Anup K.C.

None of the governments across the world had anticipated to imposing lockdown in their countries. However, given the situation that ensued with the rapid spread of infectious COVID-19, countries were left with no option but to enforce unprecedented lockdown and prohibit human mobility to stifle the spread of the contagious virus. Nepal went into lockdown from March 24 in a bid to contain the possible virus’s outbreak. Indeed it came at the cost of disruption of normal life across the entire country. The subsequent situation that followed has brought immediate and long-term challenges to the KP Sharma Oli-led government in managing the impending health crisis and also achieving set economic and development targets.
Although the lockdown is timely and has been effective so far, it is not the ultimate solution to control the virus. It must be understood the public health interventions including lockdown are only aiding to slow down the rate of transmission but never can stop the 'transmission' itself.

Cross-transmission
The grim fact is that elderly citizens, frontline health workers, people with underlying medical conditions like diabetes, cardiovascular diseases, hypertension, and cancer are more susceptible to the virus. Patients with age more than 60 years shared disproportionally high mortality with almost 90 per cent of total death and more than 80 per cent deaths were in person with one or more underlying conditions. It is found that 20 per cent health workers are left infected due to cross-transmission. The rate of infection is higher among adults than children or even elderly people. However, the disease’s impact like hospitalisation and death is disproportionately higher in elderly than adults and is much negligible in children.
Lancet has mentioned that rate of hospitalisation increases with the age. It is reported that hospitalisation rate were least in age category from 10-19 years old with 0.04 per cent, rate followed by 1.0 per cent in 20s. Among the age of 30-39 years, the hospitalisation rate has been 3.4 per cent. Hospital cares is seen to be required for 8.2 per cent of patients in the 50s which is almost double than of 40s (4.3 per cent). The rate is the highest in 60 plus population: ranging from 11.8 per cent in 60s, 16.6 per cent in 70-79 age category, and 18.4 per cent of those with 80 years. It is found that around 90 per cent of the hospitalised COVID-19 cases had some form of underlying medical conditions. Based on the given data, adults without pre-existing medical conditions are relatively safer than the elderly regarding the hospitalisation or deaths.
It must be noted that precautions and boosting immunity are equally important for all age groups including health workers, immuno-compressed patients. To stop the chances of cross- transmission, elderly and persons with underlying diseases should maintain physical distance with the adults even at homes. The exposure of the adults or elderly to crowded places and market areas is sure to increase the possibility of infection among their age group hence one should refrain from such activities. On the other hand, densely-packed slums and COVID-19 hotspots must be put under strict and constant surveillance.
At the same time, infection control measures like avoiding public gathering, social distancing; practicing respiratory hygiene, disinfecting frequently touched surfaces, toilets and bathrooms, maintaining personal hygiene and frequent washing hands must be religiously followed. The susceptibility of infection can also be reduced by boosting immunity through healthy life style, by practicing indoor exercises, taking balanced diet and by avoiding smoking and alcohol consumption.
The government can ease restriction measures for adults without any underlying diseases with due precautions so they can engage in regular activities. The COVID-19 infected adults are less likely to be hospitalised or face deaths which means the majority of adults are cured without hospital admission. But, the government should ramp up public health, diagnostic and therapeutic countermeasures so fewer proportion of adults who requires hospital admission and cases of secondary infections among vulnerable people can be cured in time without overwhelming health system.
According to WHO, 80 per cent of COVID-19 infection are mild or asymptomatic and can be managed through home quarantine and medical supervision. It is seen hospital-based care is required for 15 per cent of severely-ill and 5 per cent of critically-ill patients. In course of treatment, the patients with severe infection require oxygen while ventilators are required for critically-ill patients.
Against such backdrop, the estimated proportion that requires clinical care is almost sure to strain Nepal’s health-care systems. The nation's health care system is already facing shortage of diagnostic kits, necessary oxygen cylinders, ventilators and Personnel Protective Equipment. The government should be ready itself for the possible worst-case scenario and without any delay must mobilise its entities to focus on strengthening large-scale public health and hospital capacities. In addition, state and local governments must adopt Outbreak Response Strategy to provide health care.
Lockdown has given a window of opportunity to the government to buy time for the strengthening active surveillance, laboratory, emergency services, therapeutic countermeasures and ensure that nation's hospital capacity does not become overwhelmed following surge of patients in the aftermath of mass outbreak of COVID-19. Hotels and schools can be converted into isolation, management of mild, and low to moderate-risk, patients with COVID-19 infection.
The government must expand Simple Oxygen Therapy Systems and Intensive Care Unit (ICU) capacities of hospitals at provincial and federal level. The private hospitals simultaneously must be made more accountable during the outbreak. Learning from China, separate hospitals can be set-up temporarily for treating patients based on their symptoms, mild or severe, which will indeed prevent the cross transmission.

Human resource
The existing workforce of health practitioners will not be able to fulfill their high demand in case of mass outbreak. While coordinating with medical and professional health councils, teaching hospitals and colleges and vocational training institutions, the government can deploy temporary health human resource to ensure adequate number of health worker in its combat against the coronavirus. Nevertheless, the government must administer them the legal rights to work, impart rapid training and ensure occupational health and safety of every health worker.
To meet the growing demand of necessary medical and laboratory equipment, policy and procurement procedures can be eased for the time being however with full transparency and accountability. On the top of all, government should proceed with necessary initiatives to coordinate with neighbouring and other countries seeking logistical, technical and medical support in case there is the mass outbreak of COVID-19 in the country.

(KC is a graduate in Epidemiology and Bio-Statistics from SRM University, India)