Coronavirus Pandemic: Tasks Ahead

The times are different. The whole world is different. We have never faced a situation like this before. In a sense, we are all confused. As a responsible newspaper, we want to communicate authentic information to the public. The public needs to know what the tasks ahead are.

We are already in a place where we should not be. We were in a preparatory stage throughout the months of January and February, before the first COVID-19 case emerged. Like many other countries, Bangladesh did not go forward with strong measures. However, Bangladesh, as well as all other countries in the region, are following the international health regulations. Bangladesh already has a National Action Plan for Health Security, which includes events such as outbreaks of such viruses.

We already have a few confirmed cases, but instead of dwelling on these concerns, we must attempt to mitigate them. It is important to accept that we have many cases, and be open and clear about the fact that the number of cases is going to rise.

Misinformation and rumours are scarier than the virus itself. These things hamper the country's efforts towards mitigating and containing the spread of the virus. The media should be responsible in controlling the spread of misinformation and rumours. Right now, panic is the worst enemy. If the public starts to panic, the government would have to begin mitigating the panic, and not the virus.

We need to look into the actions of other countries which have been successful in containing the virus. Bangladesh is the 108th country to declare a case. Over 180 countries have been affected so far, which is why WHO has declared it a pandemic. The positive aspect to this is that there are a number of countries whose experiences we can learn from. COVID-19 is a new virus and so everything is a learning curve. This virus has no mention in medical textbooks, nor do we have prior experience with it, which is why it is called "novel." WHO is giving all of its efforts in order to gather more scientific information on the virus.

Physical distancing has proven to be a successful measure to slow down the transmission of the virus. Awareness on this is already rising, as you can see from the reduced traffic in Dhaka. Social or physical distancing is an individual responsibility. This is no longer solely the responsibility of the Ministry of Health. All wings of the government should be involved in this. If each person is individually conscious, there is no way the virus can travel from one place to another, since it transmits from person to person. People can leave the virus on surfaces or objects they touch, which is why we are asked to wash hands regularly.

There will be more cases in the coming days, and more contact tracing will be required. The burden on the health system will only increase, since there will be more incoming reports, and more people wanting to be hospitalised even without needing to be. Moreover, Bangladesh is on the gateway of a dengue outbreak. Recently, there were two reports of a measles outbreak.

The epidemic can be controlled by strengthening and intensifying our tracing, isolation, testing, and treatment. Social distancing will help reduce the burden on the healthcare system, and the system will then conduct contact tracing, find the patients, then isolate, test and treat them.

This is not the first time that Bangladesh has experienced an outbreak, and so it has a system in place, and a government which has already mitigated other such health crises. It is also one of the best countries for immunisation. But, the Ministry of Health needs support. The government has to repurpose its funding, resources, and human resources because there was a shortage of human resources in the health sector even before the outbreak began.

The number of coronavirus cases in the country has risen to 24. There have been talks about the country going into lockdown and a state of emergency. Before going into lockdown, however, it must be taken into consideration that there are many workers in the country who survive on daily wages. Other countries provide such workers with food and other necessities, and so we need to think about how we can support them if a lockdown occurs.

Out of the 24 coronavirus patients, three have already been sent home while the rest are still in the hospital. Therefore, we need to think about whether more hospitals need to be prepared to house more patients. The situation has not yet turned such that space cannot be given to patients in hospitals. Three or four more hospitals are also ready. The preparations by the government are not bad, but the scenario is changing every day. If the number of cases rises significantly, the government will take steps accordingly.

Coronavirus is contagious, and so the patients infected by the virus should not be admitted to general hospitals, since the virus could spread all over the hospital. This will lead to people panicking, and patients will either stop going to the hospital, or outdoor patients will try to leave. Therefore, coronavirus patients should be kept in isolated hospitals. For example, there is Kuwait Bangladesh Friendship Government Hospital which has 200 beds currently, Infectious Diseases Hospital (IDH), or Railway General Hospital. The issue is that Infectious Diseases Hospital (IDH) and Railway General Hospital do not have ICUs and dialysis machines. These facilities must be ensured when preparing other hospitals.

Personal protective equipment (PPE) must be provided to all doctors, nurses, and other medical personnel. If their personal protection is not ensured, they will be too afraid to continue treatment.

People with regular cases of cold and coughing are pouring into hospitals to be tested, which is an issue. Common cold symptoms do not equal to being infected with coronavirus. However, someone who has just travelled back from abroad might be at risk of contracting coronavirus if they have cold symptoms. If their family members within the household and other people in the area who have come in contact show cold symptoms, they are at risk as well, and their cases must be taken seriously.

Another issue is that doctors are denying treatment of patients showing cold symptoms. Where will these patients go now? They usually do not need to be admitted in wards, and mostly stay in the outdoor unit. Therefore, the PPE for outdoor doctors needs to be strengthened. A separate area could also be formed within hospitals for patients showing cold symptoms.

A top-level decision is required about Bangladesh going into lockdown. WHO says that this must be done immediately, or else controlling the spread of the virus will be very difficult. Huge numbers of people have arrived from abroad and have spread all over the country. None of them are in quarantine, and are roaming around freely. They might be responsible for spreading the virus within our communities.

In private hospitals, we usually deal with patients with non-communicable diseases. We get a lot of immuno-compromised patients. If a patient with an infectious disease comes to our hospital, they put others at risk. Hence, it is very risky to entertain these patients in our hospital.

We triage these patients by taking their history of travel, contact, etc., and try to detect the COVID-19 symptoms. Then we ask the potential suspects to go to IEDCR to get tested. The practical problem we are facing on the ground is their unwillingness to go.

Since we are a private hospital, the patients coming to us are mostly middle or upper-middle-class. This group of people are in greater denial and it is much more challenging for us to send them over to the testing centres. So, what we have to do is break this fear. There is also a fear surrounding isolation. Bangladesh has plans on creating isolation units in various places but all of these places will remain empty because the patients would prefer to stay in their own homes regardless of whether they have tested positive or negative for the disease.

The government is taking a lot of initiatives but I feel that disseminating information in the right way and in the right language is very important.

Words such as "quarantine" are quite technical and so people do not really understand the difference between "quarantine" and "isolation". "Home quarantine" actually means being quarantined in a single room.

IEDCR or Ministry of Health cannot do everything alone. All they can do is spread the awareness regarding the disease and the do's and don'ts which they are doing wonderfully. But to make sure all the necessary precautions are implemented, we need support from law enforcement agencies.

There should be other hotline numbers helping out with the non-health related concerns and queries.

We are also getting a lot of patients who are not properly disclosing their history to the doctors. We should motivate and encourage people to refrain from doing this. Media should take steps regarding this. We also need support regarding personal protective equipment. We also need to be aware of the types of masks we should be wearing and in what situations and how to wear and dispose of them.

In Bangladesh, people have mainly taken up home quarantine, which has spelled disasters for us. People who are not maintaining the standards of home quarantine must be located by the health services. Patients must be tested before being shifted from quarantine to isolation. Isolation centres should be set up, up to upazila level. Patients with common cold symptoms will be treated in upazila and district level hospitals. However, patients with severe manifestations such as difficulty in breathing, or co-morbidity, should be taken to critical care. Critical care facilities must exist in district level and tertiary level hospitals, and the mass public should be made aware of which hospitals contain these facilities. Big hospitals such as Dhaka Medical College and Hospital (DMCH) should create separate counters for patients with cold symptoms. Even patients requiring surgery must first visit this counter if they exhibit cold symptoms, before attempting to go into surgery.

Adequate PPE must be made available for personnel at every level who are handling patients. Many patients directly go to pharmacists for treatment instead of doctors; without PPE, the pharmacists will also stop working. Therefore, protection must be provided to them early on.

Politicians love talking about lockdown and state of emergency, but declaring these means the system has failed. We shall not fail; we shall tackle the situation. We will identify those who are spreading the virus in the villages, but a state of emergency cannot be declared on the entire country just because of a few cases. The country will function properly, while the health services, along with other services, control the coronavirus.

When the people of Bangladesh faced a dengue outbreak, they received care and treatment. But coronavirus is new to us. This virus first began to spread from China, but the country has since lowered its COVID-19 mortality rate significantly. The Ministry of Health in Bangladesh has been pondering for quite some time now on how to reduce the incidence of coronavirus and treat infected patients. Coronavirus has affected most countries of the world, and so WHO has called it a pandemic, but Bangladesh has not yet reached that stage.

Our Honourable Prime Minister Sheikh Hasina has been concerned about the outbreak for a long time now, and has held many discussions with her cabinet. She also sent many directives to the Ministry of Health, through the national committee on coronavirus. Large gatherings take place during meetings of the national committee on coronavirus and so future meetings will be through video conferences.

In the current context of the situation of coronavirus in Bangladesh, all preparations must be made by the Ministry of Health. The ministry has already set up two to four hospitals which can house coronavirus patients, such as government hospitals in Puran Dhaka. Kuwait Bangladesh Friendship Government Hospital has also been prepared for patients. A new gastroenterology hospital has opened, which can be used as well. It has also been decided that the Sheikh Hasina National Institute of Burn and Plastic Surgery of Dhaka Medical College will be emptied to be used for coronavirus patients. The area used in Bishwa Ijtema has been handed over to the army, where they have set up tents for future use in treating coronavirus patients. The government and Ministry of Health are not working at the speed of light, but are making moderate preparations.

During the dengue outbreak, eight to ten doctors had died. We only thanked them for their service, but did not consider that they might have had family members who depended on them financially. The lives of the doctors need to be taken into consideration by the government this time.

Incidence of coronavirus could even surpass that of dengue. Public awareness is the most important factor in fighting the spread of the virus. The general people should turn in those who are not maintaining home quarantine even though they have returned from abroad. People need to be made aware of the proper ways of covering sneezes and coughs, washing hands, and physical distancing.

The Ministry of Health has cancelled holidays for its employees. Doctors may be directed to do the same if the situation worsens. Everyone must be united in their efforts to tackle the spread of coronavirus. 70,000 doctors in different districts of Bangladesh have already been made aware of the situation through seminars and symposiums.

COVID-19 is a global issue. Therefore, Bangladesh, which is a signatory, has been preparing to implement the International Health Regulations (2005). A National Action Plan for Health Security has also been prepared in light of many global documents. This disease has only been around for three months, and WHO has already recommended whole-of-government and whole-of-society approaches. Since the disease is new, natural immunity will grow within us, or new vaccines and drugs will be formulated for treatment. However, vaccines cannot be formulated and used within a year. In the meantime, we must work using the lessons learned from the experiences of countries tackling coronavirus, such as China, Korea, Iran, and Italy as soon as possible.

Global predictions have been made that the next epicentre of coronavirus will be the Indian sub-continent, and 30 crore people will be infected. Today, we have 24 coronavirus patients, and two of them have already died. In many countries, like Germany, only 30 to 32 patients have died out of 15,000 to 20,000 infected. China has achieved zero domestic indigenous coronavirus cases in the past two days.

An estimation is required on how many patients there might be in the coming days, and how many will need to be hospitalised, will need critical care or respiratory support. Non-therapeutic interventions need to be strengthened. Some have already been enforced, such as schools have been closed down, and some areas are under lockdown.

We have limited capacity of diagnosing the disease, and it is difficult to distinguish from other viral fevers. Therefore, patients exhibiting cold symptoms are told to stay home in isolation instead of going to the hospital, and are also asked to call the two hotlines of Institute of Epidemiology Disease Control and Research (IEDCR). Patients should only come to the hospital if they have difficulty breathing. This means 80 percent of people are not required to do anything. 50 percent of our population is aged below 15 years. If they are affected, we will grow immunity against the virus. Therefore, everyone must follow this public notice.

Patients suffering from difficulty in breathing must be taken the most seriously. People over the age of 60 have many diseases, such as diabetes, high blood pressure, heart disease, kidney disease, and stroke. These patients are at high risk, and must be saved. Young people should not go to the hospital, especially the emergency unit, even if they are ill, because elderly people are at the hospital as well.

Asymptomatic people spread the virus the most, which is why mobility must be reduced as much as possible. Top-level government officials must enforce this. Communication must be done in easy language. "Quarantine" and "lockdown" are scary words, which should not be used. Alternatively, we should sincerely request those who have patients showing these symptoms in their homes, to stay isolated.

Adapting to this disease will require behavioural changes. Patients and their attendants need to bring changes in their lifestyles. The health sector must be kept alive; if our healthcare professionals fall ill, who will provide treatment? Non-essential services should be put on hold at this time, so that the health sector can slightly relax.

Infection prevention and control is required in all hospitals. We are unaware of which hospitals the coronavirus patients will go to, and so the essential requirements of infection prevention and control must be fulfilled. Community engagement must be strengthened as well.

Our target is to ensure the peak number of infected patients is not reached too quickly. If the peak is reached within three to four weeks, our health sector will not be able to cope with it. Iran, Italy, Spain, and China are countries which have more advanced healthcare facilities than we do, but the mortality rates there are 2.3 to 7.2 percent. We do not know what this rate will be in Bangladesh, but predictions suggest that it might not be as low as the more developed countries.

The mortality rate was much higher in the Wuhan province than in other parts of China, due to them not being prepared when the outbreak suddenly began. France says it is four weeks behind Italy, while Germany says it is two weeks behind Italy, and so we need to know how far behind Bangladesh is. We need to prepare within this time.

One of the reasons why we do not know how far behind Bangladesh is in terms of other countries is that, we have not tested patients. Our testing facilities are very limited, which is a big concern going forward as more and more local transmission is occurring. The next two to three weeks are crucial for us. It is important to do whatever it takes to flatten the curve, so that it does not peak. 

Given freedom, people often make the wrong choice. A few days ago, during such a situation, people went to Cox's Bazar. People also gathered in front of Manik Mia Avenue to watch fireworks. There was no concern regarding social distancing during these situations. The reason these happened could be because of the lack of communication. Secondly, people might not be taking the disease seriously. While it is important to not panic, it is also important to understand the gravity of the situation. This could very well be the most serious thing this country has dealt with in terms of public health.

I would stress again on the importance of clear and centralised communication from the government in terms of how the government is preparing and what the citizens should and should not do. So far, we have been getting contradictory messages from political and technical leaders. In the last two or three days, there seems to be a shift and the political leaders seem to have gotten more serious. This is good news.

Clear communication is also important to prevent rumour-mongering. The prevalence of misinformation has almost turned this into a two-pronged battle since with the advent of social media, it is so easy to spread misinformation. So, how do you fight it? It is important to trust only reliable information sources such as the government, IEDCR, WHO.

Next, there is the whole quarantine process which is something Bangladeshis are not familiar with. The importance of the right use of language is crucial here. The process needs to be explained to the masses in a way that they can easily comprehend. We also have to take into account that a lot of households do not have multiple rooms where people can be quarantined. Social distancing is not possible in slums.

Now, what a lot of people are asking is, what can you do if you are showing potential symptoms? The general trend is that 80 percent of the people will have very mild symptoms and the other 20 percent might need hospitalisation and more intensive care. Explaining this to people is very important since, in Bangladesh, a lot of people might be under the misconception that if they get it they will die. But, even if someone is asymptomatic, he/she might be carrying the virus so that is why social distancing is so important.

From BRAC's side, we have about 50,000 trained community health volunteers. They will be targeting around five million households to convey these awareness messages. We are also starting a mass media campaign, working alongside IEDCR to synchronise the message that will come out. This will complement the household visits. The digital media campaign has already started. We are also distributing soaps to slums in partnership with Unilever.

A big concern is when people are calling the coronavirus hotline numbers, they are unable to get through. Our testing is centralised and the first step in getting tested is calling the numbers. Secondly, after calling and being authorised for testing, IEDCR will send personnel to conduct the testing at home. But, if we cannot get through the first step, the entire testing becomes stalled. So, what people are doing now is going to the local hospitals. If an infected person does so, they are putting a lot of people at risk. Therefore, the capacity of call centres needs to be increased, testing needs to be decentralised, and the district level hospitals need to be ready. Currently, there are no hospitals outside of Dhaka prepared to receive coronavirus infected patients.

Temporary facilities for isolation should also be built. The next two to three weeks are quite crucial because when the local transmissions start, it can peak quite quickly. If it peaks very quickly, the local healthcare system may get overwhelmed and might be unable to handle the sheer number of patients. This tremendously increases fatality. Therefore, flattening this curve is very important.

Bangladesh's health institutions have a long history of controlling outbreaks. Right now, faced with coronavirus, we are only looking at the numbers of beds and testing kits available and getting disappointed after comparing the numbers with those of other developed countries. This country's public health sector was successful in controlling diseases such as malaria. Smallpox has also been eradicated. We did not let the swine flu epidemic reach Bangladesh. It stopped at localised transmissions in Dhaka.

I would like to highlight that our public health sector is very experienced although there are some resource constraints. During outbreaks, what is more important than the availability of testing laboratories, is the availability of reporting facilities in case of huge mortality numbers. This is definitely available.

If anyone in any part of Bangladesh gets extremely sick, IEDCR will be alerted through a word-of-mouth chain where the neighbouring people inform the local MPs of the area and they in turn alert the health assistants and IEDCR. Every doctor and health technologist at IEDCR is a member of the rapid response team. There are central rapid response teams who have the power to go anywhere. The districts have district response teams and the upazilas have upazila response teams.

We should be given a little credit because the disease did not spread in our country from the beginning. Due to the natural course of the disease, it was inevitable for it to reach Bangladesh but it reached us after a lot of other countries.

When the disease spreads further, the testing facilities definitely need to be decentralised but the amount of pressure currently imposed on us is making the IEDCR employees distressed. Rapid testing facilities will soon be provided.

Wuhan's first case was discovered on December 31 while Bangladesh identified its first case on March 8 due to the group efforts of Bangladesh's public health system, DGHS, IEDCR, and our airports. How can we not give credit to Bangladesh's public health system and its government?

I would say, the people of our country are much more aware than the people of Italy. Why are the mortality numbers in Italy so high despite their health system being seemingly better than ours?

The people coming back from Europe were unwilling to quarantine themselves. They did not try to understand that although they may not show any symptoms they might still be a carrier and infect others. The inability to quarantine these people is a result of the equal failure of the countries these people came from.

When we tried to take these people to Ashkona Hajj camp, they resisted and complained of lack of food inside the camps but, that was not true. After a lot of resistance from them, to ensure that the situation did not aggravate, they were all let go. But all of their addresses and phone numbers were collected and provided to the local DC and SP offices. Then they were sent to their homes with police guards. As far as I am aware, none of these people who resisted quarantine was later found to be infected. It is the people who came before or after them who might not be maintaining proper quarantine and the people from the quarantine centre in Gazipur who were found to be infected.

Community transmission has not started yet but there is definitely a chance. We are asking everyone who came from abroad to quarantine themselves.  For the 24 patients who were infected, we are tracing their contacts and asking them to be self-quarantined. But there is some lacking in this aspect. In some villages, we are also implementing community quarantine.

If the public health sector, the government and other relevant organisations put in all their efforts we will surely be able to stop community transmission. We have to be prepared for a situation similar to that of Italy. The hospital authorities need to ensure that their doctors have basic equipment such as masks and gloves to at least be able to diagnose potential COVID-19 patients. Personal protection equipment is only necessary for the doctors in the isolation ward, people working in sample collection, and the nurses taking care of the infected.

We need to stay one step ahead and take pre-emptive action. We will not lock down the whole country just yet. Control measures need to be adopted in densely populated Dhaka city, other cities and villages where committees should be established which can check on its residents' health. These committees can also help out during community quarantines. We have instructed all public transport owners/drivers to wash their vehicles after every trip and all the bus stations must have hand-washing facilities. We have proposed closures of the prayer houses since people seem to be gathering there. We would advise everyone to carry out their prayers at home. Factories must ensure hand-washing facilities and its workers should maintain proper distance among themselves during the work hours.

The private sector should be innovative to help the country during this crisis.

Behavioural changes, such as hand-washing and social distancing, can stop the spread of the coronavirus. The human mind does not understand exponential growth. Hence it is important to flatten the curve through behavioural changes right now.

In my opinion, everyone, with the help of the government, must keep the people safe and stop the spread of the virus. Secondly, we need to control the panic by educating the masses so that they understand how to properly respond to the situation. One solution could be a daily bulletin from IEDCR talking about the current status of Bangladesh in regards to COVID-19. Why is it impossible for us to find a way for the people to get in touch with the government authorities? Grameenphone and Robi are two large telecom operators in Bangladesh. Why weren't these telecoms asked by the government to man the call centres? This job should have been given to the experts.

We also need to maintain the flow of essential goods because a lot of consumers are panic buying. Essential commodities have to be made available in each neighbourhood.

The epicentre of this crisis will not be financial institutions. It will be the livelihood of the people. Thus the government needs to ensure that the livelihoods of people are not badly affected. Since people are forced to practice social distancing and not go to work, they have no means of earning. If the citizens do not get this financial support, the pandemic will eventually result in violence.

There are countries which have paid dearly and there are countries which have acted daringly in this situation. I just hope and pray that Bangladesh acts daringly to stop the spread of the virus.

I have noticed a lot of discrepancies in patients regarding disclosure of their travel history. We have had multiple patients coming from abroad who have come to the hospital breaking their quarantine. We have a lot of pneumonia patients in our hospital and we have had them even before the coronavirus infection was declared in our country. The problem that we are facing is that we have a lot of viral pneumonia patients in our hospital but we are unable to detect if they are infected with the coronavirus. Therefore, I believe the testing kit facilities should be decentralised as soon as possible. Square Hospital is ready to help out the government since we have the facilities.

I, personally, have been afraid to diagnose patients and after requesting my hospital for a week, I was finally given personal protection equipment. For patients with respiratory tract infections, we have set rules in our hospital to wear masks and wash hands. But sadly, most patients are not abiding by these rules. Although we have provided masks to all hospital employees and have provided personal protection equipment to the vulnerable departments such as paediatrics, there are a lot of patients coming in and there is a chance that they can spread the disease amongst them. We are not turning back any patient and trying our best to treat all of them.

In Bangladesh, till now, two out of the 24 patients have died. According to this information, we can say that the casualty for senior citizens in this country is 100 percent. So far, the standard status is that 82 percent of the patients can get well at home. Of the rest, three percent will not make it through and the majority of these would be the senior citizens. To prevent casualties in Bangladesh, our priority should be to target the vulnerable population. This vulnerable population requires ICUs and ventilators. 15 percent of our population is senior citizens. So, we need to calculate and determine the number of ICUs required for this amount of patients.

The government must have a strategic policy to contain COVID-19. Next, there should be strategic planning for containment. It was a wrong decision to employ home quarantine since most people in the country do not have separate rooms with attached bathrooms for such isolation to be effective. This decision has only increased chances of community transmission.

You have to undertake a strategy if you want to contain community transmission. My suggestion, therefore, is that we should continue tracing and see if we can arrange for institutional quarantine. Doing so is very easy. In places like Shariatpur and Brahmanbaria we have already tracked up to 2,500 people. If we can put those people under institutional quarantine in those places, then we can contain the spread of the disease. We are all well aware of China's experience and the steps it has undertaken. For instance, it has utilised its stadiums, gymnasiums and other such establishments for quarantining people. It has locked down people there so that no one can enter or come out of those places. Ultimately, they have been successful and now they are capable enough to help Italy and Bangladesh. We should learn from their experience.

Recently, we received a circular from the head of the institute of a medical college stating that they will not be able to supply masks to the doctors. Masks are essential for combatting coronavirus. Making these masks and PPE should not be a big problem for Bangladesh since our RMG sector already exports garments. We can see that China had instructed its firms to prepare for this and they did it and are even exporting it. Even after getting three months in hand, why have we not been able to prepare well enough to acquire protection gear, especially for the doctors and other healthcare providers? Also, just providing masks to doctors will not suffice; we need to provide all the gears for protection. So now we can rectify our limitations at personal, governmental and institutional levels by implementing home and institutional quarantine. Doing so will be very easy for the government. The implementation should be strict and done by utilising the law enforcement agencies.

We must have sufficient number of CCUs with ventilator facilities in designated hospitals. Doctors should be there in four shifts; three shifts will continue and one shift will be reserved. And all of this should operate under a team in a particular hospital. Additionally, we can give responsibility to two of our mayors to disinfect the entire city since dengue is also an upcoming threat. Thus, we need a strategic plan of action. Besides, priority should also be given to senior citizens.