizable amount is described as being asymptomatic patients.”

Minimizing the threat

“The consequence of having such an infected but asymptomatic population is that they will be difficult to detect, hence will be there in the society with the potential to spread without being diagnosed,” he added.
“Fortunately, as they are common among the close contacts, thorough screening of all contacts of a known COVID patient will reveal most of them. It is the current practice in Sri Lanka at present. Whether a patient is symptomatic or asymptomatic, the contacts should be in quarantine, if they don’t have any symptoms. The current trend is to monitor the very close contacts in quarantine centres, and most of them will undergo testing, which will help diagnose all patient categories early, preventing further transmission. The other contacts will be in quarantine, and especially in certain areas, samples of these people are also being tested.”

Treatments available

He further said that there were a lot of studies being done in various parts of the world to identify the best treatment options as well as methods of managing the disease. 

“SARS Co V 2, the virus that causes COVID 19 is peculiar that certain pathological changes it causes are different from other known viruses, and even from the SARS virus. Still, we are yet to find a drug or a solution that has proven to be of significant benefit. The WHO has initiated a study called SOLIDARITY, which will investigate the usefulness of several drugs and or combinations, in a randomized trial, one of the best ways is to assess the benefit of an intervention. Remdesivir, Lopinavir/Ritonavir, Lopinavir/Ritonavir with Interferon beta 1 a, and Chloroquine and Hydroxychloroquine are the drugs/combinations that will be assessed,” he said.
These are prescription medications and should not be used for self-medication. 

Many other trials and studies are looking at various treatment options, for this disease which is caused by a tiny particle, that even cannot be identified as a being, but has managed to bring the whole of human civilization to its knees,” he said.

Take safety measures more seriously

According to Dr Uthpala Amarasinghe, Consultant Community Physician and Head of Training at Health Promotion Bureau, people still don’t adhere to basic safety measures. 

“They would still wear masks around the neck and invite more viruses into the system. From the point of carrying a mask to wearing it, there are certain procedures to follow. A surgical mask should be carried in a sealed polythene bag. One should hold it with the loops and wear it in a way that the entire nose and mouth are covered. The dark blue side should be facing outwards. 

“But we have seen people wearing it on the head and even around the neck. The outside of the mask gets concentrated with many invisible particles and every time you touch it, your hands also get contaminated. Therefore you need to remove it again while holding the loops, fold it inwards and dispose it in an enclosed bin and wash your hands thoroughly.”

She expressed her views while addressing a group of journalists at a webinar and cautioned journalists who tend to follow such careless methods as setting a wrong example to viewers. 

“I have also seen people crossing loops and wearing surgical masks in an attempt to make it tighter. But remember that once you cross the loops, there’s an opening being formed between the face and sides of your mask. Therefore if you sneeze or cough you tend to contaminate the surroundings and it will then serve no purpose of wearing a mask. 

"Drug addicts and alcoholics should be discouraged from their habits because their immune system is already weak. Drug addicts may also travel around in search of their doses and to deliver drugs to others
- Dr. Uthpala Amarasinghe"

“On the other hand, N-95 masks have an inbuilt filter in them. But since they are rare at this hour, you need to have a surgical mask or a reusable mask. 
“But in the case of a reusable mask, you have to soak it in soapy water and wash it once you go back home, dry it in the sun and wear it after three days. 

However, we have seen people who keep reusing them without washing. The message given out to maintain at least one-metre distance between one another too needs to be reviewed. We hardly see people doing it, so it’s alright to mention that they should stand beyond one metre. Some people use hand sanitizers only, but how can we be sure that they have 70% alcohol? This is why you need to follow all safety methods at once, all the time.”
“As such, it is important to take these safety measures seriously now that we are about to implement an exit strategy,” she added. 

“If you don’t follow them you will easily take this virus home and infect your elderly parents, pregnant wife and pose a greater threat. On the other hand, every time you touch your phone, keyboard or even the spectacles you wear, it’s advisable to rub it with an alcohol rub to keep invisible particles at bay.
‘”If you come across an individual who complains of a headache, cough, or fever advice them to call the helplines 1390, 117, 1999 without asking them to visit the nearest hospital,” she said.

“People may have respiratory distress where they will feel tired after speaking one or two words. If these lines are busy they can call 1990 Suwaseriya Ambulance service or contact the area Public Health Inspectors (PHIs) or Medical Officers of Health (MOHs).

“They ask if you have been abroad recently, been at a quarantine Centre, associated someone who has returned from a Quarantine Centre and so forth and depending on the responses they will advise you on what you should do next. This way they can minimize the risk of exposure to the virus.”
Speaking on the PCR tests being performed, she said that currently tests were being conducted through sputum samples. 

“This is not as effective as a PCR blood test. There’s a certain percentage that doesn’t get detected from this sputum sampling. Therefore they need to be re-tested. This is because depending on a person’s immune system, it will take time for the symptoms to appear. 

“On the other hand, drug addicts and alcoholics should be discouraged from their habits because their immune system is already weak. Drug addicts may also travel around in search of their doses and to deliver drugs to others. Those who smoke may have inflammation in their bronchial walls and it will be easy for a virus to enter the system.”

She also advised the public to keep away from discriminating individuals who have gone through quarantine once they start going to work or when schools reopen. 
“It’s better to keep their confidentiality and disclose the most important details. Don’t go the extent of naming and shaming and discriminating them based on religion or age,” she said.

Health Authorities have decided to conduct random PCR testing on isolated communities in Colombo as means of curbing spread of the virus. Pic courtesy - AFP