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PCR testing for Covid-19: Quo Vadis?

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By Dr. Sumedha S. Amarasekara

I am on ‘Ada Derana news information texts’ and almost every day I get an ‘UPDATE: a three digit number tested positive for Covid-19. All are close contacts of earlier patients’. The Island (4.12.2020) reports that we have now crossed the 10,000 mark of Covid-19 cases in the Colombo District. What exactly does this increasing number of positive cases mean? How valid is our rationale for PCR testing? Does testing close contacts make an impact on the management of Coivd-19? Can we afford all this testing as a country?

I strongly urge everyone to view the U-tube presentation of Prof. Malik Peries (Hong Kong) as an expert and world authority on Covid-19 being interviewed by Dr. Ananda Wijewickrama (Sri Lanka) and Dr. Chamila De Silva (Sri Lanka): Myths and fallacies vs. Science and Truth of Covid-19. (https://www.youtube.com/embed/PthrJpAilQ0). Though admittedly the discussion did not revolve around the validity and rationale for PCR testing, the necessary evidence to do so can be arrived at by analyzing the data from two of the slides presented by Dr. Malik Peries – a testament to the title of the presentation.

The slide, ‘infectiousness profile of SARS-CoV-2’, clearly illustrates that the virus is most infective one day prior to that person developing symptoms. Thereafter the ability of the virus to infect diminishes. After the first week of developing symptoms the ability of the Covid-19 to infect another person becomes very low.

The other slide, ‘Duration of infectiousness – viral RNA load, virus culture vs. days illness’ correlates a positive PCR result against the infectiousness of the virus. This slide confirms that persons are no longer infective after day 10. More importantly this slide demonstrates that the PCR test can remain positive in some cases even beyond two months – when the person is no longer infective and is in fact cured.

With these scientifically proven facts, let us now look at the value of PCR testing in conjunction with what we already know about this virus and the PCR test. With regards to the virus we know that, in the vast majority Covid-19 infection is asymptomatic (or very mild) while a pneumonia is encountered in the remainder. Most of these patients (with pneumonia) will recover and only a very few of these cases will end in death. In regards to the PCR test we know, that it is not infallible i.e. a single negative result after exposure to the virus, does not exclude the possibility of one not having the virus.

First let us consider a symptomatic patient.i.e. high fever, breathing difficulty, cough, etc… strongly suggestive of having being infected by the Covid-19 virus. The PCR test has the greatest value in this case as it can confirm that he/she has got Covid-19 and is infective. He/She needs to be isolated, admitted for treatment if need be and through contact tracing all contacts should be kept in quarantine. If the initial PCR test is negative, an experienced clinician needs to be involved to determine what further action/repeated testing needs to be done.

If a symptomatic patient after repeated/adequate testing remains negative, then the conclusion will need to be made that, he /she has not got Covid-19 and accordingly his/her contacts need not be quarantined. It follows that if the contacts are still to be quarantined, then one seriously needs to question the purpose of testing in the first place. In which case you might as well quarantine all contacts of any patient who presents with symptoms suggestive of Covid-19 infection without spending further money and resources on testing!

Secondly, let us consider those who are in quarantine (close contacts). A positive result could either be, one is yet to be infective, currently infective-but asymptomatic or already has got better and is no longer infective. On the other hand a negative result does not exclude the possibility of having a Covid-19 infection. Therefore as one can see there is no real advantage/validity of testing anyone in quarantine. What needs to be done is complete the quarantine. According to the current advice and as demonstrated by the slides after 10 days in quarantine one is safe to come in to the community – no testing is needed.

Thirdly, let us consider a random test. Now once again as documented above, a positive result could mean that either he/she is yet to develop the disease, has it and is asymptomatic or has got over it. If one were to develop symptoms then the subsequent management becomes a fairly straightforward process. But what if one does not develop symptoms? The chances of this happening are invariably higher as it is a known fact that almost 70 % or more of those who have the disease are ‘asymptomatic’ and also that those who have got over the disease can be PCR positive beyond two months. As the disease spreads through the community the latter group is going to expand exponentially as well. This is where science and economics of the country need to come together. How much random testing are we to do? And more importantly what is the rationale behind this testing? If someone tests positive, what should we do? Are we to then quarantine all of his/her contacts? Lockdown and isolate areas? How valid is this scientifically? And more importantly how much money can we afford to spend on this?

When one considers that a PCR test done in the government sector is estimated at around Rs. 6000 and that the monetary relief provided to an entire family that is in a lockdown/quarantine area for a month is Rs.5000; one could argue that it would be better to provide each member/family in quarantine Rs.5000 instead of testing them at Rs. 6000 individually! As can be seen from the above discussion this actually would be logically a more scientific (and economical) approach.

The ultimate criteria that determines how well a country is managing the crisis of Coivd-19 is the number of deaths that account for this disease. In this regard (examining the statistics of different countries) two indices can be used: case fatality rate and a death rate for the population. The former records the number of deaths in relation to the number of cases. The latter is the number of deaths according to the population of the country. In interpreting this data what needs to be grasped is that any person that tests positive on a PCR is considered as a case.

At the time of writing this article according to the John Hopkins University mortality analyses (https://coronavirus.jhu.edu/data/mortality) Taiwan has the lowest death rate of 0.03/ 100k population. The case fatality rate in Taiwan is 1%. The country that has the highest death rate is Belgium, which is 148.06/100k population. The case fatality rate in Belgium is 2.9%. The highest case fatality rate is in Yemen at 28%. However, the corresponding death rate is only 2.18/100k population. On the other hand the lowest case fatality rate is in Qatar at 0.2% with a corresponding death rate of 8.59/100k population. What can be seen when one reviews this data, is that the case fatality rate has no bearing on the death rate. In other words the more testing that is done, the lower the case fatality rate, which has no actual bearing on the overall number of deaths that occur. In addition to this our data is probably skewed, since we have been attributing all deaths that have a positive PCR as Covid-19 deaths, regardless of whether the Covid-19 was the main contributory factor to the death or not.

I feel ‘we’ have been railroaded into the mentality of ‘test, test, test’ from an international perspective. The increased number of tests announced daily creates a sense of accomplishment and control of the disease. The Opposition has taken every opportunity it has to ram home this point of needing extra testing as well, without actually doing what a responsible Opposition should be doing: critically evaluating what is being done and providing constructive criticism.

Covid-19 is going to be with us for the foreseeable future. Now an antigen test is being introduced into the mix as well. How does this test compare with PCR testing? We need a rational plan based on scientific evidence as to what our testing protocol should be. This plan should be based on an economic model that can work for us. We should not be pressured into a process that has little scientific validity and more importantly something we as a country cannot afford.

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Features

Govt.’s choice is dialogue over confrontation

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By Jehan Perera

Preparing for the forthcoming UN Human Rights Council cannot be easy for a government elected on a nationalist platform that was very critical of international intervention. When the government declared its intention to withdraw from Sri Lanka’s co-sponsorship of the October 2015 resolution No. 30/1 last February, it may have been hoping that this would be the end of the matter. However, this is not to be. The UN Human Rights High Commissioner’s report that will be taken up at the forthcoming UNHRC session in March contains a slate of proposals that are severely punitive in nature and will need to be mitigated. These include targeted economic sanctions, travel bans and even the involvement of the International Criminal Court.

Since UN Secretary General Ban Ki-Moon’s visit in May 2009 just a few days after the three-decade long war came to its bloody termination, Sri Lanka has been a regular part of the UNHRC’s formal discussion and sometimes even taking the centre stage. Three resolutions were passed on Sri Lanka under acrimonious circumstances, with Sri Lanka winning the very first one, but losing the next two. As the country became internationally known for its opposition to revisiting the past, sanctions and hostile propaganda against it began to mount. It was only after the then Sri Lankan government in 2015 agreed to co-sponsor a fresh resolution did the clouds begin to dispel.

Clearly in preparation for the forthcoming UNHRC session in Geneva in March, the government has finally delivered on a promise it made a year ago at the same venue. In February 2020 Foreign Minister Dinesh Gunawardena sought to prepare the ground for Sri Lanka’s withdrawal from co-sponsorship of UN Human Rights Council resolution No 30/1 of 2015. His speech in Geneva highlighted two important issues. The first, and most important to Sri Lanka’s future, was that the government did not wish to break its relationships with the UN system and its mechanisms. He said, “Sri Lanka will continue to remain engaged with, and seek as required, the assistance of the UN and its agencies including the regular human rights mandates/bodies and mechanisms in capacity building and technical assistance, in keeping with domestic priorities and policies.”

Second, the Foreign Minister concluding his speech at the UNHRC session in Geneva saying “No one has the well-being of the multi-ethnic, multi-lingual, multi-religious and multi-cultural people of Sri Lanka closer to their heart, than the Government of Sri Lanka. It is this motivation that guides our commitment and resolve to move towards comprehensive reconciliation and an era of stable peace and prosperity for our people.” On that occasion the government pledged to set up a commission of inquiry to inquire into the findings of previous commissions of inquiry. The government’s action of appointing a sitting Supreme Court judge as the chairperson of a three-member presidential commission of inquiry into the findings and recommendations of earlier commissions and official bodies can be seen as the start point of its response to the UNHRC.

 

 

NEGATIVE RESPONSE

 

The government’s setting up of a Commission of Inquiry has yet to find a positive response from the international and national human rights community and may not find it at all. The national legal commentator Kishali Pinto Jayawardene has written that “the tasks encompassed within its mandate have already been performed by the Lessons Learnt and Reconciliation Commission (LLRC, 2011) under the term of this President’s brother, himself the country’s Executive President at the time, Mahinda Rajapaksa.” Amnesty International has stated that “Sri Lanka has a litany of such failed COIs that Amnesty International has extensively documented.” It goes on to quote from the UN High Commissioner for Human Rights that “Domestic processes have consistently failed to deliver accountability in the past and I am not convinced the appointment of yet another Commission of Inquiry will advance this agenda. As a result, victims remain denied justice and Sri Lankans from all communities have no guarantee that past patterns of human rights violations will not recur.”

It appears that the government intends its appointment of the COI to meet the demand for accountability in regard to past human rights violations. Its mandate includes to “Find out whether preceding Commissions of Inquiry and Committees which have been appointed to investigate into human rights violations, have revealed any human rights violations, serious violations of the international humanitarian law and other such serious offences.” In the past the government has not been prepared to accept that such violations took place in a way that is deserving of so much of international scrutiny. Time and again the point has been made in Sri Lanka that there are no clean wars fought anywhere in the world.

International organisations that stands for the principles of international human rights will necessarily be acting according to their mandates. These include seeking the intervention of international judicial mechanisms or seeking to promote hybrid international and national joint mechanisms within countries in which the legal structures have not been successful in ensuring justice. The latter was on the cards in regard to Resolution 30/1 from which the government withdrew its co-sponsorship. The previous government leaders who agreed to this resolution had to publicly deny any such intention in view of overwhelming political and public opposition to such a hybrid mechanism. The present government has made it clear that it will not accept international or hybrid mechanisms.

 

 

SEQUENTIAL IMPLEMENATION

 

In the preamble to the establishment of the COI the government has made some very constructive statements that open up the space for dialogue on issues of accountability, human rights and reconciliation. It states that “the policy of the Government of Sri Lanka is to continue to work with the United Nations and its Agencies to achieve accountability and human resource development for achieving sustainable peace and reconciliation, even though Sri Lanka withdrew from the co-sponsorship of the aforesaid resolutions” and further goes on to say that “the Government of Sri Lanka is committed to ensure that, other issues remain to be resolved through democratic and legal processes and to make institutional reforms where necessary to ensure justice and reconciliation.”

As the representative of a sovereign state, the government cannot be compelled to either accept international mechanisms or to prosecute those it does not wish to prosecute. At the same time its willingness to discuss the issues of accountability, justice and reconciliation as outlined in the preamble can be considered positively. The concept of transitional justice on which Resolution No 30/1 was built consists of the four pillars of truth, accountability, reparations and institutional reform. There is international debate on whether these four pillars should be implemented simultaneously or whether it is acceptable that they be implemented sequentially depending on the country context.

The government has already commenced the reparations process by establishing the Office for Reparations and to allocate a monthly sum of Rs 6000 to all those who have obtained Certificates of Absence (of their relatives) from the Office of Missing Persons. This process of compensation can be speeded up, widened and improved. It is also reported that the government is willing to consider the plight of suspected members of the LTTE who have been in detention without trial, and in some cases without even being indicted, for more than 10 years. The sooner action is taken the better. The government can also seek the assistance of the international community, and India in particular, to develop the war affected parts of the country on the lines of the Marshall Plan that the United States utilized to rebuild war destroyed parts of Europe. Member countries of the UNHRC need to be convinced that the government’s actions will take forward the national reconciliation process to vote to close the chapter on UNHRC resolution 30/1 in March 2021.

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Features

Album to celebrate 30 years

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Rajiv Sebastian had mega plans to celebrate 30 years, in showbiz, and the plans included concerts, both local and foreign. But, with the pandemic, the singer had to put everything on hold.

However, in order to remember this great occasion, the singer has done an album, made up of 12 songs, featuring several well known artistes, including Sunil of the Gypsies.

All the songs have been composed, very specially for this album.

Among the highlights will be a duet, featuring Rajiv and the Derena DreamStar winner, Andrea Fallen.

Andrea, I’m told, will also be featured, doing a solo spot, on the album.

Rajiv and his band The Clan handle the Friday night scene at The Cinnamon Grand Breeze Bar, from 07.30 pm, onwards.

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Features

LET’S DO IT … in the new normal

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The local showbiz scene is certainly brightening up – of course, in the ‘new normal’ format (and we hope so!)

Going back to the old format would be disastrous, especially as the country is experiencing a surge in Covid-19 cases, and the Western Province is said to be high on the list of new cases.

But…life has to go on, and with the necessary precautions taken, we can certainly enjoy what the ‘new normal’ has to offer us…by way of entertainment.

Bassist Benjy, who leads the band Aquarius, is happy that is hard work is finally bringing the band the desired results – where work is concerned.

Although new to the entertainment scene, Aquarius had lots of good things coming their way, but the pandemic ruined it all – not only for Aquarius but also for everyone connected with showbiz.

However, there are positive signs, on the horizon, and Benjy indicated to us that he is enthusiastically looking forward to making it a happening scene – wherever they perform.

And, this Friday night (January 29th), Aquarius will be doing their thing at The Show By O, Mount Lavinia – a beach front venue.

Benjy says he is planning out something extra special for this particular night.

“This is our very first outing, as a band, at The Show By O, so we want to make it memorable for all those who turn up this Friday.”

The legendary bassist, who lights up the stage, whenever he booms into action, is looking forward to seeing music lovers, and all those who missed out on being entertained for quite a while, at the Mount Lavinia venue, this Friday.

“I assure you, it will be a night to be remembered.”

Benjy and Aquarius will also be doing their thing, every Saturday evening, at the Darley rd. Pub & Restaurant, Colombo 10.

In fact, they were featured at this particular venue, late last year, but the second wave of Covid-19 ended their gigs.

Also new to the scene – very new, I would say – is Ishini and her band, The Branch.

Of course, Ishini is a singer of repute, having performed with Mirage, but as Ishini and The Branch, they are brand new!

Nevertheless, they were featured at certain five-star venues, during the past few weeks…of their existence.

 

 

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