25 September, 2020

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Covid-19: Emerging Questions, Testing Times 

By Rajan Philips

Rajan Philips

It is now one month after the WHO declared Covid-19 a global pandemic. Some clarity is emerging through the viral cloud about what happened, what went wrong and what might have been done differently. It is legitimate to ask if Wuhan had to be isolated from the rest of China, why could not China have been isolated from the rest of the world. Had that twin isolation been undertaken, China would have got reconnected with the world in 67 days at most, the time it took China to end the isolation of Wuhan. In fact, China’s external isolation would have ended a lot sooner. Trade connections and supply chains would have survived an immediate isolation with minimum disruptions, and would not have been catastrophically broken as they are now. This is all now hindsight, but the questions to China and the WHO are not going to go away.

There is plenty of blame to go around the world for general government inertia as well as sinister political calculations. Early warnings were ignored in the US and pandemic emergency plans meticulously prepared in western countries after the SARS crisis were not even looked at this time. The exceptions are the few East Asian countries, perhaps Australia and New Zealand down under, and Iceland and Denmark up north. There are broader questions as well – from the direct connections between the growth of global agri-business and the release of pathogens from their harmless natural settings to hit and harm human hosts, and the diminishing global investment in the study of and preparedness for communicable diseases relative to lifestyle illnesses. But the questions and the debates will have to wait for another day until the current fight against the virus is brought under control. 

There is no primeval fight or flight option. But fight and feed. Fight the virus, feed the people. That is the task of every government and it cannot get more basic for any government. And the task should not be made more difficult by the all too familiar lapses into never ending spats over race, region and religion. When nothing works, blame the unreliable Chinese or the ugly American. If neither works, blame the Muslims, especially in South Asia. The European Union that was created to end its recurrent internal wars is warring again over supplies and subsidies in the fight against the virus. And for the great NATO, it is business as usual. They will get paid for doing nothing as usual, or for desk-top testing of non-existent pandemic scenarios, unlike everyone else in the world.       

Oh, yes, “April is the cruelest month.” T.S. Eliot would never have imagined that the famous opening line of his melancholy poem, The Waste Land, would turn out to be a morbid prophesy not only for the country of his birth, but also for the country of his adoption. The United State of America, where Eliot was born, is now the epicentre of a global pandemic. And the United Kingdom, of which he became a citizen after renouncing his American citizenship, is faring proportionately the same, if not worse. Prime Minister Boris Johnson himself has become a prime patient of Covid-19. Mr. Johnson is reportedly recovering well, after being in intensive care unit but without needing ventilator support, and much to the relief of a Brexit-battered and virus-hit nation. In general, however, and as usually alarmingly in the US, marginalized people are faring the worst. 

The number of Covid-19 cases and deaths worldwide keep rising relentlessly. There are different lights in different tunnels. Europe seems to be on the mend finally, but only through a mountain of the dead. In the US the virus is surging in one state after another, but the curve appears to be flattening in general. Africa is no longer immune as it appeared to be at the start, and the worst is yet to come both for the continent’s health and its economy. East Asia is relatively stable, including China the origin of the viral quake. South Asia is sitting somewhat precariously in the middle, with India looming as the huge known unknown. That is the current picture and also the context for ongoing decision making.

Decision Making

Decisions are now being made in three interlocking planes, the science about the virus, the public action to contain its transmission, and governmental efforts to cushion the economic fallouts. The practical side of the science about the virus is all about testing. It is the paucity of testing and the lack of sufficient knowledge about the virus that has made contact tracing and physical distancing – from simple home isolation, to centralized quarantines, to total lockdowns – the only way to break the chain of transmission and stop the viral spread. 

It is the same paucity that has given rise to two, rather crude but the only available, universal metrics in the tracking of the virus and the fighting of its transmission: the number of days it takes to double the number of Covid-19 cases; and the number of tests per million population. The former helps in plotting the curve and the latter to assess the extent of the virus spread and to see if and how containment measures are working. For comparison, in the pandemic hotspots like China, Italy, Spain and the US, the number of days during which cases doubled, shrank from six to seven days at the start to three to four days during the surge.

Sufficient testing is needed to decide how and when the current isolation and distancing could be relaxed, and in what stages. Until then, there are economic fallouts to be taken care of. Unlike any of the past economic upheavals, the current shutdown is the worst supply side crisis ever, and writ large over the world like never before. While during the 2008 Great Recession, the western countries were hit hard and the peripheral economies were relatively spared, it is the global periphery that will be hit harder than the economic centres in the current showdown. Global initiatives have been either promised or called for by G20 leaders ($5-trillion), the UN ($9-trillion) and a large group of former world leaders ($5-billion) – that includes President Chandrika Kumaratunga. If any or all of them were to materialize, that would ensure a significant cashflow to peripheral countries. But how soon and how much are indeterminate, and the current beggar-thy-neighbour attitude to one another among the  western countries does not augur well for much global certainty.    

Testing delays have been universal, except again for the few East Asian countries. Even the US got tied up in regulatory knots and wasted precious time in the beginning before ramping up its testing program. The countries that are doing better in containing the virus are also doing larger number of tests than others. South Korea and Singapore are at 9,000 and 12,000 tests per million people, respectively. Australia is at 13,000 tests per million people, while Bahrain and Iceland are off the charts at 35,000 and 89,000 (multiple) tests per million. Timing is important. Germany and Italy are doing 15,000 tests per million, but they started late, especially Italy. France and England are under 5,000 tests per million, while the US and Canada are hitting close to 7,000 and 10,000 tests, respectively, but with significant regional variations. 

Testing time for Sri Lanka

By all accounts, Sri Lanka has done phenomenally well in contact tracing and supervised quarantining. The record on testing, however, is nowhere near as good. Currently, the tests are reportedly limited to patients only, and about 3500 tests have been carried out so far according to recent news reports. That would place Sri Lanka at about 175 tests per million people, and in the same South Asian camp as Bangladesh at 36 tests per million (with 6,000 tests), India at 107 (145,000 tests), and Pakistan at 212 (45,000 tests). Sri Lanka has been conducting 150 to 300 tests daily, although it is said to have the capacity to go up to 1500 tests a day. At this rate, it will take just over two months to reach a reasonable target of 5000 tests per million (i.e. 100,000 tests). There have also been suggestions that the daily test rate can go up to 12,000 tests a day, but there has been no follow up regarding an aggressive testing program  

There is then the debate, including in Sri Lanka, about what tests to perform and who should be targeted for tests. The primary test type is the diagnostic laboratory PCR (Polymerase Chain Reaction) test that detects the virus and confirms infection in a person. Multiple tests are needed in some cases before infection is confirmed. In many jurisdictions, this test and confirmation are required for ‘treating’ patients, even though, as some epidemiologists and physicians have pointed out, there is no accredited therapy for Covid-19. 

The WHO definition of a confirmed case as “a person with laboratory confirmation of COVID-19 infection”, gives PCR test a special imprimatur. Dr. Jayaruwan Bandara, Director of the Medical Research Institute, has called it “the gold standard test” for diagnosing Covid-19. Understandably so, and the same token entails many restrictive guidelines for carrying out the test. The lab work invariably takes time and it has taken too much time even in western countries to increase the laboratory throughput of test results. 

In addition, the PCR test is not a mass surveillance test to assess the spread of infection in a community. Hence the call for a second test, the serology test, that detects the antibodies that are produced to fight the virus infection. This can be used for both diagnosis and for population surveillance that will show the number of people who have been infected, including those with minor symptoms and those who are asymptomatic. Detecting asymptomatic cases is the special advantage of the serology test, knowing that asymptomatic transmission of the coronavirus is what renders it intractable. 

As against these merits of serological testing, there is conventional reluctance in (government) medical and health regulatory circles to implement a serological testing program at the early stages of an epidemic. The reluctance might be because the regulatory agencies are not prepared to apply the serology test for diagnostic purposes insofar as the test does not detect the virus or early infection. Serology tests are typically used after an epidemic to assess the levels of infection and immunity in the community to prepare for the next outbreak. This point has also been made by the Director General of Health, Dr. Anil Jasinghe, who has indicated that “PCR is the test that was used by China and South Korea, at the initial stage of Covid-19, and that tests, like blood antibody testing, were used later.” The Sri Lanka Medical Association (SLMA) has also called for expanding PCR testing instead of shifting to serology testing. 

On the other hand, the GMOA, in my understanding from news reports, has been pressing for implementing a rapid (serology) test program, and to carry out tests among 45,000 or so ‘contact traces’, who are in quarantine and are yet to be tested. In between, Chair Professors of Medicine (and specialist Physicians) from six of the island’s medical faculties, in their letter to Lt. Gen. Shavendra Silva, Chairman of the Covid-19 National Task Force and Dr Anil Jasinghe, Director General of Health Services, recommending next steps, have called for increasing test capacity and to “seek advice from virologists regarding what tests are most appropriate for use in specific scenarios.” 

Across the world, a Canadian epidemiologist, Prof. Dawn Bowdish of McMaster University, has said that serology tests “are absolutely the gold standard for understanding the spread of this infection.” So, if both the PCR and serology tests are gold standard tests according to medical experts, albeit for different purposes, why not use both – from a simple and practical policy standpoint, to serve both purposes in Sri Lanka, and since both are needed. That is, both to diagnose patients and to track the virus spread. New serology tests are already being used in a number of countries, each priced at $10 (Rs. 2000, less than the PCR test cost of Rs. 6000), and able to give results in 20 minutes. 

One more viewpoint on the matter of testing might be of particular relevance in the Sri Lankan context, with a tradition of doctors providing exceptionally good diagnosis in spite of limited resources for laboratory testing. Prof. David Fisman, Infectious Disease Epidemiologist and Physician at the University of Toronto, has suggested that given the newness of and the lack of information on Covid-19, ‘clinical case definitions’ should be used to identify Covid-19 cases where formal testing facilities are not sufficiently available. According to Dr. Fisman, clinical definitions were used during the SARS outbreak in Canada, and at the height of the current crisis in China, CT-scans were used in diagnosing Covid-19. Dr. Fisman has also suggested that in a pandemic situation such as this, every patient admitted to a hospital should be tested for Covid-19, along with healthcare providers. Testing of inmates in prisons, and other high-density dwellings and institutions would also make sense. 

At this early stage of an epidemic caused by an etiologically little-known virus, the sampling for testing is invariably not random. Optimal sampling strategies have been developed for other disease epidemics that are both time-dependent and independent, and target both the vector (virus) and the host (human) populations. For now, in the case of the coronavirus, the rather crude metric of ‘tests per million’ appears to be the only guidance everywhere. Random sampling has been reported in Iceland, but the randomness assumption there is also being contested. In the light of all this and to get to practical matters, what could be the next steps in Sri Lanka? 

Next Steps and Potential Slips

There is no further need to belabour the case, which is to implement both the PCR and the serological tests as rapidly as possible and as in many numbers as possible. Sri Lanka could learn from Vietnam, which has a low testing rate, about 1,200 tests per million people (and a total of 115,000 tests), but has aggressively carried out contact tracing and targeted ring-testing among the traced contacts to break the chain of transmission. The Sri Lankan government should support medical and health professionals to devise testing programs specific to each district, based on the experience so far and district-specific infection information, and implement them aggressively. There are medical faculties practically in every province and their resources should be leveraged to maximum benefit through co-ordination with the MRI and the Director General of Health Services. 

It would also be helpful if the government could set up a proper professional forum where all the medical voices and opinions could be channeled and consulted without their having to find independent media outlets to express themselves. There is some media muttering that some medical voices are closer to the political powers than others. But that is inevitable and in itself should not be much of a concern, provided the scientific independence of the MRI and the administrative independence of the Director General of Health Services are not compromised.

To strike a personal note, I have found the silence of Dr. Tissa Vitarana in all of this somewhat puzzling. As onetime Director of the MRI, he was a highly respected medical scientist and was universally liked as a person, as some UNP Doctors used to say, in spite of his affiliations to the LSSP. His age should not be a factor, because everybody who is somebody in the current Administration is old. Dr. Vitarana is the only medical scientist who is politically associated with the current Administration. He is the Governor for the North Central Province and is also on the SLPP National List for the parliamentary election. And he could be a source of experience and wisdom in linking medical-scientific thinking and political decision making. 

A ramped-up testing program and informed consultations based on test results will be critical in determining the next steps in coming out of the current curfew situations in the country. The virus is not going to disappear any time soon any where in the world, until an effective therapy or a successful vaccine is found. So, there cannot be a total relaxation of the current restrictive measures. In fact, it would be prudent to expect and prepare for restrictions and relaxation to alternatingly continue for rather long periods of time. And there are good practices to follow – from Vietnam, South Korea, Singapore and Taiwan. 

Singapore is currently implementing a series of “stepping up measures” to deal with a second spike in the local transmission of the virus. Singapore calls the measures a “circuit breaker”, not a lockdown or a curfew, and they are being implemented with due preparation and prior notice to avoid public confusion and transport stampedes.  The measures will initially last a period of one month, which is calculated to cover two cycles of viral incubation. Additionally, modern supermarkets and traditional ‘wet markets’ will remain open and people will be allowed shop in orderly manner while maintaining minimum physical separation. These are not difficult measures and similar measures can be easily implemented in Sri Lanka. In Colombo, and other main cities, it should not be difficult to keep markets open and designate separate days of the week for households from different areas (e.g. by streets or ward) to do their shopping.  

Overall, the government faces three challenges: containing the virus; cushioning the economic fallouts; and ensuring the survival of constitutional politics. On the first, the government deserves all the credit that has been extended to it. Hopefully, it will keep up the good work, informed by sufficient test data and appropriately adopting good practices from East Asian countries. It is too soon to pass verdict on the second challenge. Even without the virus the government was in a deep hole and the virus has made it infinitely worse. Its first responsibility is to support employees and businesses who are involuntarily locked out of work, and this goes far beyond fulfilling the already established subsidy practices. 

To that end, the government should look for immediate funding opportunities anywhere and everywhere, bilateral or multilateral. It could even send Chandrika Kumaratunga and Ranil Wickremesinghe as urgent emissaries to scour the world and not to return without foreign exchange. They could be more useful to the country from the outside than from within. Of course, they cannot emplane immediately, nor is physical travel really necessary with the new virus making virtual connections the new reality. Desperate times call for desperate measures, and no one is going to lose by working together in this crisis. Hopefully, I am not jinxing the possibility of a positive outcome for the country by publicly suggesting it. 

The government should also forcefully nix lamebrained ideas emanating from within its ranks. Two have surfaced so far – one on (ab)using the EPF savings as a stimulus source, and the other to bring back import substitution from the long-ago dead. Neither seems to have found any traction, and hopefully both are still born, or dead on arrival. This is not to say that there is no room for new ideas, only they should not be lamebrained. 

Worldwide food scarcity has been talked about even before the arrival of the virus, and its arrival makes it all the more urgent. Sri Lanka can and must re-energize its food production, but without raising barriers. It is a fact of Sri Lankan economic history that local food production has thrived only when there was no barrier at the customs, or checkpoints at district boundaries. One can be a socialist and doesn’t have to feel shy about saying this. As for new ideas, it would be worth for some in the government and the industry to explore the possibility of retooling the island’s industrial knowhow and technology in medical glove making and the garment industry to cater to the rising global demand for hospital gowns and other Personal Protection Equipment (PPE) for frontline healthcare providers.  

The third challenge is also the government’s Achilles’ heel, and where it can slip. The success here will be marked not by the extent of the SLPP’s victory at the next parliamentary election, whenever it comes, but by the extent to which President Gotabaya Rajapaksa and his Administration abide by constitutional norms in exercising executive power. A curfew without declaring emergency, avoiding emergency rule to avoid recalling parliament, and bankrolling off the national coffers, no matter how empty, without parliamentary approvals – are all jointly and severally beyond the pale in every direction. The President has the power and the option not to do any of this. And those who advise him to the contrary are not serving the President or the country well. 

The latest in this vein is the missive by Presidential Secretary, Dr. P. B. Jayasundara, to Mahinda Deshapriya, Chairman of the Election Commission. The latter was ill-advised to start a public correspondence with the President on deciding a new date to hold the now postponed parliamentary election. Dr. Jayasundara, rather than elevating the discussion, has chosen to lower it by indulging in pettifogging and seriously indefensible polemics. He has lowered the office of the President. In the midst of a generational battle against a novel pathogen, President Gotabaya Rajapaksa deserves better from his Secretary.   

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Latest comments

  • 1
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    Mr. Rajan Phillips,

    Re: COVID-19 , China-19 virus and the Para-Sinhala Para-“Buddhist “ Racism.

    “When nothing works, blame the unreliable Chinese or the ugly American. If neither works, blame the Muslims, especially in South Asia.“

    Thanks for your article. However, the fact remains that the Corona virus -19 originated in Wuhan, China, and the Chinese authorities initially suppressed it, and when they realized that it cannot be suppressed has to act,

    The same thing happened with Gotabaya Rajapaksa and Donald Trump, but Gotabaya at least listening to the health authorities, took some decisive actions, before it was to late,
    Trump, on the other hand was late, but half-hearted.

    We have the other issue of Para-Sinhala Para-“Buddhists “, racists, who are an insult to the Buddha and is a distortion of Buddhism, trying to blame the Muslims, for the Chinese virus. At least Donald Trumph was correct in calling the COVID-10 virus, the Wuhan China virus.

    Time to sue the Chinese and the Para-Sinhala Para-“Buddhists “ for premeditated misinformation,

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    Rajan, a big Thank You for presenting such perplexing details , in a simple and easy to understand essay. (as you do always). If I may add my two cents worth, when testing is combined with predictable course of the illness (time taken for incubation, symptoms to appear, spread , viral loads, infection free, timing of testing, quarantine —-etc ) ,makes strategies clinical and cost effective. For example, some countries are repeating test (multiple)in a patient to decide the end of quarantine period where as others are combining the clinical picture (single test) to decide when to come out of it. Most Bacterial infections have a known predictable course. Where as Viral Infections are little bit trickier and Covid being a novel/mutated virus, it may be some what new to medical world. But we have had plenty of time and cases (crossing millions ) to workout a reasonable clinical course and followup with reliable infection control measures. There are few, vulnerable people who will end up having complications or both such as secondary Bacterial infection superimposed on a primary Viral infection, where the morbidity and mortality (I believe up to 5%) will rise , definitely without adequate treatment. This is where reliable information becomes most vital to develop a strategy /protocol for each country considering the breakout, availability of testing/treatment, access to treatment and an effective outcome for the cost.This needs a Team work where treating physicians, virologist, epidemiologist, policy makers and rest of the front liners need to come together to formulate such customized protocols at each country,city and district levels. Last but not least as some people claim, WHO has reportedly done all the plotting, graphs, analysis and statistics but forgot that they were dealing with a Virus, and not just Human. Here we are three months passed since breakout, more than a lakh dead, millions infected and locked down for , soon going to be a month and yet perplexed.

  • 2
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    A good prognosis with logical optional courses of action. One doesn’t need to agree with all but this is infinitely better than other rantings in this forum. Thanks Rajan.

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      Very true Hela.
      A great write up.

      Soma

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    All aspects brought together in a very simple and readable style. Rajan has done the hard yards for everyone. This is an article to be carefully read and digested by anyone interested in reality and the Covid-19 situation in Lanka. Those who seek to scan it and leave nonsensical comments do injustice only to themselves.

  • 0
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    Rajan Phillips: Your article has been narrated in simple understandable english and that is the content that we read often in news pages, So everyone is happy. Yet I do not believe as the true story or any kind of vigilantism in media or investigative journalism or any kind of scholarly articles,. If you read around and write the story then it is very different and is intriguing..

  • 3
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    “The number of Covid-19 cases and deaths WORLDWIDE keep rising relentlessly.”
    \
    The writer seem to be getting carried away by his own misunderstandings, misrepresentations and lies. (Oh! that smirk!) .
    \
    Here is a test. Take a world map, or find one in the Net, and check the number of deaths and infected in the African, Latin American, South East Asian and Baltic regions of the world. (Leave out Western Europe and the US for a moment).
    \
    Hope you have enough gray matter to understand why this so-called ‘pandemic’ is being beaten up to show it as a ‘global’ epidemic.
    \
    The rich are dying and it needs publicity.

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      Antony (sic) Fernandes seems to have a few nuts and bolts missing. He too appears to be another Vajira Gunawardena who boasted falsely on previous occasions to have a PhD in virology from the University of Michigan.

  • 1
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