COVID-19: transmission, diagnosis, policy intervention, and potential broader perspective on the rapidly evolving situation in Bangladesh

On December 30, 2019, a series of viral pneumonia case of coronavirus infection was reported in relation to the Huanan Seafood Wholesale Market (South China Seafood City Food Market) in Wuhan, Hubei province, China. A week later, on January 7, 2020, the virus was isolated from the infected patients by Chinese Centre for Disease Control and Prevention (CCDC), which was initially referred to as novel coronavirus 2019 (2019-nCoV) because of being the new viral strain among their belonging family but given the official name ‘COVID-19’ by World Health Organization (WHO) on February 12, 2020 [1]. On January 20, China reported death of three COVID-19 patients and more than 200 infections, with cases also reported outside Hubei province including in the capital Beijing, Shanghai and Shenzhen. On January 21, 2020, WHO announced that COVID-19 could be transmitted by human-to-human transmission, urging the public to take measures to protect themselves from COVID-19. Elsewhere, a Chinese infectious disease specialist reported human-to-human transmission to state broadcaster CCTV, raising fears of a major outbreak as millions traveled for the holiday of the Lunar New Year [2]. The ongoing pandemic of COVID-19 confirmed to have spread in Italy on January 31, 2020, when two tourists of China were tested positive for the virus in Rome. On February 21, 2020, 16 cases were confirmed in Lombardy, with 60 additional cases and first death was found on 22 February [3]. Nepal, which reported its first instance of COVID-19, on January 24, 2020, in a man who was from China on January 5, 2020, was the first country to register a confirmed case in South Asia. From June 29, 2020 on, in every country of South Asia, one or more cases of COVID-19 were reported. On March 2020, it was confirmed that the pandemic COVID-19 had spread to Bangladesh. The Institute of Epidemiology, Disease Control and Research (IEDCR) reported the first three known cases on March 8, 2020 [4]. As of June 29, 2020, the COVID-19 had affected 213 countries and territories worldwide, with more than 10 million confirmed cases leading to more than 501,562 deaths and 5.6 million recoveries [5]. In a nation such as Bangladesh, in order to assemble resources and respond to those on time, early strategic planning and groundwork for evolving and setting up problems are crucial. In this review, we highlighted the transmission of COVID-19, vulnerable people for COVID-19, diagnosis, active steps taken by government officials, and possible wider consequences of COVID-19 outbreak till June 29, 2020; hoping to provide a guide for future studies and help in the prevention and control of COVID-19 pandemic in Bangladesh (Figure 1).

Bangladesh has confirmed its first cases of the COVID-19 as three persons were infected with the virus, including two members of one family, two of the people being infected are expatriates who have returned from Italy and the other one is a member of their family, which the Institute of Epidemiology, Disease Control and Research (IEDCR) reported to the media on March 8, 2020 [6]. The COVID-19 detection system in Bangladesh involved instability and lack of coordination, and a solution had not been found in almost last four months of the COVID-19 outbreak that had spread from Wuhan in China [7]. While the government of Bangladesh has taken measures to identify people infected with coronavirus, various departments, including those at various airports, are in complete clutter setting. Just three thermal scanners were mounted in Dhaka and one at Sylhet and Chattogram airports each to screen a large number of inbound passengers. It was reported that the UNICEF official’s arrival at the airport, her temperature was tested by a hand thermometer and no different queue maintained for female passengers [8]. A further three COVID-19 patients were identified in Bangladesh on March 16, 2020, including two females. Five more cases of COVID-19 had been identified as of March 19 and all were members of one Italy returnee’s kin. There were three more cases reported on 20 March, one female and two males, among whom one was a Bangladeshi, who came back from Italy and another patient was kept in the Intensive Care Unit (ICU). At a press briefing, the health minister of Bangladesh told that China had offered assistance by providing masks, test kits and other required materials to encounter the ongoing pandemic of COVID-19. Seven new cases were reported on March 22, 2020, among which four are abroad returnees and one of them was contaminated by the other infected person coming into contact [9]. Until the end of March, infections remained low but steeply increased in April. In both the number of cases detected and the number of deaths, the country had the highest number of positive tests to date on April 6, 2020, with 35 new detected cases and 3 new deaths, raising the number from 88 to 123 and from 9 to 12, respectively. New cases in Bangladesh grew by 1,155% in the week ending on April 11, 2020, with 186% being the highest in Asia, ahead of India, Indonesia, Thailand and Sri Lanka [6]. The total number of people infected in Bangladesh reached 10,143 and the total number of deaths was increased to 182, with five deaths across the nation on April 11, 2020 [10]. COVID-19 cases reached 10,000 marks in Bangladesh on May 4, 2020, and a record 688 infected individuals were found in one day. Bangladesh hit a record of 1,202 new affected cases, crossing 20,000 marks on May 15, 2020, while the total number of cases of coronavirus in Bangladesh was reported 20065, with a total of 298 deaths. Bangladesh crossed 40000 marks on May 28, 2020, with 2,029 new cases being reported on a single day, and till then in Bangladesh, there were a total of 40,321 COVID-19 cases, with a total of 559 deaths. Bangladesh crossed 60000 marks on June 05, 2020, recording 2,828 new cases of COVID-19 in one single day, leading the total number of cases in 60,391 with 30 more deaths, increasing the death toll to 811, having 643 recovered patients and a total of 12,804 recoveries in Bangladesh. Bangladesh reached a reported 80,000 marks on June 12, 2020 with 3,471 new cases of COVID-19 in one day and an overall figure of 81,523 cases of Bangladesh with 46 more cases of dead, and a total death count of 1,095 with 502 new recoveries, having the total number of 17,249 recoveries. On June 13, 2020, in Bangladesh, the number of cases was higher than the number of cases in China, the country where the outbreak began.
With a record of 3,803 new cases affected, Bangladesh crossed 100,000 marks in a single day on June 18, 2020. As of June 29, 2020, a record of 4,014 new cases had been registered, leading the total number of COVID-19 cases to 141,801. With 45 more death cases, the total death toll stood up to 1,783, with a total of 57,780 recoveries around the nation [6] (Figure 2).

Bangladesh reported the first death of the COVID-19 on March 18, 2020, the victim being a man in his early seventies, amid growing public concern about the government’s preparations to control the spread of the virus [11]. The death came 11 days after the first case of coronavirus had been confirmed by the country. It was reported by IEDCR that the man had underlying health problems and was contaminated with one of his relatives who had returned from Italy. The first person who died from the COVID-19 in Bangladesh was at the ICU in a private hospital in Dhaka and had several pre-existing health complications, such as Chronic Obstructive Pulmonary Disease (COPD), hypertension, heart disease, had a stent implanted in his heart and also diabetes [8]. On March 21, 2020, Bangladesh announced the second death, a 70-year-old man, from COVID-19 in the country. It was reported that few members of the victim’s family had returned from Italy and Japan and was diagnosed with comorbidity, had been receiving treatment at a hospital in Mirpur until he died from COVID-19 [10]. An older woman in her early sixties with signs of COVID-19 died in Bangladesh as the 3rd death of COVID-19 on March 23, 2020.On April 20, 2020, Bangladesh reported ten more deaths due to COVID-19, bringing a three-digit mark on its death toll, with a number of 101, a total of COVID-19 deaths in the country, warned by the experts that in view of the growing number of death cases a visible scenario could be the tip of an iceberg [10]. On May 25, 2020, Bangladesh reached a distant landmark of 501 deaths from COVID-19. A total of 53 deaths in one day from COVID-19 was witnessed in Bangladesh on June 16, 2020, were the greatest number of deaths a day recorded. Deaths due to COVID-19 reached the country’s bleak 1000 threshold on June 10, 2020.The death toll reached 1,502 on June 22, 2020 with 38 more deaths registered on that day, and as of June 29, 2020, the death toll increased to 1,787 individuals due to COVID-19 in Bangladesh [5, 6]. The elderly people and individuals with pre-existing medical conditions tend to be more vulnerable to the virus and become seriously ill [9].
As of June 29, 2020, the highest death rate of 30.1% is registered of the people who died of the disease to date were among the age group of 61-70 years. Followed by 24.9% death rate among the 51-60 age group, 16% among the 71-80 age group, 11.6% among the 41-50 age group, 7.5% among the 31-40 age group, 5.1% death rate recorded among the age group of people who were above 80 years, 3% among the 21-30 age group, 1.1% and 0.5% among the age group of 11-20 and 0-10 respectively [12]. With age, immune systems are weakening, leaving the older individuals at a significantly higher risk of developing serious complications from a respiratory disease, stated by the officials of public health. Of the total number of people infected with COVID-19 till June 29, 2020, the infection rate is high among the people of 31-40 and 21-30 age groups at 27.6% and 23.1% respectively, while the 3rd highest rate of infection is 18.5% among 41-50 age groups of people. The 4th highest infection rate is registered as 13.7% among the 51-60 age group of people, while the infection rate remained 6.4% as the 5th highest in 61-70 age group, followed by 5.6% among 11-20 age group. The infection rate is 2.6%, 2.1% and 0.7% among the 0-10, 71-80 and above 80 age groups respectively [12]. As of June 29, 2020, among the total number of confirmed cases, 69% infected individuals were registered as men and the rest 31% as women, while 80% death cases reported were men and 20% were women [12] (Figure 3).
It was stated by Dr. Li Zhang of the Chinese Centre for Disease Control and Prevention (CCDC) that men may have been more likely to be exposed to the virus at the start of the epidemic, for social or cultural reasons where women’s reduced vulnerability to viral infections could be due to the defense of X chromosomes and sex hormones which play a major role in immunity [13].
By June 29, 2020, 100% (141,801/141,801) of the cases were subject to confirmed COVID-19 regional spread; of which 70.6% (21,079) of the confirmed cases were registered from Dhaka division, followed by 14.1% (4,731) from Chattogram division, 3.7% (656) from Rajshahi division, 2.9% (505) from Khulna division, 2.8% (663) from Sylhet division, 2.2% (992) from Mymensingh division, 1.9% (857) from Rangpur division, and 1.8% (231) from Barisal division, demonstrating ‘Dhaka’ as the most vulnerable division for COVID-19 [6, 12].
The doubling time of the confirmed cases can be used for concluding the rapid spread in Bangladesh of the COVID-19 pandemic. Parameters are represented to us to see that in various divisions in Bangladesh, the number of reported cases increased quickly. As of June 29, 2020, the time in which the cases are doubling in Dhaka division is 7 days, and in Chattogram division is 7.5 days, while in Khulna, Sylhet, Rajshahi division is 8 days, and the case doubling time is 9.5 days in Mymensingh, Rangpur and Barisal division [12] (Figure 4).

COVID-19 is being diagnosed by next generation sequencing, real-time RT-PCR, cell culture, and electron microscopy in human clinical specimens all over the world [13]. There are currently several NAAT (Nucleic Acid Amplification Test) multiplex tests available commercially to identify pathogenic species in respiratory specimens in clinical virology laboratories [14-16]. The preferred method for the diagnosis of COVID-19 is the real-time reverse transcription-polymerase chain reaction (RT-PCR), which uses a nasopharyngeal swab or sputum sample sequencing [14].
Experts criticized the lack of tests carried out in this country with more than 160 million inhabitants. Newspaper and social media continued reporting further deaths of COVID-19 symptoms than the deaths reported due to COVID-19 [7]. Certain deaths were treated in COVID-19 isolation centers, while some were denied treatment in the districts, but no tests were carried out to confirm infection. Earlier, only the Institute of Epidemiology, Disease Control and Research (IEDCR) had operated COVID-19 testing in Bangladesh [10]. It was stated by Dr. ASM Alamgir, principal scientific officer of IEDCR that nasal and throat swab samples were taken from the patient at first, sample collectors were then sent from Dhaka who are experienced in collecting respiratory samples, and then the samples were processed via real-time RT-PCR, a laboratory technique for in vitro qualitative detection of COVID-19, which were only available at the IEDCR in Bangladesh [6]. The US Centers for Disease Control and Prevention suggests using a laboratory of BSL 3 (Biosafety Level) when dealing with live viruses. In Bangladesh, two BSL3 laboratories are labeled, one at ICDDR,B and the other at IEDCR [7]. COVID-19 testing was centralized for a long time only in the IEDCR, in the capital Dhaka, although symptom patients were reported all over the country [7]. The Directorate General of Health Services (DGHS), previously, had not allowed private laboratories to conduct COVID-19 tests because they might be more interested in doing business than assisting in the crisis [10]. At first, COVID-19 research facilities were in Dhaka alone, and there was no intention to extend them outside of capital due to lack of qualified staff. The former regional adviser of WHO, Muzaherul Huq, by the end of March, advised to equip the large hospitals and institutions in the country, such as – Bangabandhu Sheikh Mujib Medical University Hospital, Combined Military Hospital, ICDDR,B, Dhaka Medical College Hospital, Chattogram Medical College Hospital, Khulna Medical College Hospital, Rajshahi Medical College Hospital, Barishal Medical College Hospital, Bogura Medical College Hospital and Rangpur Medical College Hospital to test COVID-19 in Bangladesh [5, 10].
In Bangladesh, the number of COVID-19 testing laboratories have only risen over time and approximately, 4,410 tests per million people have been carried out till June 29, 2020, that are still not enough. By June 29, 2020, a total of 751,034 COVID-19 tests were conducted by 67 laboratories, with a total positive rate of 22.5% in Bangladesh (36 laboratories in Dhaka and 32 laboratories in other divisions of the country) Laboratories inside Dhaka city tested 63.1% of all the samples of COVID-19, whereas, 37.9% of the samples were tested from laboratories outside Dhaka [12] (Figure 5).
Gonoshasthaya Kendra, a Bangladeshi private hospital, had reported to develop Rapid Dot Blot, by a technical team of Gonoshasthaya-RNA Biotech Limited, a low-priced testing kit that could analyze samples to detect Covid-19 as quickly as in 15 minutes on March 18, 2020, at a cost of Tk 2 crore. The kit developed by Gonoshasthaya-RNA Biotech Limited in Bangladesh was similar to one developed by scientists in China in January 2020, as the COVID-19 outbreak escalated in Hubei province in China. The kit uses the Rapid Dot Blot technique to identify positive cases of COVID-19 within 15 minutes and searches for antibodies that are produced in the body, in response to infection with the virus and would approximately cost less than $3 dollar. As the rapid test is based on the presence of appropriate antibodies in the blood, factors such as duration of the test, existing infections, a person’s immune system, cross-reaction with certain antigens may lead to false results. RT-PCR, under normal circumstances, is the only ‘gold standard’ test for COVID-19 detection but the current situation is far from normal, and so, countries like Bangladesh suffer from intense COVID-19 test kit crisis, a rapid dot blot test could be given a fair chance [10].
In Bangladesh, On May 27, 2020, The Designated Reference Institute for Chemical Measurements (DRICM) developed viral transport media or VTM kits and reported that the chemical materials used in VTM kits are easy to collect, transport and preserve. They had supplied 5,000 kits to the Directorate General of Health Services or DGHS. The collection includes pipeline, nasal and nasopharyngeal swabs and oropharyngeal swabs. They also possess a tongue holder for easy oropharyngeal swab collections and can store samples for three days at a temperature of 4 degrees Celsius. The kits are hoped to reduce the risk of infection and contamination of samples among health workers. Such kits could also save the money used for importing swabs and tubes from Bangladesh [10].

After three confirmed COVID-19 cases diagnosed in Bangladesh, the government had put in place preventive measures to combat the spread of the deadly COVID-19 strain that has shaken the world. On March 9, 2020, Prime Minister Sheikh Hasina urged the people of Bangladesh to avoid mass gathering to protect themselves from COVID-19 and instructed them not to panic [11]. Following the first discovery of cases of COVID-19 in Bangladesh, the year-long programs taken to mark the centenary of the birth of Father of the Nation Bangabandhu Sheikh Mujibur Rahman during the ‘Mujib Borsho’ had been rearranged in public health considerations [8, 11]. The March 17 grand rally – Mujib Borsho’s flagship event – at National Parade Ground was postponed hours after the country had announced the first cases of COVID-19 on March 8, 2020, and the inauguration program had taken place in a scaled-down manner [7-8]. On the occasion of the centenary of birth of Bangabandhu Sheikh Mujibur Rahman, the T20I series between World XI and Asia XI was postponed as a precautionary measure to avoid spread of COVID-19. The Bangladesh Ministry of Education had declared to shut down all educational institutions until 31 March, and the Dhaka University from March 18 to March 28, on March 16, 2020 to avoid spreading of COVID-19 [8]. Following India’s decision to suspend all visas, with the exception of a selected few groups, the current cross-border passenger train and bus services in Indo-Bangla remained suspended from March 15 to April 15, 2020 [8]. Bangladesh suspended flights to all European countries except the UK on March 14, upon returning from Italy and Germany, two more people tested positive for COVID-19 [8, 17]. The government of Bangladesh locked down vulnerable Shibchar upazila in Madaripur district on March 19, 2020, as three more COVID-19 patients were found there. On March 21, 2020, authorities locked down Mirpur Darussalam’s Tolarbagh neighborhood in the capital, hours after COVID-19 second death was reported from the city, with four new cases of COVID-19 found on March 21, 2020 [8]. The government of Bangladesh had commanded to close all bars, hotels, restaurants and clubs until March 31, 2020, expecting to curb the COVID-19 outbreak [11]. Government agreed on March 21, 2020, for the cancellation of all major events on March 26, 2020, to commemorate the Independence Day of Bangladesh. To avoid COVID-19 from spreading, the government declared a 10-point guideline, including a general holiday for both public and private offices from March 26 to April 04, 2020, and the armed forces were deployed to all districts from March 24, 2020, to support the civil administration until further instruction on March 23, 2020 [8, 11, 17]. For students from class six to ten, the Government has taken a special step to offer video lessons. This initiative, ‘My School at My Home,’ enables students to take subject-specific video lessons in Sangsad TV at home [10, 18].
A joint effort by five organizations to manufacture four lakh equipment was made earlier for medical doctors and nurses about the lack of personal protective equipment (PPE) in Bangladesh. The government had supplied over 2.5 million personal protective equipment (PPE) to protect caregivers and doctors. However, by the end of June 29, 2020, there are 1,235,772 PPE in stock. The government also gave doctors and nurses special training in fighting this pandemic. The teaching has now been provided by over 3.7 thousand physicians, 1.5 thousand nurses and healthcare technicians from over 500 schools. Furthermore, 10,812 physicians have completed COVID-19 online courses till the start of June 2020 [5, 6, 10].
The DGHS reports that, from June 29, 2020 onwards, 629 centers across 64 districts, with 31,991 individuals capable of receiving the existing institutional quarantine capacity in the nation. A total of 18,864 people placed in quarantine facilities, 14,302 (75.8%) of whom were released. As of June 29, 2020, in total 25,838 individuals had been isolated in specified health facilities in the country, with a release of 10,896 (36%), and total of 12,464 (57.8%) still remaining in isolation facilities [10, 12]. On April 24, 2020, the highest number (6,547) of persons were reported on quarantine facilities and the figure has currently been reduced to 4,562.In total, 342,460 people were placed under home quarantine in every region from March 17 to June 29, 2020, with a release of 82.4% (282,063/342,460) to date. There are presently 21.4% (60,397 individuals) in home quarantine (Figure 6).
Apparently, COVID-19 had spread to the community transmission level in Bangladesh, reported by IEDCR. The authorities kept sticking to their argument that there was no community transmission in the region, but experts said that, too few studies had been done to reach that conclusion and recommended that the Government had to carry out more studies in all regions of the country to determine the transmission standard, and when the number of COVID-19 tests were increased, the verdict came true. The supplementary table below shows the key steps that the government has taken from January through June to counter against COVID-19 evolving situation in Bangladesh (Table 1).

With the COVID-19 pandemic unfolding in Bangladesh, there is increasing concern among people as public health experts had said the government lacked clarity in portraying the actual scenario. The former vice-chancellor of Bangabandhu Sheikh Mujib Medical University, Professor Md. Nazrul Islam, stated that the government had resorted to a ‘bureaucratic trickery’ to hide the realistic situation of COVID-19 in Bangladesh. Transparency and adequate preparedness help to keep citizens and the various authorities aware and make informed choices, but the urge to hide information or behave like the proverbial ostrich could only make things worse in this COVID-19 pandemic [10].
Relevant age group data on percentage of cases needing hospitalization, critical care, and infection fatality ratio, we can estimate these rates in Bangladesh based on population age structure [19]. It is estimated that if one percent of the total population is infected with COVID-19, nearly 1.7 million people will be infected in Bangladesh, including physicians and healthcare staffs and scientists warned that, it has the potential to double within seven days as this strain of COVID-19 would inevitably fail and overpower the potential of the existing healthcare system in Bangladesh [20-21]. COVID-19 has brought a dramatic downturn in the world’s overall lifestyle and economy in which Bangladesh has also become a victim as the rapid spread of the virus and its lethal impact made it clear that it has the capability to destroy the economy [21-22]. Asian Development Bank (ADB) estimates that Bangladesh might lose up to $3,021 billion if the current global COVID-19 epidemic turns to the worst and expects the loss would be $8.0 million in the best case and $16 million, or 0.01 per cent of GDP if it ends moderately. In the sectoral scenarios in particular, the largest GDP losses and job cuts in the business sector, including the banking, industrial and public services industries, would be $1.14 billion and 2,00,106 people respectively, followed by agriculture ($637 million, 4.58 million people), tourism ($510 million, 50,000 people), construction and utilities ($400 million, 1.18 million people) and transport service ($334 million, 67,000 people) in Bangladesh [21-23].
With the economy of Bangladesh so much dependent on China, it is apprehended that the COVID-19 outbreak may have serious consequences for Bangladesh. UNCTAD has estimated that if Bangladesh’s intermediate input imports from China decrease by 2 percent due to COVID-19, it will cost Bangladesh $16 million and probably more [19]. Leather industry will lose $15 million, The textile and apparel sector will experience $1 million loss in Bangladesh. The ADB has predicted that in the worst-case scenario, Bangladesh will lose around 1.1% of its GDP when the outbreak lasts for at least six months. It implies that COVID-19 will take $3.02 billion off the economy of Bangladesh. Furthermore, it is also apprehended that a global economic downturn could lead to 4 million (approximately) job losses [23]. COVID-19 pandemic is taking a heavy toll on Bangladesh, which is the second of clothing worldwide as the textile industry is increasingly losing orders and millions of jobs are at stake [22]. On a different note, driven by the COVID-19, the global shutdown has shuttered factories and limited travel, slashing lethal emissions from greenhouse gases that heat the atmosphere. It was stated by François Gemenne, Director of the Hugo Observatory, which studies the correlations between changes in the climate, human migration and politics, that the lockdown will save more lives from pollution mitigation than the threatened COVID-19 itself [24].

Due to social structure, economic capacity and resources, the response of different countries varied. That’s why, due to its political structures, the UK strategy to combat the COVID-19 may not be the same as China. As the number of infections has increased exponentially in the following days, Bangladesh started to face crucial circumstances. The current healthcare infrastructure in Bangladesh was however also claimed not to be very strong under the Guidelines of the WHO, and, in the case of community spread of COVID-19, the government of Bangladesh may face difficulties in managing spread in the wake of a changing situation. Bangladesh alone, without the necessary support from society and private sectors, would be an unlikely challenge for the government to combat the menace Indeed, government, non-government, independent, private, philanthropic individuals, industrialists, celebrities, sportsmen, volunteers and ordinary people are all supposed to work together in the fight against the fearful COVID-19. In addition, along with the state, citizens must preserve social isolation, their personal awareness, their basic hygiene, their self-quarantine condition and respect national and WHO laws.

None

MB conceived and developed the concept of the study. The conception and design of this research were made by MB, FBM, MSR, SD, SK, MFH and UKA. FBM wrote the draft of the manuscript. MB & SK analyzed the data. The review of the manuscript was performed by MFH, UKA, FBM, and MB.  All authors read and revised the article, and MB approved the final manuscript and hence worked as a corresponding author.

The authors do not declare any conflict of interest.