Corona virus
Introduction and types
Mechanism of transmission
Signs and symptoms, complication
Testing
Preventive measures
Global scenario
Population distribution of Nepal
Data of 2011 AD census
Estimated data of 2020AD
The testing-positive cases-cured cases-mortality data
Important highlights
Total testing labs and type of testing
Current scenario of Nepal
Distribution according to provinces
The initial policies/directions taken by government
Formation of high level committees
Sukraraj Hospital and Hub hospitals
Lockdown
Expansion of quarantine and isolation facilities
Public awareness and Protection of health workers
Case investigation and contact tracing
Surveillance
Point of entry
Local transmission and laboratory expanding
Mental health and disposal of dead
The quarantine and lockdown
Quarantine areas and facilities
Total quarantine bed by province and current status
Home quarantine
The other health problems faced by populations
Unemployment, domestic violence and mental status
Lack of access to medical care- high MMR, IMR
Lack of access to medicines
Low coverage of national vaccination program
OPD closure, less IPD admission
Others:- tourism, education, remittance, revenue collection
The lessons being learnt
Improvement in disaster management plan
Improvement in health sectors
Co-operation between government and private hospitals
Transparency
Storage and manufacturing of equipment at national levels
A medical student’s perspective on the Nepal government’s Approach to Combating the COVID-19/20 Pandemic
Corona virus
Corona viruses are named for their appearance: Under the microscope, the viruses look like they are covered with pointed structures that surround them like a corona, or crown. Corona viruses are a large family of viruses that usually cause mild to moderate upper-respiratory tract illnesses, like the common cold but may cause serious and widespread illness and death. There are hundreds of corona viruses, which circulate among such animals as pigs, camels, bats and cats but a spill-over event may cause disease in humans. Three can cause more serious, even fatal, disease- SARS corona virus (SARS-CoV), Middle East respiratory syndrome (MERS), SARS-CoV-2 or COVID-19, which emerged from China in December 2019, which changed into epidemic and were first classified as pneumonia of unknown origin but was declared a global pandemic by the World Health Organization on March 11, 2020. Based on research studies, COVID-19 may be initially found in bats, and might have then been transmitted by pangolin into humans and then subsequent human to human transmission. This animal to human transmission is mostly said to have occurred in the seafood market of Wuhan but it has also be claimed that the bio-lab near the market was responsible for the human transmission. It spread through droplets released into the air when an infected person coughs or sneezes. The droplets generally do not travel more than a few feet, and they fall to the ground in a few seconds there by making social distancing effective in preventing the spread. The incubation period is said to be of 14 days from exposure. Cough fever or chills, shortness of breath or difficulty breathing, muscle or body aches, sore throat, new loss of taste or smell, diarrhea, headache, fatigue, nausea or vomiting and congestion or runny nose are symptoms of infection. In severe cases, COVID-19 can lead to severe respiratory problems, kidney failure or death. Diagnosis is mostly made from travel history, symptoms and RT-PCR laboratory test. Radiological examinations-thin slice chest CT plays an important role as it can identify early phase lung infection, prompt larger public health surveillance and response systems. Most infected people will experience mild to moderate respiratory illness and recover without specific treatment. Those with old age and co-morbidities like cardiovascular disease, chronic respiratory illness, immunocompromised, diabetes have high risk of death. For prevention and slowing the spread of COVID-19, one is advised to wash hands with soap on regular intervals, practices social distancing-1m at least when going outside, use of mask, avoid coughing peoples, cough, sneeze after covering nose and mouth with elbow, avoid unnecessary travel. There are no vaccines or antiviral drugs to prevent or treat human corona virus infections. Treatment is only supportive. A number of anti-viral targets have been identified such as viral proteases, polymerases, and entry proteins. Drugs are in development which targets these proteins and the different steps of viral replication. A number of vaccines using different methods are also under development for different human corona viruses
Talking about global scenario of COVID-19, by 6th august, 19,246,679 total cases have been reported, 280,917 new cases, 716,745 deaths (6458 new), 6,179,501 active cases. Top countries with COVID-19 infections are USA, Brazil, India, Russia whereas Nepal lies at 65th rank. Some countries have effectively prevented further spread and risk of COVID-19, but countries like USA and India haven’t been able to slow the rate of spread due to lack of preventive measure practices and the situation is worsening day-by-day. India recorded a record breaking 62,170 new cases on 6th august. The first epidemic outbreak was in Wuhan, China followed by Italy and France, then Russia and USA, and finally India can be said to be at highest risk
Population distribution of Nepal
According to 2011 AD census, total population of Nepal was 26,494,504 with growth rate of 1.35%. The population density is 180.01/km2 with densities of 17.1%, 20.4%, 20.9%, 9.3%, 16.9%, 5.8%, and 9.6% in provinces 1-7 respectively according to 2015AD. By 2031AD, province 5 is expected to have more density than province 1. The sex ratio is 94.16 male per 100 females, literacy rate of 65.94%, life expectancy of 64.94 and 67.44 in male and female respectively, CBR is 24/1000 and CDR is 7/1000. The population is approaching stage III of population transition characterized by low fertility and low mortality rate but is currently in stage II where fertility rate is slightly more than mortality rate. Population pyramid showed decline in young age population and increase in working population. Male and female working population reached 57.8% and 61.6% with dependency ration of 67 per 100 working population in 2011AD
As per estimation, by 2020AD, the population is 29,136,808 with growth rate of 1.85%, median age-24.6 years, population density-203.3/km2, urban population-21.4%, Male and female working population reached 64% and 67%, global population rank-49 and population density rank-72.
The testing-positive cases-cured cases-mortality data
First case of COVID-19 in Nepal was reported on 23 Jan 2020 which was also the first case in south Asia. The case was 31 year male who returned from Wuhan on 9th Jan. 1st case of local transmission was reported from Kailali district on 4th April and first death was reported on 14th May. Other important figures includes 1000 cases by 28th May, 100000 RT-PCR by 8th June, 10000 cases by 23rd June, 10,000 recoveries by 13th July and 50th death by 30th July. Despite lockdown from 24th march, illegal entry to Nepal from boarder, efflux from Kathmandu also somehow affected the course of Pandemic in Nepal. On 17th April, 12 cases were reported from a mosque in Udaipur and cases increased in Udaipur on subsequent days making it 1st high risk region in Nepal.
Initially samples were sent to Hongkong due to lack of testing reagents, and equipments in Nepal. Later testing began in 3 bio-safety level-2 Laboratories in Kathmandu valley with testing its being aided from WHO. Currently, 35 Labs are assigned for COVID-19 testing throughout the country with total of 412,953 RT-PCR performed till 6th August. By 11th April, RDT tests reached all 77 districts and these were widely used for testing instead of RT-PCR until mid-May. They aren’t used now because of giving false results in most cases. RT-PCR testing increased but still was <1000/day till 2nd week of May, reached maximum of 6000 and average of 4750 by 9th July. New cases, recovery were minimal and sporadic until June. From June, average of 250 cases/day was reported with PCR of average 3000/day causing rapid increase in active and total cases but recovery was still low. 3rd July-740 new cases is still the record of maximum new cases in single day. The total tests done unreasonably declined to about 3500/day from 9th July-27th July which may or may not be associated with decrease in new cases/day to as low as 70cases/day. The same period was characterized by rapid increase in recovery rate causing heavy downfall in active cases. In past few days again the new cases/day has risen to about 250-300/day owing to end of lockdown on 21st July, or increase in testing rate of more than 5000 tests/day. Maximum RT-PCR test in single day was 10,768 on 31st July.
As per situation report of 6th August, Total RT-PCR=419575 (New=6622), 14378 tests/million population, Total cases=21750 (New=360), Total recovered=15389 (New=233), Recovery Rate=70.8%, Total death=65 (New=5). 84.6% of total infected are male and remaining are female. 8113 infected cases were of 21-30 years, 407 were of >60 years. As per Non-Resident Nepali association, 16,190 confirmed cases with 12,667 recoveries and 161 deaths are reported from 35 countries.
Distribution according to provinces showed maximum active cases (2693) and maximum death (25) in province-2, maximum discharged (4097) in province-5, minimum active cases (280) in Gandaki province, minimum death (4) in province-1 and 6, minimum discharged (501) in province-3. Khotang, Dhankuta, Sankhuwasabha, Manang, Mustang, Rukum showed no active cases in last 14 days but Rahutahat, Parsa, Kailali, Kathmandu, Mahotari still have over 500 active cases. Province-2 is badly hit by COVIID-19 with Rahutahat being severely affected and is followed by province-5.
The initial policies/directions taken by government
On 24 March 2020, the Government imposed a complete ‘lock-down’ of the country including business closures and restrictions on movement within the country and flight access in an out with exceptions in place for businesses and people in relation to supply and access to medical supplies and food. The health desk at Tribhuvan International Airport was initially strengthened to screen incoming passengers from affected regions. The ground crossing Points of Entry (PoE) at the Nepal-China border and the Nepal-India border have been similarly strengthened with closing border on 21st Jan 2020 and suspension of international and domestic flights which has been carried till now. The Government of Nepal had formed a committee to coordinate the preparedness and response efforts, including different ministries. The Humanitarian Country Team (HCT) includes the Red Cross Movement, civil society organizations. Together they worked on finalizing contingency plans which will be consolidated into an overall joint approach with the Government and its international partners. The UN had activated the Provincial Focal Point Agency System to support coordination between the international community and the Government of Nepal at provincial level.
The Sukraraj Infectious and Tropical Disease Hospital (STIDH) in Teku, Kathmandu has been designated by the Government of Nepal (GoN) as the primary hospital along with Patan Hospital and the Armed Police Forces Hospital. The Ministry of Health and Population (MoHP) has requested the 25 hub and satellite hospital network across the country to be ready with infection prevention and control measures, and critical care beds where available. The country has 26,930 hospitals beds in public and private hospitals. Likewise, 1595 ICU beds and 840 ventilators are available in 194 hospitals. MoHP has designated 111 hospitals to run COVID clinics and 28 hospitals to treat COVID-19 cases. The numbers of level I, II, and III Covid-19 hospitals are 13, 12, and 3 respectively.
Total cases less than 2000 were treated as level I were all were kept at isolation wards and symptomatic treatment were done. As case rose above 2000, the MoHP declared Public Health Emergency as per Public Health Service Act 2075. Similarly management plans were made for level III and IV in which the government would declare disaster as per Disaster Risk Reduction and Management Act 2074, Clause 32.1. On 21 March, the Metropolitan Traffic Police Division deployed 200 of its personnel to display placards with awareness messages about the disease by the roadside
Case investigation and contact tracing teams (CICTTs) were formed and mobilized at local level composed of Public health professional (lead), Health worker (paramedics/nurse), Laboratory technician/assistant. All CICTTs were trained/oriented to make them ready and were deployed. Standard operating procedure for case investigation and contract tracing were developed and were strictly followed. The CICTT mobilized Female Community Health Volunteers (FCHVs) for monitoring and follow-up where applicable. The CICTT also performed rapid epidemiological investigations of the clusters and produce analytical report to inform health actions. CICTT teams worked in close coordination with Rapid Response Teams. Necessary resources and protective measures according to level of risk were provided to the CICTT and FCHVs as appropriate.
Call-center and text-based reporting systems were established to enable effective event-based surveillance. Communicable disease epidemiological experts were designated at the federal ministry at Epidemiology and Disease Control Division (EDCD) who performed rigorous epidemiological analysis of surveillance data and present key findings and recommendations to the incident command system for decision making. National and sub-national capacity on epidemiological analysis will be built. All PoEs at international airport and ground crossings were strengthened with dedicated standard health desk equipped with adequate HR and necessary commodities. POE specific standard operating procedures (SOPs) were developed and disseminated for detection, notification, isolation, management and referrals. Tracking system were developed and implemented to track people who enter Nepal through PoEs. Necessary laboratory networks and biosafety requirements were mapped and planned for expansion of testing facilities for testing at community level. Community level screening and testing were aligned with surveillance systems. Mobile testing vans were prepared and mobilized in the high-risk communities. A designated trained team was assigned for health care waste management and decontamination for each hospital, public health lab, essential a transport such as Ambulance and quarantine stations. The deceased were burned with clear instruction as mentioned in the Dead Body Management Guidelines. Mental health services and psychosocial counseling and support were provided to the patients, families and health care workers through appropriate medium.
Various plans and policies were made for the security of health care workers. Despite this incidents of violence against health care workers surfaced in between. Adequate PPE, were provided along with health insurance to the health workers. Recently government made a decision of providing Rs 15,000 per complicated cases requiring ventilator support. As a conclusions, steps taken by government to prevent widespread outbreak of disease while preparing for it includes buying, providing, storing essential supplies, equipments, medicine, upgrading health infrastructure, training medical professionals, spreading public awareness, minimizing transmission rate, establishing quarantine facilities, providing some financial support to needy.
The quarantine and lockdown
Lockdown began on 24th March and lasted till 21st July. The first to be quarantined were the passengers and crew of the flight that evacuated the stranded from Hubei in mid-February for two weeks at Kharipati in Bhaktapur. On 21 March, around sixty passengers from COVID-19 affected countries that landed on Tribhuvan International Airport were sent to quarantine at Kharipati, Bhaktapur. Adequate institutional quarantine facilities were arranged by mobilizing available infrastructures such as schools, campuses, hostels, hotels and other accommodating facilities across the country, particularly focusing on Kathmandu valley and bordering districts. As of current data, there are total 147263 quarantine beds and 9699 isolation beds. Total people in quarantine are 9470 and 66 in ICU and ventilators as for 6th August.
This quarantine were said to be managed as per WHO guidelines but they weren’t managed as per the reports. Testing, monitoring, referral and release of the quarantined persons were done according to the protocols and guidelines approved by the MoHP. Contacts of suspected, probable and confirmed cases , those exposed to international travelers (family members and people travelling together with suspected, probable and confirmed cases) were initially kept on home quarantine but after declaration of public emergency, asymptomatic, young and those without co-morbid conditions less than 60 years of age were also send to home quarantine.
The other problems faced by populations
COVID-19 pandemic has affected the health directly by threatening people via its communicable, undetectable and death causing nature but also has brought along with it a vast range of problems. These other problems are somehow also supported by nation-wide and/or international lockdown. Lockdown meant complete cessation of everything’s except the essential items. It leads to closing of industries, factories, markets transportation and many more. This directly affected do factory workers, Day-weigh laborers, goods transporters, public transport workers, low-income workers directly as their source of income was stopped completely. It was getting more difficult for them to meet the daily needs and most of them returned bare-foot from workplace to home carrying along with them the risk of infection. Their savings ended up immediately, predisposing them and their families to starvation, lack of proper nutrition. Many died midway on their way back to home. A study showed less than half industries of industrial-state operating in lockdown that too with 8-30% of total efficiency due to breakage of the supply-processing-demand chain. Unemployment increased as lockdown extended due to returning of labor migrants, people were removed from job/ weren’t getting salaries just because small-scale start-ups, offices, school, industries weren’t able to cope with the loss brought by the lockdown as earning and profit declined to almost zero. This unemployment and fear of getting unemployed resulted in mental tension and illness like depression. Remittance was the primary source contributing to majority of GDP. Returning of labor migrants directly affected the remittance and GDP. Decrease in remittance, closure of industries, market and trade affected national tax collection as a whole. Domestic violence though less reported have increased during this period.
Vaccinations program were also affected. Despite allowance of essential services, vaccine transportation, its coverage was found to be very less. Adequate vaccine without its storage methods weren’t available to all areas of country. Along with this awareness about the vaccination date couldn’t be made by the volunteers, which led to less coverage of vaccine.
Due to risk of transmission, patients visiting hospitals for treatment decreased, even the doctors weren’t checking patients as usual, surgeries that were scheduled got cancelled and only surgical emergencies were performed. Admission of patients In patient department reduced, dental services were almost fully closed as per the governmental orders. Most people travel to tertiary care hospital from remote location to buy medicine that are not easily available like for diabetes, heart problems and other chronic conditions and used to buy them in stock. But lockdown and lack of transportation access to hospitals denied these patients from medicines needed to improve their ill conditions. This lack of transportation also caused increase in maternal mortality rate and infant mortality rate because of unsafe environment for delivery and lack of support in cases of complication. Also it was seen that hospitals refused to admit patients because they were from COVID risk areas and news of death due to such incidents were also heard on news.
Tourism is another industry that was heavily affected. They made investments and plans for the VISIT NEPAL 2020 event but it all went to vain when government cancelled VISIT NEPAL 2020 on march due to risk of COVID, closure of borders and cessation of air traffic.
All school, colleges and educational institutions were closed immediately and the long period of lockdown and COVID risk heavily hampered academic calendar, delaying board exams, new admission, etc which may have impact on the nation’s future.
The lessons being learnt
What government has done so far is commendable but not everything the government has done been successful and at its level best. Also the citizens must learn lot of things from the pandemic and not only blame the government for each and every thing. First and foremost the disaster management plans should be modified taking into account possibilities of all kind of disaster. The health sector must be focused and improvements must be done such that although the rural health care centers can’t tackle any disaster instantly, they can help by decreasing death from other modalities like unavailability of medicine, labour and delivery rooms etc. the main problem encountered during initial days were lack of PPE, masks, therefore the government and hospital’s administration bodies must keep stock of all such equipments in case of future outbreaks. Also equipments were mostly imported though now PPE and N95 masks are produced within Nepal. One lesion that can be learnt is faster manufacturing of essential equipments locally with government’s help of fast setup of factory line so that other important medical instruments, testing kits can be imported using those money. Also the poverty rate, unemployment wouldn’t have increased by this much if Nepal wasn’t dependent on remittance. This must be looked upon. Various news of corruption while buying kits and PPE were heard of, this must be minimized and cross checked so that the citizens don’t suffer from the deeds of their elected representatives. At time of turmoil, health sectors should unite i.e. private hospitals should also be loyal and support the governmental bodies in a healthy manner.