The officials of the Government Medical Officers’ Association (GMOA) including its President Dr. Anuruddha Padeniya, Secretary Dr. Haritha Aluthge, Assistant Secretary Dr. Navin De Zoysa and Media spokesman Dr. Samantha Ananda appreciate the timely responses of President Gotabaya Rajapaksa for the suggestions made by the GMOA to control the spread of the COVID-19 pandemic in the country.
In a letter to the President appreciating the steps taken by him, the GMOA stated the President has intervened and instructed the relevant authorities to close all liquor shops of the country until further notice. We the GMOA observe this as a timely and brave decision, reached to optimally manage the COVID-19 outbreak. The GMOA Executive Committee appreciates your Excellency’s response in this regard and would unconditionally back decisions of this nature, in future too, the GMOA stated in the letter.
The GMOA pointed out that a majority of COVID-19 patients detected recently had mild symptoms, with 20 percent showing no symptoms of the disease. According to experts, the sensitivity of the tests to detect COVID-19 is less than 70 percent. As such, the COVID-19 pandemic creates uncertainty and adversely affects a confident action plan. In order to minimize the uncertainty and make proper decisions for the future, the GMOA proposes the following actions,
1. Test all quarantined personnel using an algorithm proposed by experts. By such testing, positive patients could be isolated and treated in hospitals, preventing them from spreading the disease to their households as well as the community (Aggressive testing strategy, as proposed by the WHO).
2. Since the sensitivity of tests is less than 70 percent, tests should be repeated in a series to enhance the pickup rates (Test, Test, Test strategy, as proposed by WHO). 3. When ports of entry such as airports open towards the latter part of the global pandemic, all arrivals should be compulsorily (a) Tested (b) Quarantined, in order to avoid the import of new cases of COVID-19 to Sri Lanka. The above actions would pave the way to implement the “exit strategy” for COVID-19 in Sri Lanka as proposed by the GMOA to the President and the relevant authorities on April 4, 2020.
The Exit Strategy proposed by the GMOA
COVID-19 pandemic which began in the Chinese city of Wuhan extended to Sri Lanka with the first foreign patient found on January 27, 2020 and the first local patient found on March 11, 2020.
Having recognized this issue both as a ‘public health emergency’ and a ‘global health challenge’, the Government Medical Officers’ Association (GMOA) proposed studied interventions to the Government. The proposals were based on four pandemic phases declared by the World Health Organization (WHO). Strategies were aimed to reinforce the three pillars of implementation- i.e., political will, health capacity and the social capital.
Reflecting the commitment of the political will, President Gotabaya Rajapaksa initiated action on January 26, well before the first local patient was detected. On March 11, when the first local patient was identified, the GMOA made written communication to the political leadership emphasizing aggressive interventions.
Airport and all other portals of entry were shut to ensure the prevention of further entry of the virus. As measures to minimize the spread, schools were closed and curfew imposed targeting maximum social distancing. Actions were taken to enhance the health capacity, with special emphasis to safeguard the health sector human resource from Covid19. Many interventions were carried out to achieve the expected outcome from social capital. We aimed at achieving more than 80 percent social distancing and other hygiene measures applicable to COVID-19.
Having achieved reasonable success as interpreted by the WHO and other international authorities, the GMOA developed an exit strategy as the next step aiming to achieve a maximum level of normal lifestyle for the country.
The exit strategy is based on the common structure applicable to a surgical theatre in hospitals, which is supposed to be sterile in the context of a contaminated environment.
Therefore, the country will be categorized under three main zones:
- Sterile zone
- Contaminated zone
- Buffer zone
The exit strategy spells out the criteria to declare these three zones and the governance structure within every zone. In addition, border control measures will also be included. In the process of improvement of the areas, the strategy to expand the sterile zone and shrink the contaminated zone will be discussed further.
This is with the expectation of bringing about food safety, reactivation of essential medical care and uplifting the micro and macro level economy of the country.
Proposed criteria for contaminated zone is marked in red on the top of the map
• Having at least one confirmed case of COVID-19 within the last 28 days prior to declaration
• Presence of suspects or contacts of COVID-19 patients who will be tested immediately
• Following this if at any point the number of cases or suspects becomes zero for a period of 28 days the area nomenclature will be converted from contaminated zone to sterile zone.
The Governance strategy for contaminated zone
Non-corona related governance:
• Essential foods, medicine and goods must be received via a systematic delivery method to doorsteps of residents organized by the Government
• Essential services as much as possible should be online or via delivery services
• Extensive systems to deliver food and medicine to all with special focus on vulnerable groups
• With a large part of the country being opened up, resources should be diverted to provide extra support for families and individuals living in these areas
• Only those involved in essential services must be allowed to travel for work and within the contaminated zone only. Crossing the border is strictly prohibited.
Corona related governance:
• Curfew must be maintained within the zone: home and institutional quarantine is essential and 100 percent movement within the zone is prohibited.
• Masks must be used as recommended by the experts
• Home quarantine of contacts and monitoring of home quarantine by the staff of local MOH office.
• Vigilant surveillance to trace contacts of the first, second and third ring must take place.
• Extensive testing including community level testing which increase case detection must be carried out.
That is, ‘community screening’ must be carried out extensively using test methods. In doing so the borders of the sterile zone can be further extended and contaminated zone further reduced or vice versa based on the outcome of community screening.
• If detected patients are to be transported necessary precautions must be taken at all times; ensuring health care workers have PPE, ambulance is correctly handled and distance maintained
Shrinking of contaminated zones:
Contaminated zones may be as large as a whole district such as the Colombo district or smaller administrative areas. Thus, by extensive surveillance:
- Contact tracing
- Testing
- Isolation on confirmation
- Quarantine
- Aggressive social distancing / hand hygiene /face mask; we can shrink the contaminated areas gradually.
Carrying out this exit strategy will be beneficial as:
Only the needed areas will be locked out and other areas will function normally while ensuring those areas remain uncontaminated. This will reduce the burden on the Government, bring about political stability and ensure the seamless management of the nation. It will allow police and army officers to concentrate in the much needed areas and enforce the curfew better. Optimum implementation of this strategy will ensure that we are an example to the world as having controlled the COVID-19 pandemic successfully.
Border crossing principles:
Strict border crossing criteria is essential to prevent virus transmission to sterile zones, which has less restricted movements. Successful implementation of strict border control is important in a successful exit strategy.
Identification of border crossing needs.
1) Food suppliers
2) Fuel suppliers
3) Electricity and water supply
4) Health staff
5) Military staff
The movement of these personnel too needs to be highly regulated to keep the sterile zones safe and convert the contaminated zones to sterile zones.
It must be attempted to contain essential service staff in the same zone. If travel is necessary a Standard Operating Procedure must be developed with stakeholder consultation. E.g.: A doctor residing in a contaminated area travelling to sterile zone for work, need to go through a sterile chamber and get cleared to enter the zone. Supply chain mechanisms also need to be developed. E.g. A vegetable supply lorry coming from a sterile zone to a contaminated zone
(i) can change at border or (ii) come to one centre only for unloading.
The border crossing staff need to be notified and, testing for COVID-19 has to be at a very low threshold.