Rukhsana Shaheen & Md Shafiqur Rahman :
Following the COVID-19 situation in Bangladesh during April 2020, some observation and possible measures to mitigate have been suggested by the authors.
Identity disclosure: The message ‘not to panic rather to be aware about COVID-19’ itself is causing panic. What and how to avoid panic, and what measures are necessary to be aware was left untold. Most importantly, identity of quarantined or isolated persons may be disclosed, so that those who have been in contact can voluntarily come forward for reporting as contact and submit to testing. Non-disclosure of identity has probably led to creation of more panic propelling people to take extreme measures. When revealing the laboratory test report of past 24 hours, mentioning the specific location of the cases may be of more importance. This will allow the law enforcers and local people to be alert and voluntarily take to distancing and using other protective measures. Though it is ideal not to reveal identity of cases in the early stages of a new disease, but in the current situation, that stage is probably past and now revealing identity may be more beneficial.
Online assessment: The various apps and government websites that evaluates the health/COVID-19 status of a person may include birth certificate or NID as means of identifying the person. Which may then be followed up to ensure that the person seeking care was able to receive it or not, or was there any change in health status, or hiding health related information.
Online permission: In areas/ houses…that have been locked down, online permission using birth certificate no. or NID, may be given by law enforcers to come out of the area… for a specified time to attend to emergency activity. This will help to keep trace of the person’s movement too.
Communication: Lockdown, isolation, quarantine, social distancing… are terms that are new for the people of this country. Using these terms without informing what they mean and what it entails need to be sufficiently explained in words understandable to most of the people.
Lockdown principle: Areas that are locked down gives an opportunity to conduct rapid tests irrespective of biological or social differentials in the areas. Movement restriction should not be only idea behind lockdown.
Projection of trend: Many experts, based on mathematical modelling and experience of other countries, are projecting the trend of COVID-19 in Bangladesh. According to them, the number of infections and deaths will continue to increase till the end of April and mid- May 2020, after which it will decline. But this appears to be more of rhetoric, as an infection in a pandemic situation depends on many factors -virulence and pathogenicity of virus (considering mutation); physical, chemical, biological environmental factors; host (person) factors; viral load/dose response; biological plausibility and temporal relation; containment efforts by health workers; and compliance with the containment efforts by the public. There is no individual linear relationship among these factors, rather a complex that may lead to either increase over longer period or rapid decrease. Time bound predictions may be avoided.
Care versus control/prevention: Care of complicated COVID-19 cases seems to be emerging as an issue that needs immediate attention in Bangladesh. Since there is no specific treatment, care is basically symptomatic. Experience from other countries show that about one-fifth of the cases become symptomatic. The danger is with the four-fifth cases who continue to spread the disease without knowing it themselves. So, attention needs to be given to control/prevention of spread by focusing on three points – control of source (respiratory secretion) or reservoir (human) by using masks (even homemade 3 layers of cloth) and maintaining coughing etiquette by one to all; suspected cases to be early diagnosed and brought under treatment with strict quarantine and isolation, and concurrent rapid social research; blocking the channel of transmission by improving health literacy and maintaining social distancing, and special healthcare attention to the most vulnerable (comorbid conditions, immunocompromised, pregnancy, smokers…).
Testing: Though PCR is a confirmatory test but is more applicable in the early stages of the disease spread in a country or region. When community spread starts, then the presence of the disease is confirmed, and some time has elapsed making this test of less importance both in terms of specificity and cost. Though it may be done in the first week after appearance of sign-symptoms,thereafter if a patient reports late in the second and third weeks of sign-symptoms then rapid test by antibody detection may be done.
Involvement of Public Health experts: There is increasing need to involve Public Health experts as the focus is more on prevention. So far attention is being given to clinical management by clinical experts with little involvement of Public Health experts. The importance of Public Health should precede clinical management. Health workers may be grouped into three categories – Public Health workers, para-clinical health workers, and clinical health workers. They will work in community, laboratory, and in hospitals respectively with the necessary support staff. This suggested working modality may work better to control the spread of COVID-19.
Prioritization: Prioritization of health services is needed. Considering health services from three perspectives – public health services, paraclinical services, and clinical services,prioritization may be based on summation of four viewpoints – magnitude, impact, vulnerability and cost (MIVC)in the current situation of COVID-19.The following matrix shows that emphasis on public health activities is probably more necessary than other interventions.
Rotation duty: The different categories of health workforce in districts/ facilities may be divided into three groups – one group will work for 14 days and go for 14 days quarantine (irrespective of one being Cov-2 positive or not); the next group will pick up the work and continue for 14 days and then go for 14 days quarantine; the third group will be standby to join work in case of any drop-out from the working team.
Community involvement: However much the formal authorities try to convince and enforce preventive measures, none of it will be effective unless the communities realize the seriousness and actively participate in their own care and prevention, all efforts will go in vain. Informal social leaders such as teachers, health volunteers, club members, religious leaders, prestigious persons… may be approached to communicate with the community to motivate them for their own safety and wellbeing.
Counter threat: It is seen that people are harassing or threatening health workers residing in rented houses/areas when they are confronted with assumed or confirmed COVID-19 cases among health workers. Counter threats by law enforcers is not the solution. People need to understand that health workers are human too, and that they are infected when caring for the people including those who are harassing. Simultaneously, it has to be kept in mind by law enforcers that in panic or unusual situation, public may respond in unusual ways. This situation may be tackled by arranging accommodation for health workers close to their workplace for safety of both family of health worker and the community. This may be done in hotels or school building which are not functional in the current situation.
Infectious Diseases Act 2018: Laws are introduced to control unlawful activities. The law enforces need to know the intricacies of law as much as the people who come under the law when there is any breach. In Bangladesh, most people are not informed about the basic issues in the laws that affect the common people. Widespread propaganda of highlights of ‘Infectious Diseases Act 2018’ at the doorstep of the people may be done in the current COVID-19 situation to keep things under control.
Transport: Government has shut down all public and private offices, except for those providing essential services. Also, all public transports are suspended. The law enforcers on the street are trying to keep all people indoor. The essential services are provided by people most of whom probably do not have personal transport. How these people will reach their workplace to provide the essential services has to be addressed too. Taking this opportunity, some rickshaws and other vehicles are coming out on the streets to help those who need to reach their workstations, and also earn some wages. Practical need of essential service providers and transporters propel them to the streets. Safe modality for transport of essential service providers may be chalked out.
Online briefing: It is seen that the top executive of Ministry of Health gives daily online one-way briefing on Cov-2 test positivity. These briefing are very general, whereas the need of the hour was to be in direct touch with field level (frontline) health workforce online to understand their problems and guide/ take/ order immediate measures for its mitigation, and where applicable laude their efforts. These media based two-way communication would probably bring more transparency and accountability.
Setting up facilities: Demand for setting up or increasing diagnostic facilities and critical care management of COVID-19 cases is on the rise. When undertaking these activities, issues of public health cannot be over emphasized. For example, as a prerequisite of PCR for SARS-Cov 2 detection, laboratory fulfilling the minimum criteria of biosafety level is a must. Setting up biosafety level laboratory entail conforming to infrastructure and functional requisites. The regulation and decontamination of airflow (in and out) in the laboratory is necessary, else the outgoing air will carry the virus far and wide. Similarly, setting up of isolation and intensive care units will entail both infrastructure and functional prerequisites – appropriate bed, continuous oxygen supply monitored by oxymeter, room airflow, standard PPE for health worker and cases…. Hence, an infection control team composed of public health experts, public health engineers, and other support staff may be formed centrally/divisionally who will give the guidelines and monitor the setting up of laboratory facilities, isolation and intensive care units for COVID-19 cases. All efforts to minimize psychosocial trauma and maintain humane handling of cases by health workforce must be ensured.
Age distribution of cases: It is probably time to revisit the reports whereby it is seen that COVID-19 is seen more among younger age group in Bangladesh, in comparison with that seen worldwide. The reason may be that young people are ignoring the message of social distancing, or young report to diagnostic facility more for testing. Youth who ignore social distancing may be motivated to remain indoor while the elderly may be motivated to self-report for diagnosis if necessary.
Converging collective behavior: Some converging collective behavior are planned while some are spontaneous, which depends on stimulus and psychosocial response. In the circumstance when all transport movement including railway services is banned with the aim to control COVID-19, then if a government train is used by a group of people to move from one place to another, this shows a planned group behaviour. Such behaviour is not desirable and can be controlled. On the other hand, when emotional attachment or respect drive people to converge for an act (e.g., attending funeral), this is usually spontaneous and unplanned, and no one can be specifically held responsible even if this convergence was not desirable. Deleterious planned group behaviour need to be strongly and immediately handled by law, while one time deleterious unplanned spontaneous behaviour may be accepted as a lesson so that authorities are alert and foresee such possible group behaviour to take appropriate timely action.
(Rukhsana Shaheen, PhD, was an Assistant Professor of Community Medicine and currently working as freelance Public Health worker in Bangladesh; e-mail: [email protected] / Md Shafiqur Rahman, PhD, was an Associate Professor of Community Medicine and currently working as freelance Public Health worker in Bangladesh; cellphone; e-mail: [email protected])
