By Thangamuthu Jayasingam –

Dr. Thangamuthu Jayasingam

Nature (online edition) heads today 31 March 2020 as “Coronavirus latest: lockdown in Europe could have averted tens of thousands of deaths.” Infection control measures  put in place in many European countries – such as national lockdown- are reducing the corona virus.  Across 11 countries in western and northern Europe between 21,000 and 120,000 deaths will be probably have been avoided by the end of march according to a new model by a group at Imperial college London.[1] 

Isolation has been the tried and tested process of limiting the spread of contagious diseases over history and is well documented in the cases of diseases such as tuberculosis, small pox and leprosy. Many were considered as terminal illnesses and the isolation was to prevent others from being infected as cure was not possible at that point of time in history. Although vaccines have been developed for those diseases and they are not incurable anymore, we have had new examples over and over again  requiring  isolation as a best mode of reduction of infection in the system. Corona (COVID-19 Virus) is the latest in the series that had almost affected the entire world at different levels.  

Different countries have approached the problem of coping with the infection differently, but ISOLATION has been the prime mode of spread control from China to Sri Lanka. It has been noted that the countries which were reluctant to make large scale isolations have had to eventually pay the price of escalation of the infection and then subscribe to isolation controls one way or the other. Many countries have today closed their borders, stopped internal travel and transport  between cities and districts and also ships and flights have been cordoned off. These indicate the seriousness of the threat of infection by Corona Virus, as it stands today. The United States, one of the more affluent countries, has the highest number of suspected cases which go beyond 100,000 and the death toll is on the increase. They have no answer as yet.

WHO congratulated China on a “unique and unprecedented public health response reversed the escalating cases”. Early models of the disease spread without containment effort suggested that 500 million people would be infected (40% population). Within seven days of lockdown the  number of individual gave the virus dropped to 1.05, amazing says  Adam Kucharski of London school of hygiene and tropical medicine. The control measures worked says Christopher Dye, an  epidemiologist at Oxford.[2]  

Social distancing is a technical form of isolation to make the distance between the subjects far enough so that the probability of disease infection is minimized. This together with washing of hands frequently would almost nullify the chances of fresh infection from the Corona Virus. Sri Lanka  had done well regarding the control of the spread of the Virus, though we started a little late as pointed out by some authors. But as ACKNOWLEDGED  by many experts, commentators and institutions, the closure of many if  not almost all institutions and imposition of curfew have been in the right  direction towards curtailing the spread of  the infection. However the recent curfew patterns in parts of the country and the relaxation of curfews questions the fundamental purpose of all these actions, whether we are considering isolation as a prime means of reducing infection or as a  routine mechanism in the process. 

It has been observable that the social distances have been higher during normal days in the cities whereas during periods when the curfew is lifted and people pour out onto the streets to make the best use of the windows of gap in Curfew, this has extensively  reduced  the social distancing  in buses, offices especially Banks, shops, super markets, road side sales outlets etc.  Once the infection has spread increasing the distance again by reimposing the curfew does not matter. The next level operates in the family and neighborhood and thus increases the epidemic. 

The fatality rates are lower than the parellels viz SARS(severe acute resp[iratory syndrome), MERS( middle east respiratory syndrome and Ebola. But the infection also seem to spread easily than others.[3]

One infected person would be able to affect around 500 members with Coronavirus over a few weeks given the rate of spread of this Virus as 2-3 as suggested by many researchers.  This could be brought down to nearly 50 or less by increasing the social distances which was the theory behind closure of schools, airport, universities, offices and declaration of curfew. 

Best example from Seatlle:  Bedfords team calculated that over the six weeks several hundred people could have been infected. Basic reproductive number is taken as between two and three and if we half this with mitigation strategies then the outbreak will no longer grow”[4]

However, the current management of curfew where a longer period of curfew is interspersed with relaxation of the curfew negates the principle that social distancing  should be maintained, as it has reduced the social distances and negates the benefit of the social distancing during curfew to zoom into zero. This is evident in the hustle and bustle that is visible during the curfew break, when people rush out on to the streets and into the supermarkets, banks and pharmacies to stock up. T

 Prof Kalinga Tudor de Silva states, “others were seen congesting at the grocery stores, markets despite all steps by health authorities to control the pandemic”. Panic buying is a nature“ I cannot blame the public entirely. They are scared about the provisions for their families  more than the virus”[5]

There is a probability that we would, and could, be in the next cycle of the epidemic which will be worsened by this process of negating social  distancing. This was very well explained by the GMOA Vice Chair, who was on the TV recently and I presume these worthy professionals have briefed this to the Government and the corona task force.

As stated previously, the bigger the social distance the lower the probability for infection to spread. However if the mean distance is high, but frequent pockets of crowds make low distances periodically then the spread is made in the pockets, which then could infect the others singly or as a group later. I have witnessed many examples from Batticaloa from my own experience and others from social and other media.

* The recent times of curfew for Batticaloa had been lifted on Thursday 26^th march 2020 at 6 am. Re-imposed at 2 pm. Lifted again on Monday 30^th at 6 am and re-imposed at 2 pm and to be lifted on April 1, 2020 at 6 am to be re-imposed at 2 pm. The crowds that gathered at this time in banks, markets and other locations is has flouted all expectations to avoid an epidemic spread and worked against it. The crowding at markets was critically commented by many in the social media, as unacceptable crowding.

* If we had lifted the curfew on 26^th March, Thursday and re-imposed it on 1^st April 2 pm, giving a four day window, the likelihood of crowding at any one center would be less likely than during these mid-curfew hours of business. The social distancing would be higher in such case. In effect, we are promoting the likelihood of the infection by our scheduled curfews with short intermittent breaks, which makes no sense in its present form to avoid infections.

Prof Tudor Silva comments; “Sri Lanka also has a democratic political background for many decades. Hence we are  experiencing such negative effects of European democracy based on individual freedom” adding that it has proven to be grave in a global pandemic such as this.[5]

* Given that the transport to and from between districts are in place (for emergency services) including from those areas under strict curfew and areas under strict prohibition, transport through these areas is known. This increases the chances in any of the areas WHERE THE CURFEW IS RELAXED to have a higher contamination and potential spread of Corona virus. There is limited health check on those who are involved with such inter district transport to ensure that there is no spread through them. There needs to be regular check on them at least by IR thermometers so that they do not become sources of transfer of the virus.

* There is also a need to understand that this is a medical emergency and disaster and the people in charge have to be those in that profession where all others support the implementation. It would be futile for task forces to operate irrespective of the relevant sector advice (in this case the advice of the medical experts) in any aspect if the operation ‘Corona Virus’ is to be successful. I have quoted the GMOA view on the ‘social distance’ but as it is not operative in practice, I assume that they have not been heard.

* People and their needs are to be definitely considered as important but the priority is also their safety. Bitter medication is given to children at time for betterment of their health and public also have to learn to accept some difficulties during national emergencies, and they will,  as they have cooperated with the governments in the past during the periods of other calamities. But we have to be sure in our minds, that this is CORONA and it is different. We may not be able to go by previous experiences of Dengue or Chickengunea but think new and out of the box from basic principles, if we are to have success. India had issued curfew orders for 21 days which would have a great impact on the people’s daily lives, but if the alternative is to have the spread of virus uncontrolled then again the people will be at risk. 

China locked down Wuhan in mid-January a home of 60 million people. Tatem and Lai’s model suggests that there would have been 67 fold increase if not for the travel bans and lockdown. –Lessons from China by David Cyranoski, NATURE.[2]

* The office of the President and the Task Force which leads the CORONA PROJECT need to sit with the professionals and make the right decisions which may not be easy ones. The government has to decide the best course for our country given its strengths and weaknesses.. 

The recent Communiqué from the College of Community Physicians of Sri Lanka(30 March 2020)  appreciates the state for its action recommends to streamline the lockdown styartegy  and suggests that the ‘path in heightened scale’ with new strategies are essential to combat the Coronavirus infections. [6]

* The immediate need would be to increase the social distancing  to reduce the possible spread of infection and to find alternative improved efficient means of distribution of essential commodities while increasing the testing for infection at all levels. 

The cost of crowding will assuredly be more than the cost of curfew.

References: 

1. Cornavirus latest: lockdowns in Europe could have averted tens of thousands of deaths. Nature 31 march 2020.

2. David Cyranoski(2020) COVID- What’s China’s Coronavirus response can teach the world. Nature, 479-480   

3. Ewen Callaway, David Cyranosky, Smriti Mallapaty, Emma Stoye & Jeff Tollefson (2020) The Coronavirus pandemic in five powerful charts. Nature 579,482-483.

4. Amy Maxmen(2020) How much is Corona spreading under the radar. Nature (online)

5. Rajitha Jagoda Arachi (2020) Irresponsible social behavior links to lack of risk perception- Prof Kalinga Tudor Silva. Sunday Observer, 29 march 2020.

6. Flattening the epidemic curve of COVID-19 in Sri Lanka: the public health response. A communiqué from the college of community physicians of Sri Lanka, 30 march 2020