With the highly contagious B.1.1.7 variant of COVID-19 now confirmed to be the dominant strain in Sri Lanka, authorities are scrambling to prevent an unmitigated public health crisis à la India even as state hospitals run out of intensive care units (ICUs) amid record daily cases.

Of particular significance is a trend of younger people being admitted to ICUs with severe symptoms including debilitating breathing difficulties, despite no diagnoses of underlying conditions. It is unclear at present what specific age groups are receiving ICU treatment, as the ministry of health has yet to publicise that data.

According to State Minister Dr Sudarshini Fernandopulle, however, age groups from children to people over 60 have tested positive for the new strain.

“Previously it was the elderly with non-communicable diseases that were more vulnerable to the virus, but of late we have observed that more young people are showing sever symptoms,” she told EconomyNext on Thursday (29).

Origins

The B.1.1.7 variant of SARS-CoV-2, the virus that causes COVID-19, was first detected in the UK in September last year. Four months later, genome sequencing of 92 samples collected in different parts of Sri Lanka including quarantine centres confirmed that the fast-spreading UK lineage has been present in the island since at least end-January 2021, though officials now claim it wasn’t detected in the community until April 08.

The University of Sri Jayawardenapura, whose scientists sequenced the samples, told EconomyNext at the time that Sri Lanka’s existing B.1.411 strain could’ve undergone de novo mutation owing to its wide and rapid spread in the country, though it is now suspected that the source of B.1.1.7 was likely a returnee from overseas.

No matter its origin, experts say, Sri Lanka’s health authorities have known for at least two months that the UK strain was present in the community but inexplicably saw it fit to reduce testing, ignoring repeated calls from various quarters to ramp up PCR numbers.

Testing vs cases (October 2020 to March 2021) – Graphic by Thiyashi Koththigoda

Rapid rise

With a record 27,000 PCR tests conducted on Thursday, authorities have finally heeded the call to increase testing, though not before shifting the blame to the public. Chief Epidemiologist Dr Sudath Samaraweera said on April 19 that increased movement during the Avurudu holidays could result in a spike in cases in the coming weeks. Cases have indeed surged since then, with over 1,600 Sri Lankans testing positive for the virus on Friday, the country’s highest daily total yet.

The rapid rise in cases is likely due to the increased transmissibility of B.1.1.7, though President of the Association of Government Medical Laboratory Technologists Ravi Kumudesh maintains that more testing equals more cases.

Economic hardships notwithstanding, Sri Lanka’s relentless efforts in combating the virus during the first wave were praised even by the government’s harshest critics. However, since the emergence of the second wave in October last year, the authorities have been roundly criticised for putting the burden of containing COVID-19 on an increasingly epidemic-fatigued populace. Officials and decision makers have been accused of taking the people’s good will and cooperation for granted, while those entrusted with public healthcare continue to make questionable decisions and, to be quite charitable, openly endorse less-than-scientific solutions.

Younger cases

At the time of writing, the Sri Lankan strain of SARS-CoV-2 and a Danish strain previously detected in the island, officials say, have been replaced by B.1.1.7 as the dominant variant. Its mutations, according to the University of Sri Jayawardenapura, make it at least 50% more transmissible and 55% deadlier.

Dr Fernandopulle and others have highlighted the high incidence of younger people needing ICU treatment after being infected with B.1.1.7, urging the public to adhere to health guidelines.

According to Director of the Institute for Health Policy (IHP) Dr Ravindra Rannan-Eliya, the UK strain is known to have a higher viral load, which may contribute to the associated increase in severity and mortality risk.

“It’s better at initially infecting you, and probably better at multiplying once it gets in. It also produces more viruses for you to breathe out,” he told EconomyNext on Thursday.

“Both factors will lead to more young people infected and more sick young people,” he added.

The increase in younger cases with severe symptoms does not imply that older people are necessarily less vulnerable. However, Rannan-Eliya said it’s possible that severity in older patients may be less than what it was before as many of them had received their first shot of the vaccine.

“I don’t know if B.1.1.7 is any less bad in unvaccinated older people than in young people,” he said.

Blame game

The IHP director painted a grim picture of what to expect.

“The higher infectiousness is driving the increase in cases. Increased cases will also result in more ICU cases and more deaths, even if B.1.1.7 was not more fatal, which it is,” he said.

Increased infectiousness would have led B.1.1.7 to dominate the epidemic, with a share of over 50 percent, by April/May, he said, adding that the fact that the UK strain is now said to be driving the latest outbreak attests to this.

If B.1.1.7 is indeed a majority of the new cases, Rannan-Eliya said, it must have been seeded back in January. Even in the UK, he said, it took several months to become dominant.

“Blaming the public about the Sinhala & Tamil New Year is just nonsense and shifting the blame. The doctors who have joined in this ‘blame the public’ mantra are just as guilty as the politicians,” he said.

Bad to worse

State Minister Fernadopulle has joined the chorus of official voices pleading with the public to strictly follow health guidelines so that Sri Lanka doesn’t reach a “worse stage than this”.

“We urge anyone who has breathing difficulties, severe headaches, body aches or other symptoms to immediately seek medical attention,” she told EconomyNext.

Meanwhile, Health Services Director General Dr Asela Gunawardena told Derana TV in an interview this week that Sri Lanka can still contain the outbreak and no patient will be left untreated.

“It’s not too late. If we follow the guidelines, minimise travel and maintain social distance, we can go back to how things were,” he said.

Gunawardena also advised against comparing Sri Lanka’s situation with India’s unprecedented crisis.
“People here are more disciplined. A few may not follow the rules but a majority does,” he added.

The Health Services DG said Sri Lanka’s state hospitals have the capacity to accommodate 13,000 patients at once. Discussions are under way to increase the capacity, he said.

“We don’t intend to leave any patient behind to be treated at home or to die on the street. We’re still trying to get people who have tested positive to treatment centres,” he said.

This statement is amid reports that confirmed patients were waiting at home for an ambulance that never came.

Gunawardena did, however, warn that resources are limited and requested the public to extend some support to the overworked frontline workers by providing accurate information in order to get the right treatment.

“We have around 180,000 staff at the moment, enough people to treat the general public. The important thing is to keep hospital staff healthy,” he said.

IDH

Since the beginning of the epidemic, the Infectious Diseases Hospital (IDH) in Angoda has been at the forefront of Sri Lanka’s fight against COVID-19. Having treated thousands of patients who showed varying degrees of severity, the hospital has finally run out of all ICU beds.

IDH Director Dr Ananda Wijewickrama told reporters this week that most people who test positive for the virus take their time to seek medical help, and by the time they’re admitted to hospital, their condition is so severe that any treatment is rendered ineffective.

“It is very difficult to treat such cases. COVID-19 patients don’t die without showing symptoms. That is a myth. If you suspect that you have caught the virus, don’t hide it. Immediately seek medical attention,” said Wijewickrama.

“Deaths occur mainly because people are late to arrive for treatment,” he added.

The IDH director, who personally sees COVID-19 patients on a daily basis, has noted what he calls are clear differences between cases reported now and before the surge in B.1.1.7.

“Symptoms are more severe now and the odds of complications arising are higher,” he said.

The most common symptom in the new cases, according to Wijewickrama, is difficulty in breathing. Before admission to the ICU, patients are treated with various medications and are provided oxygen to make breathing easier.

“We take patients into the ICU only when symptoms are severe,” he said.

O2

Devastating accounts of patients in India dying without life-giving oxygen have given rise to fears of a similar situation occurring in Sri Lanka if the current situation, delicate as it is, gets out of hand.

According to Health Services DG Dr Gunawardena, there is no such shortage at present. A Health Ministry statement on April 27 said the two oxygen producing companies in Sri Lanka will continue to provide more oxygen than needed.

IDH Director Dr Wijewickrama too said the production capacity of the oxygen producers are three times the country’s daily need.

“We have an excellent health service when compared to any advanced country. Our staff are capable of handling these patients,” he said.

However, the Association of Medical Specialists (AMS) said in a statement on Friday (30) claimed that though there is indeed enough oxygen to supply to COVID-19 patients, only a limited amount of it can be transported in cylinders.

“There are only 28 large oxygen cylinders in the country, and they can only transport up to 2,000 to 3,000 litres of oxygen,” the AMS said.

The largest of these cylinders, the association said, are based in Colombo and Peradeniya and Sri Lanka does not have the resources to carry the oxygen in those cylinders to the patients in need.

The AMS urged the Ministry of Health to import giant oxygen cylinders that can store up to 7,050 litres of the gas.

Preventing crisis

Though the situation is already dire, experts believe it is manageable and even reversible.

Director, Allergy Immunology and Cell Biology Unit of the University of Sri Jayawardenepuar, Dr Chandima Jeewandara told reporters earlier this week:”The good news is that the UK variant is still responsive to the vaccines sed in Sri Lanka.”

The problem is, however, that Sri Lanka’s vaccine rollout has somewhat hit a snag.

Related: Sri Lanka will not receive next batch of Covishield anytime soon: Official

“We’ll be getting sputnik V in about another week’s time it. That too is responsive and so is the Chinese-made Sinopharm which shows very good efficacy against B.1.1.7,” said Jeewandara, calling for a rapid rollout that will cover as much of the population as possible.

“Once vaccination reaches a satisfactory level like in Israel, the UK and the US,  we should be able to live a normal life, in about another three to four months time,” he added.

Dr Rannan-Eliya, meanwhile, believes Sri Lanka must keep out any new variant that crops up and crush any outbreaks that may happen in the event such variants get through.

“Even countries with tough quarantine, like Australia, New Zealand and China, Vietnam, have all reported community outbreaks with new variants,” he said.
Rannan-Eliya recommends the following:

1) Secure borders – Mandatory quarantine and testing of all arrivals, and not at home.

2) Massively ramped up PCR testing of people with symptoms – not random, and not antigen, and not just in hospitals. He also calls for a normalisation of getting tested.

3) Urgent government effort to make up for lost time and purchase bigger testing machines andsupplies to support this endeavour.

4) Genomic sequencing of all positive arrivals, and five percent of all community cases, which will require the government to invest in two or three labs rather than relying on World Health Organisation (WHO) handouts.

“Without these measures, lockdowns are not going to work in the end. Even in Wuhan lockdown only worked when they started testing people at home and isolating all detected cases,” said Rannan-Eliya. 

Courtesy: Economynext