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30 March, 2020 12:36:29 PM
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Some suggestions to manage COVID-19

Maintaining minimum personal safety measures is expected from health professionals in their workplace at all times
Mohammed Abul Kalam, Ph.D.
Some suggestions to manage COVID-19

I learned a long time ago that there is something worse than missing the goal, and that's not pulling the trigger. Mia Hamm, a professional soccer player, Olympic gold medalist.
While we may not have seen the novel coronavirus and Covid-19 respiratory disease before, we have certainly seen the damage infectious disease threats pose. Given the trajectory of the COVID-19 pandemic, there is growing concern about the potential inability of health care personnel, equipment, and resources to keep pace with the need for life-saving treatment, acute hospital care, and intervention. What do hospitals and providers do when there are insufficient resources to provide care for all? Who decides who will receive treatment? What is fair and equitable? What is legally permissible? Crisis Standards of Care (CSC) planning and guidance can help providers address these and other critical issues that arise when health care systems are in crisis operations. In Bangladesh, there is none to address scarce resource allocation including, ethical decision-making, provider liability and other legal issues, and the role of Crisis Standards of Care.
Lockdown versus social distancing: It appears that in lockdown all movement within a geographical area (or small pockets) is suspended. Though many countries have done lockdown but are it showing any slowdown of propagation or is it increasing propagation within that community? The main focus should be social distancing within a social network for a minimum of 3 feet or 1 meter. Any household identified to have a diseased or exposed person may be marked by a red flag to inform others to avoid close contact and maintain social distancing strictly. The main disadvantage of lockdown is that exposed and/or diseased persons feel free to move around within that community or family and in the process expose/spread the disease more. Secondly, healthy people are psychologically traumatized leading to panic. Persons suffering from other conditions being unable to access healthcare are also physically and psychologically traumatized. Further, daily life activities are interrupted causing suffering for unaffected persons who could care for the diseased. Hence, the main message should be social distancing.  

Attitude and safety of health professionals: Maintaining minimum personal safety measures is expected from health professionals in their workplace at all times. Mask, gloves, cap, apron are a must in any normal situation. In times of crisis, the Government may support the effort. But do we practice it? As an alternative, a selected group of health workers in a health facility may be identified to care for those reporting with fever and dry cough (not with sneezing as this is not the usual symptom of COVID-19). These workers may be provided with the whole gamut of PPE, leaving the other health workers to care for other patients maintaining social distance. This will hopefully boost health workers’ morale.

PPE for confirmed or suspected COVID-19 cases: Currently everyone is concerned about PPE for all health workers and the general community. Here, the emphasis is required to contain the source/reservoir of infection that is, confirmed and suspected cases of COVID19. They are the ones who need PPE to stop any further spread and to break the chain of transmission.

Contact tracing through social network analysis: As this is an exotic viral disease, all incoming travelers from other countries were either quarantined or isolated (as the case may be), despite which some persons evaded the instructions and actively came in contact with other persons who were within their social network. Social network tracing may be done by field-level health workers, and field-level local government representative (Chairman, Member, Councilor…) to bring the contacts under active surveillance. Earmarking the household/residence with a red flag may be helpful. As the COVID-19 is diagnosed based on three dominant symptoms – fever (about 88 per cent), dry cough (about 68 per cent) and breathing difficulty (about 19 per cent), so anyone within the social network who is found to have fever and cough will be reported by the field health worker and local government representative to the local administration and health manager of the area. Restraining the suspected exposed persons may then be ensured.  

Syndromic management: The common manifestation of the viral or allergic condition affecting the respiratory tract are fever, coughing, sneezing, malaise, running nose, sore throat…. So, anyone suffering from these symptoms may be advised to stay at home and follow syndromic management with commonly available drugs, like paracetamol, nonsedative antihistamine (e.g., fexofenadine), and steam inhalation. Only when breathing difficulty develops in such patients it indicates pneumonia due to lung tissue debris, which calls for immediate medical attention at the nearby health facility preferably in secondary and tertiary level health facilities where isolation and ventilatory support are available.

Elderly with the comorbid condition: Our social system is such that the elderly are cared for within the family setup. The elderly may have associated long-standing comorbid conditions like heart disease, lung disease, kidney disease, diabetes…. Epidemiological evidence from other countries shows that the elderly are more vulnerable. So, all elderly (with known or unknown comorbid conditions) may be advised to stay home and avoid mixing with people and continue with their normal medications (if any). For any further medical support needed they may contact field-level health workers or field level local government representatives to bring them under required treatment. In the current situation, health facilities may designate a corner where the elderly may seek treatment on a priority basis.  

Shutting down of community utility-service facilities: Shutting down of some government and non-government utility facilities, except essential services, maybe evaluated at intervals in the current situation.The initiative may be taken to arrange offices in shifts (2-3 shifts) with a short duration. All privileged transports (including entitled transports) may be withdrawn, and all transports are converted to shared ones to conduct activities in shifts.  

Barter trade Communities may be encouraged to conduct barter trade – one commodity in exchange for another. This may help limit the movement of people, and help the community to survive the crisis. This may be applicable at the village level particularly.  Community transmission: As is seen that transmission is occurring within the community, that is, from the incoming traveler to the household members and other contacts → to the next level of contacts. It is high time that the government acknowledge the presence of community transmission and take up measures accordingly.  Quarantine leave The service rules mentions a ‘quarantine leave’, which over the years appears to have lost its utility. This leave may be revived to assure the service holders (government and private) that if and when quarantined, they will not have to face wage loss or loss in seniority.  

Media hype:  The varied media messages regarding ways of the spread of COVID-19, ways to tackle infection, treatment modalities, the response of health facilities, decisions by the government… appear to be confusing at times. This may increase panic and/or reluctance to adhere to the more relevant messages among the public. Moreover, this may also create a negative attitude among health workers. If the media does find some new information or ways to tackle the current situation, they may inform the concerned within the Government so that it may be picked up or modified to suit the Bangladesh situation, and implemented if necessary.  

Result based management plan (contingency plan):Inter-ministerial initiative may be taken for a result based management plan to interrupt the chain of infection of the novel coronavirus. Emphasis has to be given to three dimensions – source (respiratory secretion)/reservoir (human or animal) control, blocking the channel of transmission of the virus, and protection of the susceptible host. This plan will include the desired outcome with the necessary priority-based fund allocation.

I believe the true number of Bangladesh cases could be higher than reported by the IEDCR. Why? Because the IEDCR/Bangladesh isn’t ­­­­testing enough to get a true picture. No country has controlled transmission effectively without massive testing capacity.” This week it's going to get worse, I am afraid!

The writer is former Head, Department of Medical Sociology,

Institute of Epidemiology, Disease Control & Research (IEDCR)

Dhaka, Bangladesh

E-mail: med_sociology_iedcr@yahoo.com

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Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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