Features
Home as clinical setting for asymptomatic mild Covid-19 positive patients: What you should know
BY Dr Ruvaiz Haniffa
Head, Dept of Family Medicine Faculty of Medicine
University of Colombo And Past President Sri Lanka Medical Association
Introduction
Most people with COVID-19 develop mild or uncomplicated illness that can be managed at the primary care level, and the demand for primary care services will escalate during periods of increased transmission. Health policymakers at the national and subnational level will need to take appropriate action to support the role of primary care in the response, such as managing mild COVID-19 cases or recovery of hospitalized cases, identifying strategies to increase surge capacity, managing and maintaining stocks of personal protective equipment (PPE) and other essential supplies, and maintaining of essential services, while ensuring timely adaptation to address the needs of vulnerable groups.
With the rapidly increasing incidence of COVID-19 in Sri Lanka and the health systems possible inability to provide in hospital care for PCR positive COVID-19 patients; the HOME as a setting for clinical care provision for asymptomatic mild COVID -19 patients may indeed become possible or even necessary. In this context pre-emptive planning for provision of home-based care for carefully clinically triaged and selected patients becomes important.
As per the WHO, COVID-19 is classified in to 3 clinical entities- mild, moderate, and severe (Fig.1). People classified as having mild COIVID-19 with no symptoms should be able to stay at home, if adequately isolated from others. This also implies that if you are symptomatic even with mild COVID-19 you will require hospital admission.
See Fig.1
Care pathway for COVID-19 Positive Patients in Sri Lanka
Decision to care for COVID-19 patients at home.
This decision cannot and should not be made by the patient or the family. This decision must be made after clinical triage by a healthcare team which must include a family physician and social worker who is aware of the patient’s physical home infrastructure in addition to the past and current health status of the patient.
Home care should be considered for an adult or child with confirmed COIVD-19 when in patient care is unviable or unsafe (e.g. when heath care service capacity is insufficient). It must be understood that home care increases the risk of transmitting the virus to others at home. However, isolation of people at home and using the home as a clinical setting to provide care to carefully selected patients can make an important contribution to breaking the chain of transmission of the virus.
Home care (provided requirements are fulfilled) should ideally be considered for individuals under the age of 60yrs, do not smoke, are not obese and have no other diseases such as cardiovascular diseases, diabetes mellitus, chronic lung disease, cancer, chronic kidney disease or immune suppressed.
The decision as to isolate and care for an infected person at home depends on the following 3 factors.
1. Clinical evaluation of the COVID-19 patient
2. Evaluation of the home setting (Please see Box 1).
In the Sri Lankan context of considering home as clinical setting for COVID-19 home care the following in addition to Box 1 should also be considered.
2.1. Adequate floor space area with minimum two individual rooms, adequate natural ventilation and two toilets
2.2. Home should preferably have access to running water.
2.3. The infected patient/family should be equipped with communication facilities to contact healthcare providers routinely and in an emergency.
3. Ability to monitor the clinical evolution of the person at home.
What to monitor in a COVID-19 positive patient receiving home care
The patient and care giver must be adviced about the signs and symptoms of complications or how to recognize deterioration in their health status that requires medical attention.
The most important parameters to monitor in the home setting are fever, difficulty in breathing, fast or shallow breathing, blue lips or face, chest pain or pressure, confusion (which was not present earlier), inability to wake up, inability interact when awake and inability to drink or keep liquids down
. For infants in addition to these, grunting and inability to breast feed also must be considered. (Please note this list is not an exhaustive list and if you have any doubt, please contact healthcare team immediately)
Home pulse oximetry is a safe, non-invasive way to assess oxygen saturation in the blood and can support the early identification of low oxygen levels in patients with initially mild or moderate COVID-19 or when patient does not appear short of breath but their oxygen levels are lower than expected (Silent Hypoxia).Home pulse oximetry can identify individuals in need of medical evaluation, oxygen therapy or hospitalization, even before they show clinical signs of worsening signs or symptoms.
This author is of the view that if home care for mild asymptomatic COVID-19 positive patient is recommended the minimum requirement should also include the possession or access to a finger pulse oximeter.
What should be done to prevent other people in the house from becoming sick if a person with COVID-19 is being cared for at home?
It is highly recommend that the patient, caregiver/s are given a simple and short orientation programme to use the provided equipment and to create awareness on the ‘red-flag’ signs to look out for and contact the primary health care provider for further instructions.
There are several precautions that can prevent the spread of COVID-19 to other people in the house:
The ill person should stay in a separate room. If this is not possible, then keep at least a 1-metre distance from them. The sick person and anyone else in the same room should wear a medical mask.
Provide good ventilation in the room of the ill person and shared spaces, and open windows if possible and safe to do so.
The ill person should wear a medical mask as much as possible, in particular when not alone in the room and when at least a 1-metre distance from others cannot be maintained. Limit the patient’s movement around the house and minimize shared spaces. Ensure shared spaces (e.g. kitchen, bathroom) are well ventilated.
Visitors should not be allowed in the home.
Limit the number of caregivers to one person with no underlying conditions, if possible.
Caregivers and household members should wear a medical mask while in the same room with an ill person, not touch their mask or face during use, discard the mask after leaving the room, and wash their hands afterward.
The ill person should have dedicated dishes, cups, eating utensils, towels and bed linens. They should be washed with soap and water, and not shared.
Frequently touched surfaces by the ill person should be cleaned and disinfected at least daily.
Everyone in the household should wash their hands with soap and water regularly, especially:
– after coughing or sneezing
– before during and after you prepare food
– before eating
– after using the toilet
– before and after caring for the ill person
– when hands are visibly dirty
A cough or sneeze should be covered with a flexed elbow or a disposable tissue that is discarded immediately after use.
The waste from the ill person should be packed in strong closed bags before disposal.
The household (patient and care giver/s) should be encouraged to have steady supply of masks (essential, 3 ply surgical mask would do), face shield (optional), disposable or washable overalls (optional), 70% alcohol hand sanitizer (optional in the presence of clean running water and soap)
How long should people with COVID-19 stay at home and in isolation?
People with COVID-19 who are cared for at home should stay in isolation until they are no longer able to transmit the virus to others:
Those with symptoms should stay isolated for a minimum of 10 days after the first day they developed symptoms, plus another 3 days after the end of symptoms – when they are without fever and without respiratory symptoms.
People without symptoms should stay isolated for a minimum of 10 days after testing positive.
Please check with you Family Physician/PHI for updated release from home isolation guidelines as they subject to update.
Conclusion
Primary care is an essential foundation for the global response to COVID-19. Primary care plays a significant role in gatekeeping and clinical responses: identifying and triaging possible COVID-19 cases, making an early diagnosis, helping vulnerable people cope with their anxiety about the virus, and reducing the demand for hospital services. The role of primary care has been increasingly important as cities imposed strict control measures including non-pharmaceutical interventions and as larger hospitals closed their outpatient departments during periods of increased transmission.
There also is an increasing role of home care for COVID-19 cases within communities supported by a strong primary care system, which strengthens the trust between health-care workers and communities. A response built around primary care has also been a more cost-effective measure.
The SARS-CoV-2 Virus is doing its job. Are we as individuals, families and communities doing our job to prevent the spread of the virus? None of us will be safe until all of us are safe.
The government/health authorities by allowing the home care of mild asymptomatic COVID-19 patients are taking us the people of Sri Lanka into their confidence and giving us responsibility to actually be part of the clinical care process of COVID-19 management in Sri Lanka. Let us not disappoint the government/health authorities by misusing, manipulating, and abusing the trust they have placed in us. Let us show them that we the people of Sri Lanka if given responsibility will deliver on in it in the context of home care for COVID-19 patients.
Reference
1.
Home care for patients with suspected or confirmed COVID-19 and management of their contacts. Interim guidance 12th August 2020. Updated 2nd March 2021.
2.
Role of primary care in the COVID-19 response. Interim guidance. Revised and republished as of April 9th, 2021 (Originally published 26th March 2020).
by Dr Gotabhya Ranasinghe
Senior Consultant Cardiologist
National Hospital Sri Lanka
When we sought a meeting with Hon Dr. Ramesh Pathirana, Minister of Health, he graciously cleared his busy schedule to accommodate us. Renowned for his attentive listening and deep understanding, Minister Pathirana is dedicated to advancing the health sector. His openness and transparency exemplify the qualities of an exemplary politician and minister.
Dr. Palitha Mahipala, the current Health Secretary, demonstrates both commendable enthusiasm and unwavering support. This combination of attributes makes him a highly compatible colleague for the esteemed Minister of Health.
Our discussion centered on a project that has been in the works for the past 30 years, one that no other minister had managed to advance.
Minister Pathirana, however, recognized the project’s significance and its potential to revolutionize care for heart patients.
The project involves the construction of a state-of-the-art facility at the premises of the National Hospital Colombo. The project’s location within the premises of the National Hospital underscores its importance and relevance to the healthcare infrastructure of the nation.
This facility will include a cardiology building and a tertiary care center, equipped with the latest technology to handle and treat all types of heart-related conditions and surgeries.
Securing funding was a major milestone for this initiative. Minister Pathirana successfully obtained approval for a $40 billion loan from the Asian Development Bank. With the funding in place, the foundation stone is scheduled to be laid in September this year, and construction will begin in January 2025.
This project guarantees a consistent and uninterrupted supply of stents and related medications for heart patients. As a result, patients will have timely access to essential medical supplies during their treatment and recovery. By securing these critical resources, the project aims to enhance patient outcomes, minimize treatment delays, and maintain the highest standards of cardiac care.
Upon its fruition, this monumental building will serve as a beacon of hope and healing, symbolizing the unwavering dedication to improving patient outcomes and fostering a healthier society.We anticipate a future marked by significant progress and positive outcomes in Sri Lanka’s cardiovascular treatment landscape within the foreseeable timeframe.
by Fr. Emmanuel Fernando, OMI
Jesuit Fr. Aloysius Pieris (affectionately called Fr. Aloy) celebrated his 90th birthday on April 9, 2024 and I, as the editor of our Oblate Journal, THE MISSIONARY OBLATE had gone to press by that time. Immediately I decided to publish an article, appreciating the untiring selfless services he continues to offer for inter-Faith dialogue, the renewal of the Catholic Church, his concern for the poor and the suffering Sri Lankan masses and to me, the present writer.
It was in 1988, when I was appointed Director of the Oblate Scholastics at Ampitiya by the then Oblate Provincial Fr. Anselm Silva, that I came to know Fr. Aloy more closely. Knowing well his expertise in matters spiritual, theological, Indological and pastoral, and with the collaborative spirit of my companion-formators, our Oblate Scholastics were sent to Tulana, the Research and Encounter Centre, Kelaniya, of which he is the Founder-Director, for ‘exposure-programmes’ on matters spiritual, biblical, theological and pastoral. Some of these dimensions according to my view and that of my companion-formators, were not available at the National Seminary, Ampitiya.
Ever since that time, our Oblate formators/ accompaniers at the Oblate Scholasticate, Ampitiya , have continued to send our Oblate Scholastics to Tulana Centre for deepening their insights and convictions regarding matters needed to serve the people in today’s context. Fr. Aloy also had tried very enthusiastically with the Oblate team headed by Frs. Oswald Firth and Clement Waidyasekara to begin a Theologate, directed by the Religious Congregations in Sri Lanka, for the contextual formation/ accompaniment of their members. It should very well be a desired goal of the Leaders / Provincials of the Religious Congregations.
Besides being a formator/accompanier at the Oblate Scholasticate, I was entrusted also with the task of editing and publishing our Oblate journal, ‘The Missionary Oblate’. To maintain the quality of the journal I continue to depend on Fr. Aloy for his thought-provoking and stimulating articles on Biblical Spirituality, Biblical Theology and Ecclesiology. I am very grateful to him for his generous assistance. Of late, his writings on renewal of the Church, initiated by Pope St. John XX111 and continued by Pope Francis through the Synodal path, published in our Oblate journal, enable our readers to focus their attention also on the needed renewal in the Catholic Church in Sri Lanka. Fr. Aloy appreciated very much the Synodal path adopted by the Jesuit Pope Francis for the renewal of the Church, rooted very much on prayerful discernment. In my Religious and presbyteral life, Fr.Aloy continues to be my spiritual animator / guide and ongoing formator / acccompanier.
Fr. Aloysius Pieris, BA Hons (Lond), LPh (SHC, India), STL (PFT, Naples), PhD (SLU/VC), ThD (Tilburg), D.Ltt (KU), has been one of the eminent Asian theologians well recognized internationally and one who has lectured and held visiting chairs in many universities both in the West and in the East. Many members of Religious Congregations from Asian countries have benefited from his lectures and guidance in the East Asian Pastoral Institute (EAPI) in Manila, Philippines. He had been a Theologian consulted by the Federation of Asian Bishops’ Conferences for many years. During his professorship at the Gregorian University in Rome, he was called to be a member of a special group of advisers on other religions consulted by Pope Paul VI.
Fr. Aloy is the author of more than 30 books and well over 500 Research Papers. Some of his books and articles have been translated and published in several countries. Among those books, one can find the following: 1) The Genesis of an Asian Theology of Liberation (An Autobiographical Excursus on the Art of Theologising in Asia, 2) An Asian Theology of Liberation, 3) Providential Timeliness of Vatican 11 (a long-overdue halt to a scandalous millennium, 4) Give Vatican 11 a chance, 5) Leadership in the Church, 6) Relishing our faith in working for justice (Themes for study and discussion), 7) A Message meant mainly, not exclusively for Jesuits (Background information necessary for helping Francis renew the Church), 8) Lent in Lanka (Reflections and Resolutions, 9) Love meets wisdom (A Christian Experience of Buddhism, 10) Fire and Water 11) God’s Reign for God’s poor, 12) Our Unhiddden Agenda (How we Jesuits work, pray and form our men). He is also the Editor of two journals, Vagdevi, Journal of Religious Reflection and Dialogue, New Series.
Fr. Aloy has a BA in Pali and Sanskrit from the University of London and a Ph.D in Buddhist Philosophy from the University of Sri Lankan, Vidyodaya Campus. On Nov. 23, 2019, he was awarded the prestigious honorary Doctorate of Literature (D.Litt) by the Chancellor of the University of Kelaniya, the Most Venerable Welamitiyawe Dharmakirthi Sri Kusala Dhamma Thera.
Fr. Aloy continues to be a promoter of Gospel values and virtues. Justice as a constitutive dimension of love and social concern for the downtrodden masses are very much noted in his life and work. He had very much appreciated the commitment of the late Fr. Joseph (Joe) Fernando, the National Director of the Social and Economic Centre (SEDEC) for the poor.
In Sri Lanka, a few religious Congregations – the Good Shepherd Sisters, the Christian Brothers, the Marist Brothers and the Oblates – have invited him to animate their members especially during their Provincial Congresses, Chapters and International Conferences. The mainline Christian Churches also have sought his advice and followed his seminars. I, for one, regret very much, that the Sri Lankan authorities of the Catholic Church –today’s Hierarchy—- have not sought Fr.
Aloy’s expertise for the renewal of the Catholic Church in Sri Lanka and thus have not benefited from the immense store of wisdom and insight that he can offer to our local Church while the Sri Lankan bishops who governed the Catholic church in the immediate aftermath of the Second Vatican Council (Edmund Fernando OMI, Anthony de Saram, Leo Nanayakkara OSB, Frank Marcus Fernando, Paul Perera,) visited him and consulted him on many matters. Among the Tamil Bishops, Bishop Rayappu Joseph was keeping close contact with him and Bishop J. Deogupillai hosted him and his team visiting him after the horrible Black July massacre of Tamils.
Sri Lanka-Singapore Free Trade Agreement
By Gomi Senadhira
senadhiragomi@gmail.com
“You might tell fairy tales, but the progress of a country cannot be achieved through such narratives. A country cannot be developed by making false promises. The country moved backward because of the electoral promises made by political parties throughout time. We have witnessed that the ultimate result of this is the country becoming bankrupt. Unfortunately, many segments of the population have not come to realize this yet.” – President Ranil Wickremesinghe, 2024 Budget speech
Any Sri Lankan would agree with the above words of President Wickremesinghe on the false promises our politicians and officials make and the fairy tales they narrate which bankrupted this country. So, to understand this, let’s look at one such fairy tale with lots of false promises; Ranil Wickremesinghe’s greatest achievement in the area of international trade and investment promotion during the Yahapalana period, Sri Lanka-Singapore Free Trade Agreement (SLSFTA).
It is appropriate and timely to do it now as Finance Minister Wickremesinghe has just presented to parliament a bill on the National Policy on Economic Transformation which includes the establishment of an Office for International Trade and the Sri Lanka Institute of Economics and International Trade.
Was SLSFTA a “Cleverly negotiated Free Trade Agreement” as stated by the (former) Minister of Development Strategies and International Trade Malik Samarawickrama during the Parliamentary Debate on the SLSFTA in July 2018, or a colossal blunder covered up with lies, false promises, and fairy tales? After SLSFTA was signed there were a number of fairy tales published on this agreement by the Ministry of Development Strategies and International, Institute of Policy Studies, and others.
However, for this article, I would like to limit my comments to the speech by Minister Samarawickrama during the Parliamentary Debate, and the two most important areas in the agreement which were covered up with lies, fairy tales, and false promises, namely: revenue loss for Sri Lanka and Investment from Singapore. On the other important area, “Waste products dumping” I do not want to comment here as I have written extensively on the issue.
1. The revenue loss
During the Parliamentary Debate in July 2018, Minister Samarawickrama stated “…. let me reiterate that this FTA with Singapore has been very cleverly negotiated by us…. The liberalisation programme under this FTA has been carefully designed to have the least impact on domestic industry and revenue collection. We have included all revenue sensitive items in the negative list of items which will not be subject to removal of tariff. Therefore, 97.8% revenue from Customs duty is protected. Our tariff liberalisation will take place over a period of 12-15 years! In fact, the revenue earned through tariffs on goods imported from Singapore last year was Rs. 35 billion.
The revenue loss for over the next 15 years due to the FTA is only Rs. 733 million– which when annualised, on average, is just Rs. 51 million. That is just 0.14% per year! So anyone who claims the Singapore FTA causes revenue loss to the Government cannot do basic arithmetic! Mr. Speaker, in conclusion, I call on my fellow members of this House – don’t mislead the public with baseless criticism that is not grounded in facts. Don’t look at petty politics and use these issues for your own political survival.”
I was surprised to read the minister’s speech because an article published in January 2018 in “The Straits Times“, based on information released by the Singaporean Negotiators stated, “…. With the FTA, tariff savings for Singapore exports are estimated to hit $10 million annually“.
As the annual tariff savings (that is the revenue loss for Sri Lanka) calculated by the Singaporean Negotiators, Singaporean $ 10 million (Sri Lankan rupees 1,200 million in 2018) was way above the rupees’ 733 million revenue loss for 15 years estimated by the Sri Lankan negotiators, it was clear to any observer that one of the parties to the agreement had not done the basic arithmetic!
Six years later, according to a report published by “The Morning” newspaper, speaking at the Committee on Public Finance (COPF) on 7th May 2024, Mr Samarawickrama’s chief trade negotiator K.J. Weerasinghehad had admitted “…. that forecasted revenue loss for the Government of Sri Lanka through the Singapore FTA is Rs. 450 million in 2023 and Rs. 1.3 billion in 2024.”
If these numbers are correct, as tariff liberalisation under the SLSFTA has just started, we will pass Rs 2 billion very soon. Then, the question is how Sri Lanka’s trade negotiators made such a colossal blunder. Didn’t they do their basic arithmetic? If they didn’t know how to do basic arithmetic they should have at least done their basic readings. For example, the headline of the article published in The Straits Times in January 2018 was “Singapore, Sri Lanka sign FTA, annual savings of $10m expected”.
Anyway, as Sri Lanka’s chief negotiator reiterated at the COPF meeting that “…. since 99% of the tariffs in Singapore have zero rates of duty, Sri Lanka has agreed on 80% tariff liberalisation over a period of 15 years while expecting Singapore investments to address the imbalance in trade,” let’s turn towards investment.
Investment from Singapore
In July 2018, speaking during the Parliamentary Debate on the FTA this is what Minister Malik Samarawickrama stated on investment from Singapore, “Already, thanks to this FTA, in just the past two-and-a-half months since the agreement came into effect we have received a proposal from Singapore for investment amounting to $ 14.8 billion in an oil refinery for export of petroleum products. In addition, we have proposals for a steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million), sugar refinery ($ 200 million). This adds up to more than $ 16.05 billion in the pipeline on these projects alone.
And all of these projects will create thousands of more jobs for our people. In principle approval has already been granted by the BOI and the investors are awaiting the release of land the environmental approvals to commence the project.
I request the Opposition and those with vested interests to change their narrow-minded thinking and join us to develop our country. We must always look at what is best for the whole community, not just the few who may oppose. We owe it to our people to courageously take decisions that will change their lives for the better.”
According to the media report I quoted earlier, speaking at the Committee on Public Finance (COPF) Chief Negotiator Weerasinghe has admitted that Sri Lanka was not happy with overall Singapore investments that have come in the past few years in return for the trade liberalisation under the Singapore-Sri Lanka Free Trade Agreement. He has added that between 2021 and 2023 the total investment from Singapore had been around $162 million!
What happened to those projects worth $16 billion negotiated, thanks to the SLSFTA, in just the two-and-a-half months after the agreement came into effect and approved by the BOI? I do not know about the steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million) and sugar refinery ($ 200 million).
However, story of the multibillion-dollar investment in the Petroleum Refinery unfolded in a manner that would qualify it as the best fairy tale with false promises presented by our politicians and the officials, prior to 2019 elections.
Though many Sri Lankans got to know, through the media which repeatedly highlighted a plethora of issues surrounding the project and the questionable credentials of the Singaporean investor, the construction work on the Mirrijiwela Oil Refinery along with the cement factory began on the24th of March 2019 with a bang and Minister Ranil Wickremesinghe and his ministers along with the foreign and local dignitaries laid the foundation stones.
That was few months before the 2019 Presidential elections. Inaugurating the construction work Prime Minister Ranil Wickremesinghe said the projects will create thousands of job opportunities in the area and surrounding districts.
The oil refinery, which was to be built over 200 acres of land, with the capacity to refine 200,000 barrels of crude oil per day, was to generate US$7 billion of exports and create 1,500 direct and 3,000 indirect jobs. The construction of the refinery was to be completed in 44 months. Four years later, in August 2023 the Cabinet of Ministers approved the proposal presented by President Ranil Wickremesinghe to cancel the agreement with the investors of the refinery as the project has not been implemented! Can they explain to the country how much money was wasted to produce that fairy tale?
It is obvious that the President, ministers, and officials had made huge blunders and had deliberately misled the public and the parliament on the revenue loss and potential investment from SLSFTA with fairy tales and false promises.
As the president himself said, a country cannot be developed by making false promises or with fairy tales and these false promises and fairy tales had bankrupted the country. “Unfortunately, many segments of the population have not come to realize this yet”.
(The writer, a specialist and an activist on trade and development issues . )
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