After the World Health Organisation declared COVID-19 as a global pandemic, many countries globally clamped lockdown beginning around mid of March 2020. In Nepal, the government imposed official lockdown from 24 March when only two COVID-19 cases were recorded. It's been a week since the government lifted the COVID-19 lockdown. However, risks and fear continue as new cases of infections continue to emerge. In this backdrop Dr. Jos Vandelaer, WHO Representative in Nepal, talked to Ishwar Chandra Jha of The Gorkhapatra Daily, sister publication of The Rising Nepal, focusing around the COVID-19 trends in Nepal and WHO support to the government on the ongoing COVID response. Excerpts:
Cases of COVID-19 in Birgunj and Rajbiraj of Province 2 of Nepal are spiking at a higher rate as dozens of people in a single colony or village are found infected with the novel coronavirus of late. Does it indicate Nepal has already entered into the community transmission?
The World Health Organization (WHO) has maintained from the very beginning that there is limited community spread but no widespread community transmission in Nepal.
There is indeed a cluster of case in Birgunj. However, this cluster is due to a local transmission chain, and may not become widespread community transmission if proper steps are taken.
Spurts of cases due to local spread of disease has been seen earlier. For instance, this had happened in Triyuga Municipality in Udaypur in Province-1 in April. This did not lead to widespread community spread in Province -1 as the cases were tested and isolated promptly and contacts likewise quarantined.
If appropriate steps are taken in Province-2, then this local cluster may be controlled and not lead to widespread community transmission.
What are the other areas where COVID-19 is in the community transmission stage?
First of all, we need to understand that these stages of transmission – no cases – sporadic cases – clusters – community transmission – these are always dynamic and are not water tight or rigid categories.
That said, In Nepal, we think that two provinces (Gandaki and Bagmati) are showing sporadic cases, while the remaining five provinces are showing clusters of cases. Nepal has not yet entered the stage of widespread community transmission, although some degree of person to person spread in the community is inevitably present even in phase of sporadic transmission.
What is the situation in Kathmandu, the capital city?
Further, the case load in Bagmati province is one of the lowest and cumulative incidence rate is also the lowest in the country.
Again, this does not mean that there is no person to person transmission in the community. There is, but it has not yet become widespread.
All across the country and in Bagmati province, the daily cases are not increasing exponentially, the 7-day average is flattening out.
These are all good signs but there is absolutely no room for complacency. This may be the lull before the storm, and Nepal must be prepared for the worst.
There are a number of people without any travel history but suffereing from the novel coronavirus infection. Isn't it enough to claim that Nepal is in community tranmission stage of COVID-19?
We are reviewing available data on a daily basis. The data are not perfect, or complete but certain features stand out.
With the huge case load in June and July, the surveillance system could not interview and obtain travel history from all the cases. They could check and obtain such history from about two thirds of the cases. From those that the system could obtain such a history, 95% had a history of international travel.
Further, the case load across the country is disproportionately skewed towards males who constitute more than 86% of the cases (>75% in all provinces except Bagmati where it is 69%). This tends indicate the main at-risk group is not the population at large as you then expect to see more equal distribution between males and females. The main at-risk group so far has been migrant workers who are predominantly young males.
WHO is closely monitoring and coordinating the Vaccine development process, the last yet the rapid development is from Oxford University in collaboration with Astazeneca. Nations are already preparing and making agreement for the access of Vaccines once it gets green signal from WHO. What steps a nation has to follow and how they get their access to the company which is developing the vaccine ? What will be the role of the WHO in this process?
The WHO along with Gavi and CEPI (Coalition for Epidemic Preparedness Innovation) have set up the COVAX facility to ensure equitable access to one or more types of COVID-19 vaccines when they become available. (Please google “covax” for more info).
However, vaccine development takes time and realistically a vaccine may not be clear all trails and approval processes to be available this year. Research suggests that historically, vaccine products that have not yet entered human trials have a 7% probability of succeeding, which rises to 17% once they enter human trials. Of the 147 candidates identified by the WHO, only 18 are currently in human trials.
Will the WHO itself secure doses of Vaccine for the least developed, under-developed or developing nations or they have to do it by themselves?
The WHO will collaborate with partners like Gavi and UNICEF and CEPI to enable countries to secure and deploy doses with equity between countries and within countries.
According to the WHO, what is the Standard of PCR Test Per thousand? And where Nepal stands when seen from this angle?
In order for countries to identify new cases and effectively respond to the pandemic, testing programmes should be scaled up to the size of their epidemic, not the size of the population. Hence the number of tests per population is not a good measure to see whether countries are testing “enough”.
In that context, looking at the positivity rate (ie, out of all tests conducted, how many came back positive for COVID-19) is the most reliable way to determine if a government is testing enough. A high rate of positive tests indicates a government is only testing the sickest patients who seek out medical attention and is not casting a wide enough net. The WHO has issued guidance stating that governments should see positivity rates below 5% for at least 14 days before relaxing social distancing measures.
Positivity Rate: Countries with a very high positive rate are unlikely to be testing widely enough to find all cases. WHO has suggested a positive rate of around 3–12% as a general benchmark of adequate testing. Nepal has a positivity rate of 3%.
One can also look at the “Number of tests needed to find a confirmed case” (which is actually the inverse of the positive rate). Countries that do very few tests per confirmed case are unlikely to be testing widely enough to find all cases. The WHO suggests around 10 – 30 tests per confirmed case as a general benchmark of adequate testing. Nepal does 33 tests per confirmed case.
So on both measures Nepal performs within or very close to the expected range and is actively trying to strengthen both lab coverage and capacity.
Why the death rate in Nepal is lower than in the other East and South Asian countries and the most affected nations?
HEOC report shows a total for Nepal of 44 deaths for 18,374 cases, which means a case fatality rate of 0.24 % (44/18374 *100). The global average is 4.1%. Hence, Nepal is much lower than the global average. The main reason is that almost all cases in Nepal are among migrant workers, who are young. As you know, most deaths occur in older age groups, especially if there are underlying conditions. Because in Nepal few older people have been infected, the death rate is low.
In Nepal, so far most cases have been migrants who have returned. There has been, to our knowledge, only limited transmission in the communities. The virus is transmitted through droplets, hence the importance of physical distancing, masks, hand washing.