Rabeya Begum of Sayedabad in the capital earns two handfuls of rice by sewing old clothes on the pavement. Her simple life has been turned upside down by dengue in recent weeks.

Both her sons Rabbi and Hasan were admitted to Mugda Medical College and Hospital when they contracted dengue fever. The doctor gave them permission to leave the hospital saying that they had recovered.

After being taken home, the two boys got fever again. Brought back to the hospital as more and more patients started getting affected, they ended up on the floor due to a shortage of beds. There she is somehow passing the days and nights with her two boys.

Rabeya Begum said that after being taken home from the hospital, the fever came again. At the same time, the boys started moaning with pain all over their bodies - the dreaded 'breakbone fever' associated with severe dengue had affected them this time. Rabbi is four years and three months old and Hasan is 19 months old. On the hospital floor, there is no end to their suffering.

An angry Rabeya said, "I have repeatedly asked for separate beds for two boys. How is it possible to have three people in one bed? The ward boys behaved very badly. They say if you can stay in one bed, stay. If you can't stay, leave. So I am forced to stay with my two boys in one bed."

Rabeya also complained about the medical treatment they received.

She said, "I was forced to come again even though I returned home once according to the doctor's advice. Two boys' fever is not getting better, with pain all over the body. They can't even sit. Doctors and nurses say it will be fine. But I can't bear their suffering."

Rabeya's story is not an isolated one. Patients are complaining that even after returning home with a health clearance from the hospital, they have had to come back to the hospital. Some say they are being sent home in a hurry.

Rina Akhtar, who brought her 21-month-old son Raihan from Jurain, complained that his dengue test result was positive and he was admitted to Mugda Hospital on July 16. Five days later he was released but he was having various problems after returning home. As his condition worsened, the doctors advised him to be admitted to the hospital again on July 25. This time, he too ended up on the floor.

The little child was seen crying, trying to explain his discomfort in various ways. Rina Akhtar said Raihan was unable to move his hand due to pain, causing him to cry and scream.

Md Niatuzzaman, director of Mugda Medical College and Hospital, said that those who have been affected before and are suffering from other diseases (comorbidities) such as high blood pressure, liver, kidney, cancer are the more complicated patients. He also said as in the case of the Coronavirus, they are observing dengue patients too are presenting with complications after recovery.

"Dengue is 100% curable,"said Dr Niatuzzaman. "But for those who are affected for the second or third time, it takes some time to get back to normal health. This is why we are seeing some complications."

In this context, public health expert Dr. Lenin Chowdhury said that in the treatment of diseases like dengue, both the doctor and the patient have responsibility. Doctors should also tell patients or relatives what to do after treatment. The main requirement for dengue patients is to maintain the balance of fluids in the body. If the patient does not comply with instructions after returning home, the patient's condition will worsen again. The patient should follow the doctor's advice.

He also said some patients think doctors will magically cure them. It doesn't happen. The doctor will give three instructions to the patient. One is lifestyle, one is food and another is medicine. Most of the patients think that the treatment is only with drugs. Essentially medicine is one of the three pillars. The patients had to come back to the hospital repeatedly due to non-compliance with the other two pillars.

Armaan and Araf are twins, just 15 months old. Both are infected with dengue. They are receiving treatment at Mugda Medical College and Hospital, sharing a bed.

Their mother Arifa said that they are in a difficult situation with the two children. Both of them tested positive for dengue seven days ago. As no bed was available in the hospital, the first three days they stayed at home in Tilpapara, Khilgaon. But when their condition worsened, they had to be admitted to the hospital. Initially, there was a problem with getting a bed, but later, the two boys started sharing a bed.

Although Arifa had no complaints about the treatment, she did say they were in a state of turmoil with two children in one bed.

Since the onslaught of dengue started intensifying in July, the common problem of all public and private hospitals in the capital is a shortage of beds. In a briefing by the Department of Health this week, it was revealed that the number of hospitalisations from dengue in July were more than seven times the number in June. Such a sharp acceleration in the space of just a month came as a shock to the system. We also know now that July was the deadliest month ever for dengue in Bangladesh, with over 200 deaths. The previous highest was in November last year, when 113 people died.

Alamin, a dengue patient under treatment at Dhaka Community Medical College Hospital in Moghbazar received his test result on July 24. Despite visiting several hospitals, he did not get a bed and so started getting treatment at home. Eventually on July 26, his serial came up and he got a bed at the community hospital. In the meantime, his condition worsened significantly. His platelet count came down to 3,000.

Alamin said the physical suffering is unbearable. His stomach is swollen and painful, and he is feeling very uncomfortable inside, that he cannot explain.

Talking to the hospital authorities, patients and relatives, space constraint was found to be a common problem.

In particular, the low-income people rely on government hospitals. But most patients are not getting beds. Somehow the victims are being treated from the hospital floors. After 2/3 days someone might be moved to a bed. However, the picture of private hospitals is different - there, the floors are not occupied. Patients looking to get admitted are being given serial numbers and sent home. When their serial comes up, they are being asked to come to the hospital accordingly.

Rezaul Karim, senior staff nurse of Dhaka Community Clinic, said that the queue for beds for dengue patients is getting longer every day. Accordingly, some get a bed after one day, some after two, and so on.

The situation is particularly bad at Mugda Medical College and Hospital, which has the highest number of patients admitted in the capital. However, there is a severe bed shortage.

Director of the hospital Dr Niatuzzaman said four wards of the 500-bed hospital are dedicated for dengue treatment. Apart from this, there are several doctors and nurses who are dedicated to looking after dengue patients. And all the doctors, who are deputed from the directorate and the hospital's own doctors and nurses are working in the dengue wards by rotation. Apart from this, mid-level doctors are providing round-the-clock services in each ward.

He also said that a branch of the pathology department is being used only for dengue testing. People are working in two shifts for blood collection and reporting. Apart from this, non-dedicated booths for dengue are also providing services to dengue patients at certain times.

Despite all this, Directorate General of Health Services (DGHS) Additional Director General (Administration) Professor Ahmedul Kabir announced on July 26 that no new dengue patients can be admitted to Mugda Medical College and Hospital in the capital as the hospital has reached its maximum capacity for treating dengue patients.

Is there a way back?

On Thursday, August 3, it was reported that the number of deaths from dengue this year has surpassed all previous records, as 10 more deaths brought the annual death toll to 283 this year. Previously, the country witnessed 281 dengue deaths in 2022.

Almost 2,589 new dengue patients were hospitalised in the 24 hours till Thursday morning, bringing this year's case tally to 59,716, according to the Directorate General of Health Services data. As reported before by Dhaka Courier, this year's fatality rate, i.e. the proportion of patients who end up dying, is significantly higher than previous years. Although it has come down slightly to 0.47, it is still higher than last year's 0.40, while in 2019 it was 0.17.

Health officials and experts have stressed coordinated efforts and a national plan to battle the current onslaught of dengue.

Institute of Epidemiology, Disease Control and Research (IEDCR) adviser and infectious disease expert Dr Mostaq Hossain said it is not possible to control dengue without concerted efforts.

"To eliminate the breeding ground of Aedes mosquitoes in Dhaka and across the country, a coordinated initiative has to be undertaken," he told our sister newsagency UNB.

"We have a directive from the inter-ministerial task force. There are many initiatives that can be handled individually and many that have to be done in coordination. To clean your flat, you need the coordination of experienced city corporation workers, flat owners association volunteers and local public representatives," he added.

Dr Hossain warned that preaching would not work if there is no concerted effort to destroy Aedes mosquitoes' breeding grounds.

He also cautioned that fines won't solve issues related to public health.

"When the city corporation workers come, people will not open the door, they will not allow them to enter. Because they knew if they open the door they would be fined," he said.

"Fines can be imposed in general matters," he said, adding: "But you shouldn't drive people away by imposing fines on public health matters. Follow the framework of community engagement outlined in the local government department's guidelines."

The IEDCR adviser stressed on increasing infrastructure and workforce under the city corporations to efficiently tackle the dengue outbreak.

Jahangirnagar University entomologist Dr Kabirul Bashar said that a national plan should be prepared to protect the people of the country from dengue.

"In the coming days, a national plan should be prepared with all stakeholders by discussing, analysing what can be done to control the dengue outbreak in Bangladesh," he said. "If necessary, a national institution called the Institute of Vector Control should be established."

Dr Bashar warned that the dengue situation could worsen in the next two months.

"The next two months (August and September) are very worrying for us as the death and dengue infection rate might surpass the previous records," he said.

"In the next two months, we will see 7-8 times more dengue patients than July. That's why we have to be more careful."

He urged the authorities to identify and destroy Aedes breeding grounds in a bid to control the outbreak.

"So far, we were talking about dengue in the two city corporations of Dhaka. Now we are seeing Aedes mosquitoes spreading all over the country. Dengue has spread in other upazilas. No one knows why dengue is spreading in areas outside Dhaka," he said.

Dr Bashar called on the government to fund research to determine how the onslaught of dengue is spreading to other areas outside Dhaka.

Kabirul Bashar said that earlier 40 percent of Aedes mosquitoes in Dhaka city used to breed in under-construction buildings which has now come down to 19 percent due to the city corporation's drive.

"But this time, in the study, we found 43 percent of mosquitoes in multipurpose buildings. We have seen that the city corporation officials and residents do not go to the multipurpose buildings where the vehicles are parked. As a result, aedes larvae are growing in accumulated water there," he said.

Director (MIS) of the Directorate General of Health Services Prof. Md. Shahadat Hossain said the total number of dengue patients in the country in June was 5,056, compared to 38,429 dengue patients in July -- a staggering seven-fold rise.

"In this situation, DGHS has urged the general public to come forward along with strengthening the mosquito eradication program of the city corporation to tackle the outbreak," he told UNB.

"At present, many hospitals in the capital have been filled with patients infected by the mosquito-borne disease. We are making all efforts from the Department of Health to control the situation so that dengue patients can come to the hospital and get proper medical care."

Besides, the Department of Health is carrying out various awareness activities to make people aware, the DGHS director added.

On a hiding to nothing

Despite the rapidly worsening dengue outbreak, the two city corporations in Dhaka are failing to implement effective measures, with their response seemingly confined in recent times to realising fines from the public.

Residents in various areas of the city complain of a lack of action during the Aedes mosquito breeding season and a failure to eradicate the breeding grounds before the monsoon arrived.

Experts have highlighted that this dire situation is a result of the city corporations' inadequate efforts in controlling dengue throughout the year.

The alarming situation being witnessed today is the consequence of inadequate year-round measures to control dengue, according to Dr. Manjur Ahmed Chowdhury, an entomologist.

"The two city corporations should take preventive measures before the dengue season starts by collecting and testing mosquitoes in high-infestation areas. However, there is no such initiative, and fines alone will not benefit dengue control," he said.

He also criticised the unscientific and ineffective instructions given by the city corporations, as well as the lack of skilled manpower to handle the situation. He emphasised that using fogging for mosquito control is proven to be an ineffective method for mosquito control or eradication.

Furthermore, experts pointed out that the government's lack of effective policies for mosquito control and dengue prevention has rendered the efforts of city corporations and municipalities ineffective all over the country.

Since dengue became endemic in Bangladesh starting in 2000, till 2018 it was confined to Dhaka city. The first infections outside Dhaka were recorded in 2019. Today it is present in all 64 districts.

Public health expert Dr. Lenin Chowdhury explained that mere 'exhibitionism' of collecting fines by the city corporations without proper collaboration with the public and representatives will not effectively control dengue. He stressed the need for joint efforts to combat the issue.

The absence of laboratories and entomologists in the two cities also contributes to the ineffective control measures.

The failure of the city corporations to effectively control mosquito breeding has allowed the Aedes mosquitoes, carriers of the dengue virus, to spread across the country, leading to a serious dengue outbreak. As the situation worsens, experts warn that immediate action and proper strategies are essential to curb the dengue epidemic.

Dr. Be-Nazir Ahmed highlighted the necessity for technical expertise in mosquito control and suggested the establishment of laboratories for research on the subject.

Professor Kabirul Bashar emphasised the importance of scientific mosquito control involving the public, city corporations, municipalities, and the local government ministry.

He proposed implementing mosquito breeding ground destruction activities in conjunction with hotspot management.

Despite the city corporations' significant spending on mosquito control, the results have been disappointing, with the number of dengue cases and deaths continuing to rise. Reports of irregularities in the spraying of mosquito-killing drugs have also surfaced, raising doubts about the effectiveness of the expenditures.

In the last fiscal year 2022-23, the two city corporations spent Tk 128 crore on mosquito control, with North City Corporation's (TK 101 crore) expenses being almost four times higher than those of South City Corporation (Tk 27 crore). Money well-spent? Not on the evidence so far.

The world's leading medical journal, The Lancet, reported this week that the "best hope" for Bangladesh might be a cost-effective vaccine, and how there is a clinical trial underway of a promising single-dose vaccine developed by the US National Institutes of Health in collaboration with the University of Vermont Vaccine Testing Center and Johns Hopkins University. Bangladesh has no immediate plans to roll out either the Sanofi Pasteur dengue vaccine, which is only recommended for individuals previously infected with dengue, or a newer product developed by Takeda, both of which require multiple doses and have restrictions on who can take them.

Additional reporting by Shamima Nasrin