An employee of Mugda Medical College Hospital sprays disinfectant after a lab technician collected a nasal swab sample from a resident to test for the COVID-19 coronavirus in Dhaka on June 17. — Agence France-Presse/Munir uz Zaman
IT TAKES 11 pieces of personal protection equipment to make a perfect full set which, however, may be too many and too much — two pairs of shoe covers, two pairs of hand gloves, one head cover, one full-length gown with a hood to cover the head, a pair of goggles, two masks and a face shield, all on top of a clinical dress. Most, however, think tnhat a pair of shoe cover, a gown with or without hood, a mask, a face shield and a pair of gloves should be enough. Whatever is the practice, in a hot and humid environment, these are too much to bear while giving medical care for long hours. We must realise that death of physicians, and also of law enforcers and journalists, caused by COVID-19 is the highest in Bangladesh of all such incidents worldwide. Can this be due to the poor quality of PPE components or not using them with enough caution and finesse?
Practice of wearing masks
WHAT percentage of people wear masks, what percentage of them wear quality masks, what percentage of them use good quality masks as long as necessary and what percentage of them use good quality masks properly? Nobody knows. It is not infrequent to see people loosening or removing it when talking, sipping tea outdoors or smoking, etc. We see people very often touching the middle of the mask every now and then to fix it and often the masks are worn loosely. Why do people behave this way with their masks? They may think either that masks are not that much necessary as advised or that that the way they use the masks are protective enough. Some complain of discomfort in using mask in hot and humid weather. The authority has not reached the people with a clear guidance yet in a serious and believable form.
Lay people are hardly aware that a mask should not be used for more than four to six hours and should immediately be changed if it gets wet during sneezing and coughing as in this situation, it cannot prevent SARS-CoV-2 from entering from the surrounding into a person’s nose or mouth. Masks, unless made of clothing, might not be used repeatedly as these cannot be washed for reuse. Some people keep it in open airy places at home or sun-dry them after a day’s use to reuse after a week — seven masks used on seven days and from the eighth day they start reusing the first one in a cycle, the efficacy of reused masks has not been studied though.
The other thing a few people know is that masks used by only an infected person is 50 per cent protective to a non-infected person. For an effective protection, the non-infected person also needs to wear a mask.
Distance between two, not living together
EVERYBODY out there is infected with SARS-CoV-2 — this is how one should think to be on the safe side. It is safe to maintain a distance of six feet and not three, as we do. Even when people would be advised to keep a distance of six feet, they will hardly abide by and by three feet, they would mean not even three feet and this is what we see. Why six feet? Because airborne aerosols from sneezing and coughing may move longer distance — up to 13 feet, as has been reported. Other measures which are hardly given importance too, which nevertheless are important, are not sitting face-to-face when talking at a meeting and not to be at a distance of six feet for long since the bolus/dose of virus is time-dependent. Every minute, 200 virus particles are exhaled by an infected while talking and 1,000 particles are enough to cause infection in a healthy person while one single sneezing or coughing is more than enough to cause infection.
Research opportunities not exploited
DOES the practice of hot gurgling, drinking hot water, tea and coffee, eating spices, eg cloves, ginger, turmeric, garlic, hot steam inhalation, etc prevent COVID-19? How much Vitamin C, zinc, Vitamin D and Vitamin K prevent the development of COVID-19? Can the practice of personal protection measures be better than enforcing lockdown? What percentage of people in the country has already been infected? What are the characteristics of the people who got infected and who died, eg age, sex, occupation, residential types and locations, literacy, socio-economic status? What are the type and strain of the virus that has affected the people of the country? Are the new strains more vicious or less harmful? These bits of information could be useful in controlling future incidence of the disease and its devastation. For example, if we could know for certain whether people who work in sunlight do not catch the virus and do not die or are less likely to die, we could inform the people of this fact and tell them what to do.
We have not conducted epidemiological studies such as basic reproduction numbers and not talked about the effective reproduction number. Instead, we believe in what scientists in other countries tell us. We have not studiud the pathogenesis, not conducted any diagnostic examination or biochemical estimation, and not followed the progress of clinical features or prognosis, clinical interventions and their outcomes. We have not explained why the red zone areas show an escalating estimation under lockdown and what has been the effect of lockdown in controlling the infection in non-lockdown areas. We have followed whatever the west has tried as copycats with astounding vigour and speed only to abandon soon enough, eg, hydroxychloroquine, remdisivir, flavipiravir and ivermectin. Hospitals infuse convalescent plasma from recovered patients to dying patients but without any matched controls to compare the outcome.
Believing the unbelievable
THE first information was that Bangladesh would experience 20 million death. Then, no mask is needed except for people taking care of infected people; and yet then, a distance of three feet only is enough. Then, symptomless infected people do not infect others. Yet then, infection does not impart immunity and then, hands should be washed every 30 minutes irrespective, of whether one has the probability of touching contaminated materials or not, etc. These bits of information were fed to us without considering if they are feasible or necessary at all in all weather conditions. Does Bangladesh have scarcity of good immunologists, virologists and epidemiologists from whom could seek opinions or advice on these controversial issues? Are we too gullible to question external expert opinions?
‘Back to the basics’, but where is it?
DOES anyone know what the incidence or attack rate of COVID-19 in Bangladesh is? Let us pick up another basic estimate. Do we know what the case fatality rate or the infection fatality rate from COVID-19 in Bangladesh is? The fundamental problem is that we do not have the denominator or, rather, a correct denominator for these estimates and not even the right kind of numerator for a true estimate in the past four months or so. The responsibility lies squarely on the people who call themselves public health experts and epidemiologists for not advising the government properly, the responsibility that they have been entrusted with. All what we know is the percentage of the people who tested positive and how many of the positive cases died. But we do not know the percentage of people, not tested, infected and dead. We do not know the percentage of people have developed antibodies, which could suggest what percentage of people might still be a potential threat of transmission of the virus. We do not know the effect of practising personal and family protective devices compared with lockdown.
Explanation of recent trend of test positivity
TESTS for COVID-19 have so far been carried out on people with overt clinical features and their contacts, way below the actual number, and also some amateurs, as the test was free. Two changes were brought in — test costs some money and cases only with clinical features are tested now. These strategies have shed off the amateurs with a larger prospect to be negative. This, therefore, exhibits a bigger rate of test positivity now. In all probability, a higher positivity rate may be apparent but not actual. For the same reason, the death rate among the tested is likely to be higher, which also may not be an actual accentuation of death. The other reason may be a lesser number of tests in areas suffering from flood, which, again, should not deter genuine cases from getting tested and being cared for in hospital. Climatic conditions might not hide the number of deaths.
AM Zakir Hussain is a former director, Primary Health Care and Disease Control, former director of IEDCR, DGHS, former regional adviser of SEARO, WHO, former staff consultant, Asian Development Bank, Bangladesh and Working Group member of Bangladesh Health Watch (BHW).
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