Avoiding a Public Health Catastrophe

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Avoiding a Public Health Catastrophe

Nepal has so far successfully stopped the transmission of novel coronavirus. Whether or not the lockdown can keep the possible outbreak at bay remains a question.

--BY TAMISH GIRI

As of April 24, the number of COVID-19 infected patients in Nepal has reached 48 with 38 individuals recovered from the illness. The number is encouraging given that the small Himalayan country has so far avoided the outbreak of the deadly pathogen unlike its South Asian neighbours including India, Bangladesh and Pakistan who are struggling to control the surge of new coronavirus cases. However, the situation in Nepal could change in the coming days as indicated by a cluster of infections identifi ed in Udaypur district; among the total infected 25 are from Udaypur leading to fear among people that local level transmission of COVID-19 has started in Nepal.

According to public health expert Sushil Koirala, COVID-19 outbreak in Nepal is still at an early stage. “We have seen a surge of new cases during the second wave of the outbreak in Europe and lately from India and since we had a very high volume of inward migration before the lockdown, however, the cases still detected this late is a signifi cant worry,” he says. The slow rate of testing and detection is what concerns experts who suspect Nepal will be fl ooded by even bigger clusters of transmissions over the next few weeks. There have only been some 9,200 COVID-19 tests across the country as of April 24, according to offi cials at Ministry of Health.

Dr Sameer Mani Dixit, director of research at Center for Molecular Dynamics – Nepal (CMDN) and COVID-19 Task Force member of Ministry of Health, says that Nepal is currently in the second stage of transmission and some level of community transmission has already started while most of the infections have come from abroad.

“It does not have any prevention or containment benefi ts. One of the puzzling issues is lack of serious symptoms in most of the identified cases. It can, however, expand quickly in a very short amount of time, ” Koirala opines. He believes it is not simple or wise to confi rm that the epidemic will go one way or the other and suggests that the prevention strategy should remain the same - detecting all cases with the infection and isolating them.

Talking about the strategy to contain the virus, Dr Dixit thinks that the lockdown is a good start. However, he adds that PCR testing needs to be carried out in suspected communities to ensure that they are isolated immediately. “In the absence of tests, we need to give continuity to the lockdown where cases are seen, and loosen the lockdown in places with no cases,” he informs.

Likewise, Koirala suggests that the government’s strategy to stop the virus is working on one level as public level quarantine has prevented the disease from becoming widespread. “But we are not using the limitation of population movement with widespread testing on time. Since the test is 20-30 days late, it will not help to fi nd the exact number of cases because it increases the risk of onward transmission,” he suggests.

Koirala informs Nepal does not have many cases and so there is no flaw in managing the cases, but still, the main attention should be to prevent a widespread communitylevel outbreak. “Our current eff ort of rapid testing everyone and pretending that there is no infection is quite risky, as we know that we have widespread cases from east to west. Experience from other countries shows that a case from one city is enough to cause a major outbreak,” he opines.

Experts believe that the efforts should be more on testing, conducting community-level surveillance of early symptoms and severing the chain of transmission. “Treatment is also important, but it will only work till we don’t overwhelm the hospital capacity. And we know that the virus is so contagious that it can spread very quickly,” adds Koirala.

Amidst the growing fear of the outbreak, the tests mobilised to identify the infection have roused confusion for health workers and experts. Nepal is currently mobilising two test models, RT PCR Test and Rapid Diagnostic Test (RDT) to identify the infection. However, people testing negative in one model of the test have been tested positive while testing via another model. Dr Dixit informs that the rapid tests detect antibodies, which take up to 10 days to be produced by our bodies once infected. As antibodies remain inside human bodies for months, PCR tests detect viruses, which multiply immediately after infecting our bodies. So, if an individual is tested positive in a Rapid test while he/she tests negative in the PCR test, it indicates that the virus has already been cured. However, the majority of the countries currently are using PCR for testing the infection. So, the rapid test should not be recommended, Dixit suggests.

According to Koirala, both RT PCR and Rapid tests have advantages if they are used in the correct circumstances. He says RT-PCR detects genes associated with the virus and is better to detect at an early stage. Early detection can help to trace close contacts and contain the outbreak and to isolate the patient and provide treatment to the patient. While the rapid test detects antigen and antibody present in the blood of the patients. So, it can only detect them when the patient has developed a suffi cient level of
antibody.

Experts say that this process can take an average of 20 days from the date of infection. Since this is an acute infection and people tend to transmit the virus usually 4 to 5 days after the infection, identifying people 15 days after that has no serious prevention benefi ts. This, however, is useful when the medical team is late to detect cases, like those who have travelled from overseas 20 or more days ago. And then subsequently test all close contacts with RT PCR for active infection. So, the best utilization of the Rapid Test and PCR is complimentary. “The government using RDT to screen everyone is a wrong strategy and should be changed. All close contacts of those who are tested positive should be tested with PCR to identify infective cases,” Koirala suggests.

It has been analysed that RDT also has quality issues. RDT is easy to use but it is not always able to tell the results correctly. RT PCR which provides more reliable results (but also not 100% accurate as well) requires proper infrastructure to operate, which is not always possible to build in a short time. “We have also employed a Point of Care (POC) PCR machine in regions outside Kathmandu. The quality and eff ectiveness of these compared to RT PCR is not properly understood. That is also a lurking problem as poor detection capacity can miss infected patients early,” Koirala informs.

Health experts have observed numerous flaws in this aspect which are challenging as we do not have suffi cient infrastructure to contain a big cluster. To name some of the lacking areas, Dr Dixit identifi es that the country lacks PCR tests in adequate amounts. “We are also lacking in advice from experts. In addition to these the government is not listening to advice from the experts,” he adds. Koirala thinks that the government’s strategy of holding a large group of people without adequate infection control and forcing a large group of migrants to stay in unsafe conditions in India risks a widespread secondary transmission. He opines that these state quarantine sites can be a factory for transmission of the infection. “We are testing people with the rapid test after 14 days of quarantine but it’s certainly not going to detect people who may have acquired the infection towards the end of the quarantine time (recent infections),” he says.

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