Why decentralisation of COVID-19 testing is critical for Bangladesh

A long queue of suspected coronavirus patients, who came to the BSMMU in Dhaka for test, crossed InterContinetal hotel to reach near the Ramna Park. Photo: Mahmud Zaman Ovi

As global cases of the novel coronavirus and the death toll from the COVID-19 disease caused by the virus continue to surge, scientists emphasise the critical need to escalate testing, isolation, contact tracking efforts, and build awareness among communities in order to respond to the pandemic. Bangladesh, one of the most populous countries of the world with a density of 1,104 persons per square kilometre, is experiencing the quick spread of the COVID-19 after the first cases were found on Mar 8, 2020. The number of confirmed coronavirus cases in Bangladesh has increased by 3,462 to 122,660 as the death toll surged to 1,582 with 37 dead in 24 hours until Wednesday morning. This information explains the fact that the virus is just in everywhere already! Large-scale testing allows health services to quickly identify who has the disease and arrange for them to receive the care they need. Moreover, it helps isolate the known cases to prevent them from coming into contact with others and slows the rate of community spread or transmission. Effective testing programmes around the world allow governments and health authorities to understand how prevalent the disease is and how it is evolving.

Consequently, tracking positive test results helps authorities make evidence-based decisions in order to take measures for slowing down the spread of the disease. Government policies about testing all people with possible coronavirus infections have widely varied from country to country. However, several countries around the world have identified symptoms that may lead to COVID-19 infections. These symptoms may appear in 2-14 days after exposure to the virus. The symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, the new loss of taste or smell, sore throat, congestion or runny nose, nausea or throwing up, and diarrhoea.

Depending on the testing outcome, a critical decision is to see if they are being considered for enrolment in the hospital or health centres for possible treatment. Also, testing is important to know if the patient requires emergency medical attention upon considering the symptoms such as trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, and bluish lips or face. Moreover, generic approaches are recommended to combat community spread of the COVID-19 virus by following some generic approaches as such: (i) maintain physical distance of 6 feet (2 meters); (ii) cover the cough and sneeze with a tissue, then throw the tissue in the trash and wash hands; (iii) while visiting public areas, it is critical to wear a cloth face covering over nose and mouth; (iv) avoid touching eyes, nose, and mouth; (v) stay home when the identified person is sick, except to seek medical care; and (vi) wash hands often with soap and water for at least 20 seconds. However, in a densely populated country like Bangladesh, testing plays a critical role to perceive the spatial distribution of the virus and to take necessary measures immediately. If there aren't enough tests, asymptomatic patients may spread the virus to others in the community.

But are we prepared to test enough population while covering geographical locations in the whole country by spreading our available resources in no time? Regardless, it is critical to evaluate if the testing centres are spatially distributed proportionately across the country in order to confirm the accessibility of all to testing. According to the recent government data, Figure 1 shows that major agglomeration of the COVID-19 testing centres is befallen in and around Dhaka district (30 centres out of 60) in order to serve the maximum population. However, major district centres across the country are embracing a sharp rise of COVID-19 infected people (e.g., Sylhet, Jashore, Khulna, Chattogram, Mymensingh, and Rangpur). The 60 testing centres across the country may not be in a position to serve the influx of infected people in the coming days and weeks. Table 1 reveals that the centres are for approximately 150 million people in the country. This explains that each testing centre is supposed to serve approximately 2.5 million people with an imprecise sample of 16,000 per day. Recent data indicates that 17.22% of the tested population has COVID-19 symptoms.

Moreover, the data from Table 1 illustrates that in Barishal division, so far there is only one testing facility with a testing capacity of approximately 200 per day in order to serve approximately 8 million people. The daily testing rate remained below 400 per day until Jun 12 2020 in Barishal, Rangpur, and Sylhet divisions each while comparing the testing facilities in Chattogram and Dhaka divisions of more than 2,000 and 10,000 tests respectively. Furthermore, according to 2011 BBS data (see Table 1), Rajshahi, Mymensingh, and Dhaka divisions have a population density of more than 1,000 people per square kilometre. However, the COVID-19 testing capabilities are not sufficient to serve the huge population in these divisions.

Why do we need to conduct tests widely in diverse geographic locations?

Testing is crucial for figuring out geographically where the infection is prevalent and where it is not, and then the knowledge helps direct the public health efforts in order to combat community spread. Consequently, testing helps allocate resources where needed, which is considered as one of the basic disease surveillance factors. We may not be able to take preventive measures (e.g., declaring state of emergency, lockdown, or other needed measures) unless we know where this is happening and how many cases we have confirmed against a given population density. While it may seem obvious that a densely populated area like Dhaka city is likely to have a higher infection rate than a remote countryside, it may require enough evidence that will appear with the number of performed tests. Furthermore, testing saves time and equipment allocations in hospitals. In addition, if a particular geographic location is embracing less number of infected cases; doctors, nurses, personal protective equipment (PPE), and ventilators can be moved from that region to another where the number of cases is peaking. A now-ubiquitous term, physical distancing may be ensured with stiff measures where there are more cases found. Instantaneously, testing provides updated data for moving forward in order to make a precise prediction of resource allocation and restricting people to go outside in order to combat the community spread of the virus.

Recommendations on prioritising spatial decentralisation of testing capabilities

The South Korean experience at mitigation of COVID-19 suggests that large-scale testing is decisive and isolate the geographically infected area can halt the community spread. However, the case of South Korea may be difficult to employ in Bangladesh because of two major reasons as such: the sheer scale at which Bangladesh needs to test surpasses its test kits and lab resources. Secondly, the pandemic experience is new to the policymakers of the country and thus government decisions may change within short notice and availability of testing kits and instruments may be a scarce means to deploy immediately to all testing centres countrywide. As a result, some necessary strategies may help promoting the testing ability of the existing centres at different geographic locations while introducing new testing facilities in order to serve more population spatially throughout the country. For this, the government may plan to introduce some additional policies assuming several critical strategies are already in place as:

(i)       Enhancing testing capacity at all geographic locations based on population density by removing regulatory and trading barriers;

(ii)      Providing aid to the poor where there are more COVID-19 infected people in order to retain people at home for two weeks;

(iii)     Stipulating hospital resources in the worst affected geographic locations so that people may receive necessary treatments immediately when required;

(iv)     Using mobile phones to survey, inform, and pre-screen symptoms related to COVID-19 and advising citizens to reach nearby testing facilities where there are more cases;

(v)      If there are shortages of hospitals, clinics, and testing facilities, the government may requisite schools and similar buildings while repurposing them as testing and quarantine facilities throughout the country;

(vi)     Encouraging the decentralisation of testing facilities into more local areas so that the people do not need to travel to other cities. It may spread the virus quickly in and out of the facility zones;

(vii)    Rapidly scaling up the production and distribution of masks at different geographic locations and inspiring people to wear them in public places;

(viii)   Collaborate and enhance networks among the testing facilities so that they can share their resources according to the need in different geographic locations;

(ix)     Update the database every day at all testing facilities. This will demonstrate the need for additional resources at different locations. Moreover, local governments may take additional regulatory measures (lock down any specific area for a few days) to contest community spread locally;

(x)      Encourage volunteers to support local level facilities in order to enhance testing capacity. However, necessary protective measures are highly recommended to the volunteers so that they may not work as an agent of community spread into their local neighbourhoods;

(xi)     A critical recommendation is to introduce the COVID-19 testing centres in each district geographically (i.e., at district headquarter) in order to increase testing capacities at local level. This will ensure understanding the worst affected areas and future strategies can be taken immediately upon the availability of data.

Moreover, policymakers and public health workers should work side by side and build a strong collaboration network to inform local citizens so that the people can know about their own areas and take precautionary measures immediately.

Additionally, we are recommending that more testing facilities be introduced considering the population density, and remoteness of areas where people do not have easy access to tests. Nonetheless, all major stakeholders should come forward together to help each other in order to protect their own communities.

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Md Sultan Mahmud is an urban, rural and regional planner by training and profession currently serving as settlement planner in an UN agency at Cox's Bazar.

Khan Rubayet Rahaman is an urban planner by profession and working as an assistant professor in the department of geography and environmental studies at St Mary's University in Halifax, NS, Canada.