14 September 2020 Morbidity and Mortality o Weekly Update (MMWU) N 29 https://www.who.int/bangladesh/emergencies/coronavirus-disease-(covid-19)-update/

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Tested Confirmed Cases Recovered Dead Hotline

1,742,696 339,332 243,155 4,759 20.46 million

Test/1 million New Cases Recovery Rate IFR% AR/1 million

10,233 1,812 71.7% 1.4 1,993

Laboratories PPE Stock PoE Screening

94 COVID-19 Labs 1,026,173 512,486

Last days 97,972 Samples 3,237,994 37,839

59.8% Inside Tests 135,226 7,029

19.5% Positive Tests 1,629,613 371,989

WHO Bangladesh COVID-19 Morbidity and Mortality Weekly Update (MMWU) 14 September 2020/Vol. No29

1. Coordination

On 11 September 2020, WHO published an interim guidance ‘Antigen-detection in the diagnosis of SARS-CoV-2 infection using rapid immunoassays’. This document offers advice on the potential role of antigen-detecting RDTs (Ag-RDT) in the diagnosis of COVID-19 and the need for careful test selection. Topics in the documents include: General recommendations for the use of SARS-CoV-2 Ag-RDTs, potential use and non-use case scenarios for SARS-CoV-2 antigen detecting RDTs based on minimum performance criteria; roles for antigen detecting RDTs for case management and surveillance for COVID-19, factors influencing test performance and future updates & product specific recommendations. Full document: https://apps.who.int/iris/rest/bitstreams/1302653/retrieve

On 11 September 2020, WHO published an updated interim guidance titled ‘Diagnostic testing for SARS-CoV-2’. The document provides interim guidance to laboratories and other stakeholders involved in diagnostics for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It covers the main considerations for specimen collection, nucleic acid amplification testing (NAAT), antigen (Ag), antibody (Ab) detection and quality assurance. Topics in the documents include: Laboratory testing guiding principles, Specimen collection, shipment and storage, Biosafety practices in the laboratory, Testing for SARS-CoV-2 and Reporting of cases and test results. This document will be updated as new information becomes available. Full document: https://apps.who.int/iris/rest/bitstreams/1302661/retrieve

2. Surveillance and Laboratories

Between 8 March and 14 September 2020, according to the DGHS Press Release there were three hundred thirty-nine thousand three hundred thirty-two (339,332) COVID-19 confirmed by rRT-PCR, including four thousand seven hundred fifty-nine (4,759) related deaths (IFR 1.4%)1.

The figure below is showing daily distribution of reported COVID-19 confirmed cases and deaths, 08 March – 14 September 2020, Bangladesh.

4,500 135 Cases 4,000 120 Deaths 3,500 105 7 per. Mov. Avg. (Cases) 3,000 90 7 per. Mov. Avg. (Deaths) 2,500 75

2,000 60

1,500 45 Number of Cases Cases Number (N=339,332) of 1,000 30 (n=4,759) Deaths Number of

500 15

0 0

08/03 12/04 19/04 24/05 28/06 05/07 09/08 13/09 15/03 22/03 29/03 05/04 26/04 03/05 10/05 17/05 31/05 07/06 14/06 21/06 12/07 19/07 26/07 02/08 16/08 23/08 30/08 06/09

In the reported week (epidemiological week 37), in comparison to the previous epidemiological week, the number of new weekly COVID-19 cases decreased by 13.8% (12,363 in week 36 and 14,335 in the previous week) while, the number of COVID-19 new weekly deaths increased by 10.8% (254 and 231 respectively), leading the IFR a little increase from 1.38% in epidemiological week 36 to 1.4% in the current week but the Case Fatality Ratio (CFR) decreased from 1.98 last week to 1.93 in the current week.

1 IFR refers to ‘Infection Fatality Ratio’ which can describe the true severity of a disease https://www.who.int/news-room/commentaries/detail/estimating-mortality-from-covid-19

2 | P a g e WHO Bangladesh COVID-19 Morbidity and Mortality Weekly Update (MMWU) 14 September 2020/Vol. No29

The figure below is showing the weekly distribution of reported confirmed COVID-19 cases and deaths, 08 March – 14 September 2020, Bangladesh.

30,000 350

Weekly Cases Weekly Deaths 300 25,000

250 20,000

200 15,000

150

Weekly Cases Weekly Weekly Deaths Weekly 10,000 100

5,000

50

13,543 13,543 24,786 21,378 17,293 18,949 14,335 11,342 11,342 18,616 21,751 25,481 24,630 20,730 18,928 16,854 18,049 16,224 12,363 7,611 7,611

- 0

w12 w14 w17 w20 w22 w25 w28 w31 w33 w36 w10 w11 w13 w15 w16 w18 w19 w21 w23 w24 w26 w27 w29 w30 w32 w34 w35 w37

Out of the total 339,332 COVID-19 cases registered as of 14 September 2020, 71.7% (243,155) recovered, 1.4% (4,759) died and 26.9% (91,418) are active cases.

The figure below is showing active vs recovered confirmed COVID-19 cases outcomes per epidemiological week, 08 March – 14 September 2020, Bangladesh.

350,000 Deaths (n=4,759) Active Cases (n=91,418) Recovered (n=243,155) 300,000

250,000

200,000

150,000

100,000 Number of Cases Cases Number (N=339,332) of

50,000

0

08/03 19/04 26/04 07/06 14/06 26/07 02/08 13/09 15/03 22/03 29/03 05/04 12/04 03/05 10/05 17/05 24/05 31/05 21/06 28/06 05/07 12/07 19/07 09/08 16/08 23/08 30/08 06/09

In the epidemiological week 37, the number of COVID-19 active cases decreased by 7.3%, in comparison to the previous week (92,148 and 99,407 respectively) and at the same time, the number of recovered COVID-19 cases is as as the previous week at 19,368.

As of 14 September 2020, 26.7% cases were confirmed in people between 31 and 40 years old, 20.0% - in the age group of 21 to 30, 18.9% - 41 to 50 years and 15.2% in the age group between 51 and 60 years old. The highest death rate

3 | P a g e WHO Bangladesh COVID-19 Morbidity and Mortality Weekly Update (MMWU) 14 September 2020/Vol. No29

(31.2%) was reported in the age group of 61 to 70 years old, 27.4% in the older age group of 71 and above and 23.4% - in the age group between 51 and 60 years. Male represented 72% and 78% of the of total reported confirmed COVID- 19 cases and deaths respectively.

The figure below is showing age-sex distribution of the reported confirmed COVID-19 cases and deaths, 14 September 2020, Bangladesh.

1,728 (47%) Cases Male Female Deaths

> 80 0.6% 0.3% 5.7% 1.8% > 80

2.1% 16.4% 3.6% 71 - 80 71 - 80 0.6% 61 - 70 5.4% 2.0% 24.5% 6.7% 61 - 70

51 - 60 11.2% 4.0% 18.5% 4.9% 51 - 60

41 - 50 13.9% 4.9% 7.6% 2.4% 41 - 50

31 - 40 20.2% 6.5% 3.7% 1.5% 31 - 40

21 - 30 13.5% 6.5% 0.9% 0.9% 21 - 30

11 - 20 2.7% 2.4% 0.5% 0.3% 11 - 20

0 - 10 2.0% 1.3% 0.2% 0 - 10 72% 28% 78% 0.1% 22% 40,000 30,000 20,000 10,000 0 10,000 20,000 1,200 900 600 300 0 300 600

The figure below is showing the weekly reported confirmed COVID-19 cases, 13 April – 14 September 2020, Bangladesh.

30,000 Dhaka Chattogram Rangpur Barishal

25,000

20,000

15,000

Number Cases Number of 10,000

5,000

0 w16 w17 w18 w19 w20 w21 w22 w23 w24 w25 w26 w27 w28 w29 w30 w31 w32 w33 w34 w35 w36 w37

As of 14 September 2020, 62.7% of reported cases were from , 13.8% from Chattogram, Khulna 6.3%, Rajshahi 5.8%, Sylhet and Rangpur 3.5%, Barishal 2.5% and the lowest 1.9% from - . While, 48.3% of reported death were from Dhaka division, 21.5% from Chattogram, Khulna 8.4%, Rajshahi 6.7%, Rangpur 4.7%, Sylhet 4.5%, Barishal 3.9% and the lowest 2.1% from - Mymensingh division.

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The map below is showing the geographical distribution of reported confirmed COVID-19 cases, deaths and Attack Rate (AR), 08 March – 14 September 2020, Bangladesh

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On 14 September 2020, Bangladesh overall attack rate (AR) is 1,993 per 1 million and 100% (64/64) of districts with the total population of 170,306,468 people have reported confirmed COVID-19 cases. In the reported week (epidemiological week 37), COVID-19 weekly AR increased by 3.8% in comparison to the previous week (1982 and 1,909 respectively).

The figure below is showing the daily increase in COVID-19 overall attack rate (AR) per 1,000,000, 08 March – 14 September 2020, Bangladesh.

30 Daily Increase 7 per. Mov. Avg. (Daily Increase) 25

20

15

10

5 Attack Rate per 1 million populationmillionRate 1 Attack per

0

08/03 05/04 26/04 17/05 14/06 05/07 02/08 23/08 13/09 15/03 22/03 29/03 12/04 19/04 03/05 10/05 24/05 31/05 07/06 21/06 28/06 12/07 19/07 26/07 09/08 16/08 30/08 06/09

According to the available data as on 14 September 2020, the highest AR continues to be observed in the Dhaka division Dhaka (5,049/1,000,000). Within the Dhaka division, Dhaka city has the highest AR (20,824/1,000,000) followed by Faridpur (2,957), Rajbari (2,358), Munshiganj (1,968), (1,886), Gopalganj (1,787), (1,305), Shariatpur (1,183), Madaripur (1,032), Narsingdi (852), Manikganj (829), Dhaka (District) (816), Kishoreganj (773) and the lowest AR 683 was reported from .

The 2nd highest COVID-19 AR is reported from Chattogram division (1,340/1,000,000). Within the division, Chattogram district reported the highest AR (1,991/1,000,000) followed by Cox's Bazar (1,624), Bandarban (1,603), Noakhali (1,314), Rangamati (1,228), Cumilla (1,126), Feni (1,053), Lakshmipur (1,008), Khagrachhari (905), Chandpur (771) and the lowest AR 715 was reported from district.

The 3rd highest AR in the country was reported from (1,111/1,000,00) while the highest AR district is Khulna (2,186/1,000,000) followed by Narail (1,484), Kushtia (1,312), Jashore (1,126), Chuadanga (1,021), Jhenaidah (864), Magura (816), Meherpur (747), Bagerhat (533) and the lowest 460 in .

Sylhet division has taken the fourth highest in the overall AR with (995/1,000,000) with the highest AR in (1,531/1,000,000) followed by Sunamganj (756), Maulvibazar (703) and the lowest 662 in district.

Rajshahi division has overall AR 871/1,000,000 with the highest AR in Bogura district (1,794/1,000,000), followed by Rajshahi (1,552), Joypurhat (964), (557), Natore (478), Naogaon (403), Chapainawabganj (371) and district is the lowest at 356/1,000,000. In Barishal division the overall AR is 814/1,000,000 with the highest AR in Barishal district (1,235/1,000,000), while Barguna (838), Jhalokathi (831), Pirojpur (779), Patuakhali (747) and the lowest AR 326 was reported from in .

In the overall AR is 607/1,000,000 with the highest AR in district (924/1,000,000), while Rangpur (785), Thakurgaon (653), (543), Nilphamari (466), Panchagarh (458), (392) and the lowest AR 349 was reported from .

6 | P a g e WHO Bangladesh COVID-19 Morbidity and Mortality Weekly Update (MMWU) 14 September 2020/Vol. No29

The lowest AR is reported from Mymensingh division (474/1,000,000). having the highest AR of 592/1,000,000 followed by Jamalpur (533), Sherpur (275) and the lowest 268 in Netrakona district.

The figure below is showing the progression of Arrack Rate (per million) by divisions, 08 March – 14 September 2020, Bangladesh.

1,200 6,000 Barishal Khulna Mymensingh Rajshahi 1,000 5,000 Rangpur Sylhet Chattogram Dhaka 800 4,000

600 3,000

Attack Rate/MillionAttack 400 2,000

200 1,000 & Rate Chattogram Attack Dhaka for

0 0

04/05 11/05 29/06 06/07 13/07 24/08 31/08 07/09 18/05 25/05 01/06 08/06 15/06 22/06 20/07 27/07 03/08 10/08 17/08 14/09

The figure below is showing the weekly reported confirmed COVID-19 deaths, 13 April – 14 September 2020, Bangladesh.

350 Dhaka Chattogram Khulna Rajshahi Rangpur Sylhet Barishal Mymensingh

300

250

200

150 Number DeathNumber of 100

50

0 w16 w17 w18 w19 w20 w21 w22 w23 w24 w25 w26 w27 w28 w29 w30 w31 w32 w33 w34 w35 w36 w37

As of 14 September 2020, according to the DGHS Press Release 1,742,696 COVID-19 tests with the overall positivity rate of 19.47% (12.75% in last 24 hours) were conducted in Bangladesh by 94 laboratories: 54 laboratories (57.4%) in Dhaka city and 40 laboratories (42.6%) outside Dhaka. Hospital, a government institution has started testing this week. 59.8% (1,041,818/1,742,696) of all samples were tested by laboratories in the Dhaka city.

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The graph below is showing the comparison between the average number of samples tested and average number of confirmed COVID-19 cases, 08 March – 14 September 2020, Bangladesh.

20000 5,000 Cases - 7 days rolling average Tests - 7 days rolling average 16000 4,000

12000 3,000

8000 2,000 Number of Cases Cases Number (N=339,332) of Number of Tests Tests (N=1,742,696) Number of 4000 1,000

0 0

19/04 26/04 03/05 10/05 17/05 24/05 31/05 07/06 14/06 21/06 28/06 05/07 08/03 15/03 22/03 29/03 05/04 12/04 12/07 19/07 26/07 02/08 09/08 16/08 23/08 30/08 06/09 13/09

3. Point of Entry (PoE) and Quarantine

According to DGHS, as of 09 September 2020, the current institutional quarantine capacity in the country is represented by 629 centres across the 64 districts, which can receive 31,991 persons. A total of 32,420 individuals were placed in quarantine facilities and of them 27,620 (85.2%) have been already released. Over the same period, total of 77,209 individuals were isolated in designated health facilitates and of them 59,362 (76.9%) have been released.

The figure below is showing the number of individuals were in quarantine and hospital isolation, 03 May – 14 September 2020, Bangladesh.

5,000

Facility Qurantine Home Qurantine Cases Hospital Isolation

4,000

3,000

2,000 DailyNumber

1,000

0

17/05 24/05 21/06 28/06 02/08 06/09 03/05 10/05 31/05 07/06 14/06 05/07 12/07 19/07 26/07 09/08 16/08 23/08 30/08 13/09

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In the reported week (epidemiological week 37), the number of international flights has increased by 12.5%, in comparison to the previous week (99 and 88 respectively) while the number of passengers increased by 15.5% (21,508 and 18,629 respectively). In the reported week 843 individuals were sent to Institutional Quarantine after passenger screening at the Hazrat Shahjalal International Airport (HSIA).

The figure below is showing the weekly incoming international flights and number arrived of passengers, 27 April – 14 September 2020, Bangladesh.

99 100 20,000 Passenger through Airport 88 90 85 18,000 Facility Quarantine 82 80 Number of Flights 16,000 71 70 66 14,000 62 60 55 12,000 47 50 10,000

40 34 8,000 30

28 29 Number Flights Number of 30 23 23 6,000 Passengers Number of 21 19 17 20 13 13 4,000

10 2,000

18,541

13,602

9,731

13,213

18,799

7,469

13,624

10,418

3,938 2,773 3,800 5,927 2,474 2,807 3,183 5,256

18,629 21,508

0 0

w18 w21 w22 w25 w26 w29 w30 w33 w34 w37 w19 w20 w23 w24 w27 w28 w31 w32 w35 w36

A regular meeting of the Crisis Management Team (CMT) of Hazrat Shahjalal Int'l Airport (HSIA) held on 09 September 2020. Director HSIA presided over the meeting while participants were from the Airport Authority, Civil Aviation Authority, Airlines Authority, Ministry of Expatriates’ Welfare and Overseas Employment, Armed Police Battalion, Fire Department, CDC-DGHS, IOM and WHO. Two SOPs were published by CDC-DGHS titled 'SOP for the screening of COVID-19 at the Points of Entries (PoEs)' and 'SOP for suspected COVID-19 case in the Aircraft'. The SOPs were inaugurated by the Director HSIA and training on the SOPs are on going.

4. Case Management and Infection Prevention & Control

WHO IPC and case management team has been joined by an international expert of IPC and case management and was introduced with case management lead of government counterpart on 13 September. The international expert is going to visit and review the status of IPC and case management in some hospital and will provide advocacy for improvement.

The final report on health facilities assessment conducted by different partners has been officially endorsed by Director hospital, Directorate General of Health Services (DGHS) on 13 September. The details findings were presented, and it was emphasized that all partners should work in coordinated way in supporting government to meet the priority need in tackling COVID-19.

From DGHS, a request for 500 ICU ventilator, 100 BIPAP and 1500 units of High Flow Nasal Cannula is under active consideration by WHO. WHO has informed, director hospital for availability of dexamethasone tablet and injection available in Global stockpile (Dubai) for critical patients. WHO has already provided 200 oxygen concentrators in 17 district hospitals. WHO has started facilities orientation on infection prevention programme for health managers of DGHS and other facilities in Dhaka city. A consultation is in progress for development of training manual for IPC, triage for community health care provider (CHCP) with the support of WHO.

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According to DGHS, as of 07 September 2020, there are 14,275 general beds of which 43% (6,107) in Dhaka city and 547 ICU of which 56% (307) in Dhaka city dedicated for COVID-19 treatment. Presently 22.4% general beds and 54% ICU all over the country are occupied.

The figure below is showing geographical comparison of Cases, Hospitalized cases, Recovered cases and Deaths, 08 March – 14 September 2020, Bangladesh.

1,000,000 Cases (N=339332) Recovered (n=243155) Hospitalized (n=59938) Death (n=4759)

100,000 217,494

10,000 45,031

20,608

19,035

2,276

11,655

11,327

8,017

6,165 1,030

1,000

406

155,857

321

Number Number Log Scalein

226

212

186

24,894

16,633

15,060

9,243

8,980

6,763

102 5,725

100

2,006 1,515 2,260 2,178

784 649

12,324 38,222 10 Dhaka Mymensingh Chattogram Rajshahi Rangpur Khulna Barishal Sylhet

The figure below is showing temporal comparison of Cases, Hospitalized cases and Recovered cases, 08 March – 14 September 2020, Bangladesh.

Cases Hospitalized Recovered Poly. (Cases) Poly. (Hospitalized) Poly. (Recovered) 30,000

25,000

20,000

15,000

10,000 Cases/Addmitted/Recovered

5,000

0 w27 w28 w29 w30 w31 w32 w33 w34 w35 w36 w37

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5. Risk Communication and Public Awareness

Risk Communication and Community Engagement (RCCE) partners under DGHS and UNICEF’s coordination continue the scaled up dissemination of information and communication materials on protection measures as well as various other areas impacted by COVID-19 such as mental health, noncommunicable diseases, gender based violence etc. At sub-national level intensive work is conducted with the support of large variety of organizations, including NGO network partners from START network and Bangladesh Community Radio Association (BCRA).

In addition to the dissemination of information through a large variety of channels, RCCE partners are strengthening the monitoring and evaluation mechanisms in order to have a proper understanding of the efficiency and efficacy of the public information campaigns. In this regards, several surveys are planned or currently implemented, either online through social media or various partners platforms, either offline conducted by volunteers or SMS based evaluations.

RCCE pillar continues the close collaboration with Community Support Teams (CST), an initiative of humanitarian and development partners rolled out at field level aimed to slow COVID-19 spread in the community. CSTs activities have been expanded in Dhaka North City Corporation, with the prospect of further expanding the services in other areas. CSTs are working with communities for informing and increasing population awareness of the COVID-19 in order to increase compliance with quarantine/isolation of confirmed cases and persons with symptoms. Furthermore CSTs are intensively working to reduce burden on the healthcare system by supporting home-based treatment and management of mild to moderate cases through telemedicine and medication support of low income households.

6. Useful links for more information

 WHO Bangladesh COVID-19 Situation Reports: https://www.who.int/bangladesh/emergencies/coronavirus-disease-(covid-19)-update/coronavirus-disease-(covid- 2019)-bangladesh-situation-reports  COVID-19 Situation in the WHO South-East Asia Region: https://experience.arcgis.com/experience/56d2642cb379485ebf78371e744b8c6a  WHO global Weekly Epidemiological Update and Weekly Operational Update: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports  WHO Bangladesh awareness and risk communication materials in Bengali: https://www.who.int/bangladesh/emergencies/coronavirus-disease-(covid-19)-update  COVID-19 WHO Online Training modules: https://openwho.org/channels/covid-19  COVID-19 updates from the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of The People’s Republic of Bangladesh: https://dghs.gov.bd/index.php/en/component/content/article?id=5393  Institute of Epidemiology, Disease Control and Research (IEDCR): https://iedcr.gov.bd/covid-19/covid-19-situation-updates

Contact: Dr Bardan Jung Rana, WHO Representative to Bangladesh, [email protected] Hasan Mohiuddin Ahmed, NPO-Surveillance & Public Health Informatics, WHO-BAN, [email protected] 11 | P a g e