Current Experience and Future Challenges of COVID-19 in Sri Lanka: An Auto-Ethnographic Study

Surveillance and Public Health Actions

The Epidemiology unit issued guidelines based on WHO guidelines on January 26, 2020 in advance to reporting the first case. In parallel, a Presidential Action Committee chaired by the Health Minister was created in late January, with representation from the health sector (the Director General of Health Services, Chief Epidemiologist and healthcare leaders), political leadership (the Governor of Western province) and the Armed forces. The Police Department and local government services were added later to contain the pandemic. Airports were closed in mid-March but Sri Lankans were allowed to return in a controlled manner. The public were instructed to use the existing free government ambulance service with toll- free 24/7 hotline to transport patients to health institution and another free hotline to contact physicians for advice was established. International students and workers stranded in Middle Eastern countries were priority repatriation groups. Repatriation of 33 students from Wuhan was the first mission where the airline staff followed infection prevention strategies including changing clothes on disembarkation, disinfecting belongings and being quarantined for 14 days in a quarantine center. None of the staff or passengers was infected. Many Middle East returnees were infected with SARS CoV-2 when tested on arrival.

Repatriation was influenced by the availability of quarantine accommodation. Health declaration forms completeness was a challenge and some people did not adhere to home quarantine guidelines. All returnees were sent to compulsory institutionalised quarantine for 14 days as of March 10, 2020. Initially, quarantine accommodations were provided free of charge at governmental facilities to citizens and foreigners. Later, there was an option to be quarantined at designated hotels at reasonable rates. Currently, accommodations are available for 8000 persons at a given time in free and paid quarantine centers. Sri Lankan commercial sailors were allowed to return to their residences, after 14 day quarantine. Sailors were allowed to board ships for their next assignment and exempted the 14- day quarantine at times. International seafarers were paid by their companies for quarantine facilities. The Western province, a popular tourist and commercial hub was identified as a high- risk- area for community-spread of COVID-19. Another district called Putlam in the North-Western province, a crucial area that provided salt, vegetables, fish, and poultry to the country, was also identified as a high- risk- area as there were many Chinese workers in addition to returnees from the Middle-East and Italy.

Testing, Isolation and Tracing

Sri Lanka established Polymerase-Chain- Reaction (PCR) testing at the Medical Research Institute with support from the University of Hong Kong and was able to test the first patient within 24 hours after admission. Testing facilities were expanded at hospitals with virologists or bacteriologists. The Dengue Research Laboratory at a university started PCR testing and other universities joined later. The Institute of Nanotechnology manufactured viral swabs locally at one third of importing cost to mitigate the shortage of viral swabs. Private hospitals were allowed to do PCR testing after cost regulations were implemented. Test results had to be available within 24 hours and suspected patients had to be admitted until results were available.

The testing strategy changed from test only “symptomatic cases” of persons in quarantine to “all suspected contacts” on March 30, 2020. Sri Lanka continues to admit all PCR positive patients to COVID treatment centers irrespective of severity of disease until article submission on September 23, 2020. The National Institute of Infectious Disease Hospital had 384 beds to handle an epidemic but most of the isolation wards and rooms in other General Hospitals had to be quickly modifies to properly isolate patients. COVID-19 patient triaging, PCR testing, treatment and isolation were carried out under the supervision of clinical consultants in 14 selected hospitals initially and expanded to 30 hospitals and COVID -19 treatment centers. Two previously closed hospital buildings and an abandoned radio station in a high risk area were rapidly refurbished and converted to COVID-19 specialised treatment centers.

Since the first case identification, high risk persons continued to be tested and the second case was identified on March 11, 2020. Contact tracing was initiated and coordinated by the Central Epidemiology Unit and respective District Epidemiology teams after the first reported local case. Since all suspected persons were hospitalised public health officials were able to communicate with them and obtain travel history for contact tracing. State Intelligence services supplement information on recent movement of cases and contacts. District Regional and MOH teams to locate contacts and quarantine. Public Health Inspectors monitored quarantined persons and transported symptomatic patients to hospitals. Each patient’s information was maintained as a paper file centrally at the epidemiology unit. A list of quarantined patients in each of MOH areas is updated daily by the MOH and monitored by Regional Epidemiologists and Consultant Community Physicians. The information is shared electronically among MOHs and hospitals in the district.

Infection Prevention and Control Strategy

Heads of health institutions had to organize triage areas, isolation rooms, personal protective equipment, staff training and other logistic issues. Although ideal triage and isolation facilities were difficult to setup in rural areas, available resources were maximized to ensure social distancing. Many staff prepared their own personal protective equipment (PPE) using locally available material such as cloth for masks and clear plastic sheets for face shields. The community and non-governmental organizations donated PPEs, food and other essential to hospitals. Hand washing facilities, masking and social distancing instructions were displayed on all outpatient areas and public address systems and videos were used to give further instructions. Health Education and Infection Control Nursing Officers facilitated patient awareness and education at hospital outpatient departments (OPD). Pregnant mothers were educated at clinics and in the field by Public Health Midwives. It was challenging to continue necessary maternal health services in the field, especially when mothers of quarantined houses needed medical attention. MOH team’s coordination with other stakeholders such as the District Secretary, Deputy Inspector General of Police, higher officials as needed for relevant field activities. COVID-19 infection as occupational exposure was only seen among a few healthcare and other workers in Quarantine Centers or at the airport directly handling passengers. Health care workers and other staff who had “suspected exposure” were quarantined and tested in addition to regular random testing among asymptomatic staff in quarantine centers.

At the outset PCR testing was performed for all suspected cases and only for symptomatic contacts. Primary or secondary contacts of a positive case were cleared of surveillance after 14 day house quarantine if asymptomatic. In April Sri Lanka started testing all contacts. The military played a large role in setting up quarantine centers by mobilising their manpower and setting up quarantine centers at military camps, government buildings and naval ships as needed. Home quarantine, self- isolation and physical distancing were not always possible as many homes in Sri Lanka were small and shared by many family members. As such, establishing quarantine centers was undertaken to avoid community spread. In certain communities shared toilets and backyards made self-isolation difficult and in some communities communal eating was enabling the rapid spread of the disease. Therefore high risk contacts in such areas were also sent to quarantine centers.

When a couple of isolated cases were found in crowded urban areas in the Western province, there was complete lock down, isolating the risk areas and spread of the disease was confined to small neighbourhoods. Schools and universities were closed in mid-March. A few of public holidays were given to keep people at home which were extended to a curfew in some high risk areas. Curfews were enforced in the whole country since the third week of March. As inter-district travel was also banned some people who had travelled for jobs, medical treatment, and family events were stranded in other districts. Curfews violators were arrested and vehicles impounded. There was mass media campaign to adhere to curfews or risk of prosecution. The police played a major role to control public movement in cities. Although there was some public movements in rural areas, the risk was negligible. The health sector did not advocate masks for the general public due to an initial lack of clear evidence and absence of community transmission. However, the police implemented a strict policy to wear masks in public. With the reopening of country health officials advised public to wear masks.

Communication Strategy

Effective means of communication within the healthcare system, other sectors involved in pandemic management and the public was essential for the entire process. Online meetings were introduced to coordinate activities among national and district level authorities and it was time saving for MOH and district staff to coordinate via ZOOM meetings. A communicator was designated to inform guidelines to health institutions and to convey the needs of institutions to district authorities. Social media groups were created among health workers and institutional heads to update latest information on guidelines, issues, and up-to-date status reports. District Secretary, Deputy Inspector General of Police and officials in the Armed forces worked very closely with district health teams as needed to provide basic supplies to communities under lockdown. Following curfew declarations, this network was extended island wide to provide food, medicine and even mobile banking facilities. MOH teams provided technical guidance for social distancing and infection prevention strategies for such activities.

Mass media repeatedly promoted the importance of infection prevention strategies such as social distancing, masks, quarantine created to change the public behavior and keep them indoors. The public were educated to the difference between quarantine and isolation to alleviate phobias about quarantine and reluctance to self-isolate. The district health authorities received significant support from the community and religious leaders in managing the pandemic. PHIs visited supermarkets, workplaces and other high risk public places and displayed posters on disease preventive measures, hand washing and health habits. Public awareness was conducted at the community level by all MOH offices using public address systems. People didn’t have much option to ignore public health recommendations as this was a multi-sectoral programme. If they do not comply with PHI, the police and the government agent got involved.

Challenges and Solutions

There had been many challenges ranging from a lack of PPE to economic impact of lockdowns and other measures implemented to contain the pandemic. Authors’ description of some of these is summarized on Table 2 and potential lessons from this pandemic are presented in Table 3.

Challenge Quotes

Lack of Personal Protective Equipment ( PPE)

“Severe shortage of PPE was experienced at the beginning. Except for N95 masks most other PPE were prepared locally by staff and community. Some improvised plastic bags initially as protective aprons.” “One of the Universities designed simple helmet like wiser to prevent healthcare workers from droplets and a Technical Training Institute produced 700 of them using laser cutters and 3D printers within two days.” “Isolation rooms were partitioned by polythene sheets; some hospitals used a glass shield between patient and doctor. Somehow all hospitals managed to maintain minimal contamination using various methods.” “Initially some healthcare workers tried to stay away from potential COVID patients. However, after some time they followed necessary infection prevention precautions and by the time when cluster of Navy officers were infected, they had visited the hospitals before knowing they were infected. At that time hospital staff confidently stated they have not been exposed as they were following proper PPE precautions.”