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\begin{document}

\title{Persistent COVID-19 negative report of a physician in Bangladesh living
and visiting in Red listed country with some special precaution
followed.}



\author[1]{Sabrina Nahin}%
\author[2]{Mohammad Ashraful Amin}%
\affil[1]{Green Life Medical College and Hospital}%
\affil[2]{North South University}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\selectlanguage{english}
\begin{abstract}
COVID-19 infections have been widespread in Bangladesh subsequently. We
present the example of a 32-year-old Bangladeshi physician who worked in
a hospital and was previously involved in collecting swabs for Covid19
patients, During the pandemic, he also traveled to a red-listed country
and was continuously negative throughout the period.%
\end{abstract}%



\sloppy


\textbf{Introduction}

A COVID-19 catastrophic infection crisis, driven by the new coronavirus
SARS-CoV-2, has presented a grave threat around the world. Bangladesh
has also been affected by this viral infection(1). The World Health
Organization labeled it a pandemic based to its parabolic spread in 213
nations (2). The disease is spread mostly through direct contact with
infected patients' airborne droplets(3). To minimize the spread of
disease, rapid recognition and accurate diagnosis have become critical.
Several samples, such as nasopharyngeal or oropharyngeal swabs,
nasopharyngeal or oropharyngeal aspirates or washes, bronchoalveolar
lavage, phlegm, tracheal swab and blood, are collected from potential
SARS-CoV-2 patients. The microbiological diagnosis is confirmed using
the polymerase chain reaction (PCR)(4). SARS-CoV-2 RNA virus load in the
upper airways was considerably higher throughout the first week and
culminated at 4-6 days following onset of symptoms, when it could be
sampled. In COVID-19 individuals, the sensitivity of nasopharyngeal
scrapes was higher than that of oropharyngeal sweeps(5). But even though
the research on COVID-19 is inconclusive, lower respiratory tract
tissues include the highest viral loads in individuals with severe acute
respiratory syndrome (SARS) and Middle East respiratory disease
(MERS)(6, 7). Nucleic acid screening for severe acute respiratory
syndrome coronavirus 2 had also detected benign patients with
coronavirus infection (SARS-CoV-2)(8).In this report, we have presented
a case of persistent COVID-19 negative report of physician in Bangladesh
living and visiting in Red listed country.

\textbf{Case report}

32-year-old Muslim physician male with no substantial co-morbidities in
his past. He worked as a doctor and resided in Dhaka, Bangladesh. The
first instance COVID-19 was discovered on March 8, 2020 in Bangladesh.
During this time, the government proclaimed ''lockdown'' across the
country beginning March 23, 2020. He was participated in nasopharyngeal
swab PCR for SARS-CoV-2 collection from patients in the cardiology
department for research purposes three months later, on June 28, 2020.
He had a nasopharyngeal swab PCR for SARS-CoV-2 before being collected
and the results were negative. Before every time collecting the sample,
he always takes aseptic precautions such as wearing PPI and drafting,
medical masks, gloves, headgear, and work clothing, as well as using an
ethanol-based hand sanitizer and washing his hands with soap more than
20 times in a day. After completing the whole collection, he went back
to the nasopharyngeal swab PCR for SARS-CoV-2 on August 11, 2020, which
came out negative. In total, 36 people tested positive for SARS-CoV-2
throughout this collecting period. In the hospital, he had come into
contact with COVID-19 cases. He had no experience of any illnesses like
fever or other flu-like symptoms during the time he was collecting the
sample. On September 24, 2020, her older brother was diagnosed with
COVID-19 as a result of both PCR and HRCT involvement with whom he
lives. In this period, he always looks after his brother. He went to the
hospital and other workplaces with always a surgical mask and KN95. He
always takes a shower after returning from outside activities and he
washes his everyday clothes after each visit from outside. According to
a WHO report released on December 27, 2020, Bangladesh has a total of
509,148 confirmed cases and 7,452 deaths. He then supplied a COVID-19
sample for travelling to India on January 28, 2021, which was similarly
negative the next day. According to a WHO report dated January 25, 2020,
India had 10,667,736 confirmed cases and 1,53,470 total deaths. He
returned to Bangladesh on January 31, 2021, with a negative covid19
report. On March 10, 2021, he took another covid19 test in preparation
for a trip for family reasons, which came back negative the next day.
According to a WHO report dated March 8, 2021, Bangladesh had 550,330
illnesses and 8,462 deaths. According to a WHO report dated March 10,
2021, India has 11,244,786 confirmed cases and 157,930 total deaths. The
covid19 test for repatriation to Bangladesh was negative on March 17,
2021. Since April 20, 2021, Bangladesh has been on the UK's and other
some countries no-fly list. For entering India from Bangladesh on the
dates of 17 April 2021, 30 August 2021, 09 October 2021, 28 October
2021, 30 October 2021, he had to undergo a nasopharyngeal swab PCR for
SARS-CoV-2. He had to also again repeat the nasopharyngeal swab PCR for
SARS-CoV-2 on the dates of 22 April 2021, 4 September 2021, and 5
November 2021 in order to return to Bangladesh from India. His total of
nine sample tests all came back negative. During his stay in India, he
constantly wears a double mask and keeps his hands sanitized. He also
avoids crowds and prefers to go by private car whenever possible. In
this period, some routine blood tests were performed, including a
complete blood count, CRP, thyroid test, viral marker for hepatitis and
HIV, with normal results. (Table 1). During this time, his relative was
diagnosed with COVID-19 on June 24, 2021, and was later hospitalized.
During this time, he regularly visited the hospital and interacted with
other COVID-19 patients, as it was a COVID-19 specific hospital. He had
no symptoms of COVID-19 throughout his entire travel experience. During
this timeframe, he also had no additional medication history. He
administered the first dose of Moderna COVID-19 Vaccine on July 19,
2021, and completed the second dosage on August 18, 2021.

From the commencement of COVID-19 2020 until November 2021, he took 14
Covid19 tests and was always negative, despite being in close proximity
to COVID-19 positive cases and visiting one of the tops most cases
identified and mortality countries in the world, Asia.

\textbf{Discussion}

We reported on a clinician in Bangladesh who had a persistent COVID-19
negative report while living in close proximity to known COVID-19 cases
and visiting one of the countries with the highest death rates. The most
prevalent method for severe acute respiratory syndrome-coronavirus-2
(SARS-CoV-2) testing is based on reverse transcriptase-polymerase chain
reaction (RT-PCR) for the presence of viral RNA. The virus extraction or
positive response of polymerase chain reaction (PCR) from phlegm, nasal
sample, or throat swab is used to provide a clear diagnosis of corona
virus disease 2019 (COVID-19)(9). Because the consequences of swab
testing are affected by a variety of factors, along with the period of
swab acquisition after the onset of symptoms, the location of the
specimen, the shipping of the swab, and the procedures used in swab
collection, physicians should not rule out COVID-19 in a widely
speculated patient who has traveled to an epidemic zone(10). Thorough
viral screening for SARS-CoV-2 infections could help ensure safe
aircraft flight during the COVID-19 pandemic and slow the virus's wide
adoption. Unfortunately, the efficiency of these test-and-travel
procedures in reducing traveler risk of SARS-CoV-2 transmission of the
disease at the community level is uncertain(11). Proven test-and-travel
methods for SARS-CoV-2 infection, which include periodic viral
diagnostics surrounding airline travel, can lower both passenger chance
of infection and population-level SARS-CoV-2 transmission risk when
traveling. The clinician performed 13 Covid19 tests (Figure 1) in order
to detect for virus infection while traveling across nations. A negative
RT-PCR nasopharyngeal swab test does not rule out COVID-19. As a result,
putting too much faith in test results could be harmful, and the demand
for widespread testing could be exaggerated. Furthermore, avoiding
attempting to test the many numbers, if not millions, of mild COVID-19
instances could save a significant quantity of personal protective
equipment. Barrier protection and preemptive behavior, such as acquiring
travel or having vaccinated before traveling overseas, is influenced by
personal healthcare and well-being perspectives(12, 13). Masking, social
dispersion, handwashing, cleansing of commonly handled items, better
ventilation, self-isolation, and confinement are among the
nonpharmaceutical measures advised to minimize SARS-CoV-2 transfer.
Vaccines are the most effective way to avoid the SARS-CoV-2 outbreak.
Numerous vaccinations are being developed in many countries using
various approaches. The cornerstone of attempts to control the
propagation of SARS-CoV-2 has been preventing transmission to the virus
and, more recently, immunization against the virus(14). The percentage
of false-negative SARS-CoV-2 results from patient respiratory samples
varies between 1 and 30\%(15). There is no screening test that offers
100\% sensitivity and specificity. Despite the fact that the RT-PCR test
seems to have become the best model for detecting SARS-CoV-2 virus,
false-negative incidences have been observed. These false-negative
results can occur for a variety of causes, including detecting either
early or too late in the virus's pathogenic process, inefficient or
defective sample collecting techniques, incorrect specimen aspects, low
analytic sensitivity, low viral load, or viral shedding mutability.
These false-negative findings could have major ramifications, opening
the path for positive case aggregations to lead to adverse outcomes and
increased transmission rates throughout the population. Because false
negative RT-PCR results in cases of COVID-19 are not rare, researchers
advocate collecting upper respiratory tract samples in the acute stage
and lower respiratory samples or stool samples in the non-acute
period(16). Doctors in India who are intensively examining the second
wave state that bronchoalveolar lavage done on RT-PCR negative patients
with COVID-19 symptoms produced COVID-19 positive results. According to
a doctor quoted in the same source, 15 to 20\% of COVID-19 patients come
with the aforementioned issue, which is posing a problem for
doctors(17). In another study, a scientist said that alterations in the
SARS-CoV-2 virus may have enabled it to evade RT-PCR testing, and that
the reagents must be re-configured immediately(18). Furthermore,
epidemiology, background of exposure, and clinical signs such as fever
or pulmonary disease should all be examined when establishing COVID-19.
As a result, combining serum IgM/IgG antibody identification, nucleic
acid testing, CT scan, and clinical characteristics increases COVID-19
accuracy rate. By falsely claiming that an infected individual does not
have a disease, a false-negative test puts the entire society at danger.
As a result, this individual may spread infection throughout the
population. False negatives in group testing are far more dangerous than
false positives in solo testing.

\textbf{Conclusion}

In summary, Medical professionals are at considerable risk of
contracting in the COVID-19 outbreak, which is affecting the entire
worldwide, due to its direct interaction with COVID-19 patients. In
individuals with a diagnosis of substantial traveling or contact,
COVID-19 cannot be counted out even if there are no pulmonary
complaints. Whenever patients with suspected is significant, a lower
respiratory specimen should be taken with proper precautions and a
negative PCR test on upper respiratory samples may not be enough to
establish out COVID-19. Asymptomatic travelers would benefit from
routine test-and-travel techniques, which would lower the chance of
disease from travelling during the pandemic.

\textbf{Funding}

This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.

\textbf{Declaration of competing interest}

The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to
influence the work reported in this paper.

\textbf{Consent}

The patient's written informed consent for publishing of this case
report, as well as images, was acquired.

\textbf{Author contributions}

The article's first draft was written by MAA and SN. MAA and SN
contributed to the literature review and manuscript preparation. All
authors contributed to the final version by critically reviewing and
editing drafts.

\textbf{Ethical approval}

The article is about a case study. As a result, our Ethics Committee's
consent was not required.

\textbf{Reference:}

1. Rahman H, Fahad MAHI, Islam MN, Yasin A, Abdullah M, Al Mamun RA, et
al. Covid19 in Bangladesh: Comparative Analysis of Infected Situation
and Control Strategy.

2. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Bio
Medica: Atenei Parmensis. 2020;91(1):157.

3. Chavez S, Long B, Koyfman A, Liang SY. Coronavirus Disease
(COVID-19): A primer for emergency physicians. The American journal of
emergency medicine. 2021;44:220-9.

4. Organization WH. Laboratory testing for 2019 novel coronavirus
(2019-nCoV) in suspected human cases: interim guidance, 14 January 2020.
World Health Organization; 2020.

5. Mawaddah A, Genden HS, Lum SG, Marina MB. Upper respiratory tract
sampling in COVID-19. The Malaysian journal of pathology.
2020;42(1):23-35.

6. Memish ZA, Al-Tawfiq JA, Makhdoom HQ, Assiri A, Alhakeem RF, Albarrak
A, et al. Respiratory tract samples, viral load, and genome fraction
yield in patients with Middle East respiratory syndrome. The Journal of
infectious diseases. 2014;210(10):1590-4.

7. Tang P, Louie M, Richardson SE, Smieja M, Simor AE, Jamieson F, et
al. Interpretation of diagnostic laboratory tests for severe acute
respiratory syndrome: the Toronto experience. Cmaj. 2004;170(1):47-54.

8. Wu J, Liu X, Zhou D, Qiu G, Dai M, Yang Q, et al. Identification of
RT-PCR-negative asymptomatic COVID-19 patients via serological testing.
Frontiers in public health. 2020;8:267.

9. Feng H, Liu Y, Lv M, Zhong J. A case report of COVID-19 with false
negative RT-PCR test: necessity of chest CT. Japanese journal of
radiology. 2020;38(5):409-10.

10. Winichakoon P, Chaiwarith R, Liwsrisakun C, Salee P, Goonna A,
Limsukon A, et al. Negative nasopharyngeal and oropharyngeal swabs do
not rule out COVID-19. Journal of clinical microbiology.
2020;58(5):e00297-20.

11. Kiang MV, Chin ET, Huynh BQ, Chapman LA, Rodr\selectlanguage{ngerman}íguez-Barraquer I,
Greenhouse B, et al. Routine asymptomatic testing strategies for airline
travel during the COVID-19 pandemic: a simulation study. The Lancet
Infectious Diseases. 2021.

12. Chien PM, Sharifpour M, Ritchie BW, Watson B. Travelers' health risk
perceptions and protective behavior: A psychological approach. Journal
of Travel Research. 2017;56(6):744-59.

13. Sharon TR, Shahrabani S. Health precautions while traveling after
COVID-19. Journal of Tourism, Heritage \& Services Marketing (JTHSM).
2021;7(2):68-73.

14. Gupta S, Smith L, Diakiw A. Avoidance of COVID-19 for Children and
Adolescents and Isolation Precautions. Pediatric Clinics. 2021.

15. Kanji JN, Zelyas N, MacDonald C, Pabbaraju K, Khan MN, Prasad A, et
al. False negative rate of COVID-19 PCR testing: a discordant testing
analysis. Virology journal. 2021;18(1):1-6.

16. Jia X, Xiao L, Liu Y. False negative RT-PCR and false positive
antibody tests--Concern and solutions in the diagnosis of COVID-19.
Journal of Infection. 2021;82(3):414-51.

17. Jindal H, Jain S, Suvvari TK, Kutikuppala L, Rackimuthu S, Rocha
ICN, et al. False-negative rt-pcr findings and double mutant variant as
factors of an overwhelming second wave of covid-19 in India: an emerging
global health disaster. SN comprehensive clinical medicine. 2021:1-6.

18. CT-scan confirms infection for several RT-PCR negative reports. the
times of india. 2021.

\textbf{Table and figure}

\textbf{Table 1. Laboratory parameters of the cases}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Investigation & 01-02-2021\tabularnewline
\midrule
\endhead
HB\% & 14.6\tabularnewline
Total Leucocyte count & 8.3thou/uL\tabularnewline
Lymphocytes & 26 \%\tabularnewline
Neutrophil & 69\%\tabularnewline
Platelet count & 259 thou/Ul\tabularnewline
T3 & 0.627 uIU/mL\tabularnewline
T4 & 1.03 ng/dL\tabularnewline
Hepatitis C antibody & Non-reactive\tabularnewline
HBsAg & Non-reactive\tabularnewline
HIV 4\textsuperscript{TH} Gen Assay & Non-reactive\tabularnewline
VDRL & Non-reactive\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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\end{figure}

\textbf{Figure 1: Whole COVID-19 test sequence.}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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