Dealing with Covid-19: Lessons from the experience of Sri Lanka
This story first appeared in The Indian Express
India’s small southern neighbour has kept its Covid numbers extremely low, and the number of deaths from the disease to only 11. How did Sri Lanka do it? The country’s Director General of Health Services, Dr Anil Jasinghe, explained the areas that Sri Lanka focussed on, and the steps that it took.
Country and Covid-19 stats for Sri Lanka: Population, 21 million; Number of Covid positive cases, 2,033; Number of deaths, 11; Number of recovered patients, 1,639; Number of patients being treated in hospital, 383; Number of patients in ICU, 1.
On Sunday (June 28), Sri Lanka emerged from its nationwide lockdown, which had earlier been relaxed and re-imposed selectively. The success in controlling the spread of the novel coronavirus has prompted the government to consider reopening airports for tourists from August 1. It has also led to the country’s Election Commission to fix August 5 as the date for the parliamentary election that was put off in April due to the global pandemic.
Neither move is without risk, as a majority of Sri Lanka’s positive cases are returning Sri Lankan nationals. In an interview to The Indian Express, the country’s top health official was confident that the protocols being put in place would ensure the guard will not drop.
“We will not be able to achieve 100 per cent security. But we will be using certain tools to come close to 100 per cent so that any mishap, any leak, we will be able to do contact tracing and manage” said Dr Anil Jasinghe, Sri Lanka’s Director-General of Health Services. But he also cautioned that what Sri Lanka had achieved “is not a victory, no one can claim victory yet against coronavirus”.
Although airports will reopen at the beginning of August, any tourist arrivals will commence from later in the month. There is also the realisation that the island is not going to see a flood of arrivals. Pre-pandemic, there were 100 flights and 6,000 to 10,000 passenger arrivals every day. For now, only a small fraction of that number is expected.
“There are a lot of stakeholders in tourism, and I had a meeting with all of them and we have already almost prepared the protocols on how we will receive tourists, and how we can get them to travel in the country, and how we will bid goodbye to them,” Jasinghe told The Indian Express in an interview.
Every disembarking passenger will undergo a RT-PCR test on arrival, irrespective of whether they took the test before embarking on the journey. This will be followed by another RT-PCR test between their fifth and seventh day in the country.
Backpackers and individual tourists will not be allowed. Only tourists in groups of eight persons or more will be permitted. Families with fewer numbers will also be allowed – if they have pre-booked through a local tour agent, and paid in advance for a fixed itinerary. And the travel period has to be for a minimum of six to seven days.
“Health authorities will be tracking them during their stay. Between the 5th and 7th day, a [second] PCR test will be done, and they can’t leave the country without getting the report,” Jasinghe said. “We don’t want tourists to come for one or two days, leave the virus here [in Sri Lanka] and vanish.”
Also, protocols are being worked out with the Election Commission to ensure social distancing in polling booths. For the first time, the results of the election will not be declared on the same day as polling.
Starting early, following up aggressively
Jasinghe said Sri Lanka had been able to keep its case numbers low because of early preparations. Thermal screening and self-declarations at the country’s only international airport began in mid-January. The first PCR laboratory was up and running on January 26 — this was a day before the first case surfaced, with a Chinese woman being found Covid positive as she arrived with a group of other Chinese tourists.
The woman was isolated and hospitalised. She had not infected anyone. The first Sri Lankan national to test positive was a tour guide with an Italian group. The first Covid death occurred on March 29.
As more and more Covid positive cases came up, mostly among returning Sri Lankan tourists, President Gotabaya Rajapaksa locked down the country under a curfew from March 20, which was eased after 52 days on May 11. By then, there were 850 cases in the country.
There was also a cluster in a naval camp, which led to the quarantining of 4,000 people there from April 23 onward. The Navy cluster grew to more than 910. This cluster, along with the inbound arrivals of repatriated Sri Lankans, constituted the bulk of Sri Lanka’s case load.
Geographically, the main hotspots were confined to three or four districts in western Sri Lanka — Puttalam, Colombo, and Kalutara on the coast, and Gampaha, next to the capital district. The Tamil-dominated northern province of Jaffna did not see many cases.
Members of Sri Lanka’s St John’s ambulance service carry a can of disinfectants as they spray them in a public school to prevent the spread of coronavirus in Colombo, Sri Lanka, Monday, June 22, 2020. (AP Photo)
“The first thing we did whenever there was a case was early diagnosis, and on-the-dot contact tracing. We did not allow the virus to spread unnecessarily,” Jasinghe said. Up to 60-70 contacts were traced for some patients, but the number depended on the terrain. Dense pockets of urban slums yielded more contacts, but in villages, it was fewer. Sri Lanka was particularly aware that its ageing population and large diaspora made it particularly vulnerable to the infection.
“We did not want a situation of social transmission from clusters – we were able to keep it at cluster level. We wanted to have a situation where we will know every patient and their contacts. That we were able to manage throughout. We never had community transmission, we did not allow it to happen. Severe contact tracing, and then, severe quarantine mission, and that is where the armed forces were very useful,” Jasinghe.
The role of the military in Sri Lanka’s Covid-19 battle has drawn criticism, especially because it is seen as a creature of President Gotabaya Rajapaksa, and a political instrument in his hands.
Jasinghe said there was nothing wrong with taking the help of the military at a time like this. “Because we can’t design quarantine centres at our will, but the army can do that. You give them a building, and they will do the rest, “ he said.
The military set up 50 government-run quarantine centres in Sri Lanka. Ten hotels, including some five stars, have also been converted into quarantine centres for those who can afford to pay for a 14-day stay in these properties.
In densely populated urban slums, Jasinghe said his team used the “root ball mechanism” — a term used for relocation of trees — for quarantining, that is, evacuating the entire area into a quarantine centre.
Jasinghe’s team also readied 100 ICU beds, but so far, he said, only 10 had been put to use, and at the moment, Sri Lanka’s Covid dashboard shows only one patient in ICU.
A staff official wearing protective mask checks the display items quantity on a shelf at a Keels super market, amid concerns about the spread of the coronavirus disease, in Colombo, Sri Lanka. Reuters
Building on what already existed: primary healthcare
Jasinghe also credited Sri Lanka’s robust state-run free and universal healthcare system, through which it carried out a sustained battle against malaria and was able to pronounce victory over the disease in 2016. Sri Lanka’s public health system comprises a pyramidal structure with a network of primary health centres, district and teritary hospitals.
“One has to build on what exists. Our strength was our public health system. The more the country develops, especially in the west, they simply get rid of their public health system. But in our case, we have a full-blown public health system — we have medical health inspectors, public health midwives, and so on, and it’s all over the country. There are clear levels of care and authority. Also, we have a nicely knitted medical care and hospital system. Generally, you get good doctors, good medical care in the government sector, it is not neglected in Sri Lanka. Every 1.5 km, you have a government health centre,” he said.
Hydroxycholoroquine was the only medicine administered to Covid-19 patients in hospitals, Jasinghe said.
Sri Lanka’s strategy on testing for the coronavirus
Sri Lanka has done 1,04,272 PCR tests so far, conducting a maximum of 2,089 tests on June 3. Jasinghe said the government had the capacity to carry out more tests, and a new facility that can carry out 500 tests per day had recently opened. As the airports open, there would be a need to ramp up the testing. Jasinghe said private labs were also being roped in for that.
Though critics point to the low number of tests — slightly over 0.5 per cent of the population — Jasinghe defended what he described as the strategy of targeting vulnerable groups from which people were chosen for testing at random.
“If your situation is social transmission, then you have to test a lot, and it is still not enough. That is what is happening in Mumbai. In Sri Lanka we went in for targeted PCR. Very early on, we selected a set of hospitals around the country, and we had isolation units in each hospital. Patients with fever and respiratory symptoms were admitted to those isolation units. For them, PCR was done. That is called passive surveillance.
“And then we did PCR randomly at OPDs, thereafter we did in social settings — fish markets, among trishaw drivers, slums. This was completely random testing,” he said — arguing that as the positivity rate was less than 2 per cent in these high risk categories, it “means we don’t have social transmission, and there’s no point going to town and taking swabs from everyone”.
Jasinghe said more tests would reduce the positivity rate further. “If we take a thousand tests, all thousand would be negative — for sure,” he said.
Dealing with visitors from China
With two mega Chinese projects — Colombo Port City and the Hamabantota port — Sri Lanka gets plenty of Chinese visitors. But other than the first case of a Chinese tourist who was Covid-19 positive and was detected early, there were no other instances of the infection being brought in by anyone travelling from China.
A large group of Sri Lankan students was evacuated early on and quarantined in Boossa, a naval camp near Galle in southern Sri Lanka. Visas on arrival were cancelled for Chinese travellers, before the country closed down its airports altogether in the third week of March.
“Those Chinese who were already in Sri Lanka, they were no threat. Those who were visiting from China, they posed a threat. But we did not have much of a problem, because basically Chinese are disciplined, by their own hierarchy. The Chinese authorities complied with our rules, and they took steps ahead of us, they did not allow Chinese workers (working on projects in Sri Lanka) to move out of their work settings,” Jasinghe said.