Withdrawal of lockdown: how we should plan

Lockdown, first instituted by the Chinese government, has become an unprecedented yet effective intervention for prevention of the transmission of Covid-19 throughout the world. At present, about 3 billion of the 7.8 billion world population are experiencing different forms of lockdown. In public health, the preventive non-pharmaceutical measure of physical distancing for transmission interruption are "quarantine" and "isolation". The lockdown is neither quarantine nor isolation; it is an emergency protocol initiated by an authority that usually prevents people from leaving an area. During the last four months, different countries have applied lockdown in different ways and means, and also in different names—starting from a "single house lockdown" to a few houses, a community, town, city, region or even an entire country. The duration has varied from parts of days, whole days, weeks and even months.

Bangladesh has been maintaining a form of lockdown for over a month, since March 26, 18 days after the first coronavirus case was reported on March 8. According to recent reports, this will continue up to May 16, after which there will be a gradual withdrawal. The late closure of international flights, noncompliance with institutional or even home quarantine, uncertainty regarding the magnitude of infections carried in by migrant workers, grossly inadequate testing, insufficient preparations to handle a potential surge in number of patients and the growing insecurity among citizens probably influenced the Bangladeshi authorities in instituting the lockdown in March.

This lockdown was the most effective decision taken so far and possibly contributed to curbing widespread transmission of infections in the absence of proper "trace, test and treat" measures. There were some hiccups in planning and implementation—terming it a "holiday" led to a mass exodus from cities to villages in the midst of a festive mood, and confusion amongst RMG factories led to great grievances for workers, who have travelled back and forth despite the shutting down of public transport in fear of losing their jobs. While the lockdown has in general been quite rigorous, people roaming around in paras and mohollas have created concerns and become attractive news items and topics for talk shows. In contrast to the popular consensus on the ineffectiveness of the lockdown due to these breaches, as a public health specialist, I am happy with the lockdown in preventing inter-geographic transmission, although it was ineffective in intra-transmission within communities and was not really meant to prevent that.

Since Bangladesh has been debating on withdrawing the lockdown, how should we plan going forward? The World Health Organisation (WHO) released new guidance for governments looking for exit strategies beyond existing lockdown measures. Six criteria were identified by the WHO to ensure that governments would be able to manage a controlled and deliberate transition from community transmission to a steady state of low level or no transmission. If the Bangladesh government wants to start lifting restrictions, they must first meet the following six conditions.

Firstly, is transmission of Covid-19 under control? If we consider the curve representing reported cases, it becomes evident that the country is in an exponential phase. The increasing number of infections among healthcare providers and other service personnel makes them at risk of being super spreaders and contributing to sustained transmission. Secondly, do we have the public health capacity to detect, test, isolate and quarantine every case and trace every contact? With certainty, it may be stated that the health system is not in a position to do so.

Are hotspot risks minimised in highly vulnerable places, such as nursing homes? Bangladesh does not have many nursing homes, so this condition may not be applicable, but we could demonstrate our success in managing the few hotspots and clusters that have arisen through implementing effective lockdown. The fourth criteria that has to be met is—have preventive measures such as physical distancing and hand-washing been established in workplaces? In Bangladesh, it will take effort and time to implement proper hand-washing facilities everywhere, whereas physical distancing is almost impossible due to congested workspaces.

The fifth condition is—are risks of newly imported coronavirus cases from travellers controlled and managed? If we refer to the past, there is a possibility of ineffective controls and mismanagement in dealing with new cases from outside or within the country. Finally, are populations fully engaged and empowered to live under a new state of "normality"? This will be put to the test in the days following the easing of lockdown conditions. We are yet to make people understand the pandemic through a scientific approach. The risk communications adopted were mostly not consistent with public health norms and local contextualisation created confusion and noncompliance of preventive and protective measures like quarantine, social distancing and the use of personal protective equipment (PPE).

Regardless of easing the lockdown, there should be strict disease surveillance until we are certain of being in control of transmission, and those at risk should be assessed through epidemiology and laboratory testing. Public health capacity should be significantly increased, and a huge number of public health specialists should be involved in leading preventive interventions. The tracing capacity has to be scaled up to catch every exposed personnel on the frontlines. Laboratory testing capacities also have to be increased so that every public health demand may be fulfilled, which would require improvements in laboratories, diagnostic workforce, diversity of tests, standards, quality and uniformity.

Efforts have to be taken to ensure adequate physical distancing in workplaces, transports and homes, and face masks should be made mandatory when outside. Every workplace should have an infection control plan, a guideline, standard operating procedures and a team to implement infection control measures. There should be adequate standard PPE where required, along with adequate washing facilities. Public health teams should ensure national infection control guidelines are followed in workplaces, with the power to apply the Communicable Diseases Act 2018 with fines. Institutional quarantine has to be made mandatory for travellers coming from affected areas, within or outside the country. Risk communications also have to be standardised in order to develop public opinion based on scientific attitudes rather than misconceptions in order to have informed decisions and practices. It is only when these conditions are in place can we think of doing away with lockdowns.

Professor Be-Nazir Ahmed is a former Director of Disease Control, Ministry of Health and Family Welfare, Bangladesh.

His email address is benazir1959@gmail.com.