A need of the hour that requires layered planning
The world is slowly and hesitantly coming to terms with the fact that ending the Covid-19 pandemic will require more effort and resources, and that the world has to adapt to the evolving pandemic.
Sri Lanka is also taking steps to manage the pandemic with the available resources, and it was recently reported that the Government is considering permitting home quarantine for asymptomatic Covid-19-infected persons who do not show severe symptoms/complications. However, that entails massive responsibilities.
Home quarantine for asymptomatic patients
In addition to the health authorities’ plans to consider allowing home quarantine, several groups of medical professionals, namely the Sri Lanka Medical Association (SLMA), the Government Medical Officers’ Association (GMOA), the Association of Medical Specialists (AMS), and the SLMA Intercollegiate Committee (SMIC), in a letter addressed to President Gotabaya Rajapaksa on 6 May, also recommended the same.
The groups said that the Government should consider authorising the isolation of families affected by Covid-19 in their homes, while also authorising the home-based management of asymptomatic Covid-19 infected persons under a proper monitoring system handled by healthcare professionals. This system, however, should be complemented with necessary arrangements to transfer needy patients with pneumonia to the closest designated hospitals, the letter further read.
The facilities for non-Covid-19 diseases have also become limited, and the management of such diseases does not receive adequate attention, the letter noted, adding that this situation may even lead to an increase in the deaths of patients with non-Covid-19 diseases.
Raising concerns about the number of patients staying at home while waiting for a bed in an intermediate Covid-19 treatment facility, they further noted that significant delays in providing beds and in-patient care to those in need have become a frequent occurrence, and that in this context, an increase in the number of deaths would be unavoidable.
However, when contacted on 9 May, the National Operations Centre for the Prevention of the Covid-19 Outbreak (NOCPCO) Head, General Shavendra Silva told The Morning that he had not received the said letter, and that there was no plan to permit home quarantining for asymptomatic patients.
Meanwhile, SLMA Ethics Committee Secretary Dr. Surantha Perera said that while the concept of home quarantine is the need of the hour, there are a number of practical aspects that need to be taken into account to ensure that Sri Lanka benefits from this move. He also noted that it would be a collective effort that starts from the policymaking level, and requires the contribution of all ground-level healthcare workers for its successful implementation. He opined that if the Covid-19 cases continue to increase, home quarantine would be the way forward.
He added: “When we implement the concept of home quarantine, it is only for a specific group, i.e. asymptomatic Covid-19-infected persons, since Sri Lanka does not have adequate facilities to keep all asymptomatic persons at hospitals. However, asymptomatic patients may also be difficult to identify sometimes, especially due to the condition called silent hypoxia, and it poses a certain challenge in the early detection. Therefore we need a mechanism to identify and monitor such conditions as well.”
According to medical practitioners, silent hypoxia is a form of oxygen deprivation that is more difficult to detect than regular hypoxia, and the ability to detect it in Covid-19 patients before they begin to experience complications such as the shortness of breath is crucial in order to prevent Covid-19-related pneumonia from progressing to a much critical level.
He added that what medical practitioners are generally trying to identify are the common symptoms seen in the initial stages of Covid-19, and that only after identifying such symptoms is it possible to decide whether the infected persons should be referred to treatment facilities.
When questioned about the importance of having proper guidelines in place before permitting home quarantine, Dr. Perera said that first and foremost, it is mandatory to adhere to the general Covid-19 safety guidelines such as wearing facemasks, sanitising hands, and maintaining social distancing among family members.
He noted that since some residences may not have the necessary facilities for home quarantine, that factor should also be taken into account. “If a suitable environment is available, home quarantine may be a viable option,” he emphasised, adding that there are certain guidelines developed by medical practitioners that have been forwarded to the SLMA as well.
Dr. Perera further added that the decision to permit home quarantine is merely an initial step that has to be taken as a policy decision, and that logistics-related aspects also need to be assessed to make it successful.
He noted: “Permitting home quarantine is a policy-level decision we have to take at the higher level, and it is still under discussion. I hope that it will be implemented very soon. However, in addition, we have to pay attention to the logistics-related aspect of this decision. We can take policy-level decisions easily, but, at the end of the day, when it comes to the practicality of these plans, we have to take into account how exactly we are going to implement them.”
In this process, the contribution of ground-level healthcare workers such as public health inspectors (PHIs) is crucial, as they are the ones dealing closer with the general public than any other healthcare worker, according to Dr. Perera.
In this regard, he said: “We have Medical Officer of Health (MOH) divisions, and also PHIs and nurses working under the MOHs. They have a mechanism to reach out to and monitor the houses and identify the concerns. There are a number of practical aspects we have to evaluate when it comes to implementing the plan to allow home quarantine.”
When queried about the importance of having a practical and effective monitoring mechanism to ensure that home quarantine actually benefits the country, he added: “The mechanism we have in place currently, which can be used in this connection, is centred around MOHs. If we create and implement a mechanism based on MOH-based divisional levels, it would be more practical.
“Under each MOH, there are PHIs and midwives, and the MOH divisions are divided into smaller units under the PHIs and midwives. These officers are familiar with all the households in their respective areas, and they have the ground-level statistics and information. Most importantly, they are very close to the public as well. So, the monitoring mechanism should involve them, especially because they are closer to the public, and because the doctors working in the curative care services sector do not have the facilities to visit each house individually.
“But if we can develop a proper surveillance system, when there is a suspected Covid-19 infected person who is developing symptoms and is in need of medical assistance, the ground-level healthcare workers can take swift and necessary steps together with the authorities.
“However, this is also a challenging task, since it is not like transporting a regular patient. Transporting a person infected with Covid-19 is a process that requires more efforts due to the nature of the Disease and the public’s perception about it. It is also important to ensure the safety of the healthcare workers as well.”
Dr. Perera also said that when it comes to managing the Covid-19 pandemic, all countries, and not only Sri Lanka, face logistics-related issues, and that since Sri Lanka is a developing country, dealing with such matters may be a somewhat more difficult task for the country.
Meanwhile, PHIs’ Union of Sri Lanka (PHIUSL) Secretary Mahendra Balasooriya also expressed approval for permitting home quarantine, and said that the PHIs would support it if the Government decides to do so. He noted that taking into account the exacerbating Covid-19 situation, the PHIUSL had also put forward a proposal in March requesting the same. He added that if the health authorities decide to go ahead with this plan, it is the PHIs who would take the primary responsibility of ensuring its successful implementation.
He explained: “In some areas, the number of daily cases and first-level contacts are so high that it is almost difficult to manage the situation. Taking this situation into account, since hospital facilities are also inadequate, we requested that permission be granted to allow home quarantine for asymptomatic Covid-19-infected persons under PHIs’ supervision. When looking at the status quo of the Covid-19 pandemic in the country, no matter how many new treatment facilities are made and added to the system, they would not be sufficient.”
According to Balasooriya, even though creating new treatment facilities is important, it is more important to strengthen the process of identifying areas at the highest risk and imposing necessary travel restrictions to stop the spread of the virus.
Speaking of asymptomatic Covid-19 infected persons who are currently staying at their residences due to their health situation not being critical, Balasooriya added: “The PHIs provide all the support they need.”
Pointing out practical issues pertaining to the hospitalisation of Covid-19 infected persons, he explained: “There are five Health Ministry approved laboratories that have the facilities to perform PCR tests, and any person can get a PCR test done as per medical advice. The report is usually a confidential one, and the person who is getting the test done is the one who receives the report first.
“If they test positive for Covid-19, the relevant laboratory lets them know that their Covid-19 status would be conveyed to the health authorities. Then, the relevant information is referred to the other health authorities such as regional epidemiology units and the PHIs, which takes several days. In the meantime, the infected person stays at home.
“Usually, the priority is to hospitalise the infected person for 10 days, and sometimes, by the time the health authorities contact the infected person for purposes of treatment, it has already been around 10 days.
“In a context where it is likely to take several more days until the facilities for the hospitalisation of the infected person become available, there is no point in hospitalising them. This is one of the reasons why we requested that home quarantine be allowed, and there are a large number of asymptomatic Covid-19-infected persons in various places.”
Multiple attempts to contact the State Minister of Primary Health Care, Epidemics and Covid-19 Disease Control Dr. Sudarshini Fernandopulle to obtain more information about the guidelines necessary to monitor home quarantine, proved futile.
Even though home quarantine is still under discussion in Sri Lanka, quarantining Covid-19-infected persons in their homes, especially when they are asymptotic and/or do not show any critical symptoms/complications that cannot be managed at their homes, is currently taking place in many other countries. International health organisations have identified it as a solution to the soaring Covid-19 cases and limited treatment facilities.
The World Health Organisation (WHO), issuing a set of guidelines titled “Home care for patients suspected of or with confirmed Covid-19 and the management of their contacts” said that when adopting home quarantine as a preliminary measure to care for Covid-19-infected persons, it is critical to ensure that caregivers (parents, spouses, and other family members or friends providing informal care, as opposed to the care provided by formal healthcare providers) have appropriate training and guidance on how to care for the patients, as well as how to minimise the risk of infection, including training on important hygienic procedures, and on recognising the signs that the Covid-19 patient’s condition is worsening and that he or she needs to be sent to a health facility.
In addition, the WHO recommends that health workers and caregivers providing support in homes should be provided with the appropriate personal protective equipment (PPE) for the tasks that they are expected to perform, and for them to be trained in PPE use and removal.
WHO guidelines also say that even though caring for an infected person at a home, rather than in a medical or other specialised facility, increases the risk of transmitting the virus to the others in the home, the isolation of infected persons can make an important contribution to breaking the chains of the transmission of the virus. The decision as to whether to isolate and care for an infected person at home depends on three factors; namely, the clinical evaluation of the Covid-19 infected person, the evaluation of the home setting, and the ability to monitor the clinical evolution of an infected person at home.
When it comes to infected persons who are asymptomatic or those with mild or moderate disease-related symptoms without risk factors leading to poor outcomes, they may not require emergency interventions or hospitalisations, and could be suitable for home isolation and care, the WHO said, adding that two requirements, however, need to be fulfilled in the home setting. They are that conditions for implementing appropriate infection prevention and control are met, and that close monitoring for any signs or symptoms of deterioration in their health status by a trained health worker is feasible.
Moreover, the WHO guidelines extensively outline factors that need to be considered when assessing households. Among them are: “Is the person with Covid-19 living alone? If so, what support network do they have? If not, who is living in the household with them?”; “How is the person with Covid-19 and their family living?”; “How feasible and practical would it be to implement recommendations?”; “What alternative options are available?”; “What are the needs related to disability, caring responsibilities for adults, older adults, or children?”; “What are the needs of other household members?”; “How feasible is it for one caregiver to be identified to support the person with Covid-19 at home?”; “What do household members know about Covid-19 and preventing transmission in the home?”; “What are their information needs about Covid-19 and transmission prevention?”; “Does the household know where to seek additional support or information related to care for the person with Covid-19 if needed?”; “What does the person with Covid-19 and/or their household members think they need to be able to cope at home?”; “Does the family understand when to call for medical assistance?”; “Do they have the means to call for medical assistance?”; “What are the psychosocial needs of the person with Covid-19 and household members?”; “What support is available to them related to coping with the emotional impact or the fear of stigma?”; “What is the economic impact on the household?”; “Who is the primary provider financially?”; “What is the impact if that person needs to be isolated and/or to carry additional household or care responsibilities?”; “Which health facility and, if possible, named professional, is responsible for following up on the care of the person with Covid-19, and how will the follow up of this care be maintained?”
Trained health workers or public health personnel, or both, should be appointed for the duration of the home care period, that is, until the patient’s symptoms have completely resolved; while the monitoring of patients and caregivers in the homes can be done by trained community workers or outreach teams, the WHO added.
In an era when almost all countries are struggling to mitigate the Covid-19 pandemic, looking into all possible alternatives to utilise the limited resources for patients in a critical condition is the need of the hour. However, these decisions, especially when it comes to permitting home quarantine, should be effective and safe, and should not beget another wave.
The health authorities are yet to take a final decision in this connection. However, the practical aspects this move entails should receive the utmost attention for it to actually help Sri Lanka manage the pandemic.