Few test facility, inability to quarantine returnees expose holes

As fears rise about the potential of spreading of coronavirus or Covid-19 in the country, the authorities' handling of incoming passengers and its extremely limited testing capabilities expose a gaping hole in the government's preparation to fight the deadly virus.

None of the passengers who scrambled to Dhaka from Covid-19 hit Italy and elsewhere have been subjected to compulsory quarantine. They have been let go home after just checking their body temperatures.

It is very likely that one or more of them might just be carriers of the germ in their bodies which is yet to manifest through temperature rise or other symptoms. If such passengers are allowed to go home, they would pass the virus on, epidemiologists point out.  

In the last two days, according to IEDCR sources, some 400 passengers have arrived in Dhaka from Italy. None of them have been tested or quarantined. But the chilling reality is, it is from Italy that coronavirus has spread to at least 27 countries.

These returnees are supposed to be self-quarantined, but the reality is they are found circulating in their neighbourhoods freely.

One testing lab, 2500 kits in country of 170 million

The second weakness is no less grave – the lack of adequate testing capacity. So far Bangladesh has only one testing laboratory which too has only about 2,500 testing kits of which over 241 have already been used.

This is an extremely low testing capacity in a country of 170 million. One of the key elements in fighting Covid-19 is having very robust and high number of testing facilities.

The more people can be tested the more accurately the disease can be mapped and action taken to quarantine the infected.

South Korea, that has successfully contained the virus, had tested 4.85 persons in every 1000, Bahrain tested 5.61 persons and China's Guangdong province 2.82 persons. Countries which are grappling with the crisis have much lower testing rates. Italy had tested 1.42 persons (the rate was even lower in the beginning and was later scaled up after the situation worsened), Spain tested 0.37 persons (it is now the epicenter of the virus in Europe), the USA did only 0.02 persons.

In case of Bangladesh, a large number of affected people may remain undetected because of such low number of tests.

The low number of detected patients so far may not be of any real solace because of such low number of tests conducted. The same is true for India where only 0.0003 persons in every 1,000 have been tested and so it claims a low infection rate.

Situated in the same region, Pakistan is doing a much better job in testing and detecting Covid-19 patients and earning praises. It has shutdown airports and closed educational institutions already. It has arranged to set aside around 2,000 isolation beds to keep the suspected patients. 

Extraordinary screening arrangements had been made at the points of entry by the authorities. At the moment, Pakistan has seven diagnostic labs which are capable of conducting 15,000 tests. Naturally, WHO praised Pakistan's efforts. 

Tests are so important

Vigorous efforts in testing large portion of the population is important in containing the virus outbreak, according to experts. 

Assistant Professor of the Virology Department of Shaheed Suhrawardy Hospital Dr Jahidur Rahman explained that guidelines of both WHO and Bangladesh government call for laboratory testing for three categories of people: those who have fever with cough or respiratory problem and visited a corona-infected country in last 14 days; who have fever with cough after coming in contact with returnees from abroad and who have been admitted to hospital with fever, cough and respiratory problem but no specific reason detected in test. 

Currently, the first two categories of people are being tested, and the third one is ignored, meaning that the IEDCR is not following its own guideline, he pointed out.

Testing and isolating patients has been also stressed by US experts. "No matter how your health systems or political systems are organized, the keys to epidemic control remain the same - test, trace, isolate and inform," Jessica Justman, a professor of medicine in epidemiology at Columbia University, has said. 

Professor Dr Saif Ullah Munshi, chairman of virology of BSMMU told The Business Standard that any suspected case should undergo tests to prevent the virus from spreading in the community. 

"Here, crisis of test kits might become acute. So 10 suspected cases could be chosen methodologically to make sure that the virus is not making its way into a community," said Prof Ullah.

South Korea, which has the highest infection tally in Asia outside of China, is testing more than 10,000 people a day, the fastest pace globally.

Efficient testing has allowed South Korea to isolate and treat infected people early, thereby slowing the virus' spread and lowering the mortality rate to less than 1 percent.

On the other hand, Japan drew criticism for not testing enough people, which raises the prospect of scores of undetected infected people remaining un-quarantined and spreading the virus more widely. There is a rising concern that the US is facing such a quandary as it emerges that the pathogen has been circulating for much longer than known in some states.

"More testing, not less, is needed to investigate how the virus is spreading or if it starts adopting new transmission mediums," the World Health Organization's China Representative Gauden Galea said in an interview on Monday.

"You can't fight a virus if you don't know where it is," WHO Director-General Tedros Adhanom Ghebreyesus said Thursday. "That means robust surveillance to find, isolate, test and treat every case, to break the chains of transmission."

With one single testing facility, Bangladesh falls woefully short on this count. It may mean, the number of identified patients we are seeing might be only the tip of the iceberg.

The Business Standard has come to know from at least four large hospitals in Dhaka that they have been turning away suspected cases.

Dhaka Medical College and Hospital (DMCH) doctors say they have seen a sudden spike in atypical pneumonia where patients are coming with infection on both lungs in a bad condition, a typical symptom of Covid-19. A large private hospital also said it was also receiving such patients.

All the hospitals referred them to IEDCR. However, IEDCR is testing only those patients who have foreign travelling history and people who have come in contact with foreigners.

Chairman of The Medicine Department at DMCH Professor Mujibur Rahman told The Business Standard that this was a time for flu and so pneumonic patients were coming in an unusually bigger number compared to the previous year. Some of them were in serious conditions.

Hospital sources said said it had sent 12 such patients to IEDCR and all of them were tested negative. However the hospital would not comment whether these patients had returned from abroad or whether they had come in contact with returnees.

It's no way to do quarantine

China stunned the world when it put Hubei province, along with its capital Wuhan city, in a lockdown in late January, effectively quarantining 60 million people in an unprecedented move aimed at curbing the outbreak.

Research has shown that the measure did slow the spread of the coronavirus overseas. The lockdown of Wuhan likely reduced overseas transmission of the virus by almost 80 percent, according to a paper published in The Journal of Science on March 6 by a team led by researchers at Northeastern University.

Italy went a step further than China earlier this week, becoming the first country to attempt a nationwide lockdown -- but only after the death toll grew nearly ten-fold in a week.

Assistant Professor of Virology Department of Shaheed Suhrawardy Hospital Dr Jahidur Rahman questioned the wisdom of not doing quarantine of the returnees.

"The kind of inefficiency that the authorities have shown in handling the Italy returnees is unbelievable," he said. "How can our authorities be so indifferent to the global pandemic? It makes the claim that the government is prepared to face coronavirus sound hollow."  

He raised the importance of quarantine when he said those who are returning from abroad must be subjected to compulsory quarantine.

Home quarantine under question

Bangladesh authorities are advising the returnees to be home quarantined. According to IEDCR, currently four patients are in institutional quarintine while 2, 314 remain in home quarintine as of last evening.

"But home quarantine will never be effective," said Dr Jahidur Rahman. "Mass quarantine facilities should be built in stadiums and unused buildings."

Professor Muzaherul Huq, former adviser to the WHO, said the returnees are sent back to their villages where they have no attached toilets and as such they cannot maintain quarantine. So sending them to self-quarantine is risky.

"And since it is risky these people should have been sent to compulsory quarantine in government facilities," he observed.

Further, these people will infect others in their family through self-quarantine as he will in one way or other come in contact with family members, said Prof Dr Nazrul Islam, former vice chancellor of Bangabandhu Sheikh Mujib Medical University.

Prof Nazrul, who is a virologist, also said such home quarantine, if not properly monitored will lead to spreading of the virus.