by Kelum Maddumage
Introduction
Outbreak of COVID-19 was first reported in Wuhan Province in Chinain December 2019. On 30 January 2020, World Health Organization (WHO) declared the outbreak as a Public Health Emergency of international concern and on 11 March 2020, WHO recognized it as a pandemic. As of now it has spread to number of countries in the world and Sri Lanka cannot be an exception.First COVID-19 patientin Sri Lanka was reported on 27 January 2020, that of a Chinese national but first Sri Lankan COVID-19 patient detected in Sri Lanka on 11 March 2020.
Sri Lanka faced the First Wave of COVID-19 from March – September 2020 and assessment by Chinese YICAI Research Institute in September 2020 ranked Sri Lanka as number 2 in terms of prevention measures of the epidemic. Since October 2020, Sri Lanka is experiencing the effects of the Second Wave of COVID-19 and research by an Australian Think-Tank Lowy Institute in January 2021 placed Sri Lanka at number 10 on the list of countries responding best to the pandemic.
Sri Lanka’s preparation for COVID-19
Vision of the President for combatting COVID-19 is “proactive intervention to prevent any outbreak of COVID-19 within Sri Lanka”. All preparations and actions by the Government of Sri Lanka (GoSL) are within this intent. Sri Lanka acted well before the pandemic hit the region. The National Action Committee for COVID-19 was established on 26 January 2020, a day before the detection of first COVID-19 patient in Sri Lanka. The committee was tasked to strategize measures to prevent any outbreak in Sri Lanka. Health sector was prepared for any medical emergency while other sectors were also prepared for any eventualities. Defence Forces were kept ready and were given the mandate to establish and handle quarantine centers. Police was given the directives to be prepared for enforcement of law during any situation. State Intelligence Service was tasked to undertake researches on global and regional developments and to assess possible impacts on Sri Lanka.
The GoSL took many other proactive actions as epicenter of the virus shifted from East to West. The GoSL promptly imposed travel restrictions for arrivals mostly from affected countries starting from 10 March 2020 and imposed total travel restrictions into Sri Lanka by 20 March 2020. All arrivals were directed to central-quarantine. It was made compulsory for persons who came before 10 March 2020 to self-quarantine themselves. Many actions in the field of medical and health care were also taken. These include strengthening of health service, obtaining enough testing materials for COVID-19, infrastructure developments in already available hospitals, dedicating certain hospitals for COVID-19 testing / patients and even constructing separate hospitals for COVID-19 patients. In mid-March 2020, the GoSL established the National Operation Centre for Prevention of COVID-19 Outbreak (NOCPCO) to spearhead combined operations of combatting COVID-19.
Sri Lanka’s approach for COVID-19
The GoSL strategy in combatting COVID-19 is a whole-of-government approach. It cascades down from the vision and the direction of His Excellency the President. Sri Lankan approach broadly focuses on four Lines of Operations (LOO); (a) Military / Police / Intelligence (b) Medical and Health Care (c) Psychological and (d) Economy and Well-being of Community. Overall concept of the Sri Lankan approach is as Diagram 1.
Military / Police / Intelligence line of operation
This line is focusing on prevention of virus getting into Sri Lanka, contain if already present within the country and prevent further spreading through various processes. This LOO size the pandemic into a manageable scale for medical and health care sector to handle and also enables medical and health care LOO. This is an exclusively intelligence driven process. This LOO contributes largely to identify the origin of the virus, identify the vulnerable communities, possible contaminations and prevent the spreading through human mobility. Essence of the strategy is based on Detection (D), Isolation (I) and Tracing (T); DIT Model. Each component in the model overlaps and complements each other. General concept of the DIT model is as Diagram 2.
Detection is twofold; detecting positive cases and detecting vulnerable communities. Detection process is combined with big-data analysis, verification of records with various agencies like Immigration and Emigration, Registration of People, Voter Registration., etc. Based on the results of detection, Isolation is used to segregate different communities through number of measures to include community to oblige to self-quarantine, central-quarantine in quarantine centers, enforcing curfews to restrict the mobility of communities and thereby prevent the spreading, isolation of vulnerable areas and complete lock-downs if necessary. Tracing is an important process and is employed to identify the root cause / origin of the case. Tracing is heavily based on ground intelligence and big-data analysis. Information from Telcos are of high value. Tracing would identify the family associates (FA), close associates (CA), distance associates (DA) of a patient, his / her movement details, contacts, places visited., etc. Results of tracing would propose persons / communities for self-quarantine / central-quarantine., etc.
Medical and health care line of operation
This line is focusing on early detection, isolation and provide treatment while contact tracing through primary healthcare staff. It also involved in promoting public health preventive measures to prevent disease from spreading. Testing facilities performed by a network of Laboratories, grassroots level actions by the Epidemiology Unit with the support of Public Health Inspectors and Medical Officers of Health, smooth functioning of hospitals and quarantine of exposed persons are of paramount importance in this regard. Health Surveillance, Detection through Testing and continuous Health Monitoring are the essence in this process.
Health Surveillance is focused on detection of cases through exposed contacts to quarantine measures, comprehensive and rapid contact tracing of the infected persons and case identification through severe / acute respiratory illness or even through post mortem testing of all suspected sudden deaths. Detection of positive cases are done through (a) laboratory confirmation of suspected persons admitted to hospitals(b) sampling of associates of already positive cases (either they are in self-quarantine or central-quarantine) (c) random sampling of high risk / vulnerable communities and high risk / vulnerable areas and (d) sampling at border control points. Health Monitoring of exposed persons are monitored and if symptoms appear are admitted to quarantine hospitals for investigation while those who do not get symptoms are tested before being released from quarantine hospitals. Simple process of detection is depicted below:
Detection is twofold; detecting positive cases and detecting vulnerable communities. Detection process is combined with big-data analysis, verification of records with various agencies like Immigration and Emigration, Registration of People, Voter Registration., etc. Based on the results of detection, Isolation is used to segregate different communities through number of measures to include community to oblige to self-quarantine, central-quarantine in quarantine centers, enforcing curfews to restrict the mobility of communities and thereby prevent the spreading, isolation of vulnerable areas and complete lock-downs if necessary. Tracing is an important process and is employed to identify the root cause / origin of the case. Tracing is heavily based on ground intelligence and big-data analysis. Information from Telcos are of high value. Tracing would identify the family associates (FA), close associates (CA), distance associates (DA) of a patient, his / her movement details, contacts, places visited., etc. Results of tracing would propose persons / communities for self-quarantine / central-quarantine., etc.
Medical and health care line of operation
This line is focusing on early detection, isolation and provide treatment while contact tracing through primary healthcare staff. It also involved in promoting public health preventive measures to prevent disease from spreading. Testing facilities performed by a network of Laboratories, grassroots level actions by the Epidemiology Unit with the support of Public Health Inspectors and Medical Officers of Health, smooth functioning of hospitals and quarantine of exposed persons are of paramount importance in this regard. Health Surveillance, Detection through Testing and continuous Health Monitoring are the essence in this process.
Health Surveillance is focused on detection of cases through exposed contacts to quarantine measures, comprehensive and rapid contact tracing of the infected persons and case identification through severe / acute respiratory illness or even through post mortem testing of all suspected sudden deaths. Detection of positive cases are done through (a) laboratory confirmation of suspected persons admitted to hospitals(b) sampling of associates of already positive cases (either they are in self-quarantine or central-quarantine) (c) random sampling of high risk / vulnerable communities and high risk / vulnerable areas and (d) sampling at border control points. Health Monitoring of exposed persons are monitored and if symptoms appear are admitted to quarantine hospitals for investigation while those who do not get symptoms are tested before being released from quarantine hospitals. Simple process of detection is depicted as Diagram 3.
Psychological Line Of Operation
Theme of psychological line in fighting COVID-19 is “Life First”. Giving the right information of the COVID-19 situation in the country to local public and to the international community is of vital importance in order to keep them well-informed. This would prevent any misinformation or disinformation by unverified sources. President’s Media Division (PMD) acts as the official source of information of GoSL initiatives / actions and continues to provide right information to the public through its website, twitter and Facebook. Conceptualization of psychological line is as follows as Diagram 4.
NOCPCO continues to work with public information campaigns through regular media briefings on COVID-19 situation, statistics and operations related to combat COVID-19. Epidemiology Unit (EPID) and Health Promotion Bureau (HPB) of Ministry of Health also update official figures in their websites. Several actions have also been implemented to build confidence of the public over the GoSL approach in fighting COVID-19 and the ability to control the situation. Experts from different fields have extensively used State and Private media (both TV and radio channels), social media forums / platforms to share the right information with the general public through a number of discussions / programmes. Likewise, printed media has also been used.
Economy and well-being of community line of operation
This LOO is focusing on maintaining the economy focusing on future in the country whilst looking after the immediate well-being of population by providing them with uninterrupted food supplies and medicines. Further, it looks at the mid and long term economic strategies against possible future global economic recession due to pandemic situation. The GoSL established a dedicated Task Force to undertake this responsibility. In mid and short term, the Task Force is to cover the administration of essential services to continue civilian life in areas and has also been tasked with the responsibility of taking measures to distribute products in liaising with all the institutes while paying attention to the activities undertaken by other agencies to maintain normalcy in the civilian life.
This Task Force is to steer the relevant institutes to create a productive economy through the formulation of a unique economic structure based on novel initiatives. Implementation of joint operations to establish a people-centric economy which will promote domestic industrialists and entrepreneurs is another objective of this Task Force. The Task Force comprises of Governors, Secretaries to Ministries, Tri Forces Commanders, Acting Inspector General of Police, Chairmen of several Departments, Corporations and Authorities and District and Divisional Secretaries.
Synergy of the Sri Lankan approach
None of these lines could produce desired results by working in isolation. Intelligence is required for precise situational awareness for other lines to act. Medical and Health Care need to coordinate with Military / Police / Intelligence line to detect, isolate and trace. Similarly, psychological and economic lines require inputs from intelligence for their responses. Thus, coordination and cooperation between different lines and synchronization of ground and technical intelligence is pivotal in this effort. Further, coordination and cooperation between line Ministries, Tri-forces and Police, Departments, Corporations, Authorities, Local Government Systems, all State and Private Sectors partners are of paramount importance in this. Such synchronization is the masterpiece in Sri Lankan approach in combatting COVID-19 since the first case in March 2020.
Controlling mechanism of spread of COVID-19
Process adopted by the GoSL in both First and Second Waves in controlling the spread of COVID-19 is akin to Hammer and Dance theory by Tomas Pueyo. Sri Lankan approach was focusing on using various aggressive proactive measures (Hammer) in anticipating spikes of cases and bring the spread of virus under controllable level (Dance) so that the health sector can handle the case load without exhaust. This process is continuous and reviewed after each case or cluster then adopted to the next case or cluster with the experiences gained by handing previous cases or clusters.
Versatility during the second wave
Discovery of a positive patient on 03 October 2020 from an apparel company considered as the beginning of the Second Wave in Sri Lanka. Preparedness and experiences from the First Wave assisted Sri Lanka to cope-up with the outcomes of the Second Wave. The President’s vision remains as same as “proactive intervention to prevent any outbreak of COVID-19 within Sri Lanka” whilst policy for the Second Wave is to “proactively controlling, countering and managing the outbreak whilst keeping the economy moving”. Overall strategy adopted during the Second Wave remains as same; application of four LOOS and the process used also akin to the “Hammer and Dance” theory. However,this time, the process is adaptive based on different dynamics to include the importance of up-and-running the economy whilst controlling, countering and managing the pandemic situation.
The GoSL quickly converted already available quarantine centers into Intermediate Treatment Centers (ITC) and expand hospital capacities to absorb incoming patients, increased testing capacities in many folds and introduced new testing algorithm. In contrast to central-quarantine for first line of contacts during the First Wave, this time, the GoSL adopted strict home-quarantine for all first line of contacts. It also employed extensive contact tracing, identification of vulnerable areas / groups, continued testings in those areas / groups, imposed quarantine curfews, isolations and lockdowns based on test results, conducted continuous medical surveillance in those areas and planned exit-strategies based on outcomes of subsequent testings. All these happened whilst ensuring uninterrupted food and medical supplies to those who were under quarantine, isolation and / or lock-down or otherwise as well.
District Level Committees comprising of heath, defence, police and other authorities to handle localized spread within districts have also been established and certain authorities of controlling, countering and managing have also been decentralized. Gradual opening of country’s economy, education, transport, essential services, government and private sectors, tourism, etc. commence under strict health guidelines. This process is dynamic, flexible and adaptive.
Conclusion
Spreading of COVID-19 pandemic in the world is continuing and different countries have employed different ways and means to combat the spreading. The GoSL strategy in combatting COVID-19 is a whole-of-government approach focused on prevention, containment and management. It cascades from the vision of the President; “proactive intervention to prevent any outbreak of COVID-19 within Sri Lanka”. There is no “one-fit-all solution” to this pandemic. Sri Lankan model is unique, an aggressive, continuous, dynamic, flexible and adaptive model
