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COVID-19 and Bangladesh: Challenges and How to Address Them

COVID-19 and Bangladesh: Challenges and How to Address Them POLICY BRIEF published: 30 April 2020 doi: 10.3389/fpubh.2020.00154 COVID-19 and Bangladesh: Challenges and How to Address Them 1 2 3 Saeed Anwar , Mohammad Nasrullah and Mohammad Jakir Hosen * Department of Medical Genetics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada, 2 3 Experimental Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada, Department 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 Edited by: the impact of the pandemic. Zisis Kozlakidis, International Agency for Research on Keywords: COVID-19, novel coronavirus, testing, healthcare, community mitigation, non-therapeutic intervention, Cancer (IARC), France infection prevention and control Reviewed by: Md. Kamrul Hasan, INTRODUCTION Jahangirnagar University, Bangladesh Md. Shamsuzzaman, Konkuk University, South Korea 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 *Correspondence: address it. It is a rapidly evolving and emerging situation. In <5 months after the first emergence Mohammad Jakir Hosen jakir-gen@sust.edu 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 Specialty section: the world are working hard to understand better the biology of nCoV-2 and the epidemiology of This article was submitted to the novel coronavirus disease-19 (COVID-19). The estimated basic reproductive number of the Infectious Diseases-Surveillance, virus is significantly higher than many other infectious diseases, and this can potentially result in Prevention and Treatment, the capacity of health facilities becoming overwhelmed, even in the countries that have the most a section of the journal developed healthcare systems (2). An estimated 20% of cases lead to clinically serious and complex Frontiers in Public Health conditions. With some sporadic cases of serious illness in younger individuals, adults >60 years of Received: 28 March 2020 age and with co-morbid conditions make up the most vulnerable group. Accepted: 14 April 2020 There are as yet no vaccines or antiviral drugs approved for the disease, and hence, non- Published: 30 April 2020 therapeutic interventions to control the spread of the virus are the most effective measures Citation: to control the disease (3). Worldwide, billions of people are staying at home to minimize the Anwar S, Nasrullah M and Hosen MJ transmission of the virus. Many countries are adopting preventive measures, e.g., remote office (2020) COVID-19 and Bangladesh: activities, international travel bans, mandatory lockdowns, and social distancing. Bangladesh, a Challenges and How to Address Them. Front. Public Health 8:154. lower-middle-income country and one of the world’s most densely populated areas, is struggling doi: 10.3389/fpubh.2020.00154 to combat the spread of the disease. In this write-up, we briefly articulate the current scenario of Frontiers in Public Health | www.frontiersin.org 1 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh COVID-19 in Bangladesh and provide some recommendations On March 15, the country banned all flights coming from on how the country can combat this pandemic. 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 BANGLADESH’S RESPONSE TO COVID-19 just 55 days from January 21 (9). Although the Institute of Epidemiology, Disease Control and Research (IEDCR) claimed With almost every country adopting aggressive non-therapeutic that it tested every single person who entered the country, measures to control the spread of nCoV-2, Bangladesh in Southeastern Asia has followed the same trend; however, there there has been intense criticism of the testing facilities in the ports of entry (10, 11). Beginning on March 16, the country is an ongoing debate as to whether measures have been adopted adequately and implemented efficiently. The country confirmed imposed a 14-day obligatory quarantine to all travelers who entered the country (12). It attempted to bring travelers coming the first COVID-19 case in its territory on March 7, though many experts speculated that nCoV-2 may have entered the country from Italy—which was then declared a new epicenter of the pandemic—to a quarantine site. The move was sharply criticized earlier than that but had not been detected due to inadequate monitoring (4). As of April 13, the country had reported 803 cases due to a lack of arrangements, and the travelers were allowed to enter the country by themselves on the condition of 14- of COVID-19, and the death toll stood at 39 (Figure 1) (5–7). However, concerns have been raised that extreme insufficiency day-long self-isolation. Since then, hundreds of expatriates who came from COVID-19-affected countries have been seen out of testing assays may be leaving many cases undetected in in the streets and gatherings—traveling to tourist sites, meeting the country. In response to the emergence of the virus, Bangladesh admittedly reduced international flights, imposed with friends and families (13). On March 19, the country deployed the army to supervise two quarantine facilities in thermal scanner checking, and shut down schools; however, offices maintained their regular schedules until March 26. Dhaka (14). 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). Frontiers in Public Health | www.frontiersin.org 2 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh From the first week of March, Bangladesh started to postpone and groups (24). Later, in two instances, the country declared all mass gatherings, including the 100th-anniversary celebration extensions of the nationwide lockdown, keeping it in place event of the birth of its founder, Sheik Mujibur Rahman, as a through April 25 (25, 26), and these people coming from preventive measure against the spread of nCoV-2 (15). Despite different areas of the country had to head back to their these measures, tens of thousands of people gathered in a special home residences (24). On April 5, the country announced a prayer session for protection against nCoV-2 in Lakshmipur, suspension of all international travel except flights to and from despite not having the local Government’s permission. Afterward, China until April 14 (25). It also declared that, as of April 9, the Government banned all political, social, cultural, and some 60 areas of the country, with half of the places in the religious rallies and gatherings in the country (16). Amid this capital city, would be under a specialized form of localized crisis, the country witnessed voting in three constituencies, where lockdown to fight the spread of COVID-19. A specialized people had to go to the voting centers in person to cast their votes. lockdown was also imposed on Cox’s Bazar, a southern district Meanwhile, the health ministry said that nCoV-2 has spread to of the country where many Rohingya refugees live (27). These the community transmission level (17). Rohingya refugees, as well as older individuals anywhere in the Bangladesh admittedly has a severe shortage of testing kits: it country, constitute the most potentially vulnerable groups to does not have more than 100 thousand testing kits in stock, of virus infection. which only some 20 thousand have been distributed to different testing facilities around the country (9, 18). The country received SOCIAL DISTANCING PROTOCOL IS some testing kits, PPE, masks, and infrared thermometers from TOUGH TO MAINTAIN IN MANY AREAS OF China to deal with the crisis in the country; however, this BANGLADESH amount only covers a small portion of the country’s actual needs (19). In the meantime, utilizing the rapid dot blot technique, As mentioned earlier, Bangladesh did not impose any strict Ganashystha Kendra (a local health institution), claimed that it protocol initially, and millions of people were out on the streets, had developed a testing kit that can detect nCoV-2 in several especially in Dhaka, which is a megacity with 46 thousand people minutes for just BDT 350 (∼4 USD) (20). Although many living per square kilometer (28). It appears that social distancing experts questioned the efficiency of the method the kit uses, is tough while taking public commutes and living in the slums. the institution has reportedly obtained government approval to In the context of massively populated and lower-middle-income import raw materials to mass-produce the kits. It is worthy countries like Bangladesh, enforcement of social distancing—as of mention that a very similar rapid testing kit developed and recommended by the WHO to stop the nCoV-2 spread—sounds marketed by a Canadian company, which received approval in fancy but impractical. Indeed, staying at home is unlikely to be as some Asian and European countries, was refused approval by the effective here. health authorities of Canada on the grounds that it may produce Dhaka, the capital of Bangladesh, is alone home to some 1.1 a high rate of false-negative results (21). million slum dwellers (29). These slum dwellers, most of whom On March 25, Bangladesh declared the enforcement of have never gone to school and currently live in extremely close lockdown for 10 days effective from March 26. With the quarters, are hardly aware of the threat from nCoV-19. The range enforcement of this lockdown, travel on water, rail, and of household earnings of slum dwellers in Dhaka is around BDT air routes is banned and road-transportation is suspended. 8,000/month (<100 USD/month), and they spend >70% of their All non-essential organizations, businesses, and educational earnings on food and housing (30). Even a 400-mL bottle of hand institutions are closed, except for pharmacies, groceries, and soap per slum, which costs around BDT 80 (∼1 USD), is hard for other unavoidable necessities. Following the declaration, many them to afford. Besides, every 10–16 families have access to only people from the major cities, especially from Dhaka, started to one bathroom/toilet, where there is no regular supply of water leave the city by various means, including overcrowded public (30, 31). Along with the slum dwellers, Bangladesh also hosts over transport services, with a high risk of contracting COVID-19 and a million Rohingya refugees, most of whom are living in close in violation of the government instructions. On the same day, quarters in refugee camps where the sanitization facilities are Bangladesh issued a temporary release to its ailing former prime even scarce (32). Fear of COVID-19 is already gearing up among minister from prison, and consequentially, thousands of political the displaced people in these camps. Immediate enforcement followers greeted her in Dhaka, defying the lockdown imposed of social distancing is, in every way, practically impossible in a by the Government (22). It was predictable that on the release country like Bangladesh. of a political leader of her fame, a huge gathering might occur; however, she was temporarily released on humanitarian grounds (22, 23). INADEQUACY OF COVID-19 TESTING On March 2 and 3, when the initial 10-day-long lockdown FACILITIES measure was about to be completed, thousands of service and factory workers started heading back to major cities, e.g., Dhaka, Five weeks after the detection of the first COVID-19 case Narayanganj, Gajipur, and Chittagong, ignoring the risk of in Bangladesh, the IEDCR had only tested 11,223 people, nCoV-2 spread (24). The country’s efforts to reduce the spread constituting approximately 68 tests per million population (5, 7) of the virus in Bangladesh suffered in their implementation (Figure 2). It is perhaps among the worst-ranked countries for due to the lack of coordination between different authorities nCoV-2 testing rate, though the mortality rate is comparatively Frontiers in Public Health | www.frontiersin.org 3 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh FIGURE 2 | Number of tests done daily. The rate of testing rose significantly 4 weeks after the identification of the first case of COVID-19 in the country (5). higher (7). It should be noted that in the first 3 weeks after MITIGATION MEASURES TO FIGHT the detection of the first COVID-19 case in Bangladesh, the COVID-19 WITH LIMITED RESOURCES IEDCR was the sole diagnostic facility in the country of 180 million people, and the daily testing rate remained below The situation in Bangladesh is rapidly evolving, and it is 100 per day (33). The centralization of COVID-19 diagnosis comparable with many other countries, e.g., France, Japan, which facilities is somewhat plausible, as most hospitals do not have have lately seen a devastating impact from the virus (Figure 3) enough personal protective equipment (PPE). However, this (1, 7). In this situation, most sensible governments would opt for left the mass of people and healthcare workers in an awfully a total lockdown for an undeclared time at very high financial susceptible condition. As a result of the combined lack of costs under the precept that lives should be saved first, and PPE and diagnostic testing capacity, fear, and anxiety geared counting the loss to businesses may wait. Some countries, e.g., up among the mass population, and many healthcare workers Italy and Spain, have already adopted such measures (38, 39). refused to provide any service. With much criticism from In fact, with no effective therapeutic strategies available for different sectors, the health authorities of the country ultimately COVID-19, lockdown is perhaps the best-known measure that decided to expand its testing numbers from April 3 (33). could mitigate the situation (40). However, in Bangladesh, where Currently (April 11, 2020), there are 17 labs across the country a significant proportion of the total population lives hand to working on testing probable/referral cases of COVID-19, and mouth, lockdown is not a feasible idea. With no savings and a few more labs are being established in different districts, work, how will poor and marginal people feed themselves if there including one in Sylhet at Shahjalal University of Science and is a prolonged lockdown? This is an issue that the Government Technology (34, 35). must address when declaring any lockdown or emergency that The situation became even complicated as four doctors at may stay in place for 2 or more weeks. With help from the the Dhaka Medical College and Hospital, the largest hospital in armed forces, the Government may think about starting a Bangladesh, were sent into home quarantine after they handled “hygienic” rationing system in case of locking down for a more a person who was later identified as having COVID-19. Later extended period. on, many more doctors and health workers were sent into Among the preventive measures for COVID-19, including quarantine, and many of them tested positive for COVID-19 aggressive tracing of cases and contacts, strict quarantine, and (36, 37). The health system of Bangladesh depends on around screening, as well as education to promote good hand hygiene 100 thousand registered doctors, and if these very few doctors practices, should be put in place (41, 42). Immediate expansion compared to the population size are unable to provide their of testing labs to every district and major localities is urgently healthcare service as a result of the unavailability of PPE, this needed to test every patient with symptoms, and millions of could have potentially catastrophic consequences. testing kits are necessary for conducting aggressive detection of Frontiers in Public Health | www.frontiersin.org 4 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh FIGURE 3 | Total number of COVID-19 cases daily after the identification of the 10th case in Bangladesh and in 10 other countries (1, 7). Bangladesh’s trendline is comparable with the trendlines of France and Japan. As of now (April 13, 2020), the trendline of the US remains far lower (74 total cases on day 28) than Bangladesh’s until the 28th day after the identification of 10 positive cases. cases (18). Students at life science departments in universities the situation mitigates. Home office laws should be imposed, can be trained to carry out COVID-19 case diagnosis. The whenever possible. molecular genetics, biochemistry, and molecular biology labs in Additional measures must be taken promptly, anticipating the the universities and medical colleges across the country should potential challenge that would be faced by the hospitals in the case be quickly transformed into COVID-19 case detection labs. The of an upsurge of COVID-19 cases. The Government must source country can also seek help from China and South Korea on how enough protective gear for the healthcare workers who will have it can channel extensive detection surveys (43, 44). With help to tackle COVID-19 patients in the frontline. With expert help from the armed forces and trained volunteers, the schools could from China and South Korea, Bangladesh should immediately be turned into quarantine centers. The Government will have organize specialized training for all physicians, resident doctors, to come forward to make sure that its marginal population has and intern doctors. access to proper hygiene, maybe by supplying free sanitizer and A total of 7% of the country’s population are senior citizens mobile washrooms. All offices and businesses, except medical (45). Most of these senior citizens and many mid-aged people centers, pharmacies, and groceries, should remain closed until in the country have non-communicable disorders, including Frontiers in Public Health | www.frontiersin.org 5 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh chronic obstructive pulmonary disease (11.9%), cardiac disorders basic knowledge would be the key to controlling the spread of the (4.5%), diabetes (9.7%), and asthma (5.2%), and they are virus (57). especially vulnerable to COVID-19 (46–49). Besides, there are around 1.3 to 1.5 million cancer patients in the country (50). NEED FOR A CONSIDERABLE AMOUNT Moreover, the prevalence of smoking is highest in Bangladesh OF FUNDS among the South Asian countries (49). Studies have reported that people who smoke and have cancer have a higher risk Above all, Bangladesh must source a decent emergency support of developing serious complications. Although there is still a fund to help its workers, employers, parents, marginal people, dearth of understanding of the association between COVID- and hosted refugees. It has already received fast-track support 19 severity and cancer and smoking, these could likely be of USD 100 million from the World Bank; however, this is far correlated (51, 52). In the case of an upsurge of people from the actual amount needed for this country of 180 million who belong to the vulnerable groups contracting COVID-19, people (58, 59). Additionally, the country has recently unveiled they may require hospitalization and intensive care. Hence, an economic stimulus package of ∼8 billion USD to counter the ventilation supports in every hospital, clinic, and medical center adverse effects of the pandemic (34). The country may temporally is a must. The country has so far arranged only 112 beds postpone all non-essential developmental works and gather a across the country in intensive care units for patients with modest amount of money to support its people in fighting this COVID-19 (53). The tech start-up and innovation companies crisis. Also, top business organizations and international funders emerging in the country should take it as a challenge to should come forward to help Bangladesh fight the COVID-19 design a cheap but rapidly deployable mechanical ventilator challenge. Only a supportive and empathic collaborative effort device. All non-essential surgeries and hospital admissions can help the world, especially the low and lower-middle-income should be canceled immediately to make sure the hospitals countries like Bangladesh, overcome this crisis. are not unnecessarily occupied. Hospitals can become a source CONCLUSIONS of COVID-19 transmission, and it is advisable to decentralize healthcare services and, whenever possible, to provide care at Preparedness is the key to addressing any health crisis, and home. Government rest houses and private hotels can be turned so far, Bangladesh, as a lower-middle-income country, has into emergency response healthcare facilities. Moreover, as a numerous limitations in restricting the spread of the virus. riverine country, Bangladesh has a huge water transport system. While continuing the lockdown at any cost with more strict Large water vehicles, including steamers and launches, can be maintenance, the country has to expand its testing and healthcare used as mobile healthcare facilities for the people who live in facilities. It has to ensure a constant supply of PPE for healthcare remote areas. workers. Above all, improvised and timely measures taken with proper coordination may help the country to fight the lethal virus. COPING WITH MENTAL STRESS DUE TO The Government will not be able to mitigate the situation alone COVID-19 (60); individual efforts from the citizens, direct involvement of the nation’s public health experts, and international help are Fear and anxiety about the pandemic are causing overwhelming urgently needed. As the situation intensifies, the world is closely stress for everyone (54, 55). While receiving mixed messages piles watching how Bangladesh will navigate this crisis. up the stress, sharing the real facts and understanding the actual risk reduces the stress. Moreover, this helps the authorities to AUTHOR CONTRIBUTIONS organize better and manage the crisis. Social activists, television and print media, social workers, and religious and political MH conceived the study. SA wrote the first draft. MN leaders should come forward to help in the dissemination of commented on the draft and contributed to the writing of scientifically factual information on nCoV-2 and COVID-19 the manuscript. All authors approved the final version of among the mass population of Bangladesh. For instance, the the manuscript. Imams (a Muslim leadership position) of each mosque could play a vital role in fighting this extraordinary crisis in Bangladesh FUNDING (56). Together, the media personalities and political and religious leaders could help spread basic knowledge on COVID-19- No specific grant was received for this study. However, SA was supported by the Maternal and Child Health related issues to the mass populace, especially the marginalized communities. Given the high level of illiteracy among the slum (MatCH) scholarship and Alberta Innovates Graduate Student Scholarships (AIGSS). and village population, the dissemination of COVID-19-related REFERENCES 2. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl 1. Dong E, Du H, Gardner L. An interactive web- J Med. (2020) 382:1199–207. doi: 10.1056/NEJMoa2001316 based dashboard to track COVID-19 in real time. 3. Bootsma MCJ, Ferguson NM. The effect of public health measures on the Lancet Infect Dis. (2020). doi: 10.1016/S1473-3099(20) 1918 influenza pandemic in U.S. cities. Proc Natl Acad Sci USA. 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Burden of asthma, dyspnea, and chronic April 11, 2020). cough in South Asia. Int J Chron Obstruct Pulmon Dis. (2017) 12:1093– 60. Wang J, Xu C, Wong YK, He Y, Adegnika AA, Kremsner PG, et al. 9. doi: 10.2147/COPD.S133148 Preparedness is essential for malaria-endemic regions during the COVID- 50. Hussain SA. Comprehensive update on cancer scenario of Bangladesh. South 19 pandemic. Lancet. (2020) 395:1094–96. doi: 10.1016/S0140-6736(20) Asian J Cancer. (2013) 2:279. doi: 10.4103/2278-330X.119901 30561-4 51. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. (2020) Conflict of Interest: The authors declare that the research was conducted in the 21:335–7. doi: 10.1016/S1470-2045(20)30096-6 absence of any commercial or financial relationships that could be construed as a 52. Cai H. Sex difference and smoking predisposition in patients with COVID-19. potential conflict of interest. Lancet Respir Med. (2020) 8:e20. doi: 10.1016/S2213-2600(20)30117-X 53. Maswood MH. Only 112 ICU Beds for Coronavirus Patients in Bangladesh: Copyright © 2020 Anwar, Nasrullah and Hosen. This is an open-access article Lack of treatment Preparations May Spell Disaster. (2020). Available distributed under the terms of the Creative Commons Attribution License (CC BY). online at: https://www.newagebd.net/article/104016/only-112-icu-beds-for- The use, distribution or reproduction in other forums is permitted, provided the coronavirus-patients-in-bangladesh original author(s) and the copyright owner(s) are credited and that the original 54. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological publication in this journal is cited, in accordance with accepted academic practice. impact of the COVID-19 epidemic on college students in China. Psychiatry No use, distribution or reproduction is permitted which does not comply with these Res. (2020) 287:112934. doi: 10.1016/j.psychres.2020.112934 terms. 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COVID-19 and Bangladesh: Challenges and How to Address Them

Frontiers in Public Health , Volume 8 – Apr 30, 2020

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POLICY BRIEF published: 30 April 2020 doi: 10.3389/fpubh.2020.00154 COVID-19 and Bangladesh: Challenges and How to Address Them 1 2 3 Saeed Anwar , Mohammad Nasrullah and Mohammad Jakir Hosen * Department of Medical Genetics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada, 2 3 Experimental Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada, Department 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 Edited by: the impact of the pandemic. Zisis Kozlakidis, International Agency for Research on Keywords: COVID-19, novel coronavirus, testing, healthcare, community mitigation, non-therapeutic intervention, Cancer (IARC), France infection prevention and control Reviewed by: Md. Kamrul Hasan, INTRODUCTION Jahangirnagar University, Bangladesh Md. Shamsuzzaman, Konkuk University, South Korea 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 *Correspondence: address it. It is a rapidly evolving and emerging situation. In <5 months after the first emergence Mohammad Jakir Hosen jakir-gen@sust.edu 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 Specialty section: the world are working hard to understand better the biology of nCoV-2 and the epidemiology of This article was submitted to the novel coronavirus disease-19 (COVID-19). The estimated basic reproductive number of the Infectious Diseases-Surveillance, virus is significantly higher than many other infectious diseases, and this can potentially result in Prevention and Treatment, the capacity of health facilities becoming overwhelmed, even in the countries that have the most a section of the journal developed healthcare systems (2). An estimated 20% of cases lead to clinically serious and complex Frontiers in Public Health conditions. With some sporadic cases of serious illness in younger individuals, adults >60 years of Received: 28 March 2020 age and with co-morbid conditions make up the most vulnerable group. Accepted: 14 April 2020 There are as yet no vaccines or antiviral drugs approved for the disease, and hence, non- Published: 30 April 2020 therapeutic interventions to control the spread of the virus are the most effective measures Citation: to control the disease (3). Worldwide, billions of people are staying at home to minimize the Anwar S, Nasrullah M and Hosen MJ transmission of the virus. Many countries are adopting preventive measures, e.g., remote office (2020) COVID-19 and Bangladesh: activities, international travel bans, mandatory lockdowns, and social distancing. Bangladesh, a Challenges and How to Address Them. Front. Public Health 8:154. lower-middle-income country and one of the world’s most densely populated areas, is struggling doi: 10.3389/fpubh.2020.00154 to combat the spread of the disease. In this write-up, we briefly articulate the current scenario of Frontiers in Public Health | www.frontiersin.org 1 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh COVID-19 in Bangladesh and provide some recommendations On March 15, the country banned all flights coming from on how the country can combat this pandemic. 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 BANGLADESH’S RESPONSE TO COVID-19 just 55 days from January 21 (9). Although the Institute of Epidemiology, Disease Control and Research (IEDCR) claimed With almost every country adopting aggressive non-therapeutic that it tested every single person who entered the country, measures to control the spread of nCoV-2, Bangladesh in Southeastern Asia has followed the same trend; however, there there has been intense criticism of the testing facilities in the ports of entry (10, 11). Beginning on March 16, the country is an ongoing debate as to whether measures have been adopted adequately and implemented efficiently. The country confirmed imposed a 14-day obligatory quarantine to all travelers who entered the country (12). It attempted to bring travelers coming the first COVID-19 case in its territory on March 7, though many experts speculated that nCoV-2 may have entered the country from Italy—which was then declared a new epicenter of the pandemic—to a quarantine site. The move was sharply criticized earlier than that but had not been detected due to inadequate monitoring (4). As of April 13, the country had reported 803 cases due to a lack of arrangements, and the travelers were allowed to enter the country by themselves on the condition of 14- of COVID-19, and the death toll stood at 39 (Figure 1) (5–7). However, concerns have been raised that extreme insufficiency day-long self-isolation. Since then, hundreds of expatriates who came from COVID-19-affected countries have been seen out of testing assays may be leaving many cases undetected in in the streets and gatherings—traveling to tourist sites, meeting the country. In response to the emergence of the virus, Bangladesh admittedly reduced international flights, imposed with friends and families (13). On March 19, the country deployed the army to supervise two quarantine facilities in thermal scanner checking, and shut down schools; however, offices maintained their regular schedules until March 26. Dhaka (14). 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). Frontiers in Public Health | www.frontiersin.org 2 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh From the first week of March, Bangladesh started to postpone and groups (24). Later, in two instances, the country declared all mass gatherings, including the 100th-anniversary celebration extensions of the nationwide lockdown, keeping it in place event of the birth of its founder, Sheik Mujibur Rahman, as a through April 25 (25, 26), and these people coming from preventive measure against the spread of nCoV-2 (15). Despite different areas of the country had to head back to their these measures, tens of thousands of people gathered in a special home residences (24). On April 5, the country announced a prayer session for protection against nCoV-2 in Lakshmipur, suspension of all international travel except flights to and from despite not having the local Government’s permission. Afterward, China until April 14 (25). It also declared that, as of April 9, the Government banned all political, social, cultural, and some 60 areas of the country, with half of the places in the religious rallies and gatherings in the country (16). Amid this capital city, would be under a specialized form of localized crisis, the country witnessed voting in three constituencies, where lockdown to fight the spread of COVID-19. A specialized people had to go to the voting centers in person to cast their votes. lockdown was also imposed on Cox’s Bazar, a southern district Meanwhile, the health ministry said that nCoV-2 has spread to of the country where many Rohingya refugees live (27). These the community transmission level (17). Rohingya refugees, as well as older individuals anywhere in the Bangladesh admittedly has a severe shortage of testing kits: it country, constitute the most potentially vulnerable groups to does not have more than 100 thousand testing kits in stock, of virus infection. which only some 20 thousand have been distributed to different testing facilities around the country (9, 18). The country received SOCIAL DISTANCING PROTOCOL IS some testing kits, PPE, masks, and infrared thermometers from TOUGH TO MAINTAIN IN MANY AREAS OF China to deal with the crisis in the country; however, this BANGLADESH amount only covers a small portion of the country’s actual needs (19). In the meantime, utilizing the rapid dot blot technique, As mentioned earlier, Bangladesh did not impose any strict Ganashystha Kendra (a local health institution), claimed that it protocol initially, and millions of people were out on the streets, had developed a testing kit that can detect nCoV-2 in several especially in Dhaka, which is a megacity with 46 thousand people minutes for just BDT 350 (∼4 USD) (20). Although many living per square kilometer (28). It appears that social distancing experts questioned the efficiency of the method the kit uses, is tough while taking public commutes and living in the slums. the institution has reportedly obtained government approval to In the context of massively populated and lower-middle-income import raw materials to mass-produce the kits. It is worthy countries like Bangladesh, enforcement of social distancing—as of mention that a very similar rapid testing kit developed and recommended by the WHO to stop the nCoV-2 spread—sounds marketed by a Canadian company, which received approval in fancy but impractical. Indeed, staying at home is unlikely to be as some Asian and European countries, was refused approval by the effective here. health authorities of Canada on the grounds that it may produce Dhaka, the capital of Bangladesh, is alone home to some 1.1 a high rate of false-negative results (21). million slum dwellers (29). These slum dwellers, most of whom On March 25, Bangladesh declared the enforcement of have never gone to school and currently live in extremely close lockdown for 10 days effective from March 26. With the quarters, are hardly aware of the threat from nCoV-19. The range enforcement of this lockdown, travel on water, rail, and of household earnings of slum dwellers in Dhaka is around BDT air routes is banned and road-transportation is suspended. 8,000/month (<100 USD/month), and they spend >70% of their All non-essential organizations, businesses, and educational earnings on food and housing (30). Even a 400-mL bottle of hand institutions are closed, except for pharmacies, groceries, and soap per slum, which costs around BDT 80 (∼1 USD), is hard for other unavoidable necessities. Following the declaration, many them to afford. Besides, every 10–16 families have access to only people from the major cities, especially from Dhaka, started to one bathroom/toilet, where there is no regular supply of water leave the city by various means, including overcrowded public (30, 31). Along with the slum dwellers, Bangladesh also hosts over transport services, with a high risk of contracting COVID-19 and a million Rohingya refugees, most of whom are living in close in violation of the government instructions. On the same day, quarters in refugee camps where the sanitization facilities are Bangladesh issued a temporary release to its ailing former prime even scarce (32). Fear of COVID-19 is already gearing up among minister from prison, and consequentially, thousands of political the displaced people in these camps. Immediate enforcement followers greeted her in Dhaka, defying the lockdown imposed of social distancing is, in every way, practically impossible in a by the Government (22). It was predictable that on the release country like Bangladesh. of a political leader of her fame, a huge gathering might occur; however, she was temporarily released on humanitarian grounds (22, 23). INADEQUACY OF COVID-19 TESTING On March 2 and 3, when the initial 10-day-long lockdown FACILITIES measure was about to be completed, thousands of service and factory workers started heading back to major cities, e.g., Dhaka, Five weeks after the detection of the first COVID-19 case Narayanganj, Gajipur, and Chittagong, ignoring the risk of in Bangladesh, the IEDCR had only tested 11,223 people, nCoV-2 spread (24). The country’s efforts to reduce the spread constituting approximately 68 tests per million population (5, 7) of the virus in Bangladesh suffered in their implementation (Figure 2). It is perhaps among the worst-ranked countries for due to the lack of coordination between different authorities nCoV-2 testing rate, though the mortality rate is comparatively Frontiers in Public Health | www.frontiersin.org 3 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh FIGURE 2 | Number of tests done daily. The rate of testing rose significantly 4 weeks after the identification of the first case of COVID-19 in the country (5). higher (7). It should be noted that in the first 3 weeks after MITIGATION MEASURES TO FIGHT the detection of the first COVID-19 case in Bangladesh, the COVID-19 WITH LIMITED RESOURCES IEDCR was the sole diagnostic facility in the country of 180 million people, and the daily testing rate remained below The situation in Bangladesh is rapidly evolving, and it is 100 per day (33). The centralization of COVID-19 diagnosis comparable with many other countries, e.g., France, Japan, which facilities is somewhat plausible, as most hospitals do not have have lately seen a devastating impact from the virus (Figure 3) enough personal protective equipment (PPE). However, this (1, 7). In this situation, most sensible governments would opt for left the mass of people and healthcare workers in an awfully a total lockdown for an undeclared time at very high financial susceptible condition. As a result of the combined lack of costs under the precept that lives should be saved first, and PPE and diagnostic testing capacity, fear, and anxiety geared counting the loss to businesses may wait. Some countries, e.g., up among the mass population, and many healthcare workers Italy and Spain, have already adopted such measures (38, 39). refused to provide any service. With much criticism from In fact, with no effective therapeutic strategies available for different sectors, the health authorities of the country ultimately COVID-19, lockdown is perhaps the best-known measure that decided to expand its testing numbers from April 3 (33). could mitigate the situation (40). However, in Bangladesh, where Currently (April 11, 2020), there are 17 labs across the country a significant proportion of the total population lives hand to working on testing probable/referral cases of COVID-19, and mouth, lockdown is not a feasible idea. With no savings and a few more labs are being established in different districts, work, how will poor and marginal people feed themselves if there including one in Sylhet at Shahjalal University of Science and is a prolonged lockdown? This is an issue that the Government Technology (34, 35). must address when declaring any lockdown or emergency that The situation became even complicated as four doctors at may stay in place for 2 or more weeks. With help from the the Dhaka Medical College and Hospital, the largest hospital in armed forces, the Government may think about starting a Bangladesh, were sent into home quarantine after they handled “hygienic” rationing system in case of locking down for a more a person who was later identified as having COVID-19. Later extended period. on, many more doctors and health workers were sent into Among the preventive measures for COVID-19, including quarantine, and many of them tested positive for COVID-19 aggressive tracing of cases and contacts, strict quarantine, and (36, 37). The health system of Bangladesh depends on around screening, as well as education to promote good hand hygiene 100 thousand registered doctors, and if these very few doctors practices, should be put in place (41, 42). Immediate expansion compared to the population size are unable to provide their of testing labs to every district and major localities is urgently healthcare service as a result of the unavailability of PPE, this needed to test every patient with symptoms, and millions of could have potentially catastrophic consequences. testing kits are necessary for conducting aggressive detection of Frontiers in Public Health | www.frontiersin.org 4 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh FIGURE 3 | Total number of COVID-19 cases daily after the identification of the 10th case in Bangladesh and in 10 other countries (1, 7). Bangladesh’s trendline is comparable with the trendlines of France and Japan. As of now (April 13, 2020), the trendline of the US remains far lower (74 total cases on day 28) than Bangladesh’s until the 28th day after the identification of 10 positive cases. cases (18). Students at life science departments in universities the situation mitigates. Home office laws should be imposed, can be trained to carry out COVID-19 case diagnosis. The whenever possible. molecular genetics, biochemistry, and molecular biology labs in Additional measures must be taken promptly, anticipating the the universities and medical colleges across the country should potential challenge that would be faced by the hospitals in the case be quickly transformed into COVID-19 case detection labs. The of an upsurge of COVID-19 cases. The Government must source country can also seek help from China and South Korea on how enough protective gear for the healthcare workers who will have it can channel extensive detection surveys (43, 44). With help to tackle COVID-19 patients in the frontline. With expert help from the armed forces and trained volunteers, the schools could from China and South Korea, Bangladesh should immediately be turned into quarantine centers. The Government will have organize specialized training for all physicians, resident doctors, to come forward to make sure that its marginal population has and intern doctors. access to proper hygiene, maybe by supplying free sanitizer and A total of 7% of the country’s population are senior citizens mobile washrooms. All offices and businesses, except medical (45). Most of these senior citizens and many mid-aged people centers, pharmacies, and groceries, should remain closed until in the country have non-communicable disorders, including Frontiers in Public Health | www.frontiersin.org 5 April 2020 | Volume 8 | Article 154 Anwar et al. COVID-19 and Bangladesh chronic obstructive pulmonary disease (11.9%), cardiac disorders basic knowledge would be the key to controlling the spread of the (4.5%), diabetes (9.7%), and asthma (5.2%), and they are virus (57). especially vulnerable to COVID-19 (46–49). Besides, there are around 1.3 to 1.5 million cancer patients in the country (50). NEED FOR A CONSIDERABLE AMOUNT Moreover, the prevalence of smoking is highest in Bangladesh OF FUNDS among the South Asian countries (49). Studies have reported that people who smoke and have cancer have a higher risk Above all, Bangladesh must source a decent emergency support of developing serious complications. Although there is still a fund to help its workers, employers, parents, marginal people, dearth of understanding of the association between COVID- and hosted refugees. It has already received fast-track support 19 severity and cancer and smoking, these could likely be of USD 100 million from the World Bank; however, this is far correlated (51, 52). In the case of an upsurge of people from the actual amount needed for this country of 180 million who belong to the vulnerable groups contracting COVID-19, people (58, 59). Additionally, the country has recently unveiled they may require hospitalization and intensive care. Hence, an economic stimulus package of ∼8 billion USD to counter the ventilation supports in every hospital, clinic, and medical center adverse effects of the pandemic (34). The country may temporally is a must. The country has so far arranged only 112 beds postpone all non-essential developmental works and gather a across the country in intensive care units for patients with modest amount of money to support its people in fighting this COVID-19 (53). The tech start-up and innovation companies crisis. Also, top business organizations and international funders emerging in the country should take it as a challenge to should come forward to help Bangladesh fight the COVID-19 design a cheap but rapidly deployable mechanical ventilator challenge. Only a supportive and empathic collaborative effort device. All non-essential surgeries and hospital admissions can help the world, especially the low and lower-middle-income should be canceled immediately to make sure the hospitals countries like Bangladesh, overcome this crisis. are not unnecessarily occupied. Hospitals can become a source CONCLUSIONS of COVID-19 transmission, and it is advisable to decentralize healthcare services and, whenever possible, to provide care at Preparedness is the key to addressing any health crisis, and home. Government rest houses and private hotels can be turned so far, Bangladesh, as a lower-middle-income country, has into emergency response healthcare facilities. Moreover, as a numerous limitations in restricting the spread of the virus. riverine country, Bangladesh has a huge water transport system. While continuing the lockdown at any cost with more strict Large water vehicles, including steamers and launches, can be maintenance, the country has to expand its testing and healthcare used as mobile healthcare facilities for the people who live in facilities. It has to ensure a constant supply of PPE for healthcare remote areas. workers. Above all, improvised and timely measures taken with proper coordination may help the country to fight the lethal virus. COPING WITH MENTAL STRESS DUE TO The Government will not be able to mitigate the situation alone COVID-19 (60); individual efforts from the citizens, direct involvement of the nation’s public health experts, and international help are Fear and anxiety about the pandemic are causing overwhelming urgently needed. As the situation intensifies, the world is closely stress for everyone (54, 55). While receiving mixed messages piles watching how Bangladesh will navigate this crisis. up the stress, sharing the real facts and understanding the actual risk reduces the stress. Moreover, this helps the authorities to AUTHOR CONTRIBUTIONS organize better and manage the crisis. Social activists, television and print media, social workers, and religious and political MH conceived the study. SA wrote the first draft. MN leaders should come forward to help in the dissemination of commented on the draft and contributed to the writing of scientifically factual information on nCoV-2 and COVID-19 the manuscript. All authors approved the final version of among the mass population of Bangladesh. For instance, the the manuscript. Imams (a Muslim leadership position) of each mosque could play a vital role in fighting this extraordinary crisis in Bangladesh FUNDING (56). Together, the media personalities and political and religious leaders could help spread basic knowledge on COVID-19- No specific grant was received for this study. However, SA was supported by the Maternal and Child Health related issues to the mass populace, especially the marginalized communities. Given the high level of illiteracy among the slum (MatCH) scholarship and Alberta Innovates Graduate Student Scholarships (AIGSS). and village population, the dissemination of COVID-19-related REFERENCES 2. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl 1. Dong E, Du H, Gardner L. An interactive web- J Med. (2020) 382:1199–207. doi: 10.1056/NEJMoa2001316 based dashboard to track COVID-19 in real time. 3. Bootsma MCJ, Ferguson NM. The effect of public health measures on the Lancet Infect Dis. (2020). doi: 10.1016/S1473-3099(20) 1918 influenza pandemic in U.S. cities. Proc Natl Acad Sci USA. 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