As the country opens up, we must work together to keep each other safe
I have a longish story to tell. I tested negative twice in ten days despite having symptoms and being exposed in my home. My 16-year-old daughter and three of my household staff were tested positive 10 days ago -- none of them had stepped out once from the house in over two months.
We are a prime example of how even the best laid plans can go awry. Of course, we reinstated stricter measures after this setback and except for me, the other Covid negatives were isolated to different places. Doctors opine that even if tests come negative in such circumstances, I would still be considered positive. I am a stubborn person; I want to know for sure if I was infected or not and will definitely go for the serological test at some point.
Bangladesh saw the highest number of positive cases on May 29 -- 2523 out of 11,301 tested, an astounding 22% -- until it was surpassed on May 31 with 2,545 cases. The rate of infection is rising with each passing day, hospital beds are getting filled up, especially with members of the law and order agencies who are repeatedly exposed.
When these numbers suggest that we should go for stricter measures of lockdown, the government surprised the nation by doing the opposite. Scary, right? Whatever happened to flattening of the curve? How can the health care facilities manage the surge?
Sadly, when the debate between lives versus livelihoods is put forward, it becomes a difficult choice for a country like ours. I am not making a case for any side as I do realize that major decisions are usually backed by facts and data that would benefit the larger group of the people. One third of the population worldwide remained under lockdown at any given time in the last three months and in countries like Malaysia, Thailand, Sri Lanka, and Vietnam it yielded the desired outcome of lowering the case numbers and fatalities to single digits.
These countries always had an extensive plan to initiate the detect, test, isolate, contact trace, and treat strategy among the wider population under lockdown, along with ensuring food security and providing economic stimulus. Of course it helps that all of them have a robust public health system, have invested in the medical sector for years, and were also better prepared for an epidemic given their previous experiences with SARS, H1N1, etc.
They are currently in the process of lifting their lockdowns in phases by following the WHO criteria. In Bangladesh too, the economic stimulus was announced, food security -- the foremost concern of the government -- was addressed, but we cannot expect the existing less than inadequate public health system to be overhauled in two months.
The case for transparency
Coming back to the topic of Covid numbers and situation, I have some observations from my experience with my family in the last two weeks. We were 11 people in my house, including my 77-year-old mother. Due to a hole in the system, my daughter contracted the disease, she had fever for a day and some sniffling. The exposure obviously called for testing all the members of the household. Three other people tested positive and all of them remained asymptomatic.
So, had we not tested, we would have never known about those three cases. What does this tell us? Can we make a case out of it and assume that a large number of asymptomatic cases exist in the community who are silently spreading the disease? If the entire scenario of our cases were represented to us differently, then how would we feel?
For instance imagine the report came out like this -- in Bangladesh we have had a total of 45,000 cases out of which almost 12,000 people were/are asymptomatic, 24,000 have very mild to moderate symptoms, 9000 plus people needed hospitalization but most are recovering, and 600 people unfortunately succumbed.
Is that a better representation? Does it make a difference in perception about the disease? Would we feel more confident going back to work? Mind you, the numbers are just my imagination based on my observation and I am thinking out loud.
The point is, if data is made more transparent, it will help people come to terms with the reality with positive expectations. However, the fact of the matter remains, our immune systems dictate our response where the exposure to viral load also plays an important role.
Countries that did lift lockdowns have had to reapply emergency brakes from time to time. Germany, Singapore, South Korea, China, Malaysia -- all of them had to reimpose restrictions depending on the new surge of cases. Bangladesh may have to do the same, we may see a steep rise and fall followed by undulating waves. We will have to learn to live with Covid till a vaccine or a specific treatment is developed. The former is the better of the two options but retroviruses like SARS-CoV2 are perpetually mutating which makes developing an effective vaccine difficult.
So, what is our duty as the country opens?
Collective responsibility to look out for each other. We can only remain safe if our families, friends, neighbours, and the entire community are safe. Wearing a mask is made mandatory, it will always give protection from inhaling aerosolized virus-laden air at any place. Save that N-95, wash it, and reuse it, or alternatively, use a surgical mask or make your own.
Masks provide protection from both symptomatic and asymptomatic spreaders. Avoid going to crowded places if not essential, use glasses/sunglasses on top of masks. Wash hands for 20 seconds as many times as needed or use hand sanitizers.
Owners of offices may need to rethink the ventilation and have more natural air pass through. Closed spaces with recirculating AC air, rooms without windows or vents, have trapped air. These places are reservoirs of viruses, 15-30 minutes in such places without masks increases health risks. Everyone must maintain six feet physical distance. Vitamins C & D, zinc, black seed oil, tulsi tea infused with ginger, cloves, cardamom, and cinnamon -- all of this and a daily dose of sun and outdoors will help boost the immune system.
Best to set a comprehensive set of self and group protocols if a person is having symptoms or has tested positive. Having a family physician on speed dial is a must, locating the nearest testing booth and hospital should be on the list. The elderly in the family and community must always remain protected.
Were the hospitals given a national guideline?
The government has established a comprehensive Covid-19 treatment protocol based on what has worked so far. Oxygen saturation, anti-coagulation therapy, usage of Remdesivir or Favipiravir, change of positions if a patient is intubated are all recommended in hospital settings depending on disease severity.
For home, using an oximeter has disease prognostic value, if oxygen saturation is less than 92% and patients have shortness of breath then he/she needs high flow oxygen which is better managed at a hospital. Health facilities will require segregation of Covid from non-Covid areas, as well as triage setting with proper isolation.
Can we increase our efficiency in terms of testing?
Testing needs to be ramped up. There are FDA-approved rapid antigen and serological testings available. Rt-PCR is the best option, but it is expensive, time consuming, and requires trained technicians. The FDA-approved antigen testing is cheaper and can scale up the testing numbers to millions within a day with detecting Covid in minutes. Yes, there is still a chance that it will give false negative results, but as a diagnostic test it will still be cheaper and faster to repeat.
Serological tests provide 99% accuracy in detecting people who have had Covid already. The presence of IgM (early antibody) and IgG (10 days after symptom onset) antibodies in the plasma confirms that a person has already had Covid irrespective of symptoms. Sometimes past Covid positives may not have a high titre of antibodies in their blood, which may be due to their T-cell mediated immunity playing a stronger role than humoral immunity where B-cells/plasma cells are involved in producing antibodies.
Nevertheless, a serological test will identify the people who can donate their plasma for plasma therapy, and can be the cases studied further to see how long they remain immune to SAR-Cov2 and finally provide them the immunity passport to join the workforce. The UK and Singapore have started this.
A lot of speculation about WHO not yet recommending these tests is going around. If that is the case then WHO also does not recommend lifting lockdowns when disease transmission is not under control, when hot spot risks are not minimized, when schools and workplaces have not taken established preventive measures, and when communities are not fully educated, engaged, and empowered to live under a new normal.
We are yet to fulfill these criteria but are reopening to save our livelihoods and our economy. Given the circumstances for better decision making, we need to increase these testing capacities. In the Global Health Security Index, it is clearly stated that one of the few strengths of Bangladesh health parameters is having strong laboratory capabilities at the national level. Now is the time to utilize this.
Finally, we need to use each other’s strengths. The government needs to concede and save resources by utilizing the strength of the private sector. Collaborate with NGOs to use their community health workers in aid disbursements or awareness programs and relieve our law enforcement personnel.
Pharmaceuticals and the RMG sector have already come forward by producing lifesaving drugs, PPEs, and masks -- they deserve their due recognition. The makeshift hospitals and private sector initiatives of quarantine centres will be needed for the greater good. Public-private coordination will enhance better service and at the same time increase capacity.
Ultimately data and numbers tell a story and having a youthful demography and the lockdown of the past two months have kept our numbers looking good. Let us work together to keep it that way.
Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Masters in Healthcare Leadership.