Behind the masks

In January Nepal became the first country in South Asia to start the Covid-19 vaccination drive. Today, despite delays and a devastating second wave, close to 15% of the population is fully inoculated.

Recent surveys show that 97% of Nepalis would take the Covid vaccines if available. Used to pollution, mask wearing is also high among urban Nepalis.

With minimal vaccine and mask resistance, Nepal should have by now had the pandemic under control. And although the spike in cases after the lockdown was partially lifted in July is flattening out, the daily death rate is still high and the risk of a new Covid-19 surge is greater than before.

Graph from IHME for Nepal showing reported total fatalities from Covid-19 (orange line) and the estimated actual deaths counting excess fatalities including unreported cases (green line). For example, on 25 August, the reported total was 10,614, but the excess deaths from Covid-19 including unreported was projected at more than 37,000. If 90% of the population started wearing masks (green dotted line), nearly 6,000 Covid-19 deaths would be prevented by 31 December (red dotted line). 

Go to IHME site for interactive Nepal graphs.

Source: The Institute for Health Metrics and Evaluation (IHME) an independent global health research center at the University of Washington.

Experts say the vaccination drive appears to have created a false sense of security among those with jabs to believe that they are now fully immune to the coronavirus.

Ironically, the government’s promotion of masks also may have been too successful – with many thinking it will protect them from the virus even if they crowd around. A case in point is the Saparu festival crowd in Bhaktapur earlier this week (pictured above).

“If you are going to crowd in that way for an extended period there is no point in wearing a mask,” states epidemiologist Lhamo Yangchen Sherpa.

“Many still don’t know that the virus transmission is through the airborne route, and we cannot be careless knowing how infectious the delta variant is and that the majority of the people are still unvaccinated, particularly children,” she adds.

Masks and vaccines just reduce infections and serious symptoms, they are not foolproof. And epidemiologists warn that available vaccines do not stop even those who are vaccinated from transmitting the virus.

New studies have also shown that even the protection vaccines provide will be wearing off, so Nepalis with jabs will be needing third booster shots even before the eligible population is fully vaccinated.

Covid-19 vaccines save lives by ensuring that infected people do not have serious symptoms, and do not require hospitalisation. But vaccinated people can be carriers at the same rate as those unvaccinated if they have been infected with a delta variant.

“What I’m seeing now is a surge of overconfidence among younger people who are vaccinated, they are risking everyone else not yet vaccinated, especially as Dasain-Tihar nears,” says virologist Sher Bahadur Pun at Teku Hospital. “We are creating an ideal condition for the next surge or the third wave to take place.”

Recent studies have shown that an individual infected with delta variant even if vaccinated can have a high viral load -- as high as that of an unvaccinated person. This means they can be carriers of the virus just like unvaccinated people.

The real surge in Covid cases last year took place after the festivals when millions of Nepalis travelled from Kathmandu to their home villages and took the virus to the remotest corners of the country.

This resulted in higher fatalities, especially in rural Nepal with limited health care facilities.  A recent report found that despite fewer cases, Dolpa, Mugu and Humla districts had fatality rates of 7%, 6% and 5% respectively – compared to only 0.9% in Kathmandu.

The delta variant and its higher transmissibility despite vaccinations have made the situation worse this time around. Covid-19 is here to stay, and managing it requires behavioural change and taking safety measures such as hand washing, physical distancing and masking a necessary part of our lifestyle.

Earlier this year, researchers at Yale and Stanford University ran a large-scale randomised controlled trial to identify a precise combination of strategies that are successful in changing mask-wearing habits.

They found their NORM strategy worked well. NORM stands for:

- No cost masks distributed at scale

- Offering information about mask-wearing

- Reinforcement in public places by intercepting non-mask wearers

- Modelling and endorsement by trusted leaders

After a successful pilot trial in Lahore with 5 million people, NORM is being scaled up to cover the whole of Pakistan. The Bangladesh Rural Advancement Committee (BRAC) is aiming to reach 81 million people with NORM methods. In India, the program is being tried out in Gujarat and other states by the Self Employed Women’s Association (SEWA).

Mask-wearing rates have tripled where NORM methods have been implemented, helping save thousands of lives. The campaign was launched earlier this month in Nepal in the densely populated urban centre of Thimi, Sunsari’s rural areas, and Melamchi which has been battered by earthquakes and floods.

The plan is to distribute up to 450,000 masks through volunteers who go back to the community every 10 days to monitor progress in uptake. The pilot will be scaled up across the country with one million masks donated by Hanes, a US clothing brand arriving in Nepal shortly.

The NORM pilot in South Asia is being funded by the Bill & Melinda Gates Foundation and the Covid-19 Crisis Management Centre (CCMC) has endorsed the campaign in Nepal.

“We hope that the NORM mask-wearing approach will enable behaviour change throughout our nation and help to curb the negative effects of Covid-19,” says Brig Gen Arun Neupane, who heads the medical division of the CCMC.

Preeti Adhikary of the NORMalizing Mask Project in Nepal says the campaign has been received well, with many more local governments willing to participate.

She says: “Despite the vaccine rollout there is still a lot of uncertainty. So we must educate the public that even after vaccination we must follow safety protocols, which only comes with behavioural change which is what we are trying to do.”

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How to get QR coded vaccine certificates

Vaccine certificates are now the new passports for international travel, much like in the past when passengers from certain countries were required to present the WHO-approved yellow cards at airports.

This month, there were long queues of migrant workers at Teku hospital waiting for rubber-stamped papers to certify vaccination before they flew off to destination countries. The letter did not have a digitally-registered QR code, and risked being invalid.

This finally prompted the Health Ministry to set up an online application with photo, ID, vaccination card and a self-declaration form for a scannable digital vaccine certificate accessible with encrypted link and QR code acceptable internationally.

The QR code is linked to the officially-authorised database hosted and managed by the Health Ministry so the system is authenticated.

WHO Nepal has been helping the Health Ministry with technical support on the digitisation of vaccination records to ensure that no one is left behind from accessing the Covid-19 vaccination and facilitating the equitable allocation of Covid-19 vaccine.

The WHO support includes training, design and development of the ministry’s software system and IT equipment, and electronic vaccination registration system in seven selected municipalities in seven provinces.

Vaccination digitisation can be done in three ways: pre-registration, on-site registration and post digitisation. Pre and on-site registration are used for digitisation of new vaccination records whereas post digitisation will be used for the digitisation of people who are already vaccinated and have certificate cards.

“Recordkeeping is important to ensure that there is no duplication but measures must be taken so that there is no crowding at the vaccination centres, turning them into breeding grounds for the virus,” says a virologist at Teku Hospital Sher Bahadur Pun. “We need more vaccination centres and safety protocols must be implemented strictly at every booth.”

Public health experts say the digitisation can help control the pandemic in the long run if properly implemented, since the documentation will assist in vaccine equity as the inoculation drive gains pace.

Epidemiologist Lhamo Yangchen Sherpa says that online registration is important in reducing crowds at vaccination centres. But, she adds, “Since this is more applicable in areas with Internet access and for people with a smartphone, SMS with individual inoculation timing might be more effective.”

To register for online vaccine certificate, visit the website: https://vaccine.mohp.gov.np/public-request-form