The chaos when curfew was lifted should not be allowed to recur.

Six Chair Professors of Medicine (and specialist physicians) have expressed their opinion on an exit strategy from the current Covid-19 lockdown.

Prof. Janaka de Silva (University of Kelaniya), Prof. Sarath Lekamwasam(University of Ruhuna) Prof. SAM Kularatne (University of Peradeniya), Prof. Sisira Siribaddana (Rajarata University ), Prof Saroj Jayasinghe (University of Colombo), Prof. Kamani Wanigasuriya (University of Sri Jayewardenepura) have written a letter to Lt. Gen. Shavendra Silva, Chairman of the Covid-19 National Task Force and Dr Anil Jasinghe, Director General of Health Services, expressing their opinion with some recommendations.

Full text of the letter:

“We the undersigned six Chair Professors of Medicine (and Specialist Physicians) in Sri Lanka, wish to express our opinion on an exit strategy from the current COVID-19 lockdown in Sri Lanka, for your consideration.

The first case of COVID-19 was diagnosed here on 28th Jan 2020, in a Chinese tourist. The 2nd case was diagnosed nearly 6 weeks later, on 12 March (a tour guide who contracted the infection from Italian tourists). Since then, the spread of infection has been relatively slow; it took nearly a week for the case load to double from 50 100 (from 19 to 25 March); and in the 10 days since then (26 March to 4 April), the case load has not yet doubled – the Ministry of Health has reported 12 cases and five deaths up to 5 April 2020.

The government acted swiftly in order to contain the outbreak in Sri Lanka; schools and universities were declared closed on 13 March; people were asked to work from home from 16 March onwards; and the international airport at Katunayake was closed to inbound passengers from 19 March onwards. An all-island curfew was declared on 20 March and everyone except those working in the essential services has been required to stay home. In the most affected (and highly populated) districts, curfew has not been lifted since then, except for 8 h on 24 March. Most importantly, our security forces and the health authorities have been very successful in contact tracing and isolation of contacts, as well as in quarantine of returnees from countries with the high incidence of COVID-19.

However, this lockdown has come at a cost. Many people with other illnesses have experienced difficulties in accessing treatment and medication. Nearly 10% of our population is 65 years of age or older and suffer from ailments that require regular medication. Non-communicalble diseases such as hypertension, diabetes mellitus etc., affect a significant proportion of our people, and they too need to be on regular medication in order to prevent complications. Despite the best efforts of the government, many people have found it difficult to obtain their medicines during the lockdown, as evidence by long queues outside pharmacies (which reduced after they were kept open). In terms of economic productivity, the cost to the apparel industry alone as estimated at LKR 2 billion, while the tourist industry is at a standstill. Daily wage earners have no means of supporting their families.

The curfew has also resulted in a fear psychosis in our society, with wild rumours being spread and false treatments being suggested. Even health workers are reluctant to treat patients with fever and cough. The fear of this illness has also led to severe social stigmatization of patients.

It is clear therefore, that in the near future, Sri Lanka will have to come out of lockdown, even while COVID-19 transmission continues to increase in other countries. The basis on which this decision is made should be very carefully considered based on scientific evidence and could be informed by the strategies followed by other Asian countries, such as, China, South Korea, Vietnam and Singapore that have been successful in containing transmission.

Recommendations:

The current level of restriction should continue for now and be reviewed after the New Year. If the level of transmission is not high as evidenced by the daily number of new cases and a slow doubling time of cumulative cases, the curfew can be relaxed in stages, district-wise (eg one district per province on given days of the week). The chaos that occurred on Tuesday 24 March, when curfew was lifted for just a few hours, should not be allowed to recur. However, areas with high numbers of patients could be cordoned off and kept under stricter control measures or lockdowns.

1. Supermarkets, hospitals, food markets, more petrol stations and pharmacies could remain open for a period of time, to be decided by the task force, on a daily basis. As in China, each household could be issued one pass to allow one person to go out to get essentials in their own neighbourhood. Travel between towns and cities should be discouraged. The Colombo Port, utilities, medical supplies, logistics companies and food processing firms should remain open, as they are now, to ensure availability of supplies.

2. Require everyone to wear a face mask and practice social distancing in public, and follow guidance on hand washing in order to avoid infection. Large gatherings (eg more than 10 people) should not be allowed.

3. We need to strengthen capacity in the health sector. This includes the following measures:

a. Increase testing capacity so that all those with contact with COVID-19 positive persons can be tested, and not just those with symptoms. Seek advice from virologists regarding what tests are most appropriate for use in specific scenarios, and make every effort to stock on supplies.

b. Continue public health measures such as contact tracing, self-isolation and quarantine as present.

c. Provide all health personnel who are at risk of exposure to infection with personal protective equipment. Take immediate steps to purchase adequate stocks, locally produced whenever possible, of masks, personal protection equipment, ventilators and ICU beds, and even test kits, to cope with a possible surge in cases.

d. Harness capacity in the private health sector, under stringent regulatory control, for testing and patient care if the need arises.

4. Enforce a strong system for surveillance and reporting from all around the country, so that if the incidence goes above a certain level (eg more than 50 cases a days, as in Singapore) stringent measures can be re-imposed.

5. Consider further easing of controls if the number of new cases remains flat over a period of time (eg 2-3 weeks). Eg lift the ‘work from home’ policy, to resume work in government offices, factories, and other important areas, re-open schools and universities. The airport could be opened for inbound passengers, initially only from countries with low transmission rates, and particularly for Sri Lankan citizens who wish to return home. However, this should be done in a tightly controlled fashion, with continued imposition of compulsory 14-day quarantine on all returnees, regardless of their country of origin.

6. There is increasing frequency of people sowing ethnic disharmony through social media. The TV stations too seem to highlight the issues in a manner that promotes stigma. They should report situations with respect. Stigma and the trend to blame certain groups could push the epidemic underground with devastating consequences for all.

We take this opportunity to thank you for your leadership during this hour of crisis.

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