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.