1Department of Medical Genetics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
2Experimental Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
3Department of Genetic Engineering and Biotechnology, School of Life Sciences, Shahjalal University of Science and Technology, Sylhet, Bangladesh
As the coronavirus outbreak quickly surges worldwide, many countries are adopting non-therapeutic preventive measures, which include travel bans, remote office activities, country lockdown, and most importantly, social distancing. However, these measures face challenges in Bangladesh, a lower-middle-income economy with one of the world's densest populations. Social distancing is difficult in many areas of the country, and with the minimal resources the country has, it would be extremely challenging to implement the mitigation measures. Mobile sanitization facilities and temporary quarantine sites and healthcare facilities could help mitigate the impact of the pandemic at a local level. A prompt, supportive, and empathic collaboration between the Government, citizens, and health experts, along with international assistance, can enable the country to minimize the impact of the pandemic.
Introduction
With the outbreak of novel coronavirus-2 (nCoV-2) declared a pandemic and an international public health emergency by the World Health Organization (WHO), the entire world is working to address it. It is a rapidly evolving and emerging situation. In <5 months after the first emergence of the virus in December 2019, nearly two million people in 185 countries around the globe have been identified as confirmed cases of coronavirus disease 2019 (COVID-19) (1). Researchers across the world are working hard to understand better the biology of nCoV-2 and the epidemiology of the novel coronavirus disease-19 (COVID-19). The estimated basic reproductive number of the virus is significantly higher than many other infectious diseases, and this can potentially result in the capacity of health facilities becoming overwhelmed, even in the countries that have the most developed healthcare systems (2). An estimated 20% of cases lead to clinically serious and complex conditions. With some sporadic cases of serious illness in younger individuals, adults >60 years of age and with co-morbid conditions make up the most vulnerable group.
There are as yet no vaccines or antiviral drugs approved for the disease, and hence, non-therapeutic interventions to control the spread of the virus are the most effective measures to control the disease (3). Worldwide, billions of people are staying at home to minimize the transmission of the virus. Many countries are adopting preventive measures, e.g., remote office activities, international travel bans, mandatory lockdowns, and social distancing. Bangladesh, a lower-middle-income country and one of the world's most densely populated areas, is struggling to combat the spread of the disease. In this write-up, we briefly articulate the current scenario of COVID-19 in Bangladesh and provide some recommendations on how the country can combat this pandemic.
Bangladesh's Response to COVID-19
With almost every country adopting aggressive non-therapeutic measures to control the spread of nCoV-2, Bangladesh in Southeastern Asia has followed the same trend; however, there is an ongoing debate as to whether measures have been adopted adequately and implemented efficiently. The country confirmed the first COVID-19 case in its territory on March 7, though many experts speculated that nCoV-2 may have entered the country earlier than that but had not been detected due to inadequate monitoring (4). As of April 13, the country had reported 803 cases of COVID-19, and the death toll stood at 39 (Figure 1) (5–7). However, concerns have been raised that extreme insufficiency of testing assays may be leaving many cases undetected in the country. In response to the emergence of the virus, Bangladesh admittedly reduced international flights, imposed thermal scanner checking, and shut down schools; however, offices maintained their regular schedules until March 26.
FIGURE 1
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Figure 1. Current situation regarding COVID-19 in Bangladesh (April 13, 2020). (A) Total number of cases identified in Bangladesh (5, 6); (B) number of cases identified daily (5, 6); (C) number of actives cases daily (5, 7); (D) number of daily death incidences and total deaths (5).
On March 15, the country banned all flights coming from Europe except the United Kingdom; however, the authority still allowed flights from Europe to land in an airport (8). As a result, over 631 thousand people entered the country in just 55 days from January 21 (9). Although the Institute of Epidemiology, Disease Control and Research (IEDCR) claimed that it tested every single person who entered the country, there has been intense criticism of the testing facilities in the ports of entry (10, 11). Beginning on March 16, the country imposed a 14-day obligatory quarantine to all travelers who entered the country (12). It attempted to bring travelers coming from Italy—which was then declared a new epicenter of the pandemic—to a quarantine site. The move was sharply criticized due to a lack of arrangements, and the travelers were allowed to enter the country by themselves on the condition of 14-day-long self-isolation. Since then, hundreds of expatriates who came from COVID-19-affected countries have been seen out in the streets and gatherings—traveling to tourist sites, meeting with friends and families (13). On March 19, the country deployed the army to supervise two quarantine facilities in Dhaka (14).
From the first week of March, Bangladesh started to postpone all mass gatherings, including the 100th-anniversary celebration event of the birth of its founder, Sheik Mujibur Rahman, as a preventive measure against the spread of nCoV-2 (15). Despite these measures, tens of thousands of people gathered in a special prayer session for protection against nCoV-2 in Lakshmipur, despite not having the local Government's permission. Afterward, the Government banned all political, social, cultural, and religious rallies and gatherings in the country (16). Amid this crisis, the country witnessed voting in three constituencies, where people had to go to the voting centers in person to cast their votes. Meanwhile, the health ministry said that nCoV-2 has spread to the community transmission level (17).
Bangladesh admittedly has a severe shortage of testing kits: it does not have more than 100 thousand testing kits in stock, of which only some 20 thousand have been distributed to different testing facilities around the country (9, 18). The country received some testing kits, PPE, masks, and infrared thermometers from China to deal with the crisis in the country; however, this amount only covers a small portion of the country's actual needs (19). In the meantime, utilizing the rapid dot blot technique, Ganashystha Kendra (a local health institution), claimed that it had developed a testing kit that can detect nCoV-2 in several minutes for just BDT 350 (~4 USD) (20). Although many experts questioned the efficiency of the method the kit uses, the institution has reportedly obtained government approval to import raw materials to mass-produce the kits. It is worthy of mention that a very similar rapid testing kit developed and marketed by a Canadian company, which received approval in some Asian and European countries, was refused approval by the health authorities of Canada on the grounds that it may produce a high rate of false-negative results (21).
On March 25, Bangladesh declared the enforcement of lockdown for 10 days effective from March 26. With the enforcement of this lockdown, travel on water, rail, and air routes is banned and road-transportation is suspended. All non-essential organizations, businesses, and educational institutions are closed, except for pharmacies, groceries, and other unavoidable necessities. Following the declaration, many people from the major cities, especially from Dhaka, started to leave the city by various means, including overcrowded public transport services, with a high risk of contracting COVID-19 and in violation of the government instructions. On the same day, Bangladesh issued a temporary release to its ailing former prime minister from prison, and consequentially, thousands of political followers greeted her in Dhaka, defying the lockdown imposed by the Government (22). It was predictable that on the release of a political leader of her fame, a huge gathering might occur; however, she was temporarily released on humanitarian grounds (22, 23).
On March 2 and 3, when the initial 10-day-long lockdown measure was about to be completed, thousands of service and factory workers started heading back to major cities, e.g., Dhaka, Narayanganj, Gajipur, and Chittagong, ignoring the risk of nCoV-2 spread (24). The country's efforts to reduce the spread of the virus in Bangladesh suffered in their implementation due to the lack of coordination between different authorities and groups (24). Later, in two instances, the country declared extensions of the nationwide lockdown, keeping it in place through April 25 (25, 26), and these people coming from different areas of the country had to head back to their home residences (24). On April 5, the country announced a suspension of all international travel except flights to and from China until April 14 (25). It also declared that, as of April 9, some 60 areas of the country, with half of the places in the capital city, would be under a specialized form of localized lockdown to fight the spread of COVID-19. A specialized lockdown was also imposed on Cox's Bazar, a southern district of the country where many Rohingya refugees live (27). These Rohingya refugees, as well as older individuals anywhere in the country, constitute the most potentially vulnerable groups to virus infection.
Social Distancing Protocol is Tough to Maintain in Many Areas of Bangladesh
As mentioned earlier, Bangladesh did not impose any strict protocol initially, and millions of people were out on the streets, especially in Dhaka, which is a megacity with 46 thousand people living per square kilometer (28). It appears that social distancing is tough while taking public commutes and living in the slums. In the context of massively populated and lower-middle-income countries like Bangladesh, enforcement of social distancing—as recommended by the WHO to stop the nCoV-2 spread—sounds fancy but impractical. Indeed, staying at home is unlikely to be as effective here.
Dhaka, the capital of Bangladesh, is alone home to some 1.1 million slum dwellers (29). These slum dwellers, most of whom have never gone to school and currently live in extremely close quarters, are hardly aware of the threat from nCoV-19. The range of household earnings of slum dwellers in Dhaka is around BDT 8,000/month (<100 USD/month), and they spend >70% of their earnings on food and housing (30). Even a 400-mL bottle of hand soap per slum, which costs around BDT 80 (~1 USD), is hard for them to afford. Besides, every 10–16 families have access to only one bathroom/toilet, where there is no regular supply of water (30, 31). Along with the slum dwellers, Bangladesh also hosts over a million Rohingya refugees, most of whom are living in close quarters in refugee camps where the sanitization facilities are even scarce (32). Fear of COVID-19 is already gearing up among the displaced people in these camps. Immediate enforcement of social distancing is, in every way, practically impossible in a country like Bangladesh.