Nepal detected its first COVID-19 case on January 23. It took the country two more months to detect its second case on March 23. Since then the number of cases has jumped to 295 with the deaths of two people. Nepal will certainly detect many more COVID-19 cases in the coming days, although the lockdown clamped since March 24 has helped in delaying the spread of the disease to some extent. Is Nepal prepared for, what could turn out be, the worst days in its history? Will hospitals be able to handle patients? Rupak D Sharma and Sabitri Dhakal of The Himalayan Times discussed these issues with Jos Vandelaer, a medical doctor and World Health Organisation country representative to Nepal since July 2015. Excerpts:
What does the World Health Organisation know about the coronavirus so far?
We know it’s a new virus. There are questions about the exact origin of the virus and we are currently looking into it. But we know it’s a coronavirus and it is spread through human droplets, which is very different from air transmission. So the virus is not in the environment as many assume. We know the virus affects people and it seems the older the people the more severe the infection. There are still lots of questions around the role of children in transmission of the virus and experts worldwide are looking into them. So, we still don’t know many things about the virus. And we will have to make adjustments based on the findings of scientific researches.
Every virus changes its strain when it moves from one human body to the other. The WHO has done some studies in Nepal on the virus as well. How different is the virus found in Nepal?
Small changes are seen in viruses as they move along. That’s absolutely normal. Worldwide, the genomes of the viruses are being sequenced. They are the identity of the virus from the genetic point of view. We have sequenced the genome of one virus in Nepal so far, which was extracted from the first person who tested positive in January. That was done in a laboratory abroad as we were able to ship that virus outside the country. That virus was 99.99 per cent similar to the one seen in Wuhan, China, as the person who was infected had returned from Wuhan. But we have not been able to export viruses seen in Nepal since March because of the lockdown. I know that the government and other partners are looking into the possibility of conducting genome sequencing in Nepal. But right now we have not been able to do so. So we cannot say whether the genome of the virus seen in Nepal since March is any different from others seen globally.
Don’t you think Nepal needs to sequence the genomes of more viruses to find out the nature of infection here?
Yes, more genome sequencing would certainly help us understand what’s going on. But we should not expect something extraordinary because we never know what comes out. When we talk about genome sequencing, we very often think we have a different situation here than elsewhere. But that may not be the case. Yes, Nepal has not detected many positive coronavirus cases. That may be because Nepal locked itself down early on, which may have curtailed transmission of the virus. So it is possible that Nepal may have the same type of virus but the measures it took produced different results in terms of transmission.
Nepal has few coronavirus cases. But cases have doubled in the past few days and people have started dying as well. How severe will the situation be in the coming days? Can WHO make a prediction for Nepal?
It is very difficult to make a prediction on this issue. Cases will go up for sure. But it’s difficult to say how many people will be affected. Spain, for instance, is one of the worst affected countries in terms of population. But even there less than 0.5 per cent of the population was diagnosed with COVID-19. That’s one in 200 people. And 80 per cent of those who were infected had mild symptoms and did not have to go to the hospital. The remaining 20 per cent were in need of advanced treatment. People assume that when a virus hits a country, everybody will fall sick. That is not what we have seen so far in other countries. One of the things that is not so clear is the proportion of the population that gets infected but does not show symptoms. Some of the antibody studies have shown that may be five or 10 per cent of the population, depending on the country, gets infected but does not show any symptom. So even if only 0.5 per cent of the population is seen with symptoms, quite a large number of cases may have been unknown.
The worst thing about this disease is transmission through asymptomatic patients. In Nepal, more than 80 per cent of those who are infected are not showing any symptom of the disease. This is why tests are necessary as asymptomatic patients can transmit the disease rapidly. But don’t you think Nepal is lagging behind in conducting tests, especially PCR tests, which are more reliable?
I don’t think Nepal is lagging behind in testing people. First of all, you have to determine who to test. Vast majority of the countries test people with symptoms because governments face problems testing everybody due to lack of kits. Nepal hasn’t seen many symptomatic cases till now. I think only three persons in Nepal had symptoms when they were tested. So, Nepal is trying to identify possible hotspots, where people may have been infected.
Lately, Nepal has also started testing people who are kept in quarantine sites regardless of whether they have symptoms. Most of these quarantine sites house people who have travelled, and they are the ones who test positive. And most of the quarantine sites have people who have returned from India. Many of these people are healthy but still test positive for coronavirus. The reason why so many asymptomatic cases are being found is that Nepal is not looking for symptomatic cases. It is looking for people who are at risk. This approach has yielded positive results but we also need to be careful about what conclusions we draw from that. One conclusion is that quarantined people test positive even if they do not show any symptoms. But we need to ask how did they get infected? Have they travelled recently? Did they come into contact with someone who had travelled. That’s why it is very important to do case investigation and trace the contacts of infected persons. But it would not be appropriate to extrapolate the results of quarantine sites to the rest of the country. So if ‘x’ per cent of people in quarantine sites test positive, then you cannot say similar per cent of people may have been infected throughout the country. And at the moment we don’t have evidence to say that the virus is circulating outside the quarantine sites.
And what about the tests, as most of those that have been performed are rapid diagnostic tests, which are not very reliable?
Many other countries perform antibody tests (commonly referred to as rapid diagnostic tests in Nepal) only after the epidemic expands rapidly. These test results are generally representative of the entire city or an area. So, Nepal’s approach on this front is quite different.
Are you saying RDTs are not relevant for Nepal at this moment as we have not seen many cases?
We know that antibodies are seen 10 to 14 days after being infected. Antibodies tell you that the person has been in touch with the virus but it does not tell you when the person got infected. There are also quality issues regarding RDTs for antibodies. But let’s not get into that. So, it is very difficult to use antibody tests for anything else than to basically assess the level of antibodies generated by the disease. If you want to see whether a person harbours the virus, then you need to do a PCR test. The RDTs or antibody tests will not tell you whether you have the virus.
What do you think of the measures taken by the government so far to contain the spread of coronavirus disease?
Lockdowns help in slowing down the epidemic. But they do not help in interrupting the transmission. To interrupt the transmission, you have to isolate individuals. During the lockdown period, the government has taken a number of measures to better prepare itself for the fight against COVID-19. And a lot of work has been done on the front of training and preparing hospitals. The government has designated COVID-19 hospitals so that people know where to go when they get infected. The government has also expanded the laboratory network. We should not forget that there was only one laboratory in Nepal in January that could conduct PCR tests. Now there are 19 laboratories around the country. The government has also done a lot of work in terms of preparing guidelines; and the government’s coordination has vastly improved. We have to see how the epidemic will play out. But there seems to be a lot of fear among the population that once the cases go up everybody will fall sick and a large number of people will die. Yes, a large number of cases will be detected in the coming days, but the whole population will not fall sick.
What if a third of the population, or approximately 10 million people, fall sick and one per cent of those who have fallen sick, or 100,000 people, are in need of hospital beds. This is an optimistic scenario considering some of the studies that are saying 60 to 70 per cent of the world’s population will ultimately get infected. Can Nepal handle such a situation as little more than 3,000 hospital beds have been allocated for isolation of COVID-19 patients?
First of all, none of the countries so far has seen a third of the population getting infected by the disease. Even antibody tests done in some of the countries have shown infection in five to 10 per cent of the population. So, right now, we should not be talking about a rate as high as 33 per cent, or a third of the population. The Nepal government has said it will be difficult for it to handle the situation once cases exceed the 10,000 mark. You are right that the number of intensive care unit beds are limited here. But every country has a limited number of ICU beds. China built a 1,000-bed hospital overnight, but you cannot do that in a country like Nepal. So, Nepal has made as much preparations as it could in terms of dedicating hospital beds and providing training. But the health system in Nepal overall is not very strong and we all know this, so you need to work with what you have. Currently, asymptomatic cases are being treated in hospitals, but as the number of cases goes up priority will be given to serious cases and those who need oxygen.
So far, only richer countries are seeing a surge in cases. What are your recommendations for a low-income country like Nepal with few beds dedicated for COVID-19 patients?
Our advice would be to ask Nepal to get as ready as possible with the means that it has. You cannot dedicate all the hospitals for COVID-19 treatment because people will need regular healthcare services as well. And you cannot expect a country like Nepal to build COVID-19 hospitals with hundreds of beds overnight. That’s just unrealistic! So focus should be divided between treatment and epidemiological aspects, such as case investigation and contact tracing because you need to know why a case has popped up and who else may have been infected.
That way you can isolate the infected patients. Lockdown has helped in containing the number of cases, but it is a blunt weapon. So, the important thing will be to isolate the infected ones so that the virus does not spread. And we are working very closely with the government to help it prepare for the fight against the disease.
Lockdown is likely to make people poorer, reducing their calorie intake in the coming days and thereby making them more susceptible to other diseases. What is your take on this issue?
On the one hand, you have a disease that you have to contain, and on the other, the measures to contain it have their own drawbacks. So how do you balance that out? That’s the issue every country is struggling to deal with. In Nepal, it is affecting day labourers, who do not earn any money if they do not work for a day. Here, the government needs to take measures so that the most immediate needs of the most vulnerable are met. So, a measure like lockdown is not just a health issue but an economic issue as well. So you need to strike a balance, which is difficult to find because we have never dealt with such a situation before.
The lockdown has also affected immunisation programmes in Nepal, which are crucial to keep the future generation healthy. How will it affect Nepal?
More than 90 per cent of Nepali children are immunised with antigens, which makes Nepal one of the top countries in the world to successfully implement immunisation programmes. But many of these programmes, such as the measles-rubella vaccination campaign, have been halted because of the threat of COVID-19. But I also understand that a number of immunisation programmes are restarting in a number of places, which is good. You can ride on the wave of past successes for a short time because you won’t have an outbreak if you stop immunisation programmes for two weeks. But if immunisation services are interrupted for too long you will start building up a cohort of children who are not immunised and they may be susceptible to vaccine-preventable diseases. That’s why our discussions with the government not only revolve around tackling COVID-19, which is important, but ensuring essential services, like immunisation or provision of drugs for tuberculosis or HIV patients, are catered one way or the other.
Lately, new types of symptoms are also being seen in children because of COVID-19. Does the WHO have any recommendation on that front?
What we have seen is that the disease seems to be very mild in children. But if you have a child who has been severely infected, he or she needs to be treated in a similar way as an adult. Although we know healthcare needs for children would be much less than an adult, that does not mean they do not require treatment.
Lastly, would you like to add anything more?
One of the important things is that people should not panic because of COVID-19. The level of panic around COVID-19 in Nepal is not proportional with the effects of the disease. This may stigmatise people who are infected. So, let’s try to approach this disease in a very rational way and let’s apply what we know about this disease. What you know is that if you maintain distance, chances of getting infected are almost zero. That is the basic message which gets lost because of the fear that one cannot trust anyone. Many also think that you get infected if the virus touches your skin, which is not true. You get infected if the virus enters your body through the mouth, nose or eyes. That’s why you need to wash your hands. I’ve seen people shopping in Bhatbhateni Supermarket and drivers delivering drinking water jars in protective gear. That’s irrational behaviour! Also, as many as 10 million people will not get infected at once in Nepal. There is no reason that will happen based on experience of other countries. That number is far too high by any standard. I understand people are worried here but those worries should not turn into panic or behaviour that stigmatises others.
A version of this article appears in e-paper on May 18, 2020 of The Himalayan Times.