Possible containment interventions for Dhaka’s existing hospitals
With Covid-19 failing governance of global health, many developed countries such as the USA, UK and Italy have succumbed to stress resulting from the increasing number of Covid-19 positive cases (Baniamin et al, 2020). While the likes of the country such as South Korea, Japan, and Singapore have taken good preventative measures, China and India have also shown progress in taking good mitigative measures (Baniamin et al, 2020) along with effective containment strategies.
Back on March 8, 2020 Bangladesh had identified the first Covid positive patient. Since then it took thirty-four days for the country to reach its 1000th Covid-19 positive cases ("Bangladesh Coronavirus: 2,144 Cases and 84 Deaths - Worldometer", 2020). As of April 19, there are 1994 active Covid-19 cases in the country ("Bangladesh Coronavirus: 2,144 Cases and 84 Deaths - Worldometer", 2020) with Dhaka division having 86% of the total cases in the country (IEDCR,2020).
With new patients being identified each day and patient clusters emerging throughout the country especially in Dhaka City, Bangladesh no longer has the luxury to take preventative measures. It's time that the country plans stronger containment strategies to flatten the curve.
What is a “containment strategy”?
A coordinated response in “containment strategy” helps prevent community transmission (Rio & Walensky, 2020). Intending to reduce community transmission, the Indian government has proactively made an informed decision of establishing a “cluster containment strategy,” which involves the identification of “hotspots”-these locations are usually areas of elevated incidence or prevalence, higher transmission efficiency or risk, or a higher probability of disease emergence (Lessler et al, 2017).
The objective of this strategy remains to contain the virus within a geographic location by breaking the transmission cycle while also reducing the morbidity and mortality from Covid-19 (Containment Plan, Ministry of Health and Family Welfare Government of India, nd).
As per the “Containment Plan for Large Outbreaks,” the Ministry of Health and Family Welfare of the Government of India demarcates 3km radius around the epicentre or the residence of the positive case and then has additional 5km radius of the buffer zone where strict quarantine protocols (Family Welfare Government of India, nd, Sharma 2020) are followed.
A well-planned containment strategy and 21 days curfew, has allowed our neighbour to keep their Covid-19 case curve from peaking. The World Health Organization (WHO) had earlier praised India’s intervention for lowering their Covid-19 growth rate by 40% since adopting their nationwide lockdown (Srivastav, 2020; Chitravanshi, 2020). As of now, India has extended its lockdown till May 3, 2020.
India and Bangladesh are more than just neighbours, we have an analogous relationship, which originates back to our rich history as well as our high population density, similar cultural affiliation, family structure/dynamics, religious sentiments, residential segregation (comparable informal settlement clusters in cities), and poverty issues. Therefore if India has been able to keep their Covid-19 cases low, certainly Bangladesh can take the cue in terms of identifying hotspots followed by strict “Cluster Containment Strategies” and curfew to prevent further local transmission.
As highlighted in the infographic, it is evident that having lockdown, and 6am-6pm curfew has allowed Bangladesh to keep the count of Covid-19 cases down, without lockdown or containment measure as of April 19, Bangladesh would have had 10,656 people suffering from Covid-19.
But can our country fare better with the strategies, in terms of following a better containment plan?
Where to start with strategy?
To strategize the disruption of amplification of the viral transmission, countries should account for Covid-19 patients to have access to life-saving treatment, without compromising overall public health, clinical operations and safety of health workers ("Operational considerations for case management of Covid-19 in a health facility and community Interim guidance 19 March 2020", 2020).
WHO reports that after contracting Covid-19 about 40% of patients have a moderate disease that may require inpatient care; while 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have a critical disease that requires mechanical ventilation ("Operational considerations for case management of Covid-19 in a health facility and community Interim guidance 19 March 2020", 2020).
According to this, about 60% of Covid-19 cases once screened and identified as either “moderate”, “severe” or “critical” are likely to seek treatment at all points of access to the health system, including primary health centres, clinics, hospital emergency units, and ad hoc community settings ("Operational considerations for case management of Covid-19 in a health facility and community Interim guidance 19 March 2020", 2020). This makes these facilities extremely critical as from hotspots with a cluster of cases residing in the premises, if not contained and managed properly, further transmission of Covid-19 can happen to patients, staff, or caregivers present in the location or the vicinity of the health facility.
As of April 12, Bangladesh has only 7693 isolation bed designated for Covid-19 cases (WHO, Covid situation report 7). 29% of this facility is currently located in Dhaka city. With high population density and the highest number of Covid-19 cases in the country, Dhaka city is highly likely to experience a surge of Covid-19 cases. Therefore, its imperative that the 14 designated hospitals, health centres, as well as the 10 screening facilities at the city (corona.gov.bd) are capacitated, with containment plans.
The Map shows these designated facilities as the epicentre of the virus in the Dhaka Division, which are treating and screening Covid-19 positive patients. Adopting effective mitigative measures in these locations is extremely crucial to breaking the transmission of the virus along the 3KM radius of the hospital location and follow up with a containment strategy.
Upon analyzing the map it is evident that the epicentre based containment zones are highly clustered throughout the Dhaka City Corporation especially with the overlap of the red hotspot in She-e-Bangla Nagar, Bangshal, Chak Bazar, Dhanmondi, Gulshan, Shahbagh, Sutrapur, Lalbagh, Mirpur, Kalabagan, Bangla Nagar, etc. These zones should be equipped and contained properly to prevent transmission from them.
As the surge of patients increases in coming days, along with preventing community transmission, WHO suggests several immediate public health interventions which need to be followed irrespective of transmission scenario :
Community messaging: dissemination of Covid-19 relevant information, having community hotline and other referral services as well as ensuring access to community coordinated networks with local government authority, public health unit/district medical officer, prehospital care services.
Health facility readiness: Health facility readiness should be evaluated to identify their response capacity in terms of supply of procurement and distribution plan for personal protective equipment (PPE) and biomedical equipment (including oxygen, ventilators), including a contingency plan for shortages.
The designated hospitals need to ensure that they develop policies for visitor restriction, e.g. visitors to confirmed cases or visitors who are sick with an acute respiratory infection (ARI), including for parents or caregivers accompanying minor patients, etc.
Health staff readiness: Strengthen clinical management as well as ensure training on clinical management of Covid-19 for designated clinical staff. The health facilities need to ensure that key documents are available (SOPs, guidance). These facilities need to develop staffing plans to identify and appropriately supervise staff for repurposing and surge at the health facility level, based upon local and national strategy. Also, measures for the protection of occupational health, safety, and security of health workers – prevention of violence, addressing fatigue, and access to health care and social support has to be ensured.
Referral system readiness: Designate transport systems and ensure screening and referral pathways for patients to prevent stigmas associated with Covid patients.
Designate Covid-19 treatment areas: Areas (beds, wards, ICU) need to be designated within the designated health facilities and plan for a probable surge of patients. Also, it’s essential to revise discharge criteria.
Maintenance of essential health services: The impact of repurposing health system capacities for Covid-19 care should be evaluated regularly, to ensure business continuity tasks, and workforce has to be redistributed and repurposed where necessary.
While many of the developed countries with high global health security index(countries preparedness for pandemic) and best health care systems in the world are struggling to overturn the spread of the novel Covid-19, Bangladesh has somewhat kept the count of Covid-19 cases lower than anticipated with lockdowns and 6-6 curfew, but now the country needs stronger mitigating measures to stop further local transmission.
Rukhsar Sultana is working at ICCCAD as a Research Associate. Her research interest lies in climate change, displacement and public health.
Jony Ferdous is working in Bangladesh Geographical Information System(BGIT) as a GIS specialist and his research interest is in environment and geography.
Nafis Fuad is working at ICCCAD as a Research Officer and his research interest lies in climate change and displacement.
This story is a part of Covering Climate Now’s week of coverage focused on Climate Solutions, to mark the 50th anniversary of Earth Day. Covering Climate Now is a global journalism collaboration committed to strengthening coverage of the climate story.