KEYWORDS
COVID-19, novel coronavirus, 2019-nCoV, developing countries, low and
middle-income countries, Sri Lanka, South East Asia, older adults
Evidence to date shows that older adults over 60 are at a higher risk of
getting severely sick and dying from Coronavirus disease 2019
(COVID-19). This risk increases further for older adults with underlying
medical conditions such as cardiovascular disease, diabetes, chronic
respiratory disease, and cancer. A recent publication by Lloyd-Sherlock,
P. et al suggest that this has important implications for the way in
which public health and clinical responses should be developed. These
researchers emphasize that these implications have been largely
overlooked in both high and low and middle-income countries (LMICs) when
providing guidance, which can have a greater impact in LMICs, where 69%
of the global population is over 60 and health systems are still
developing. Lloyd-Sherlock, P. et al discuss four points of concern to
consider when developing public health and clinical responses to protect
older adults in LMICs from COVID-19. This paper applies these four
concerns to the context of Sri Lanka and provides simple and immediate
measures to proactively prevent the spread of COVID-19 among older
adults in Sri Lanka.
Sri Lanka has one of the fastest aging populations in South and
South-East Asia due to early progress in reducing fertility rates,
increasing life expectancy, economic development, and rising burden of
non-communicable diseases (NCDs). In 2015 the population over 60 years
was 13% of the total population in Sri Lanka, which is projected to
increase to 20% by 2030. According to World Bank 10.47% of the Sri
Lankan population was 65 years and above in 2018, which is approximately
2.27 million people. It is imperative that Sri Lanka takes note of the
concerns discussed below and take precautionary methods to prevent the
spread of COVID-19 among the most vulnerable populations in Sri Lanka in
a timely manner.
The first issue that is most concerning to Sri Lanka and other similar
LMICs is the ability of health systems to respond to the increases in
demand in the case of a COVID-19 surge, especially for those needing
respiratory support, a large number of whom are likely to be
older. Previous research has found that health systems in LMICs have
limitations on capacity at regular days and are likely to face
difficulties in providing older adults the care needed during a
pandemic. Sri Lanka should consider and prepare for potential
difficulties that the health care system may face if COVID-19 is not
contained in time. Most importantly, it is imperative that Sri Lanka
takes immediate preventative measures discussed here as well as
additional measures to prevent and lessen the potential unbearable
burden that COVID-19 could bring to Sri Lanka’s health care system.
The second concern for LMICs is the older populations that are being
cared for in long-term care homes (LTCs) or similar facilities. LTCs in
LMICs are often not as well-regulated and the care and services provided
are not yet at an equal standard when compared to high-income countries.
Therefore LTCs in LMICS may not be as prepared as those of high-income
counties to tackle a COVID-19 surge. In high-income countries like the
United States of America and Canada, there is already evidence of
COVID-19 compromising nursing home residents. All deaths in Canada as of
16 March, 2020 (4) have occurred in care homes. The risk could likely be
higher in LMICs such as in Sri Lanka if appropriate measures are not
taken in time.
While the window of opportunity is still open for Sri Lanka, the
government must take immediate precautionary measures to protect the
lives of those who are most vulnerable. Health officials in Ontario,
Canada have taken measures to restrict visits to long-term care homes
and similar facilities to only “essential” visits where “essential”
visits mean allowing family visits in end of life or critically ill
situations. While this is a difficult arrangement for family members and
residents, at the moment limiting visits can help save the lives of
loved ones in LTCs. It is important to maintain the quality of lives of
older adults while they are isolated through means such as using
available technology to help them stay in touch with their family
members. In addition to restricting visits, it is essential to actively
screen LTC staff and residents moving to or returning to LTCs, which
includes measures such as checking for symptoms and gathering
information about travel history and contacts. LTCs must instruct all
staff to self-screen at home and staff with symptoms of an acute
respiratory infection not to come to work and report their symptoms to
LTCs. All staff should be aware of early signs and symptoms of acute
respiratory infection. Therefore, providing training and education on
precautionary methods to staff in LTCs and similar facilities is
crucial. All residents and essential visitors must be educated on
precautionary and screening process as well. Such measures are being
implemented in countries like Canada and are imperative in preventing
unnecessary exposure and spread of COVID-19 among the most vulnerable
populations in Sri Lanka.
The third concern is the inclusion of older adults in government
responses. Social distancing policies must consider the circumstances of
older adults living in the community, particularly those living alone or
dependent on others for care and support. These older adults are at risk
of running into difficulties in obtaining food and other essential
supplies if the country has to take longer and more extensive quarantine
measures. Appropriate actions that Sri Lanka can take in order to assist
older adults are to provide essential supplies to their households,
especially those who are living alone and may not have caregivers
around. In remote areas of the country, older adults are likely to go to
the stores by themselves, potentially increasing their risk of exposure,
especially in high risk areas. The government must prepare to assist
older adults living in the community in collaboration with the Ministry
of Social Services and Ministry of Health, through the use of emergency
relief and public assistance programs if needed, and by working with
non-governmental organizations (NGOs) such as HelpAge Sri Lanka, who are
key stakeholders in assisting the aging population in Sri Lanka.
In addition, amid COVID-19, policymakers must remember that a large
number of older people may be uninformed and may not have access to
adequate information on prevention and precautionary methods. Older
adults in remote areas may have limited access to obtaining reliable
information. These older adults must be given special attention to and
provided with adequate information. Furthermore, it is important to
educate citizens to look out for older adults who may be living alone
while keeping in mind to keep a distance with older adults if
individuals are sick themselves.
The fourth concern is the common family dynamic of grandparents taking
care of grandchildren, which provides an added risk of exposure for
older adults as caregiving duties make it impossible for them to
self-quarantine. Providing options for alternative child care methods,
or providing some flexibility and relief around work hours for workers
with children, especially for health care workers, may be helpful in
reducing the risk of exposure to older adults. Another family dynamic
that is common in Sri Lanka is the increased level of informal support
older adults usually receive from their immediate family. Informal
caregivers who are taking care of older adults must be prepared by
documenting detailed instructions for care where applicable and plan to
have people to help out in case the primary caregiver falls ill.
For those who have the resources, making use of technology to stay
connected to older family members while keeping a social distance is a
measure that can be taken to reduce the risk of exposure to older adults
living in the community. Leading Canadian internet providers have waived
home internet overages for residential customers until the end of April,
allowing families to stay connected while practicing social distancing.
The provision of supportive measures as such, but are most applicable to
Sri Lanka must be considered through government and other available
resources.
The time to act is now. These measures must be taken as preventative
measures which means taking action before detecting a wide community
spread to achieve the most favourable results. Sri Lanka being a LMIC
and therefore more vulnerable, must take immediate actions while there
is still time to minimize the impacts COVID-19 could potentially have on
the country. While these measures are specifically suggested for LTCs,
measures that are applicable to other health care facilities and
community-based settings must be adopted accordingly.