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The overall COVID management of the government is commendable. However, the government and related stakeholders should explore alternative approaches to the current rigid regime for quarantine and treatment of returnees and COVID-19 positive cases – Pic by Shehan Gunasekara
COVID-19 was spreading in Wuhan, China from late December 2019 and on February 2020 the first batch of 33 (mainly students) were evacuated to Sri Lanka and kept in 14-day quarantine in an army facility. Since early March returnees from selected countries were required to undergo mandatory quarantine in various camps. After, COVID-19 was made pandemic by WHO on 11 March, our international airport was closed on 19 March for all incoming passengers, though kept open for outgoing passengers for a brief time.
Many returnee expats who arrived before the strict enforcement of quarantine, were subsequently found to be COVID-19 positive, hence causing community pocket clusters. The government of Sri Lanka took swift action using contact tracing and minimised further community transmission of the COVID-19.
The action of the COVID-19 task force, including the front line health professionals, intelligence personnel and the security forces under the direction of the President is commendable and even appreciated by many world leaders. The enforced curfews and movement restrictions have been largely effective except for the sudden hikes among Navy personnel. As of 30 May, even the Navy cluster has been largely brought under control.
However, the continued closure of the airport took a heavy toll on the expat community, many of them lost jobs and are stranded. Many of the expats who were planning to return to their country of origin were denied the opportunity to come back and the government is facing heavy criticism from many corners for not standing by the expats during their time of despair. This article critically explores the current COVID-19 management practices and how it can be improved and provide some solution with a view of urgently opening the airport for all incoming passengers of Sri Lankan origin.
Key issues involved:
Although a large population of Sri Lankan origin lives with their families in Europe, USA and Australia, most of them have chosen to stay put even during the pandemic. Majority of these migrants are living in those countries by their own choice, hence, despite the heavy tolls in Europe, there is no expected heavy inflow of Sri Lankans (except those who came from Italy).
However, the demographic pattern of expat employees in West Asia (especially Middle East) is a different ball game where mostly the expats are employed due to sheer economic compulsion, rather than by their own preferred choice. Majority of them, except for few who are employed as professionals, are essentially poor unskilled, domestic workers or self-employed who are going through heavy physical, mental and emotional hardships just to protect their families from hunger and to give them basic decent living.
Immediately after the pandemic declaration, the number of COVID-19 positive cases dramatically increased in Europe, USA and the Gulf countries. Sudden increase and rapid spread of the virus is mainly attributed to the very nature of the camp type accommodation where heavy concentration of employees are sharing minimal facilities. In many cases the recommended social distancing norms are not practical if not impossible. Similar scenarios are found in detention camps (e.g. Kuwait from where the first batch of detainees were returned).
Considering the increased number of COVID-19 positive cases, all Gulf countries implemented COVID-19 containment protocols including closure of all non-essential services. Accordingly, almost all employers lost their regular income. As a result, many of Sri Lankan employees lost their jobs, salaries deferred and suddenly found themselves in a nightmare. Some companies while retaining their staff, reduced the salaries through indirect and non-voluntary means. Apart from regularly employed personnel substantial numbers are engaged in self-employment (such as taxi drivers, food mess operators, cleaners, day workers, small vendors, etc.) They also lost their regular income.
The overall situation which arose unexpectedly, left them with no choice other than returning to Sri Lanka. Naturally it is their expectation to return to Sri Lanka to avoid further expenditures (and in some cases starvation).
Many welfare support groups and the embassies are currently helping some of the affected employees. However, there are no rosy pictures, when all those who were reasonably earning were forced to depend on the generosity of others. Knowing that the pandemic is going to stay for a while, the No. 1 priority of those impacted is to return to Sri Lanka without further delays.
Hence it the responsibility of the current government to facilitate early repatriation of the stranded employees as well as to assist those who are willing to visit their families at this time of despair.
Kuwait returnees
As part of a program to bring back Sri Lankans, the government gave priorities to students all over the world. A limited number of special flights were operated from Middle East including UAE, Kuwait and Qatar. Whilst all the passenger lists was either selected or endorsed by the COVID-19 task force, the repatriation of detainees was done through Kuwait government flights (2 Nos) during late May. Upon arrival and having gone through the PCR tests, approximately 200 returnees were found to be COVID-19 positive, hence the government decided to slow down the repatriation process. Although Sri Lankan and other flight operators indicated their willingness to start regular commercial flights from 1 June, the plans are currently shelved due to government decision.
Citing the limited quarantine facilities and treatment capacities (which are exclusively government operated through COVID-19 Task force), the right of return of expat employees are unduly delayed.
Whilst there are proposals to open the airport from August for tourists, there is no specific information available for Sri Lankan overseas employees and their families.
Current approach to COVID-19 prevention for oversees returnees
Currently all returnees are taken to Government-run quarantine centres (or hotels in some cases where the returnees bear the cost) and detained for 21 days. All are subjected to PCR tests and if found positive, taken to COVID isolation wards and treated. Those found to be negative, are released from detaining centres.
Since the current PCR test takes 2-3 days, there is no option other than to send all returnees to quarantine centres.
From the writer’s research, it was noted that alternative approaches are employed by various government and in some case the COVID-19 management is more effective than what is practiced in Sri Lanka (Kerala is a living example). The author encourages all relevant authorities to explore such practices and adopt a more flexible yet effective COVID-19 management for all returnees.
Testing methodology for COVID-19
Many variants of molecular or serological tests are currently employed internationally.
Molecular tests look for signs of an active infection.
They usually involve taking a sample from the back of the throat with a cotton swab. The doctor then sends the sample off for testing.
The sample will undergo a polymerase chain reaction (PCR) test. This type of test detects signs of the virus’s genetic material.
A PCR test can confirm a diagnosis of COVID-19 if it identifies two specific SARS-CoV-2 genes. If it identifies only one of these genes, it will produce an inconclusive result.
Molecular tests can only help diagnose current cases of COVID-19. They cannot tell whether someone has had the infection and since recovered.
Serological tests: These tests detect antibodies that the body produces to fight the virus. These antibodies are present in anyone who has recovered from COVID-19.
The antibodies exist in blood and tissues throughout the body. A serological test usually requires a blood sample.
Serological tests are particularly useful for detecting cases of infection with mild or no symptoms.
New testing for COVID-19 within 5 minutes: Abbott Laboratories received emergency use authorisation (EUA) from the US Food and Drug Administration (FDA) for the fastest available molecular point-of-care test for the detection of novel coronavirus (COVID-19), delivering positive results in as little as five minutes and negative results in 13 minutes.
What makes this test so different is where it can be used: outside the four walls of a traditional hospital such as in the physicians’ office or urgent care clinics.
The new Abbott ID NOW COVID-19 test runs on Abbott’s ID NOWTM platform – a lightweight box (6.6 pounds and the size of a small toaster) that can sit in a variety of locations.
Because of its small size, it can be used in more non-traditional places where people can have their results in a matter of minutes, bringing an alternate testing technology to combat the novel coronavirus.
Abbots are ramping up production to deliver 50,000 ID NOW COVID-19 tests per day. This comes on the heels of our announcement last week of the availability of the Abbott RealTime SARS-CoV-2 EUA test under FDA EUA, which runs on m2000 RealTime molecular system for centralised lab environments. Combined with ID NOW, Abbott expects to produce about five million tests in April.
Testing remains a crucial step in controlling the novel COVID-19 pandemic. Continuing to supply healthcare providers with new technologies to help curb the spread of infection is a top priority for public health officials and healthcare providers.
(https://www.abbott.com/corpnewsroom/product-and-innovation/detect-covid-19-in-as-little-as-5-minutes.html)
Experiences of other countries of rapid COVID-19 testing: Qatar: Stepping up its fight and surveillance against the novel coronavirus (COVID-19) and expanding the scope of early detection of infected cases, Qatar will soon introduce the rapid testing procedure “to test a large number of people in less time”, a senior official of the Ministry of Public Health (MoPH) said on Wednesday.
“At present, we are doing PCR (Polymerase Chain Reaction) test which has 99 to 100% accuracy. Rapid test procedure is also being recommended to test more number of people. We are making arrangements to get the best available rapid test kits, mostly from South Korea,” said MoPH Director of Public Health Sheikh Dr. Mohamed bin Hamad al-Thani.
“With rapid test facility, we can have more tests but the accuracy of the tests is lower compared to PCR and in some cases it is very low. However, we will soon introduce the most reliable rapid test approved by the (US) Food and Drug Administration,” explained Sheikh Mohamed.
(https://www.gulf-times.com/story/659814/Qatar-to-introduce-rapid-test-for-Covid-19-soon)
Experiences of other countries of rapid COVID-19 testing: Hong Kong: CK Life Sciences (0775) said yesterday it has signed a distribution agreement with Biolidics of Singapore to distribute a serology-based 10-minute rapid detection kit for COVID-19, with an accuracy of more than 95%.
“As antibodies take time to develop and may not be detectable in the early stage of infection, results have to be interpreted in conjunction with clinical presentation as well as results of other tests,” said Melvin Toh, Vice President and Chief Scientific Officer of CK Life Sciences. The detection kit is for health professionals and is not intended for home use, Toh added.
Alan Yu, vice president and chief operating officer, said the kit has already been deployed in Singapore and the Philippines and will be available in Hong Kong in April 2010.
The kit has received provisional authorisation from Singapore’s Health Sciences Authority and approval from the Food and Drug Administration of the Philippines. It is preparing for the European Union and US markets.
(https://news.rthk.hk/rthk/en/component/k2/1521926-20200422.htm)
Selection of quarantine methodology
While the quarantine method exclusively chosen in Sri Lanka is government-run, COVID-19 managed centres (including some hotels), the home-based quarantine centres are successfully used in most part of the world. The home-based quarantine expects those involved to be responsible and follow strict health guidelines. In fact, WHO has issued guidelines for ‘Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts: interim guidance, 17 March 2020’
(https://apps.who.int/iris/handle/10665/331473).
Experience of other countries in using home quarantine: Kerala: Kerala revised its home quarantine guidelines and the new instructions are meant for those who are coming from other parts of the country. According to principal health secretary Rajan Khobragade, who released the guideline, it was based on the advice received from the state expert committee that it was decided to stick on to home quarantine. The expert committee had pointed out that by choosing institutional quarantine, the infection transmission is high as such centres had limited facilities. The new guidelines also bring forth certain changes in the testing process also.
Who will be allowed to undergo home quarantine? As per the guideline, all those returning from other states will be subjected to a medical examination and those who are symptomatic will get admitted to the COVID-19 hospitals for treatment. Only those who have no symptoms and whose RTPCR test results are negative will be sent for 14 days’ home quarantine.
What are the prerequisites for home quarantine? According to the health department, only those who have a separate room at their houses with attached bathroom facilities will be allowed to choose home quarantine. It will be assured that the person who chooses home quarantine had the stipulated facilities. It will be examined by a team comprising of health, local self and police personnel. The person who undergoes home quarantine will be asked to sign a self-declaration form before doing the same.
What if the team denies home quarantine? Such people could either choose the institutional quarantine facilities or paid quarantine facilities of hotels arranged by the government.
The changes that have been brought to the testing: It has been decided to put away the stipulation to carry out RTPCR test on the seventh day of surveillance; Upon availability of rapid antibody test kits, testing will be carried out on those categories who had high social contact; If they test positive, it will again be confirmed through RTPCR test; At present one who gets declared positive via RTPCR test will have to undergo further testing on alternative days. This testing will now be carried out from the seventh day of confirmation.
(https://www.newindianexpress.com/states/kerala/2020/may/11/kerala-revises-home-quarantine-guidelines-for-people-returning-from-other-states-2141940.html)
Experience of other countries in using home quarantine: Oman: The Ministry of Health had issued guidelines (March 2020) for home-quarantine if someone gets infected with the COVID-19 virus. The ministry also warned that anyone failing to adhere to these guidelines would face legal action.
(https://timesofoman.com/article/2870162/Oman/Guidelines-for-COVID-19-home-quarantine-issued-in-Oman)
Enforcement of movement restriction during home quarantine: Hong Kong: During February, Hong Kong confirmed that recent visitors to China’s Hubei province would be tagged and tracked with wrist bands. Each of the clunky looking kits connected to a patient’s smartphone, with “an alert sent to the authorities if the wristband moves too far from the phone, or if either device was broken.” Those breaking the rules risk arrest and detention.
The devices were intended to police quarantines, with a fear that isolated patients would ignore restrictions and venture out and about. During the initial containment, people did contravene mandatory home quarantine orders and arrest warrant were issued. Those caught were sent to quarantine centres, losing the right to stay home.
Fast forward a month and the technology has been fully productised, China-style. Last week, Hong Kong’s Secretary for Innovation and Technology Nicholas Yang Wei-hsiung announced that the tech is ready for the big time, to “improve monitoring for the outbreak.”
(https://www.forbes.com/sites/zakdoffman/2020/03/17/alarming-coronavirus-surveillance-bracelets-now-in-peoples-homes-heres-what-they-do/#536a80ce4533)
Enforcement of movement restriction during home quarantine: Karnataka: To tackle the menace of quarantine violations and also to improve monitoring, the Karnataka government directed those home-quarantined for suspected coronavirus infection and patients in isolation to send selfies every hour.
(Read more at: https://english.manoramaonline.com/news/nation/2020/03/31/coronavirus-covid19-karnataka-quarantine-watch-app-selfie.html).
Other alternatives for quarantine
From the above example quoted, home quarantine can be effectively implemented which can provide much relief to the government run-quarantine centres. However, if the government does not want to allow home quarantine for inbound passengers, some of the following can be used to supplement the existing quarantine centres:
Use of private hospitals for COVID-19 treatment
The government may use private hospitals for treatment of COVID-19 patients. In many parts of the world the government facilities are grossly inadequate and the private hospitals are also designated for COVID-19. Our neighbour India provides ample examples of this methodology. Even in our case the existing private hospitals can be utilised to treat COVID-19 patients with necessary health guidelines. In fact, as in India government can insist on private hospital for treatment of COVID-19 patients.
Examples of using private hospitals for COVID-19: Kolkata: In the wake of coronavirus COVID-19 pandemic, the West Bengal government on 23 April ordered the state-run private hospitals to provide free treatment for COVID-19 patients, adding that the entire cost will be borne by the state government.
(https://zeenews.india.com/west-bengal/west-bengal-govt-orders-private-hospitals-to-provide-free-treatment-to-coronavirus-covid-19-patients-2278568.html)
Examples of using private hospitals for COVID-19: Gurukam: The district magistrate on 26 May issued an order stating that private hospitals and clinics refusing treatment to people will be penalised as per Epidemic (1987) act without any prior notice. See:
(https://timesofindia.indiatimes.com/city/gurgaon/gurugram-private-hospitals-to-face-action-if-they-deny-treatment-to-those-with-covid-19-symptoms/articleshow/75998186.cms).
Examples of using private hospitals for COVID-19: Delhi: New Delhi, 9 May. Amid a spurt in coronavirus cases in the national capital, the Delhi government has roped in three more private hospitals with a total of 150 beds to treat COVID-19 patients.
In an order issued on Saturday, Delhi Health Secretary Padmini Singla declared Fortis in Shalimar Bagh, Saroj Medical Institute in Sector 19, Rohini and Khushi Hospital in Dwarka for admitting confirmed or suspected cases.
(https://www.businessinsider.in/india/news/3-more-private-hospitals-to-treat-covid-19-patients-in-delhi/articleshow/75644486.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst)
Options for repatriation of expats
The best option for repatriation is to allow commercial flights to bring in inbound passengers. This will allow most of the expats to pay for their air travel back to Sri Lanka. As an additional precaution the number of passengers could be limited to implement the social distancing guideline mandated by WHO guidelines. Majority of the expats would be willing to pay an additional premium for the increased safety.
From the social media posting it was noticed that the special flight is packed to full capacity which increases the chance of new transmissions amongst the passengers. The situation could be avoided if more numbers of commercial flights are made available.
For the stranded expats who are unable to pay for the travels expenses, the SLFBE may use the insurance claims or other means available (such as Itukama Fund). Government also may commence specific fund raising for the expats issue for which assistance from hosting countries and other NGOs and the general public could be sought.
Conclusions
The overall COVID management of the government is commendable. However, the government and related stakeholders should explore alternative approaches to the current rigid regime for quarantine and treatment of returnees and COVID-19 positive cases.
Rapid testing for COVID-19 is becoming more popular in many parts of the world for cheaper, faster and reliable testing against COVID-19. This test methodology can be established in the airport itself and the results can be obtained in much quicker time (within 5 min to 20 min depending on the test kit supplier).
Though there is some concern over the accuracy of the rapid test, for the very purpose of initial screening, such testing in the airport itself would largely assist to segregate where the passenger can be directed to viz, isolation, hospital, or selected quarantine centre or even for home quarantine.
Home quarantine is successfully used in many parts of the world including Kerala, Karnataka. Kerala authorities prefer home quarantine rather than institutional quarantine. With adequate security control and frequent inspection of the home quarantines, the burden on government operated quarantine centres can be reduced.
Private hospitals are effectively used in many parts of the world to treat patients tested positive for COVID-19. Even in Sri Lanka the private hospitals can be used to supplement the government designated COVID-19 treatment facilities. It is worthwhile to note that the mild cases can be treated from home as per the WHO issued guidelines.
The social stigma for the corona patients shall be eliminated with positive media support. The overall population shall learn to live with COVID-19 for the foreseeable future as the virus cannot be completely eradicated from the world.
Given the above consideration, and with stronger decision making from the government, the right of return of deserving and willing expatriates can become a reality sooner than later.
