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25 Jun 2020

Author: Md. Sultan Mahmud

Why decentralization of covid-19 testing centers are critical for combating the pandemic in Bangladesh?

As global cases of novel corona virus (Covid-19) exceed 7.5 million with confirmed global death toll of more than 431,000 (Until June 14, 2020), scientists emphasize 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 populous countries of the world with a density of 1,104 persons per sq. km. is experiencing the quick spread of the Covid-19 after the first case found on March 8, 2020. So far, until June 14, 2020, total reported case of Covid-19 in the country is 87,520 with a death toll of 1171. 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 needed. Moreover, it helps isolating the known cases to prevent them from coming into contact with others and slows the rate of community spread or transmission. Effective testing programs around the world allow the 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 2-14 days after exposure to the virus as described in several documents, such as: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or throwing up, and diarrhea.

Depending on the testing outcome, a critical decision is to see if they are being considered for enrollment in the hospital or health centers for a 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 meter); (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 critical role to perceive spatial distribution of the covid-19 virus and to take necessary measures immediately. It is worth noting that if there aren’t enough tests, symptomatic patients should get them and may spread the virus to others in the community.

At this point, the question emanates whether 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 centers are spatially distributed proportionately alongside the number of population across the country in order to confirm accessibility for covid-19 testing opportunities for all. According to the recent government data obtained from reliable website, Figure 1 shows that major agglomeration of the Covid-19 testing centers are befallen in and around Dhaka district (30 centers out of 60) in order to serve maximum population. However, major district centers across the country are embracing a sharp rise of Covid-19 infected people (e.g., Sylhet, Jessore, Khulna, Chittagong, Mymensing, and Rangpur). Note that, number of total 60 testing centers across the country may not be in a position to serve the influx of covid-19 infected people in coming days and weeks. Table 1 reveals that there are 60 covid-19 testing centers in order to serve approximately 150 million people in the country. This explains that each testing center is designed to serve approximately 2.5 million people with an imprecise sample of 16,000 per day. Recent data (as of 12 June 2020) indicates that 17.22% of the tested population have covid-19 positive symptoms in their body who are accessing to the testing centers sparsely distributed in the country.

Figure 1, Map of Bangladesh demonstrating the spatial distribution of Covid-19 testing centers (currently operating as of June 15, 2020) in the country. In addition, the map reveals population density in the country. Full size map

Moreover, the data reveals from Table 1 illustrates that in the Barisal 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 remains below 400 per day until June 12 2020 in Barisal, Rangpur, and Sylhet division while comparing the testing facilities in Chattogram and Dhaka division of more than 2,000 and 10,000 tests test respectively. Furthermore, according to 2011 BBS data (see Table 1), it can be depicted that Rajshahi, Mymensingh, and Dhaka division have a population density of more than 1000 people per square kilometers area. However, the covid-19 testing capabilities are not sufficient to serve the huge population in these named divisions. Table 1, Exhibits area in each divisional boundary, population (i.e., total and density), number of testing facilities, and number of total tests as of 12 June 2020 per lac (i.e, 100,000). Data source: Bangladesh Bureau of Statistics (BBS) 2011 by accessing the website www.corona.gov.bd on 12 June 2020.

Why do we need to test widely in diverse geographic locations?

Testing is crucial to figuring out geographically where the infection is and where it is not, and then the knowledge helps directing the public health effort 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 begin to control (e.g., declaring state of emergency, lockdown, or other needed measures) the pandemic 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 the hospitals upon knowing who is or is not infected with the virus. In addition, if a particular geographic location is embracing less number of infected cases; doctors, nurses, personal protective equipments (PPE), and ventilators can be mobilized from that region to another where number of cases are at the pick. A now-ubiquitous term, physical distancing may be ensured with stiff measures where there are more cases found geographically. Instantaneously, testing provides updated data for moving forward in order to make precise prediction of resource allocation, and restricting people to go outside in order to combat community spread of the virus.

Few recommendations for prioritizing spatial decentralization 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 policy makers 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 centers countrywide. As a result, some necessary strategies may help promoting the testing ability of the existing centers at different geographic locations while introducing new testing facilities in order to serve more population spatially throughout the country. For this, government may plan to introduce some additional policies assuming several critical strategies are already in place as:

• Enhancing testing capacity at all geographic locations based on population density by removing regulatory and trading barriers;
• Providing relief aid for the poor people where there are more covid-19 infected people in order to retain people at home for two weeks;
• Stipulating hospital resources in the worst affected geographic locations so that people may receive necessary treatments immediately when required;
• Using cell 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;
• If there are shortages of hospital, clinics, and testing facilities, government may make requisition of schools and similar buildings while repurposing them as testing and quarantine facilities throughout the country;
• Encouraging the decentralization of testing facilities into more local area so that people do not need to travel other cities. It may spread the virus quickly in and out of the facility zones;
• Rapidly scale up the production and distribution of masks at different geographic locations and inspire people to wear them in public places;
• Collaborate and enhance networks among the testing facilities so that they can share their resources according to the need in different geographic locations;
• Update the database every day at all testing facilities. This will demonstrate the need of additional resources at different locations. Moreover, local government may take additional regulatory measures (lock down any specific area for few days) to contest community spread locally;
• 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 neighborhoods;
• A critical recommendation is to introduce the covid-19 testing centers in each districts 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 data availability of infected patients.

Moreover, policy makers and public health workers should work side by side and build a strong collaboration network to report up to date information for local citizens so that people are fully aware about their own area and can 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 test themselves of Covid-19 virus infections. Nonetheless, all major stakeholders should come forward together as a nation under this pandemic to help each other in order to protect their own communities.

Authors of this article:

Md. Sultan Mahmud is an urban, rural and regional planner, and serving in an UN Agency in Bangladesh. He can be reached at the following email: sultan.mahmud@daad-alumni.de

Dr. Khan Rubayet Rahaman is an urban planner and serving in the department of geography and environmental studies at St. Mary’s University, Halifax, NS, Canada. He can be reached at the following email address: khan.rahaman@smu.ca

Disclaimer: This article has been published in bdnews24.com on 25 June 2020.