By Wichakshana Dharmawardena –
It’s now July 2020 and the Kandakadu Rehabilitation Centre cluster has happened. The way it appears to me, it happened because two major stakeholders dropped the baton. Those baton dropping stakeholders were A) Primarily, the Epidemiology Unit of the SL Ministry of Health headed by the Chief Epidemiologist B) The doctors who attended on the sick parades of the Rehab Center inmates.
Let’s take the less guilty party first. The doctors who attended the sick parades of the inmates. According to an interview with the Rehabilitation Commissioner General who is a retired and recalled Major General, daily, as is usual with any large enclosed population (such as in boarding schools, resident campuses, military camps) a certain number of the 1000 plus inmate population in the twin centres Senapura and Kandakadu report colds, fevers, coughs, sore throats and stuff. This daily presentation of various symptoms is called ‘the sick parade’. A visiting doctor from the Polonnaruwa hospital attended to this Kandakadu/Senapura Rehab sick parade daily and treated them.
On the face of it, you might feel very strongly that these doctors from the Polonnaruwa Hospital are to blame for disregarding these coughs. sore throats and fevers without conducting PCR tests. You might feel that if they had had the competence, foresight and the smartness to test some of these on the sick parades, Sri Lanka today would be without the heart ache of the widespread Kandakaadu cluster. You might feel that just like a whole bunch of government officers are held accountable today for failing to prevent the Easter attacks, these Polonnaruwa doctors should be sued for medical negligence. But would you be right in feeling this way? If not, why not? Why aren’t these Polonnaruwa doctors guilty of gross negligence at worst and incompetence at best? –
These doctors are technically not guilty because they had to technically follow testing guidelines set out by the Epidemiology Unit of the Ministry of Health.
But being not guilty on a technicality does not mean there is no guilt. I believe they are GUILTY of not being sharp enough, not being alert enough to the possibility of HIDDEN VIRUS in a community which had up to that point, only been reporting infections from quarantine centres, navy camps and the imported cluster.
That, one or few infected individuals could have escaped the drag net of the active case finding enterprise of the government and may have spread the virus around and given birth to underground cells of the infection was a possibility that the Epidemiology Unit of the SL Ministry of Health constantly warned the public about.
In this, the Epid Unit was acting like the typical government department. It was missing the elephant in the room.
The Epid Unit was too busy warning the public- beware of the hidden virus, there may be some infections that we failed to find and these may have created secret underground infected cells and you might run into these secret carriers of the virus in busses, trains, election rallies, crowded places. so beware, wash hands, wear masks and avoid crowds
All the time, the Unit was missing something, a vital life lesson the CHIEF EPIDEMIOLOGIST should have learnt at his mother’s knee – ඔවා දෙනු පරහට තමා සම්මතයෙ පිහිටා සිට. Before pontificating to the public about the threat of the hidden virus, secret infection cells, he should have put his own house in order by updating the clinically suspected case definition of Covid 19, to enable non-specialist medical practitioners, dealing with the general public, to detect underground infected cells.
IF there were some infected persons they missed in their first round of cluster extinguishing, active case finding missions, and if these escaped infections had created secret infected cells, these new secret infections will NOT present with an open contact history, they will NOT have a travel history because Sri Lankans have not been travelling overseas since March. They will NOT have a history of travel or residence in an area designated as a high Covid transmission area.
Trying to detect a person from the community who had got infected through one of these hypothetical secret cells, using the Epid Unit case definitions would be like trying to detect an ISIS terrorist using the following definition- ‘if a person wears a black burka, carries a long sword and displays on his garment in Arabic letters, the legend ‘Kill the infidel’, investigate him he could be a terrorist’. When the terrorist presents as a clean-shaven handsome youth in Levi’s and a funky t-shirt, this definition will fail and those depending on the definition will fail to investigate.
Similarly, during the first round in Sri Lanka, infected Nalin, infected Haneem and infected Anjan would have had a clear contact history, travel history, residence in a high transmission area when they presented to the not too sharp, non-specialist medical practitioner with cough, sore throat, fever, phlegm and sneezing. The Epid case definitions would have been enough then, to enable the not too sharp, non-specialist medical practitioner to categorise them as suspicious cases and refer them for testing. But not in the second round. When the infected Roshan, infected Ijaz and infected Mallar, having been inducted into Covid 19 by a secret cell, birthed by an infected person who escaped the active case finding drag-net during the first round, presented with cough, fever, sore throat, sneezing, the average medical practitioner will pass them by with a yawn because the Epid case definitions do not have them covered.
So, what are these Epid case definitions?
The Epid Unit of Sri Lanka, on the face of it, are good fellows. According to (https://www.epid.gov.lk/…/final_draft_of_testing_strategy_v…) the latest published version of Sri Lanka’s Covid testing strategy, CASES WITH COVID-19 LIKE SYMPTOMS FROM THE COMMUNITY THAT FIT INTO SUSPECTED CASE DEFINITION should be tested. This is good right? Way better than some areas of the world where they require your Oxygen Saturation level to drop to a certain dangerous level before you are eligible to get any medical assistance let alone a test? It Sounds better certainly. But is it? A lot depends on THE SUSPECTED CASE DEFINITION. According to the latest circular, (https://www.epid.gov.lk/…/Corona_v…/covid-19_cpg_version.pdf), “The present recommendation is to isolate and test all clinically/epidemiologically suspected cases of COVID-19 infected patients”
And a clinically suspected case is?
. A. A person with ACUTE RESPIRATORY ILLNESS (with Cough, SOB, Sore throat; one or more of these) with a history of FEVER (at any point of time during this illness), returning to Sri Lanka from ANY COUNTRY within the last 14 days.
B. A person with acute respiratory illness (with Cough, SOB, Sore throat; one or more of these) AND having been in close-contact* with a confirmed or suspected COVID-19 case during the last 14 days prior to onset of symptoms;
C. A person with ACUTE RESPIRATORY ILLNESS (with Cough, SOB, Sore throat; one or more of these) with a history of FEVER (at any point of time during this illness), with a history of travel to or residence in a location designated as an area of high transmission of COVID-19 disease as defined by the Epidemiology Unit, MoH, during the 14 days prior to symptom onset.
D. A patient with acute pneumonia (not explainable by any other aetiology) regardless of travel or contact history as decided by the treating Consultant.
E. A patient with fever and in respiratory distress as evident by RR>30 per minute, SpO2 <90% on room air, regardless of travel or contact history and without a definable cause, as decided by the treating Consultant
Did any Kandakadu Rehab inmate (or a staff member or a counsellor) presenting to the sick parade with cough, fever, sore throat meet these case definitions?
According to these definitions, was any inmate, staff member, counsellor at the Kandakadu Rehab Centre presenting to any doctor with cough, sore throat, fever, technically eligible for a PCR? No
Were these case definitions even relevant for the post-curfew, pre-Kandakadu Sri Lankan society? No.
Would infected Roshan, infected Ijaz and infected Mallar (who got infected through a secret infection cell started by a patient who escaped the first active case detection Covid mission in SL) be caught by this definition? NO. Should the chief epidemiologist be held accountable? YES FOR NOT MAKING THE CASE DEFINITION WIDE ENOUGH TO MAKE SURE ANY PATIENT WHO PRESENTS WITH COVID LIKE SYMPTOMS IS ROUTINELY TESTED FOR COVID IRRESPECTIVE OF TRAVEL AND CONTACT HISTORY , THE ONLY WAY TO DETECT ANY UNDERGROUND INFECTIONS.
Ministry of Health used to take pride that the last Covid 19 patient from the community was reported on 30 April 2020.
What this 30 April last case from the community meant was that all Covid 19 cases discovered after 30 April 2020 were members of the Navy cluster or an imported case or a local contact of the imported cases. That is, infected joes and janes from the Sri Lankan community WERE found after 30 April, not that they weren’t, but they all had an epidemiological link to the Navy cluster or to an imported case. Also, not that all these jacks and janes from the community were residing in a quarantine centre or a Navy/Army/Airforce camp when their infection was detected-some of them were living in the community, at their homes- i.e. the wife and child of that Army officer who got infected by some returnees from Kuweit, while helping them to fill forms at the Airport and that person from Batticaloa who was a contact of a Navy person. However, because they had a clear epidemiological link to these two major clusters, Naval and the Importeds, they were technically, from an epidemiological perspective, not from the community.
Now that was a major achievement- no cases from the community reported after 30 April 2020. With that under their belt, the Ministry of Health, the Epidemiology Unit, the medical profession, the general practitioners- specially the private practising GPs, needed to be on extreme alert, on a surveillance mode powered by extreme caution, even paranoia to detect any fresh wave of cases created by any infected escapees from the first dragnet. These new, secret infections would NOT present with an open contact history, because the person who started their transmission chain ESCAPED the active case detecting mission during the hammer phase; they will NOT have a travel history because Sri Lankans have not been travelling overseas since March. They will NOT have a history of travel or residence in an area designated as a high Covid transmission area because Sri Lanka did not have any civilian areas designated as high transmission areas at the time of the Kandakadu cluster discovery. The last civil area of high Covid 19 transmission, pre- Kandakadu, was Batticaloa- on 5 June 2020, Daily Mirror reported, “Meanwhile, the Epidemiology Unit said Rangala Navy Camp, Navy headquarters, Welisara Navy base and Batticaloa have been identified as current high risk areas in the country”.
Let’s take a hypothetical case, to understand how the Kandakadu cluster could have happened right under the not-too sharp noses of the Polonnaruwa doctors, under whose medical supervision the Kandakadu Rehab inmates were.
A fisherman living in Trinco goes fishing in the North seas. He meets some fishermen from Tamil Nadu poaching in SL waters. They are old friends and usually exchange fish, sweet meats, the odd smuggled item or even some Kerala Ganja. This time, a Tamil Nadu fisherman gives his old friend, the Trinco fisherman ‘somethin special’ – Covid 19. The SL fisherman comes ashore and gives it to his wife, who develops sore throat, fever, cough and goes to the local private practice of an MBBS doctor. Would she be tested?
Does she conform to any case definition given by the Epid Unit? . A) She did not return from abroad within the last 14 days. B) She was not in close contact with a confirmed Covid case during the last 14 days. Confirmed Covid cases are not allowed into the community in Sri Lanka. She was not in contact with a suspected Covid case as far as she knows. C) She does not have a history of travel to or residence in an area designated by the Epid Unit as a high Covid transmission area. D) She does not have acute pneumonia E) She is not in respiratory distress. No, she would not be tested. Not during a Covid complacent phase and not by a GP. An alert, informed medical practitioner would hear faint alarm bells, IF he bothered to take any history and learned that the husband was a fisherman. But alert and informed general practitioners are rare animals. The complacent, non-alert medical practitioner, fully backed by the complacent, non-alert Epid case definitions, diagnoses viral fever and gives paracetamol, dexamethasone, vitamin C and fexofenadine. The wife goes home and shares the medicines with her husband who has also developed symptoms. With medicine, their symptoms improve and two days later they go to see their son, who is in the Kandakadu Rehab centre. It’s visiting day after a long hiatus caused by the Covid curfew and they had been missing their son. The rest is history.
What would have prevented this? An alert and sharp chief epidemiologist. Forget case definitions. Why weren’t elderly care homes, drug rehabilitation centres and other enclosed communities with involuntary detainees selected to conduct random PCR tests in? Random PCR tests have been carried out among three-wheel drivers, Pettah porters, visitors to the Pettah railway station, delivery service personnel, Keselwatte and a whole lot of other places. Why weren’t elderly homes, nursing homes of long-term sick, detained drug rehabilitees, designated as high risk in Sri Lanka, given the experience of the rest of the world?