Sri Lanka Medical Association SLMA writes a letter to President and released it to media. The Sri Lanka Medical Association SLMA is ever grateful to Your Excellency and the Government of Sri Lanka for declaring a “lockdown” (restriction of movement throughout the country) at the most crucial hour, which essentially salvaged Sri Lanka from getting into the abyss of a major catastrophe; a breakdown of the healthcare system of the country which in turn would have led to a breakdown of all systems.
I, along with the SLMA Committee to advice on matters related to COVID 19, wish to bring to your kind attention the following important facts with regard to controlling of COVID-19 epidemic in Sri Lanka. In addition to the SLMA Council members and the members of the Intercollegiate Committee, Professor Neelika Malavige, Professor Malik Peiris and Professor Kamini Mendis, contributed to the discussion.

  1. Recommendation with regard to the continuation of the lockdown – We gathered information from consultants working in clinical settings and laboratories to find out the current usage of the capacity of the health care system.
    a. Physicians indicated that the brunt of the outbreak is now concentrated in the main hospitals and all wards are well over their full capacity with symptomatic patients. There are many COVID patients as floor-patients in medical wards.

b. Information from the ICUs indicated that other than the dedicated 82 ICU beds, another lot of about 70 more patients are treated in ordinary ICUs at the time of discussion. This situation compromises the care given for patients with Non-COVID issues. There are about 500 more patients on oxygen therapy, treated in High Dependency Units.
c. Consultants from laboratories indicated the same or higher rates of PCR positivity despite overall PCR positive numbers remain same, when compared to previous weeks.

This information confirms that hospitals are overwhelmed with cases. As expected, it is too early to see a visible impact of the lockdown on the healthcare system. Opening the country at this juncture would invariably facilitate the spread of the infection leading to increasing number of cases that in turn would cause a complete paralysis of the healthcare system. As such, while we are convinced of the benefits of the lockdown to the healthcare system, we are compelled to recommend a further extension of the
lockdown by at least another week. Keeping grocery shops opened may facilitate compliance by the public with a longer lockdown.

  1. The need to review the vaccination programme
    We are appreciative of the decision taken by the Government of Sri Lanka to vaccinate healthcare officials and other frontline workers such as the police, the tri-forces etc., initially with the highest priority.
    However, we are of the opinion that the vaccination strategy as implemented at present is flawed and needs a composite review urgently. In a setting particularly troubled by a continuous short supply of vaccines, we emphasize the need for an efficient vaccination strategy targeting high-risk groups to achieve maximum control which would avoid the necessity for repeated lockdowns.
    In cognizance with the data available from the rest of the world, the death analysis of patients from the MoH, Sri Lanka, indicates that 73% of deaths occur in people over 60 years of age and 83% of deaths were in people with co-morbidities. Research findings have clearly
    demonstrated that vaccination reduces deaths and complications in patients infected with COVID-19. Research evidence does not support benefits of vaccination to reduce transmission of infection unless a large majority of the population is vaccinated. As such, there is clear and compelling evidence to support prioritisation of vaccination of older adults more than 60 years, followed by people with comorbidities in the age group of 30– 60 years. However, there is no appreciable benefit in vaccinating people with the highest mobility in so-called hotspots, as is currently carried out in the Sri Lankan setting.
    Furthermore, we emphasize the need of a definitive roadmap providing priority of vaccination in certain geographical locations. Presence of a roadmap would help in gaining the confidence of our people on the vaccination programme. Selection of Grama Niladhari divisions of high risk locations for vaccination cannot be recommended as the infection would have already

spread and the majority would have developed immunity by the time the vaccination programme is carried out. The opinion of experts with regard to selecting the geographical location is to select high-risk provinces or districts and to vaccinate high risk people in crowded areas such as main cities in those selected provinces or districts. An equal amount of vaccines could also be given to hospitals to immunize high-risk people with comorbidities. Along with vaccinating high-risk persons, people working in higher numbers in enclosed areas with longer shifts in economic hubs and other essential congregate settings also could be prioritized.
We urge the Government of Sri Lanka to provide a solution to the 600,000 people awaiting the second dose of the Covishield vaccine as early as possible. We see that offering them the first dose of Sputnik V following a quick clinical trial of the efficacy of such a manoeuvre as a reasonable option to solve the issue. Monitoring antibody levels 2 weeks following vaccination with Sputnik V in about 100 people who have had the 1st dose of Covishield vaccine may provide a reasonable answer to this question. The importance of documenting the adverse effects during such a clinical trial also needs to be emphasized. Further, we wish to highlight the need in future to reserve the second dose in instances where a second dose is in the schedule.

  1. Reporting meaningful data – We understand that the primary role of the Epidemiology Unit of the Ministry of Health is surveillance and reporting the data in a meaningful manner to facilitate the decision-making process aimed at mitigating the outbreak.

We would like to inquire from the Epidemiology Unit of the Ministry of Health as to whether they have data regarding PCR positivity rates in factories that are kept open, in case a necessity arises to advise the Government in this regard?
There had been a significant reduction of the number of PCR tests carried out over the last two weeks. We understand that the majority of reported PCRs are exit-PCRs that do not measure the extent of transmission in the community. Unless PCRs are carried out proactively, it is likely that the usefulness of the results of analysis of samples with a majority of exit-PCRs will remain low despite the disease spreading rapidly. Similarly, unless the disaggregated test results based on context categories and geographical locations are analysed, the inference made by all PCRs together is likely to be most erroneous.
We are informed by one of our experts, Professor Kamini Mendis that they are in the process of compiling a document giving important surveillance indicators. We urge the Epidemiology Unit of the Ministry of Health to pay more attention to the surveillance
indicators and present the data of relevant indicators to arrive at meaningful decisions. We, from the SLMA Council and the Intercollegiate Committee, would be greatly indebted to you if an appointment could be kindly granted to us to discuss this issue further with your good self. We remain committed to assist you in all your endeavours to safeguard the health of the nation.