When Sri Lanka Lost Control of COVID

Devana Senanayake and Janik Sittampalam

“Everything changed around mid-May [2021]. The original case definition for COVID-19 cited symptoms such as fever and shortness of breath but in May, patients had a sore throat, asthma exacerbation, headache, runny nose, and body pains,” said Dr. Kurukularatne, the managing director at Sarva Medicare and Wound Care Clinic in Boralesgamuwa, Sri Lanka. “We tested these patients for COVID-19 and found that a lot of these turned out positive. We then suspected that there may be a new variant in the country.”

“Young people came in and collapsed at our clinic. There are people who would immediately lose consciousness because they could not breathe,” he said. “One lady came in and said she had an asthma attack, but it turned out to be COVID-19. Hours later, she died at home, just before the ambulance arrived.”

In June 2021, Sri Lanka confirmed the first community case of the Delta variant of COVID-19. From August to September 2021, amid the “Delta peak,” almost three patients died every hour in the country, including young adults and children.

“There was a 23-year-old male patient in my ICU. He had obesity and had been connected to the ventilator. He had an [oxygen] saturation of 82. When put on the ventilator, his saturation did not increase at all. Then he died,” a nurse told The Diplomat in August 2021. “Almost everyone that was put on a ventilator died. I have only seen one patient live.”

By the summer of 2021, workers on the frontline had never been busier. They had to bear the burden of daily death and also hear about the infection of loved ones at home. Then, one by one, they started to become infected. One nurse, a mother, discovered that she and her baby had both been infected with COVID-19. Many times, they could not even return to their hostels because of the risk of an outbreak. They had to sleep in areas full of COVID-19 patients they had already treated. Despite their toil and time, they received no special treatment.

A Public Health Inspector (PHI) in a hospital in the North-Eastern province described coordinating the disposal of deceased patients’ bodies, an experience he went through multiple times. Once close family and relatives had paid their respects, the death was noted by the local administrative body and a date and time for the funeral was set.

“We prepare in advance. The family has to send a casket to us. Once that is done, the hospital releases the body. The casket is sealed and the ambulance transports the body,” he confided in me. “Then the final rites are performed. With the help of people from the mortuary, the body is put inside the pit and burned.” In Sri Lanka, COVID-19 victims are not buried but burned.

He revealed that many times, family members and relatives never laid eyes on their loved ones again after attendants carried them in a stretcher to an ambulance.

After going through this process multiple times, the PHI started to experience vicarious trauma. He is haunted by the pain of patients and bereaved family members to this day.

Death became omnipresent in Sri Lanka. Whereas previously the media had published extensive details about each COVID-19 victim’s identity and the lives they led, these details vanished amid the avalanche of death during the Delta peak. So many people died that lives could not be mourned or valued as they deserved.

The same PHI noticed a sense of apathy in people: “People have lived around COVID for some time and it has become a normal part of their lives. The only people that feel the impact of death rates are the people from the dead person’s family. The other people in their communities don’t care about the dead person. They just don’t care.”

COVID-19: The First Wave

The deadly wave of COVID-19 that hit Sri Lanka in the summer of 2021 was a sharp contrast from 2020. Unlike many countries in North America, Europe, and the rest of Asia, Sri Lanka had an excellent response to the first wave of COVID-19 in March 2020.

A study published in PLOS ONE, a peer-reviewed journal, noted Sri Lanka as an positive outlier, even in Asia. It identified the series of techniques the country used to successfully control the virus. Sri Lanka closed all its borders and set up a quarantine system, including a compulsory 14-day quarantine for returnees from overseas. Laboratories for COVID-19 tests were set up for the early identification of COVID-positive patients. A “passive case detection phase” tested patients that fit into the case definition of COVID-19 and admitted them into isolation centers in chosen hospitals. Moreover, patients that had a link to a case in a quarantine center or at home had to be tested. If the test came back positive, the patient was transferred to a hospital and their close contacts had to be traced by the Disease Surveillance System.

After the initial months of the pandemic, the spread of the virus was limited to three clusters (the most important called the “Welisara Navy camp” cluster). Data published at the end of June 2020 confirmed that Sri Lanka had no community transmission.

“If you go back to April and May 2020, they sort of got it down to zero. We did well on that end. We had zero local transmission, which was a great achievement,” said Dr. Ravi Rannan-Eliya, executive director of the Institute of Health Policy. “Most countries did not get there and we did not have that initial first wave which Europe and much of the world had.”

By the end of June 2020, only 11 people had died and 2,042 people had been infected in Sri Lanka. But by September 2021, the death rate had risen to 9,185 and 440,302 had been infected. What happened?

The ultimate failure of Sri Lanka’s COVID-19 response cannot be distilled down to one cause. Saroj Jayasinghe, emeritus professor of Clinical Medicine at the University of Colombo, noted the complexity of the situation.

“The problems are multifactorial. There is no one explanation for it. This is a complex and an uncertain scenario,” he said.

Among the factors to consider are complacency, limited transparency, and unclear communication techniques. Meanwhile, Sri Lanka’s PCR testing system, quarantine procedures, and vaccination drive all proved unable to cope with the additional strain of the Delta variant. These problems intersected to worsen the spread, with the brunt of the impact borne by the elderly, patients with comorbidities, and healthcare workers.

Complacency

After the first wave, decision-makers became complacent in their COVID-19 response. In April, the Sinhala and Tamil New Year is celebrated and people move across the island. Several days of celebrations bringing together family and friends are held both indoors and outdoors.

In early April 2021, Sri Lanka was recording just 200 cases per day, including overseas returnees already in quarantine as well as two clusters of domestic transmission. The situation seemed under control.

“Before the country let people celebrate Sinhala and Tamil New Years, the PHI Union asked for travel restrictions,” said Secretary of the Public Health Inspectors Union Mahesh Balasuriya. “We noticed people in vehicles and leisure centers. They traveled around the country, particularly to rural areas that are their ancestral homes. We said if this was not prevented, the situation could spiral out of control.”

The state did not adopt the recommendations.

The Sinhala and Tamil New Years celebrations sparked new clusters, which created the perfect environment for the new Delta variant to wreak havoc. Daily case counts rose from 200 to over 1,000 by the end of April.

“The virus’ impact could be seen in two weeks. As predicted, the New Years cluster started in May and patients could be seen across the country,” Balasuriya said.

At the end of April, Sri Lanka’s death toll from COVID-19 had reached 678 people. By May 30, the number of deaths had doubled to 1,441; the figure would double again in June.

Lack of Transparency

Still, the government attempted to downplay the problem. Even during the Delta peak, in August 2021, the deputy director general of Health Services, Dr. Hemantha Herath, denied the presence of community transmission. He said that the situation in Sri Lanka at the time did not match the World Health Organization (WHO) definition. Herath instead peddled a state-sanctioned narrative that reckless behavior by individuals was behind the spike in cases.

“They are fixated on a WHO definition of community transmission. Why not admit it?” Rannan-Eliya said in August 2021. “It is clear that there is transmission in the community as anyone could likely be infectious. In Sri Lanka, there are probably 100,000-200,000 people that have COVID-19 in every district and every divisional secretariat.

“It is everywhere. There is no safe area. I mean, not to admit this is stupid.”

The lack of transparency around the label “community transmission” represented an abuse of public trust.

Bad PR and No Communications Plan

“Communication is everything in a pandemic. There is complex science that needs to be communicated to the public to minimize fear and alarm,” said Shashika Bandara, a Ph.D candidate in Global Health at McGill University. “Science evolves and not everyone can understand it. The public has to understand the means to lead their lives and minimize the risk.”

Rannan-Eliya pointed to the clear and repetitive tactics employed by New South Wales in Australia as a positive example. The NSW premier in his daily broadcasts asked people to take a clear course of action if sick – do a PCR test and then isolate and inform contacts to do the same. His team repeated this information every two minutes. Website and social media pages run by the state echoed the same message. This helped involve people in the state’s response to COVID-19.

Rannan-Eliya noted that NSW’s clear and repetitive communications tactics instilled a sense of responsibility that helped contain the spread of Delta in 2021. According to a report by the Doherty Institute, people took personal responsibility if sick and acted in the interest of their community. This has not been the case in Sri Lanka, because people have not been coached in how to take the best course of action.

Instead, the Sri Lankan government swung suddenly from no restrictions to a confusing minefield of them. For example in May 2021, as the number of infected people and deaths rose sharply, the state issued a series of measures to control the spread. At first, the state said no one could leave their houses from 11 p.m. to 4 a.m. until May 31 – but insisted this was not a curfew. Then it was announced that people could only leave their houses during the weekend based on their National Identification Card (NIC) numbers. Oddly, none of the restrictions applied to people who were eligible for vaccination or those employed in important economic sectors, such as the textile or agriculture industries. There was a state of constant confusion about what the restrictions were and who they applied to.

The lack of transparency and the unclear public relations and communications tactics left people in a state of dissonance. No one understood the situation or the reality clearly – they could only sense the extent of the calamity. The reality of disease, death, and scarcity failed to match the narrative created and perpetuated by the state. And so people continued to mourn and fear in private.

“I received a call at three o'clock from a lady. Her father, aged 53, had COVID-19 and just needed oxygen for the night. At this point, both our public and private health system had no space. We could not find a bed for him or any ventilation,” Dr. Ruvaiz Haniffa told me in September 2021, in the middle of Sri Lanka’s Delta peak. “Six hours after our call, he died.”

The doctor, a consultant family physician and head of family medicine at the University of Colombo, has been haunted by the patient’s death. If the facilities had been available, he could have been saved easily.

Tests

After the first wave passed, Sri Lanka retained many of its control measures such as PCR tests, compulsory quarantine, and border controls through the end of 2021. Nevertheless, the failure to invest more in PCR tests, which would have allowed Sri Lanka to make full use of the tests as a control measure and a complementary measure to quarantine and border controls, cost the country dearly.

PCR tests are probably the most important measure to control the spread of COVID-19 – more impactful than mobility reductions, school closures, and mask use. “A tenfold increase in the ratio of tests to recently reported cases reduced the reproduction number by 9 percent across a range of testing levels,” Rannan-Eliya and his team wrote in a paper about the importance of PCR tests.

China was the only country to counter Delta effectively, and they conduct an extensive number of tests.

“Every fever case in every province is tested. People that enter suspected buildings are also tested. There is a strict enforcement of this,” Rannan-Eliya said. He pointed out that, despite the large population of China’s major cities, the government will institute mandatory city-wide testing at the first sign of a cluster.

Another useful method is to increase the number of tests at the primary care level, rather than test only suspected patients. This is based on a system developed by Kamini Lokuge, an associate professor at ANU. If there is no outbreak, 1 in 1,000 tests are conducted. When there is an outbreak, the number of tests is raised. New Zealand raised tests from 5,000 to 30,000 tests per day.

Rannan-Eliya noted that in April 2020, as the first wave came under control, the state failed to invest in PCR tests and see their importance as a control and maintenance measure.

Several experts, such as Jayasinghe, doubt Sri Lanka’s ability to test as recommended by the study. He does not believe that the necessary number of tests can be conducted and sustained over a period of time in the country.

“Entire households cannot be tested. That is not an option.” he said. “Technicians need full PPE, have to take all the precautions to prevent infection, have to carry all necessary paraphernalia and have to take samples back to the lab at a particular time. This is almost an impossible task on a national scale.”

“The Chinese could do this because they had the money, equipment and human resources. They had the money to ask people to stay at home and support them. They had the PCR kits produced there. They also have a huge number of resources such as people to carry out tests and PCR machines,” Jayasinghe said.

Rannan-Eliya, however, counters that Sri Lanka did not even try. “In early 2020, not even the Americans could install substantial testing capacity. However, several countries took testing seriously and spent the next months ramping up capacity,” he said. “Why did it have to be gradual? By June 2020, because of demand, countries could only receive the equipment in six months.

“Did the [Sri Lankan] state put in the orders? I can tell you, they did not.”

Rannan-Eliya pointed out that it was not only high-income countries that prevailed in using PCR testing effectively. Some low-income countries in Asia, such as Cambodia and Bhutan, invested in PCR tests and retained the progress they made to control COVID-19 in early 2020.

“Cambodia is not exactly a developed country and is much poorer than Sri Lanka. Bhutan does not even have a medical school. But Cambodia and Bhutan invested in PCR tests and ramped it up so that by the end of 2020, they had a better capacity than Sri Lanka,” he said.

Quarantine Leaks

Several studies noted that border controls prevented the entrance of COVID-19 into Sri Lanka early on. Despite this, the victories of secure border controls can only be maintained if “leaks” into the community are detected and addressed quickly. To do this, PCR tests are a key maintenance measure.

In June 2020, Sri Lanka had secure borders, a quarantine system, and zero cases in the community. At that point, the country should have been conducting 20,000 tests per day as recommended by Lokuge’s study. Despite this, numbers fell to between 1,000 and 2,000 PCR tests per day.

Professor Neelika Malavige published a paper suggesting that a quarantine leak happened at some point in May or June 2020.

“Quarantine is not perfect – there are leaks,” said Rannan-Eliya. “When the Brandix outbreak happened, the press reported that people at factories had symptoms for some time. For the virus to reach 200-300 cases, it had to have spread for several months.”

R. Rathnayake, who was blamed for the outbreak at a Brandix garment factory in October 2020, seemed to confirm Rannan-Eliya’s suspicion in an interview with the Daily Mirror. She said that even before her case was confirmed to be COVID-19, many employees in the factory had flu-like symptoms. Rannan-Eliya labeled the Brandix cluster as an amplification event rather than the site that birthed the second wave in Sri Lanka.

“Brandix had been the amplification event because at this point [COVID-19] had already been spreading in the community. Then it slipped into a place full of people and exploded,” he argued.

Unlike Sri Lanka, Australia and New Zealand had anticipated quarantine leaks and aimed to detect transmission chains before they exploded. “We did not do that. We collapsed our tests and then we lost the battle. We lost the war in June 2020,” said Rannan-Eliya.

While the battle had been “lost,” the number of casualties could have been reduced if precautionary measures had been taken in the early months of 2021. At this point, Sri Lanka was only recording 100 cases per day.

“Sri Lanka had reached a point where it could have beaten the virus because the reproduction number had been about 1.05. This meant that a 10 percent reduction in transmission could have reduced the virus to zero… If Sri Lanka had doubled or tripled their PCR test, the virus could have been cleared by February [2021].”

Instead, in December 2020, Sri Lanka relaxed border restrictions and opened up to international travelers in a “Pilot Tourism Project.” A series of Ukrainian tourists entered the country and moved around in a “bio bubble” of local hotels as well as nature, historical, and cultural sites. Despite precautions, this increased the probability of the entrance of another variant and another outbreak.

Countries such as China and Australia had Delta outbreaks, but they were able to detect it quickly: “What they see is that it goes from zero to many cases and it is Delta. In Sri Lanka, thousands of cases already existed and one or two people had Delta but they could not be found,” said Rannan-Eliya. “We lost it. We lost it in June [2020] and had a chance when Alpha variant came in January and February to crush it in February and March. We did not do that and that laid the basis for Delta.”

Vaccine Distribution

Sri Lanka has a much-praised vaccination drive. As of mid-February 2022, 64 percent of the population had been fully vaccinated and 76.7 percent of the population had received one dose. But in the crucial early stages, the government made a misstep that may have needlessly increased the death rate.

When vaccinations began, instead of prioritizing those at most risk – the elderly and those with pre-existing conditions – the state decided to vaccinate anyone above 30. The Government Medical Officers Association (GMOA) asked for the vaccination drive to focus on people 60 year and older. The president endorsed the recommendation but failed to implement it.

“Instead, they vaccinated people between 60-30 years [as well as those over 60],” said Dr. Naveen de Zoysa, assistant secretary at the GMOA. “What was the rationale behind this? We lost many people because the vaccination drive failed to immunize people over the age of 60. We have to understand the demography – the elderly population in Sri Lanka is larger and more vulnerable to the disease.”

Another problem in the vaccine roll-out was the geographical distribution of the vaccines. One local media outlet reported the distribution of Pfizer, one of the few mRNA vaccines available in Sri Lanka, as limited to Puttalam and Mannar. Another publication reported that the Pfizer vaccine was being distributed to 18-30 year olds in Hambantota – the ancestral home of the ruling Rajapaksa family.

“They provided Pfizer to people in Hambantota. What rationale did they have for this action?” questioned Dr. De Zoysa. The GMOA had advocated for the mRNA vaccines to go to schoolchildren.

The Future

The Delta wave may be over, but the hard lessons learned can help Sri Lanka avoid another disaster – whether fueled by Omicron or a future variant.

There are several studies that criticize “Vaccine Euphoria” – the relaxation of public health measures due to the belief that vaccines have completely ended the pandemic. Experts such as Jayasinghe are concerned about such optimism. He believes that vaccines are only part of the solution to the COVID-19 pandemic.

"Vaccines help us reduce the death rates and the number of severe infection cases. The vaccines are not going to eradicate the pandemic. There is no single solution,” he said.

“As the virus mutates, the response needs to adapt. If the rate of transmission is reduced, this helps our healthcare system and also buys time. Time is needed until medicines are developed, repurposed, and become available. This idea COVID-19 can be eradicated soon is incorrect.”

Rannan-Eliya also does not believe that vaccines alone can solve the problem. “[Even] with vaccination we understand that herd immunity is not possible. This belief that you could protect yourself until this pandemic disappeared is not feasible,” he said.

Rannan-Eliya believes that vaccination combined with “test, trace and isolate” policies are the best defenses against COVID-19, particularly as the threat of future variants remains.

“As long as the virus continues to circulate in the population, it will continue to mutate. I think trying to keep variants out of Sri Lanka is impossible. We were not able to do it before,” said Rannan-Eliya. “There are already variants which are worse than Delta. The problem is if you get mutations which are more immune resistant and also as infectious as Delta. There is a continual risk that we will get a game changing variant in the next year.“

Bad decisions, failed control measures, and maldistribution of resources have a cost. This is reflected in the number of lives lost and people infected in the Delta peak. On April 1, 2021, Sri Lanka had recorded a total of 91,917 COVID-19 cases and 571 deaths since the start of the pandemic. By October 1, 2021, as the peak of the Delta wave finally passed, those figures had ballooned to over 518,000 cases and just under 13,000 dead.

There has also been another cost, one that is hidden and perhaps more lethal: the continuous, unrelenting toll taken on workers in healthcare, the backbone of Sri Lanka’s pandemic response.

“We have 24-hour days and need PPE all the time… We have to mask up even in our breaks. It’s hard to breathe,” a nurse at the National Hospital of Sri Lanka said. “It is only when we return home that we have the opportunity to breathe properly.”