WHO and global public health experts have been continually highlighting the importance of widespread testing, contact tracing, isolation and quarantine as the key steps to control the exponentially growing curve of the novel coronavirus diseases 2019 (COVID-19) pandemic.
In most countries, testing for COVID-19 is still largely based on risk profile that includes testing of patients who have symptoms and are at high-risk, or have travelled abroad or have come in contact with a COVID-19 patient.
As some countries are bringing the curve down, testing is also being extended to include people with mild symptoms from areas with clusters of COVID-19 cases.
The government of Bangladesh has already extended testing of COVID-19 patients to 18 laboratories around the country. The number of tests being performed daily is also increasing with a proportional increase in the number of confirmed COVID-19 cases.
Given the high population density, increasing community transmission and limited resources, it is ambitious to expect that Bangladesh will be able to extend testing of COVID-19 cases to effectively cover wider community.
On the other hand, Bangladesh is in a unique position to rapidly scale up contact tracing.
What is contact tracing?
Contact tracing is a term commonly used in outbreaks of infectious diseases to understand how an infectious disease is spreading in a community.
It has two purposes: to figure out who a sick person caught the illness from, and to find out who they have been in contact with while infectious so that all possible contacts can be quarantined early.
Different countries are applying different innovative approaches for contact tracing, including deploying volunteers who are actively collecting information, using digital smart phone-based apps and also using location trackers.
The country’s infrastructure and social context will decide which method for contact tracing is feasible.
How is Bangladesh different?
Bangladesh has tightly knit social network, specifically in rural areas, which means that community members know each other.
Additionally, rural areas have community-based services provided by both government and non-government organizations (e.g. BRAC).
Within the community-based services, there is an extensive cadre of 185,000 community health workers (CHWs) across the country. These CHWs are selected from their own communities and trained to treat common medical conditions, promote a wide variety of health behaviours, and refer patients to preventive and curative services as appropriate.
Bangladesh has been a role model in successfully implementing national programs including family planning program, tuberculosis control program and integrated management of neonatal and childhood illness though CHWs.
The evolving COVID-19 crisis once again provides Bangladesh with the opportunity to actively engage CHWs in contact tracing and be the trailblazer for other low- and middle-income countries
Once a patient residing in a rural area is confirmed for COVID-19, CHW from the area where the patient lives can be notified.
The CHW can then contact the person over telephone to collect a list and get in touch with people who may have been in contact with the person confirmed to have the disease.
Subsequently the people who came in contact with the confirmed COVID-19 patient can be contacted directly over the phone by the CHW, give instructions about what the contacts need to do and monitor the contacts for two weeks to check if they develop symptoms.
The information collected can be uploaded to Institute of Epidemiology, Disease Control and Research (IEDCR) database through community clinics or directly though telephone.
In regard to trust building, which is essential in contact identification and tracking, CHWs are well placed as potential contact tracers. They are accepted by the community because they are selected from the community and answerable to the communities for their activities.
Contact tracing through CHWs might not be applicable in urban areas, where the population is much more dispersed.
IEDCR in collaboration with ICDDRB have ongoing surveillance for different infectious diseases in 20 tertiary hospitals in geographically diverse locations. These surveillance sites are staffed with dedicated field staff who are trained in health data collection and can be leveraged for tracing of contacts in urban areas.
Medical and nursing students or students enrolled in Master of Public Health program can also be mobilised to trace contacts of COVID-19 patients in urban areas.
Contact tracing can be included as part of the educational training program providing the opportunity for capacity building of health workers for future health crisis.
Monetary incentive for contact tracers may help in optimal data collection during these difficult times.
In some cases, we will need broader contact tracing approach. Public health alerts can be put out in places where cases may have worked, visited, or attended classes and may have been in close contact with people they personally don’t know so that people who might have in those places during the same time can get in touch with IEDCR.
One might consider these as bold steps. But the COVID-19 pandemic has created a global crisis of a magnitude that we have never had to deal with in our lifetime. The unique nature of the crisis underscores the need for creative and expeditious actions, focusing first and foremost on country-specific public-health infrastructure and the science of containment and mitigation strategies.
Dr Nusrat Homaira, MBBS, MPH, PhD is a Respiratory Epidemiologist and Senior Lecturer with University of New South Wales, Sydney Australia. Md Saiful Islam is an Infection Prevention and Control Scientist and a PhD researcher at University of New South Wales, Sydney Australia. Dr Zakiul Hassan is an Infectious Disease Researcher at ICDDRB, Bangladesh
