By Dr. Dineshani Hettiarachchi Sirisena
[caption id="attachment_79406" align="alignleft" width="200"]
Prof. Indika Karunathilake[/caption]
The Covid-19 pandemic has undoubtedly become an era-defining challenge the world over. It has implications not only in the public health sector, but also in the global economy and political landscape. Its consequences, both short and long term, are less understood. To get a glimpse of its trajectory, we spoke to Sri Lanka Medical Association (SLMA) President Prof. Indika Karunathilake.
According to Prof. Karunathilake, the present strategy for the prevention of Covid-19 is unique to Sri Lanka. The Government of Sri Lanka and the Ministry of Health have adopted a policy of pre-emptive quarantining and isolation of suspected contacts even before they develop symptoms. This approach has proven to reduce the margin of error as seen by the spread still being limited to clusters, as opposed to the spread in community faced by many countries at the moment.
The SLMA has been able to bring together professionals from different medical specialties under one umbrella to guide the policymakers in the country, and this has been pivotal in mitigating the spread of the virus.
Covid-19 trend in SL: Why we need to crush the curve
A mathematical model for prediction was developed by SLMA Vice President Prof. Manuj Weerasinghe and Dr. Nishantha Perera from the Department of Mathematics of the University of Colombo (UoC). According to their predictions, tight control is required to maintain a manageable patient load; the maximum number of coronavirus cases we can handle at the moment is around 2,000, and anything more than that will put the healthcare system in serious jeopardy.
In order to maintain active cases below this range, we cannot deviate from the predicted trend for Sri Lanka under strict regulation of movement and physical distancing. Hence, Prof. Karunathilake emphasised that it is in the country’s best interest for the SLMA to liaise with professional bodies to advise decision-makers of the country.
In this regard, two fundamental strategies are possible:
Figure 1 – Mitigation strategy[/caption]
What does the future hold?
From observations around the world, it seems there will be a peak followed by a downward trend. Once this peak is reached at least 28 days, the time between two incubation periods must elapse for things to return to normalcy. However, this period will also have to be monitored closely as we don't know the behaviour of this novel coronavirus fully at the moment.
Countries that have successfully flattened the curve have had cases spiking again after interventions were relaxed. Hence, the need for schools and universities to remain closed is imminent. Although it should be recognised that such closures may have negative impacts, we must now work towards a distance-teaching culture and we might have to rethink how we function as a society going forward. At this juncture, it is not certain that suppression will succeed in the long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time.
How populations and societies will respond remains unclear, echoed Prof. Karunathilake, in line with predictions made by Imperial College London in the paper titled “Impact of non-pharmaceutical interventions (NPIs) to reduce Covid-19 mortality and healthcare demand”. Depending on how cases evolve, we will need to take precautionary measures to up social distancing measures or on if we will be able to release them. That is the dance of R (reproduction); in this method, the ultimate aim is to keep the transmission rate below 1, and currently it is at 1. Practically speaking, it is a dance of measures between getting our lives back to normalcy and spreading the disease – one of economy vs. healthcare (Figure 2).
[caption id="attachment_79413" align="aligncenter" width="800"]
Figure 2 – The hammer and the dance method[/caption]
What should be the testing strategy?
There’s a lot of public speculation regarding testing for Covid-19. The SLMA released a joint statement on 6 April 2020 with the Ceylon College of Physicians (CCP) and Sri Lanka College of Microbiologists to address some of these pressing issues regarding diagnostic and screening tests for Covid-19.
The policy on testing differs from country to country; it depends on what stage their community has reached in the pandemic curve and the level of preparedness in the specific context. There are two types of tests – one that tests for the virus itself and another blood test that shows the immunity towards Covid-19 by looking at antibodies.
The World Health Organisation (WHO) recommends confirmation of cases of Covid-19 by nucleic acid amplification tests (NAATs) such as a reverse-transcription polymerase chain reaction (RT-PCR) which is currently done in Sri Lanka. Antibodies are proteins that help the immune system identify and eliminate threats. Once the antibodies are made, they help the body neutralise future infections from the same threat. In patients who have recovered from Covid-19 or who may have carried the virus without realising it, a serological test can show who carries antibodies, even if the virus is no longer present.
However, this test cannot replace the value of the RT-PCR test in the acute diagnosis of Covid-19 (Figure 3). Many in-house and commercially available assays are used in different laboratories across the world. A new rapid test that offers results in minutes rather than hours or days is also on the horizon. However, its deployment is yet to be defined.
[caption id="attachment_79414" align="aligncenter" width="800"]
Figure 3 - RT-PCR test[/caption]
Our responsibility
These are trying times for all of us but we can decide to meet this challenge head-on. This can only be done by adhering to current best practices and guidelines. We should stay at home and maintain social distancing to avoid contact with outside individuals as much as possible. Take extreme precautions with the more vulnerable groups in society and aid the current system in place.
Finally, Prof. Karunathilake stated that in his capacity as the President of the SLMA, he and his team of experts are working tirelessly to disseminate information and inform the leaders of their expert advice as we face this challenge head-on.
Prof. Indika Karunathilake[/caption]
The Covid-19 pandemic has undoubtedly become an era-defining challenge the world over. It has implications not only in the public health sector, but also in the global economy and political landscape. Its consequences, both short and long term, are less understood. To get a glimpse of its trajectory, we spoke to Sri Lanka Medical Association (SLMA) President Prof. Indika Karunathilake.
According to Prof. Karunathilake, the present strategy for the prevention of Covid-19 is unique to Sri Lanka. The Government of Sri Lanka and the Ministry of Health have adopted a policy of pre-emptive quarantining and isolation of suspected contacts even before they develop symptoms. This approach has proven to reduce the margin of error as seen by the spread still being limited to clusters, as opposed to the spread in community faced by many countries at the moment.
The SLMA has been able to bring together professionals from different medical specialties under one umbrella to guide the policymakers in the country, and this has been pivotal in mitigating the spread of the virus.
Covid-19 trend in SL: Why we need to crush the curve
A mathematical model for prediction was developed by SLMA Vice President Prof. Manuj Weerasinghe and Dr. Nishantha Perera from the Department of Mathematics of the University of Colombo (UoC). According to their predictions, tight control is required to maintain a manageable patient load; the maximum number of coronavirus cases we can handle at the moment is around 2,000, and anything more than that will put the healthcare system in serious jeopardy.
In order to maintain active cases below this range, we cannot deviate from the predicted trend for Sri Lanka under strict regulation of movement and physical distancing. Hence, Prof. Karunathilake emphasised that it is in the country’s best interest for the SLMA to liaise with professional bodies to advise decision-makers of the country.
In this regard, two fundamental strategies are possible:
- Flattening the curve – also known as a “mitigation strategy”. This focuses on slowing but not necessarily stopping the epidemic from spreading by reducing peak healthcare demand while protecting those most at risk of severe disease from infection
- The hammer and the dance method – this is total suppression which aims to reverse epidemic growth, reducing the case numbers to low levels and maintaining that situation indefinitely. However, each policy has major challenges since the bare minimum essential services need to function
Figure 1 – Mitigation strategy[/caption]
What does the future hold?
From observations around the world, it seems there will be a peak followed by a downward trend. Once this peak is reached at least 28 days, the time between two incubation periods must elapse for things to return to normalcy. However, this period will also have to be monitored closely as we don't know the behaviour of this novel coronavirus fully at the moment.
Countries that have successfully flattened the curve have had cases spiking again after interventions were relaxed. Hence, the need for schools and universities to remain closed is imminent. Although it should be recognised that such closures may have negative impacts, we must now work towards a distance-teaching culture and we might have to rethink how we function as a society going forward. At this juncture, it is not certain that suppression will succeed in the long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time.
How populations and societies will respond remains unclear, echoed Prof. Karunathilake, in line with predictions made by Imperial College London in the paper titled “Impact of non-pharmaceutical interventions (NPIs) to reduce Covid-19 mortality and healthcare demand”. Depending on how cases evolve, we will need to take precautionary measures to up social distancing measures or on if we will be able to release them. That is the dance of R (reproduction); in this method, the ultimate aim is to keep the transmission rate below 1, and currently it is at 1. Practically speaking, it is a dance of measures between getting our lives back to normalcy and spreading the disease – one of economy vs. healthcare (Figure 2).
[caption id="attachment_79413" align="aligncenter" width="800"] Figure 2 – The hammer and the dance method[/caption]
What should be the testing strategy?
There’s a lot of public speculation regarding testing for Covid-19. The SLMA released a joint statement on 6 April 2020 with the Ceylon College of Physicians (CCP) and Sri Lanka College of Microbiologists to address some of these pressing issues regarding diagnostic and screening tests for Covid-19.
The policy on testing differs from country to country; it depends on what stage their community has reached in the pandemic curve and the level of preparedness in the specific context. There are two types of tests – one that tests for the virus itself and another blood test that shows the immunity towards Covid-19 by looking at antibodies.
The World Health Organisation (WHO) recommends confirmation of cases of Covid-19 by nucleic acid amplification tests (NAATs) such as a reverse-transcription polymerase chain reaction (RT-PCR) which is currently done in Sri Lanka. Antibodies are proteins that help the immune system identify and eliminate threats. Once the antibodies are made, they help the body neutralise future infections from the same threat. In patients who have recovered from Covid-19 or who may have carried the virus without realising it, a serological test can show who carries antibodies, even if the virus is no longer present.
However, this test cannot replace the value of the RT-PCR test in the acute diagnosis of Covid-19 (Figure 3). Many in-house and commercially available assays are used in different laboratories across the world. A new rapid test that offers results in minutes rather than hours or days is also on the horizon. However, its deployment is yet to be defined.
[caption id="attachment_79414" align="aligncenter" width="800"] Figure 3 - RT-PCR test[/caption]
Our responsibility
These are trying times for all of us but we can decide to meet this challenge head-on. This can only be done by adhering to current best practices and guidelines. We should stay at home and maintain social distancing to avoid contact with outside individuals as much as possible. Take extreme precautions with the more vulnerable groups in society and aid the current system in place.
Finally, Prof. Karunathilake stated that in his capacity as the President of the SLMA, he and his team of experts are working tirelessly to disseminate information and inform the leaders of their expert advice as we face this challenge head-on.