Lines of Operation of the Military, Police and State Intelligence for combatting COVID-19 in Sri Lanka

Coronavirus (COVID-19) pandemic is spreading across the world and Sri Lanka is no exception. It was first reported in Wuhan Province, China in December 2019 and as of now, it has spread to a number of countries in the world. The first COVID-19 patient in Sri Lanka was reported on 27 January 2020; and the virus seemed active in Sri Lanka with the detection of the second patient on 11 March 2020. On 30 January 2020, the World Health Organization (WHO) declared the outbreak as a Public Health Emergency of International Concern; and on 11 March 2020, WHO recognized it as a pandemic. As of 8 May 2020, more than 3,918,600 positive cases have been reported in 200 countries and territories; and nearly 270,700 have died due to the pandemic.


Introduction
Coronavirus  pandemic is spreading across the world and Sri Lanka is no exception. It was first reported in Wuhan Province, China in December 2019 and as of now, it has spread to a number of countries in the world. The first COVID-19 patient in Sri Lanka was reported on 27 January 2020; and the virus seemed active in Sri Lanka with the detection of the second patient on 11 March 2020. On 30 January 2020, the World Health Organization (WHO) declared the outbreak as a Public Health Emergency of International Concern; and on 11 March 2020, WHO recognized it as a pandemic. As of 8 May 2020, more than 3,918,600 positive cases have been reported in 200 countries and territories; and nearly 270,700 have died due to the pandemic.

Sri Lanka's preparation for COVID-19
The first Chinese national detected as COVID-19 while on tour in Sri Lanka prompted national level proactive action to prevent an outbreak within the country. The government activities for COVID-19 prevention followed the vision of His Excellency the President, "Proactive interventions to prevent any outbreak of COVID-19 within Sri Lanka". The National Action Committee for COVID-19 was established on 26 January 2020. State Intelligence Service was tasked to undertake research on developments in the world and to assess possible impacts on the region, particularly on Sri Lanka. During the preparedness phase, health sector was ready for any medical emergency and defence forces were prepared to establish and handle quarantine centers. The Government of Sri Lanka (GoSL) also established the National Operation Centre for Prevention of COVID-19 Outbreak (NOCPCO) to spearhead combined operations to combat COVID-19. NOCPCO has been playing a pivotal role in actualizing the vision of His Excellency the President.
The GoSL imposed travel restrictions for arrivals from affected countries starting from 10 March 2020 and total travel restrictions into Sri Lanka by 20

· Military/ Police/ Intelligence Line of Operation
This LOO targeted at identifying the source of infection and preventing transmission from an infected individual. In the process, vulnerable communities and groups were identified and contacts were traced for confirmed patients. For this purpose, the Detection, Isolation and Tracing (DIT) Model was adopted for mitigating the outbreak ( Figure 2).

Sri Lanka's approach for COVID-19
The GoSL strategy in combatting COVID-19 was a whole-of-government approach, which focused on four Lines of Operations (LOO) (Figure 1).
Each component in the model overlaps and complements with each other. This LOO contributed largely to identify the source of infection in individuals, the vulnerable communities and possible contacts; and to prevent the transmission through minimizing human mobility.
Detection: Detection was of twofold; detecting positive cases and detecting vulnerable communities. Positive cases were identified by the Medical and Health Care LOO from suspected patients and highrisk individuals. Vulnerable groups were identified from high-risk arrivals from other countries and those exposed to the virus locally. This detection process was combined with big-data analysis and verification of records with various agencies, such as immigration, emigration and electoral registers.

Isolation:
Community-based self-quarantine, central-quarantine in quarantine centres and demarcating lockdown areas were the measures used for isolation of potential contacts of COVID-19 patients. In addition, the confirmed COVID-19 patients were isolated in designated hospitals. Security Forces, Sri Lanka Army in particular held a massive responsibility of establishing and running the quarantine centres; shifting people into quarantine centre; and looking after people in quarantine centres during their stay. Police played a major role in isolating villages / areas and enforcing curfews to restrict the mobility of communities Tracing: Contacts were traced to limit the spread of illness from a confirmed patient. Similar efforts were made to identify the source of infection for the index case. Primarily, contact tracing and source identification were done by both preventive and curative health teams (initial history taking upon admission). This was supplemented by ground intelligence and big-data analysis in the LOO. Medical and Health Care LOO focused on early detection, isolation and provision of treatment while tracing the contacts through field primary healthcare staff. It also involved in quarantining of exposed persons in the community while promoting the essential public health measures to prevent disease transmission. Active case detection was performed on exposed contacts identified through comprehensive and rapid contact tracing of infected persons and by screening and performing investigations on suspected patients with severe/ acute respiratory illness or post-mortem testing of all suspected sudden deaths. In addition, random sampling of highrisk/vulnerable communities/areas and sampling at border control points were also performed. In certain instances where community transmissions were reported, the surveillance was expanded to include the monitoring of geographical spread of the virus, transmission intensity, disease trends, characterization of virologic features and the assessment of impacts on health care services.
When a suspected case is admitted or when laboratory confirms the case, the hospital or laboratory notifies the area medical officer of health (MOH), regional epidemiologist and the Epidemiology Unit immediately. The surveillance activities are done through the network of 345 MOH areas around the country and are also coordinated with military, police and intelligence where it is necessary. The primary healthcare team comprising MOH and public health inspector (PHI) investigates all exposed to the infected person based on a contact history of 14 days prior to being detected; and identifies anyone to be quarantined and the potential source of infection. The exposed persons are monitored for 14 days and if symptoms appear, they are admitted to designated COVID-19 hospitals for investigation. Those who do not get symptoms are tested before being released from quarantine. The laboratory testing facilities have been provided by a network of laboratories across the country. The algorithm for PCR testing was defined by the The operationalization of DIT Model is as follows (Figure 3):

Figure 3: Operationalization of the DIT Model
Epidemiology Unit.
Overall health surveillance is coordinated by the Epidemiology Unit. The Epidemiology Unit not only compiles the data but also randomly visits the areas to ensure that the investigation and quarantine are done as per national guidelines which are based on guidelines of the WHO. Medical and Health Care LOO is exclusively spearheaded by the Ministry of Health.

· Psychological Line of Operation
This LOO focused on the cognitive domain of the community. It provided right information about COVID-19 situation in the country and in the world, measures taken by the government to prevent and control the spread of COVID-19, medical and health care instructions, adhering to the law and order and consolidating the national narrative/ solidarity. Psychological LOO touched the full spectrum of social fabric, each ethnicity and religion. Conceptualization of psychological LOO is presented in Figure 4.
The motto of psychological LOO in fighting COVID-19 was "Life First". President's Media Division (PMD) acts as the official source of information of GoSL initiatives/actions and continues to provide

· Economy and Well-Being of Community Line of Operation
In line with the GoSL policy and long-term economic objectives, a task force was established to revive the economy and eradicate poverty, while paying special attention to the challenges posed and opportunities emerged in Sri Lanka in the wake of COVID-19 outbreak. This Task Force comprised governors, secretaries to ministries, Commanders of the Sri Lanka Tri-forces, Acting Inspector General of Sri Lanka Police, and chairpersons of several departments, corporations and authorities and district and divisional secretaries.
It was given the responsibility of steering the relevant institutes to create a productive economy through formulation of a unique economic structure based on novel initiatives. Implementation of joint operations to establish a people-centric economy, which will promote domestic industrialists and entrepreneurs is another objective of the Task Force. In mid and short term, the Task Force ensured continuation of essential services to maintain normalcy in the civilian life in the face of COVID-19 crisis. Detailed scope of Maddumage KS. JCCPSL 2020, 26 (Special Edition on COVID-19) right information to the public through its website and social media. The NOCPCO conducted regular media briefings on COVID-19 situation, statistics and operations. Epidemiology Unit and Health Promotion Bureau (HPB) of the Ministry of Health updated official figures in their websites. Several actions have been implemented to build confidence of the public on GoSL's approach in fighting COVID-19 and the ability to control the situation. Experts from different fields have extensively used state and private mass media, and social media forums/ platforms to share the right information with the general public through a number of discussions/programmes.

Figure 4: Conceptualization of the Psychological LOO
the Task Force included distribution of rice, vegetables and other products to the communities in all districts, strengthening farmers and the local economy, encouraging and assisting farming activities and home gardening, providing monetary assistance to farmers promoting the use of organic fertilizers, organizing of co-operatives and other retailers/business networks.

Synergy of the Sri Lankan Approach
None of these LOOs could be expected to produce desired results by working in isolation.

Controlling mechanism of the spread of COVID-19
Process adopted by the GoSL since its first local case is akin to "Hammer and Dance" Theory by Tomas Pueyo. The GoSL used various aggressive proactive measures (Hammer) in anticipating spikes of cases and brought the spread of virus under controllable level (Dance) so that the health sector could handle the case load without exhaustion. This process is continuous and reviewed after each case or cluster. Lessons learnt on previous cases or clusters were adopted in the next case scenarios. Figure 5 indicates the cases reported in Sri Lanka since 11 March 2020 and each spike in the graph is corresponding to a cluster.
Groups of persons returning from overseas, local tour guides, gem businessmen, persons arriving from overseas after religious activities, drug network clusters and a group of naval soldiers were a few clusters of cases managed in Sri Lanka. Mechanics of 'Hammer and Dance Theory' have equally applied to each of these clusters. Each time, the 'hammer'aggressive proactive measures -have channelled the virus to 'dance' under a controllable level.
Cluster 4: First patient in this cluster was reported on 15 April 2020. Three more patients were reported the following day from the same area, and vigorous isolation and lockdown of vulnerable communities began on 16 April 2020. On the next day, people living in overcrowded places in this cluster were shifted to quarantine centres out of Colombo. This minimized any exponential spread within the area and outside. Many cases reported thereafter were within the quarantine centres, but minimal impact was observed on the society ( Figure 6).

Conclusion
COVID-19 pandemic spreads around the world across different countries. Despite many researches and scientific studies, no credible vaccine has been developed to-date. In absence of such, prevention and containment are considered as the best available option. GoSL strategy in combatting COVID-19 is a 'Whole-of-Government' approach focused on prevention, containment and management. Sri Lankan model is an aggressive, strenuous and continuous process but comparison of data related to COVID-19 in the world suggests that Sri Lankan approach is a unique, dynamic and an effective model.