From clueless to confident: Six months of handling Covid-19 patients

On the night of June 21, the pulse oxygen saturation level of M. Mazibul Haque Kislu had dropped to 65; the normal range is 95 to 100. He had been suffering from fever for the last three days. The drop of the oximeter number meant that the flow of oxygen to his blood and cells was critically low to survive for long.

He was turned on his chest on the hospital bed and immediately hooked up with the central oxygen supply at the Barguna District Hospital. It took three more days to confirm that he had been infected by the coronavirus.

Meanwhile, he had been moved from Barguna to the capital and had to change hospitals thrice. But the life of Mazibul, with a fragile heart, could be saved, an unimaginable feat a couple of months back, said Dr Kamrul Azad of the Barguna hospital. Mazibul is alive but can't be said well. He still suffers from respiratory distress.

It is now six months since the first cases of the Covid-19 in Bangladesh were confirmed by the Institute of Epidemiology, Disease Control and Research (IEDCR). When the government announced a countrywide shutdown in a matter of two weeks after the first identified cases to contain the virus transmission, no one could foresee that the pandemic would stay here for more than a month or two.

But it did. While the many preventive and control measures like test, isolation and contact tracing only underlined the inefficiency of the authorities, there have been success stories as well.

Treatment protocol has been developed, and the government has focused on improving logistics at public hospitals across the country. As a result, experts say, treatment has become accessible for more people with critical symptoms of the Covid-19.

Looking back, a developing country like Bangladesh does not seem to have gone all wrong in dealing with the pandemic. 

The average infection rate over the last 10 days dropped to 15.7% from 18.13% in the previous 10 days. Whereas the average death rate from August 19 to September 7 was 1.37%, 0.03 percentage point higher than that of the earlier 10 days. The recovery rate has also gone up by 5.37%, a review of DGHS data shows.

The steps proved to be right as "we look back"

The lockdown in four wards of Shibchar municipality,enforced by the local administration from March 19 seems to have been the right decision. It prevented the virus from spreading in the area after non-resident migrants returned from hotspots like Italy. Shibchar is an upazila in the Madaripur district, 84km from Dhaka with a population of more than three lakh. 

Similar restrictions on movement were imposed in the capital's Tolarbag at Mirpur, a densely populated area, after the first person who died of the disease was found to be a resident of the locality.

"Those steps proved to be right as we look back," said Kinkar Ghosh, epidemiologist at the Dhaka Shishu Hospital. In many cases, local administrations took prompt measures whereas the health ministry and the Directorate General of Health Services failed to do so, he added.  

The nationwide shutdown was still days away. Migrants workers in the capital were given time to go back to their homes when they had lost jobs and income. Close at hand, many people in the neighbouring country, India at the time died before the coronavirus could kill them as they pitifully walked thousands of kilometres from Delhi and other metropolitan cities to their villages. 

There was a lack of coordination on this side of the border as well. Garment workers set off to join work on foot, motorbikes and pick-ups in the first week of April amid the shutdown when employers decided to open their factories. In the wake of criticism, the garment owners finally backtracked on their decision, making the workers return to their faraway homes once again by any means possible.

Improved hospital management, treatment brought down fatalities

Hospitals were unprepared to deal with patients when doctors, nurses and support staff were wary of the coronavirus infection. Critical patients died, being rushed from one hospital to another in the absence of the guidelines as to who should be treated where.

Later, panicked people with mild symptoms or no symptoms crowded the dedicated hospitals for Covid-19 treatment while critical patients could not be given a bed.

Over time, doctors and nurses have become seasoned and they now screen patients thoroughly before admitting them. That has eased the pressure on hospitals, said Sami Al Hasan, a doctor at Kurmitola General Hospital.

Besides, most people now prefer to stay home with mild symptoms since they have more information on the nature of the disease and they now know that a majority of the patients – 80%-- get well without suffering any critical health condition. 

Back in May and June, severely-ill patients had to wait for a bed in intensive care units to get uninterrupted oxygen supply. When the DGHS pledged to set up more ICU beds, doctors repeatedly demanded installation of central oxygen supply lines at public hospitals to save Covd-19 infected patients.

Eventually, many hospitals, including the Kurmitola hospital in the capital, got the system installed.

A hundred patients having moderate symptoms get oxygen support simultaneously while undergoing treatment at two wards. Two more wards are being equipped to provide support of that standard.

The six-month-long experience has also boosted the doctors' knowledge about treatment.

In the initial days of the pandemic, doctors observed that a few patients deteriorated fast on the 12th or 13th day after contracting the virus. Doctors were puzzled at this sudden dip in condition as it did not match with anything they knew.

"We literally adopted major changes in treatment as we went along as there was no information about the Covid-19 in textbooks. Our everyday experiences taught us how to treat patients," said Dr Md Harun Ur Rashid, the registrar of the ICU at the Kurmitola Hospital.

A significant development has been the reduction of unnecessary use of drugs. Doctors are more decisive and selective now when it comes to prescribing plasma therapy or drugs like Remdesivir.

Two to three of every 10 patients at the ICU, as Dr Harun observed, also suffer long-term or permanent damages to their lungs. They need prolonged medical supervision. Doctors can identify them and administer medicine and treatment now more readily. 

All these measures have brought down the death rates at the ICU. Though no study has been conducted yet to statistically back up such a claim, Dr Harun guesstimated that the ICU fatality at Kurmitola General Hospital came down to 50-55% in recent days from 75-80% in April and May. 

What to do next

The World Health Organization, in the meantime, has completed six months after it first announced a global health emergency from Covid-19 in January. There were fewer than 100 cases outside China and no deaths at the time.

Global infection figure was 2.72 crore people on September 7. The death figure stands around 8.8 lakh on the same day at the time of writing this report.

In a speech acknowledging the landmark, the WHO Director-General Dr Tedros Adhanom Ghebreyesus highlighted the ongoing need for vigilance and preventative measures as the virus continues to accelerate.

Dhaka Shishu Hospital Epidemiologist Kinkar, however, thinks that flattening the curve through test, isolation and contact tracing is not possible in Bangladesh, given the limited logistics and resources. 

When transmission has been high at the community level and there are threats of virus infection from asymptomatic patients, the best move could be to make people aware so that they follow the health safety rules like frequent hand washing, wearing masks and avoiding crowds.

"There is a long journey ahead before a vaccine will be available to us. We have to prepare well to ensure best utilization of a vaccine," Kinkar said.

For that research should begin immediately to find out how many have possibly got infected once, how many have antibodies and how long the antibodies protect people against the virus. Because as the virus travels from one continent to another or from one country to another, it mutates. Mutations also change its strength.

"We need to know more about the virus infecting us. Unless we do that, we won't be able to take advantage of a vaccine," Kinkar said.

So far, Bangladesh has had 3,27,359 people confirmed infected as of September 7, 2020. The death toll was 4,516 on the day.