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Home as clinical setting for asymptomatic mild Covid-19 positive patients: What you should know

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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).



Features

Govt. actions must be for people’s benefit

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President at the Independence Day ceremony on Saturday

By Jehan Perera

The government celebrated the 75th Anniversary of its independence from colonial rule under tight security.  President Ranil Wickremesinghe did not even deliver a speech on the occasion.  He had an excellent written speech, but chose not to deliver it for reasons not known.  The speech was circulated later. The exclusion of the general public from the parade grounds was another notable feature of the Independence Day event.  Under normal circumstances, Galle Face green where the celebration took place, is packed with people who come to enjoy the sea, the fresh air and the vast expanse of greenery.  The spectacle of a military parade and an air show provided an occasion that people would not have wished to miss if they had been given the chance to attend it.  But the government was clearly insecure and wanted to make sure it controlled the situation, which accounted for large security deployments.

The general public were kept away from the celebrations as the government feared that if they were permitted into the area some of them might protest.  Indeed, the previous night a sit down public protest (satyagraha) organised by a mostly youthful group of protestors was water cannoned and forcibly broken up.  The youth were protesting against the misallocation of resources for celebration at a time when the country’s people have little cause to celebrate.  Although there was a large presence of security forces, they stood by when a group of political thugs attacked the peaceful protestors.  When the satyagrahis resisted the attack they were chased, beaten and arrested by the security forces. The government was less concerned to win the hearts and minds of its people than to conduct its Independence Day event without disturbance.

 Ironically, the manner of the celebration, with the general public not present at the site of celebration, and security forces out in strength on the roads, was reminiscent of the days of war that the country experienced decades past.  In those days too, the Independence Day celebrations took place under tight security, with the people preferring to stay in their homes than to brave possible LTTE bombs. This throwback to the past is relevant as those years of war have contributed in no small measure to the economic collapse that has befallen the country and blighted the life of its people.  More than 70 percent of the population have reduced their food intake and 40 percent of the population have descended below the poverty line.  In recognition of the connection between ethnic conflict and economic underdevelopment, President Wickremesinghe has prioritized a political solution to the ethnic conflict without delay.

PUBLIC ANGER

The public protests against the celebration of Independence Day was not only in Colombo but also in other parts of the country, most notably in the north of the country.  The main Tamil political party as well as smaller ones also called for a boycott of the Independence Day events and did not participate in them.  University students in Jaffna declared a hartal and flew black flags.  Most of the people, however, showed no interest either way. There was no display of national flags in a spontaneous manner nor did the government make such an appeal.  It seemed as if the government was celebrating Independence Day for itself.  Gleaming new vehicles with police escorts drove in assorted governors, ministers and other dignitaries into the stalls where they would seat themselves with all the national television stations focusing on them. However, to the general public watching the celebrations on their television sets, the sight of the luxury vehicles bearing the dignitaries would have been infuriating.

 Not even a year ago, these same political leaders were hiding in the face of the protest movement that took to the streets in the aftermath of the collapse of the national economy and declaration of national bankruptcy.  The general public, many of whom had never taken part in public protests, came to the streets to protest.  They came from near and far, children with their parents, the elderly and the differently abled, to demand the exit of the government leaders who had stolen the wealth of the country and brought the masses of people, including them all, to near penury.  These same people who watched the Independence Day events on television would have been greatly angered to see those same political leaders now disembarking from luxury vehicles while they scraped the bottom of the barrel in their homes.  What they demand from the government, both in street protests and in their homes, is an end to impunity for corruption, abuse of power and extravagance in  public life, which the government appears to be shying away from.

 The question arises for whose benefit was Independence Day celebrated in this manner?  Independence Day in a situation of economic collapse was celebrated in a most unimaginative manner.  The government tried to heed the public opprobrium regarding the cost of the event, and reduced the size of the military parade.  It also axed the cultural parades that represent the aesthetic side of life.  Independence Day should have been celebrated differently, not for the political leaders and not for the international community, but for the people.  This event did not receive much international publicity.  It would not have changed the way the world sees us.  It did not touch the hearts of the Sri Lankan people either.  They were watching on their television sets and conscious of the expenditures that were being incurred for no good reason, and certainly not for their benefit.

BOLD PLEDGES

The celebration of Independence Day could have been done differently.  The government could have recognised the poverty that has ravaged the lives of the people.  It could have organised an Independence Day event that demonstrated an ethos of care for the people.  It could have brought a thousand schoolchildren from the poorest families around the country, and from all ethnicities, religions and castes, and made them a symbolic presentation of schoolbooks and school clothes that would have reflected the government’s commitment to invest in the country’s children.  This was an opportunity lost and would work to the detriment of the government which will be reflected in its electoral performance at the forthcoming local government elections. President Wickremesinghe’s pitch that the country needed a plan to become a developed country in 2048 is to miss people’s concerns to get by the day.  In his televised speech to the nation he said “Let us devote ourselves, unite as children of one mother. Let us make our country one of the most developed in the world by 2048, when we will celebrate 100 years of independence.”

 Despite all the criticism of the priorities of President WIckremesinghe and the government there are still many who continue to place their hope that the president will succeed in problem solving that is in the national interest.  One of President Wickremesinghe’s bold pledges has been to resolve the ethnic conflict that gave rise to three decades of war and to reach a situation of national reconciliation in this 75th year of Independence and “unite as children of one mother”.  When he first committed himself to this task three-months ago, there was some anticipation that this ambitious task may even occur prior to Independence Day itself, or “mission accomplished” would be announced on the auspicious day.  This has not been the case and it appears that even the first steps are yet to be made.  Now the focus of attention will be the president’s policy statement on February 8 when he reconvenes parliament following its prorogation by him a fortnight ago.

 National reconciliation in an ethnically divided society is never an easy proposition.  It requires the support of multiple actors in multiple sectors.  An indication of the president’s determination in this regard was the singing of the national anthem in both Sinhala and Tamil languages at the Independence Day event. This was after a lapse of four years and reflects the president’s resolve to overcome the divisions of the past.  It must be noted that it was under his leadership as prime minister in the period 2015-19 that the national anthem was sung again in Tamil on Independence Day after the passage of many decades.  There are elements in the president and his government that require support from civil society.  We need to overcome the legacy of past mistakes and forge ahead to a future in which lessons have been learnt and mistakes not repeated.

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Issues in fully implementing the 13th Amendment – Police Powers

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President J. R. Jayewardene and Indian Prime Minister Rajiv Gandhi at the signing of the Indo-Lanka Accord, which paved the way for the 13th Amendment..

By C. A. Chandraprema

While most provisions of the 13th Amendment to the Constitution have been implemented, sticking points have persisted with regard to two matters – the devolution of police and land powers. Appendix I of the Provincial Councils List in the Ninth Schedule of the Constitution provides for the devolution of police powers. The implementation of these provisions will entail the division of the Sri Lanka Police Force into a National Police Division which includes special units such as the CID; and a Provincial Police Division for each Province, headed by a DIG.

According to Section 6 of Appendix 1, the IGP shall appoint a DIG for each Province with the concurrence of the Chief Minister of the Province. If there is no agreement between the IGP and the Chief Minister, the matter will be referred to the National Police Commission, which after due consultations with the Chief Minister shall make the appointment. Thus, the effective appointing authority of the provincial DIG is the Chief Minister. Section 11 stipulates that all Police Officers, serving in units of the National Division and Provincial Divisions, in any Province, shall function under the direction and control of the provincial DIG who, in turn, will ‘be responsible to’ and ‘under the control of’ the Chief Minister in respect of the maintenance of public order and the exercise of police powers in the Province.

According to section 12.1, it is the Provincial police forces that will maintain law and order and be responsible for the prevention, detection and investigation of all offences in the Province except for the 11 specified offences allocated to the National Police Division which are as follows: international crimes, offences against the State, offences relating to the armed services, offences relating to elections, currency and government stamps, offences against the President, Ministers, MPs public officials, judges, etc., offences relating to state property, offences prejudicial to national security, offences under any law relating to any matter in the national government list and offences in respect of which courts in more than one province have jurisdiction. Most of these offences are not really a part of day to day police functions and occur infrequently. Thus, under the 13A, it is the Provincial Divisions which will handle the bulk of actual day to day police work.

Provincial Police to the forefront

Signifying the extent to which the National Police Division will be expected take a back seat, Section 10.1 of Appendix 1 requires members of the National Police Division to ordinarily be in plain clothes, except when performing duties in respect of the maintenance of public order. For all practical purposes, the only uniformed police force, visible to the public, will be the Provincial Police. Recruitment to the National Police Division is to be done by the National Police Commission and to the Provincial Police Divisions by the respective Provincial Police Commissions. According to Section 4, the Provincial Police Commissions will be made up of a) the Provincial DIG, b) a person nominated by the Public Service Commission, in consultation with the President; and c) a nominee of the Chief Minister of the Province. Thus the Chief Minister has complete control over both the Provincial Police Chief as well as the Provincial Police Commission.

In addition to the above, according to Sections 7 and 8 of Appendix 1, the Provincial Police Commissions, which are completely under the sway of the Chief Minister, will have a say in deciding on the cadre and salaries and even the type and quantity of firearms and ammunition used by the Provincial Police forces. However, the potentially horrendous implications of Sections 7 and 8 are mitigated to some extent by the proviso that ‘uniform standards and principles’ shall be applied across the board with regard to these matters for all Provincial Police Divisions.

When recruitment for the Provincial Police Forces are to be carried out by Provincial Police Commissions which are completely under the sway of the Chief Ministers of the Province, the politics of the Province will become the politics of the Provincial Police force, as well. The most obvious foreseeable result of recruiting, within the Province for the Provincial Police force, is that the Northern Province Police force will be predominantly Tamil, the Eastern Province police force largely Tamil and Muslim, and the police forces of all other Provinces, predominantly Sinhala. The implications of politicians, elected on communalistic political platforms, having armed police forces under their control, to further their political objectives, should be clear to anybody. For a country like Sri Lanka which has experienced protracted conflict between ethnic and religious groups, the police powers provisions in the 13A are a guaranteed recipe for disaster.

An equally important consideration is the fact that crime prevention, detection and investigation is very much an inter-provincial, countrywide activity in this country. The creation of nine separate Provincial Police Divisions, answering to nine different lines of command, will seriously hamper the crime fighting capacity of the police which we now take for granted. Today, the IGP and the police force, under him, acts on the imprimatur of the national government, and its outreach extends to every nook and corner of the country. If the 13th Amendment is fully implemented, and the principle day to day police functions, such as maintaining law and order, and crime fighting, becomes the exclusive preserve of the various Provincial Police forces, whose authority does not extend beyond the borders of their Provinces, even pursuing a criminal across Provincial borders will become a tedious, process heavy with bureaucratic procedures and the entire country is going to suffer as a result. (The Colombo and Kotte city limits will not belong to the Western provincial police division but to a Metropolitan police under the National Division according to Item 1 on the Provincial Councils List.)

Readers may recall the 2005 incident during the ceasefire where some policemen, attached to the National Child Protection Authority went into an LTTE held area in search of a fugitive European pedophile and were arrested by the LTTE police. If the police powers in the 13A are fully implemented, in a context where some Provincial administrations are going to be openly hostile to the national government, as well as to other Provincial administrations, similar incidents will become day to day occurrences. The sheer practical impossibility of effectively carrying out police work in a small, densely populated country divided into nine separate police jurisdictions, manned by police forces under nine different lines of command was one of the main reasons why the police powers in the 13A have remained unimplemented for the past 37 years.

Political control over Provincial Police forces

While the IGP will nominally remain the head of the Sri Lanka Police force, even under the 13A, actual day to day police work will become the preserve of the provincial DIGs, acting under the direction and control of the respective Chief Ministers. Under Section 12.4(b) of Appendix 1, the IGP’s discretion in matters related to crime fighting will largely be centered on assigning investigations to units of the national division, like the CID, if he believes that is required in the public interest. But even to do that, he will need to ‘consult’ the Chief Minister of the Province and to have the approval of the Attorney General. Appendix 1 does not have provisions for any mechanism to enable the Provincial Police forces to work in unison in crime fighting or indeed any mechanism that can respond expeditiously to crime fighting requirements throughout the country.

The 13A was passed into law nearly four decades ago, in a different era. In the new millennium, the dominant trend has been to prevent politicians from influencing the police force but the provisions in the 13A seeks to do exactly the opposite.

Even though the new millennium has seen three Constitutional Amendments, (the 17th, 19th and 21st) promulgated for (among other things) the depoliticisation of the police force, Appendix 1 of the Provincial Councils List in the Ninth Schedule of the Constitution, was left largely untouched. I use the word ‘largely’, because the 17th Amendment did make a few changes in Appendix 1, but that was only to reduce the powers of the President. The Chief Minister’s powers over the Provincial Police remained untouched.

The total and complete politicisation of the police force, envisaged in the 13A, renders it out of step with the times. It was just a few months ago that the 21st Amendment to the Constitution was passed and under its provisions, the President cannot appoint the IGP unless the Constitutional Council approves his recommended candidate and the President cannot appoint the Chairman and Members of the National Police Commission except on the recommendations of the Constitutional Council.

How will the people of this country react if the police powers, envisaged in the 13A, are implemented, and they wake up one morning to find that the Chief Ministers have been given effective control over the appointment of the provincial DIGs and complete control of the Provincial Police Commissions?

How will the people react when they find that the country has been rendered ungovernable overnight because the police force has been fragmented into nine separate police forces, under nine different chains of command? The gestation period for the fallout resulting from a wrong decision with regard to the police powers laid out in the 13A will not be years or months but weeks and days. Hence this is an area where the government will have to proceed with great caution.

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Valentine’s Day gig in Kolkata

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Yohani: Super excited to perform in Kolkata

Yes, Valentine’s Day is fast approaching…one week from today, and there’s going to be lots of action on Tuesday, February 14th.

The showbiz scene will have plenty to offer those who celebrate this day.

Our very own Yohani, who is now a mega star in India, will be in Kolkata, on Valentine’s Day.

And this is what she has to say:

“See you all on 14th February, 2023, as I would be coming for my maiden gig in the city of joy. Super excited, thrilled to meet you all.”

However, a Valentine’s Gala will be celebrated, four days ahead – on February 10th – at the Claireport Place Banwuet and Convention Centre, in Toronto, Canada.

This event, they say, has been put together to support a very talented young band (youths of Sri Lankan origin), called BluPrint, whose passion for Sri Lankan music has thrilled Toronto audiences for the last seven years.

The members have been a part of a series of sold out concerts, starting from API concert series, in 2016, to BluPrint’s Roots, in 2022.

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