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Nepal reported its first COVID-19 case in a student returning from Wuhan, China, on January 23, 2020. As part of its earliest response to the COVID-19 pandemic, the country installed health desks with thermal scanners at Tribhuwan International Airport. Subsequently, the health desks were extended to other regional airports and ground crossing points of entry (PoE) at the Nepal-China and Nepal-India borders. Nepal’s land borders with India and China were soon closed, except for cargo trucks and for emergency use. The Tatopani border was sealed from January 31, 2020, and has not been used since.
On March 23, 2020, the country announced a nationwide full lockdown and suspended all international flights, after the second case was detected in a passenger who had flown in from Paris. All non-essential businesses, except for small grocery stores, hospitals, and pharmacies, were closed. People were asked to stay home, and restrictions were placed on large gatherings and public transport. The government imposed a 14-day home quarantine on those who had come in contact with the confirmed, suspected, and probable cases. People exposed to international travellers were also asked to self-quarantine at home.
There were 17,994 cases and 40 COVID-19 related deaths when the lockdown was lifted after four months on July 21, according to The Kathmandu Post.
With the increase in people’s movement and cross border mobility after the lockdown, cases have been rising at an alarming rate in densely populated cities, including Kathmandu.
On August 19, the three-district offices in the Kathmandu Valley issued a week-long prohibitory order, restricting transport and shutting down businesses in worst hit towns and districts across the country. The order was renewed three times and further extended till September 17 with some relaxations, as cases continued to soar.
On September 18, 2020, Nepal reported the highest single-day surge of 2,020 new cases, with 859 new infections in Kathmandu Valley, both highest daily records till date. According to The Kathmandu Post, more than two-thirds (12,640) of the total 15,135 cases in the Valley
were confirmed after the prohibitory orders were imposed on August 19.
As of September 23, the country’s coronavirus tally stands at 66,632, with 18,142 active cases, 48,061 recovered cases, and 429 deaths, according to the Ministry of Health and Population (MoHP), Nepal. The country has conducted 904706 PCR tests so far.
According to the data of WHO Country Office for Nepal (September 9, 2020), Nepal is running the PCR tests from 47 designated COVID-19 laboratories, of which 34 are government, and 13 are private.
Currently, all the central hospitals, provincial hospitals, medical colleges, academic institutions, and hub-hospitals have been designated to provide treatment for COVID-19 cases, according to the Nepal’s Health Sector Emergency Response Plan, May 2020.
With Dashain fast approaching, the government has resumed long-route travel and domestic flights in the country, worrying health officials of new clusters of infection across the nation, as they fear that many infected people in the valley, who are still out- of-contact, could spread the virus to other parts of the country. According to the Metropolitan Traffic Police Division, a total of 12,813 people left the Valley on September 18, alone.
Challenges
After the lockdown, cases have been rising in four digits, many health workers have been infected, the state-run hospitals are facing a shortage of beds and ventilators for COVID-19 patients, and contact tracing efforts have been hampered by the false identification of infected people.
In an interview with The Kathmandu Post (August 27,2020) Dr. Sameer Kumar Adhikari, joint-spokesperson for the Health Ministry, said that the country has been focusing on preventive measures due to limited number of Polymerase Chain Reaction (PCR) kits, Viral Transport Mediums (VTMs), and ventilators. According to him, there are 900 ventilators and 2,600 ICU beds across the country. But, not all of them are allocated for COVID-19 patients and there are concerns many infected people might not get proper care, as cases are escalating so rapidly. According to the government, there are currently 984 ICU beds and 490 functional ventilators for COVID-19 patients (TKP, August 15, 2020.)
As many infected people are in home-isolation due to lack of beds in government hospitals, doctors are worried of transmission among family members, since not all infected individuals are likely to have a separate room and bathroom facilities that are necessary for self-isolation. The MoHP said that a total of 18142 people are in home- isolation, and 7171 people are quarantined as of September 23, 2020.
To solve the bed shortage, the health ministry has asked all community and private hospitals to reserve 20 percent beds for coronavirus patients. There are around 350 private hospitals and around two-dozen community hospitals across the country, of which around 75 private hospitals and a dozen community hospitals are in Kathmandu Valley.
While the doctors agree the need to provide beds for COVID-19 patients, they want the government to prepare separate facilities exclusively to care for coronavirus patients. They are not in favor of admitting COVID-19 patients in all private hospitals for fear of spreading the infection in medical facilities, like Italy. In March, Italy admitted COVID-19 patients into hospitals throughout its northern region. The hospitals then soon became hotspots for the virus, infecting patients and health workers, and pushing the healthcare system to breaking point.
“The authorities should have equipped the country to ramp up test, trace, and treat, rather than focusing just on restrictions,” Dr. Subhash Prasad Acharya, head of Critical Care Department at the Tribhuwan University Teaching Hospital told The Kathmandu Post on August 27, 2020.
“The government by now should have taken a 500-bed hospital or medical college under its control and converted it into a fully COVID-19-dedicated hospital.”
Dr. Bhim Acharya, former director at the Epidemiology and Disease Control Division, also told the Post that using all private hospitals for treatment of COVID-19 patients couldn’t be imagined. He says the ad-hoc decision of the Health Ministry cannot solve problems, but instead could spell more disaster, and the success in saving the frontline health workers largely determines the success in tackling the spread of the virus.
According to a MoHP report (September 3, 2020), around 800 health workers across the country have tested positive, and one has died due to COVID-19, so far. Among the infected health workers, more than 200 are doctors. The lack of adequate masks, gloves, face shields, and personal protective equipment in both private and government hospitals have made the healthcare workers vulnerable to the infection. According to reports, health workers have been compelled to use the same masks for over a week, and even reuse disposable masks after washing. The growing infection in healthcare workers has also impacted the healthcare facilities that are treating non-COVID aliments, depriving many people with chronic aliments of medical consultations.
There is also a growing concern about the infected people in the Valley who are still out-of-contact. According to Gyan Bahadur Oli, the COVID-19 focal person at Public Health Division of Kathmandu Metropolitan City, more than 500 coronavirus infected people are currently out of contact and many of them are from outside the Valley (TKP, September 19). According to him, on an average, 12 people who are tested positive daily are out-of-contact. Many people, who are living in rented rooms and apartments, have been found to be giving false information to health officials for fear of being stigmatized by neighbors and landlords, which has further increased the risk of community transmission.
Where did we go wrong?
False negative reports by rapid diagnostic test (RDT) kits was one of the main causes that led to the spread of virus in the early days of testing.
A lot of people were sent home from quarantine facilities after their RDT results came negative. As a result, people thought they were not infectious when they actually were, and unknowingly went on to infect others. Though health experts were against the use of RDT kits and suggested directly using RT-PCR tests, like Korea and other countries, the government continued using RDT kits.
While the antibody tests earned a lot of bad reputation for its false negative results, the studies say that it takes up to a week before our 
body starts producing antibodies after being exposed to a virus. So, RDT can show false negatives if conducted too soon. RDT tests are used best as a supplementary test for patients who have already tested positive for the virus. This test tells if one has been exposed to the virus at some point and is useful to determine how much the virus has spread in the community.
Besides buying the wrong test kits, the government also bought faulty PCR machines, and failed to arrange proper quarantine facilities to those coming from India that largely contributed to the ongoing transmission of virus in the community. Dozens of people were placed in the same quarantine facility with out screening and without considering the risk of transmission from the infected to the uninfected individuals.
After 14 days of quarantine, even those who had tested negative should have been monitored further and treated like infected cases, as despite having negative results they could have been tested positive after 14 days. According to studies, people who have been exposed to the virus, or have many symptoms of illness, are likely to test positive after 14 days, even if their current results are negative.
A study in Annals of Internal Medicine by researchers at Johns Hopkins University found that the effectiveness of RT-PCT tests varied dramatically over the course of COVID-19 infection. The study reported that the chance of getting a false negative result in the first few days before the symptoms appeared ranged from 100 percent on day one to 67 percent on day four. As symptoms began to show, false negative results fell to 38 percent on day five to 20 percent on day eight, and it rose again every day after that.
This means that there are high chances of getting false negative results before the symptoms show up. According to Harvard Medical School, a person with COVID-19 may be contagious 48-72 hours before starting to experience symptoms. And, many people without symptoms are more likely to spread the illness, because they might not be isolating themselves and adhering to other measures to prevent the spread of virus.
The government has been criticized for not having a proper plan of action to tackle the present health crisis. “The authorities should have a well-thought-out plan as to why they are imposing restrictions and why they are going to lift them. The restriction period by all the governments across the world is used to plan and prepare. We are not out of the threat yet, and an even bigger threat is looming large,” said Dr. Sher Bahadur Pun, chief of the Clinical Research Unit at Sukraraj Tropical and Infectious Disease Hospital, talking to The Post on September 1, 2020.
What next?
The government hasn’t been successful in slowing down the spread of virus by resorting to lockdown and prohibitory orders.
Apart from mass testing, effective tracing, and preparing separate facilities for treating COVID-19 patients, doctors are now demanding for seroprevalence surveys to control the spread of the virus. According to Dr. Megnath Dhimal, chief researcher at Nepal Health Research Council, “Seroprevalence tests help us identify the risk and contain the spread of infection. Such studies help us locate high-risk areas, so that the authorities can declare restrictions on those areas and perform polymerase chain reaction tests.”
Seroprevalence surveys can provide data on the prevalence of the virus in communities and help break the transmission chain to a large extent, preventing the virus taking hold in society.
Dr. Prabhat Adhikari, an infectious disease and critical care expert, also asserted that seroprevalence tests should be done without delay, as it is significant in conducting pool testing. According to him, polymerase chain reaction tests may not detect the virus after two weeks since infection, but a serology test can provide information on the infection by detecting the antibody. Thus, it helps understand the status of the virus penetration in society.
The government does not have a single medical personnel or expert in crisis management in the COVID-19 Crisis Management Center (CCMC) that was formed to coordinate the preparedness and response efforts to manage the current pandemic. Public health experts want the government to form a network of experts in critical care, disease surveillance, case management, risk communication, and information and communication technology to fight the virus in a comprehensive way. They have also been demanding to increase efforts in community-wide awareness and education to dispel the fear of insecurity and stigmatization around the COVID-19.
There is a lot we don’t know about the SARS-CoV-2, and one of the reasons COVID-19 is spreading so rapidly is because people are often unaware if they are infected. As such, health experts suggest that, along with testing, tracing, and treatment, taking effective prevention measures, such as social distancing, wearing masks, and handwasing, is still essential to control the spread of infection in the community.
References:
1. “Nepal records highest single-day spike in coronavirus cases with more than 2,000 new infections”, September 18, 2020, The Kathmandu Post, (https://kathmandupost.com/health/2020/09/18/nepal-records-highest-single-day-spike-in-coronavirus-cases-with-more-than-2-000-new-infections)
2. “Health officials raise alarm as country sets new single-day coronavirus spike with 2,020 cases”, Anup Ojha, Septembe 19, 2020, The Kathmandu Post (https://kathmandupost.com/national/2020/09/19/health-officials-raise-alarm-as-country-sets-new-single-day-coronavirus-spike-with-2-020-cases)
3. Ministry of Health and Population, Nepal, (https://covid19.mohp.gov.np/)
4. WHO Nepal Situation Updates on COVID-19, Wednesday, September 19, 2020, (https://www.who.int/docs/default-source/nepal-documents/novel-coronavirus/who-nepalsitrep/21-who-nepal-sitrep-covid-19.pdf?sfvrsn=664ec3d5_2)
5. Health Sector Emergency Response Plan, May 2020, Ministry of Health, Nepal.
6. “By extending restrictions, government is barking up the wrong tree, experts say,” Arjun Poudel, August 27, 2020, (https://kathmandupost.com/national/2020/08/27/by-extendingrestrictions-government-is-barking-up-the-wrong-tree-experts-say)
7. “Government directs private health institutions to set aside 1,000 beds for Covid patients, but they say it’s impossible”, Timothy Aryal, August 27, 2020, The Kathmandu Post, (https://kathmandupost.com/health/2020/08/27/government-directs-private-health-institutions-to-set-aside-1-000-beds-for-covid-patients-but-they-say-it-s-impossible)
8. “As Covid-19 cases rise, government plans to place patients in all hospitals, but public health experts say it could be tricky”, Arjun Poudel, August 10, 2020, The Kathmandu Post,(https://kathmandupost.com/health/2020/08/10/as-covid-19-cases-rise-government-plans-to-place-patients-in-all-hospitals-but-public-health-experts-say-it-could-be-tricky)
9. “Coronavirus in Italy fills hospital beds and turns doctors into patients”, Loveday Morris, March 4, 2020, The Washington Post, (https://www.washingtonpost.com/world/europe/coronavirus-in-italy-fills-hospital-beds-and-turns-doctors-into-patients/2020/03/03/60a723a2-5c9e-11ea-ac50-18701e14e06d_story.html)
10. “As Covid-19 affects healthcare workers, non-Covid patients left in limbo”, Arjun Poudel, September 3, 2020,The Kathmandu Post, (https://kathmandupost.com/health/2020/09/03/as-covid-19-affects-healthcare-workers-non-covid-patients-left-in-limbo)
11. “Cluster infections cause cases to soar in Valley despite restrictions”, Arjun Poudel, September 4, 2020,The Kathmandu Post, (https://kathmandupost.com/health/2020/09/04/cluster-infections-cause-cases-to-soar-in-valley-despite-restrictions)
12. “Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction–Based SARS-CoV-2 Tests by Time Since Exposure,” Lauren M. Kucirka, Stephen A. Lauer, Oliver Laeyendecker, Denali Boon, and Justin Lessler, May 13, 2020, Annals of Internal Medicine, (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240870/)
