How Nepal must prepare for 3rd Covid wave

This is the second installment of a series by the Nepal-Johns Hopkins University Covid-19 Vaccine Advocacy Group. The first part titled ‘Once Nepal gets vaccines, it has to be fairly distributed’ appeared in Nepali Times 10 July.

Nepal has undergone two ‘waves’ of Covid-19 infection. In infectious disease jargon, waves of infection describe the curve of an outbreak, referring to a rise and fall in the number of cases.

There was a sustained period of relatively low numbers of new infections between the first wave which ran through mid-October to mid-November of 2020 and the second wave that started in mid-April of 2021.

The second wave ravaged most South Asian countries and was noted for its severity and transmissibility. It was more devastating than the first, with increased hospitalisations and deaths. Many of us had heard of or knew someone during the first wave, be it a family member, friend, colleague or neighbour who was infected with Covid-19.

But in the second wave, almost all of us personally knew someone, who not only got infected but even succumbed to the virus. Thus, it was no longer a disease that led to fatal outcomes in the elderly and immunocompromised, but could have severe life-threatening complications in healthy, young people as well. The highly infectious nature of the virus that hit South Asia the second time was later found to be a new strain called the Delta variant, first identified in India.

The World Health Organisation (WHO) recognised the Delta variant as a variant of concern because of its increased transmissibility. A recent study in China reported that the Delta viral load to be 1,260 times higher than the original virus thus causing the higher transmission rates.

Although the infections by the Delta variant seem to have slowed in South Asia, it is currently ravaging many Southeast Asian countries. This variant is known to be the dominant strain circulating in many countries and newer variants of the Delta called ‘Delta plus’ have been detected in Nepal.

As more research and studies are conducted on new variants of the SARS-CoV-2 virus that cause Covid-19, and especially the Delta strain, one thing is clear -- vaccination against Covid-19 has been shown to reduce serious illness and death even against the Delta variant.

Increasing vaccination coverage so as to reduce the size of the susceptible population is the only way to prevent new variants of the virus and beat this pandemic. As vaccines trickle into Nepal, another question to ask is what can be done to prepare ourselves to mitigate a potential third wave?

Build on the positive outcomes of the second-wave 

Some positive outcomes of the deadly second wave through the help of government agencies, foreign aid, non-profit organisations and individual donors/volunteers to fill the void in the overburdened and fragile health system are as follows:

  1. Secure enough oxygen cylinders and oxygen generators and improve the hospital infrastructure to manage surge in hospitalisations
  2. Increase hospital beds
  3. Set up new isolation centres in both urban and rural areas
  4. Rapid antigen tests to be widely used in places where the PCR test cannot be implemented.

The rapid surge in Covid-19 infections in the second wave instilled new fear in many people resulting in mask wearing and social distancing being more strictly followed and anecdotal evidence suggests that vaccine hesitancy has also reduced.

We need to further strengthen the capacity of health facilities to deal with surges in cases by establishing Covid-19 wards at primary health care centres (PHCC) and higher level health facilities, and supplying skilled health workforce, enough oxygen cylinders and hospital beds to such facilities.

It is imperative that the positive outcomes of the second wave be maintained and improved upon to avoid another pandemic pandemonium.

Increased testing  

The next clear gap is testing volume and capacity. Compared to other countries, Nepal is not testing enough and needs to ramp up testing nationwide.

For instance, the daily Covid-19 tests per 1,000 people as of 4 August was much lower at 0.34 in Nepal compared to 1.27 in India, 2.83 in the United States, 6.92 in Australia and 11.18 in the United Kingdom.

PCR testing services need to be expanded in the rural areas as such facilities are disproportionately higher in Bagmati province and urban areas. It has been a year and a half since the start of the pandemic, and yet PCR lab services have not reached all districts.

If not PCR, at the least rapid antigen testing services should be made continuously available in every district until such PCR labs can be set up to prepare for a potential third wave. Data from testing is vital to understand the epidemiology of the virus and its transmission – person, place and time are the data points required consistently to track this virus.

Along with expansion of testing services, it is essential to address testing hesitancy that is driving individuals with Covid-19 like symptoms to stay home without being tested. More than 100 laboratories that are equipped with PCR equipment remain under-utilised. Addressing the social stigma associated with Covid-19 positive status via trusted members of the community can help reduce testing hesitancy.

Clear, consistent and enforced travel regulations

Although the government has increased quarantine measures for unvaccinated travelers entering through international flights, its enforcement remains an issue. Monitoring air travelers, and not allowing for exceptions is important.

While ongoing efforts are in place to increase the number of health desks at Indian border entry points, we recommend these efforts continue and expand across the border region. Increased screening for cases using rapid antigen tests and implementation of quality isolation facilities for a nominal or no fee near the border crossings for those presenting with symptoms and/or testing positive are also key.

A collective sense of responsibility by citizens and travelers to be accountable and follow government protocols is equally imperative. Evading entry points without providing proof of vaccination or having gone through screening is no longer acceptable. We have to put forth the larger health and well-being of our communities and societies that we will enter post travel.

Case contact tracing

Just as important are case contact tracing efforts which the local level wards are given the responsibility to implement and oversee. Sharada Magar, a registered nurse who supported contact tracing efforts during the second wave in Gulmi district, told us: “The effectiveness of contact tracing effort remains questionable due to poor monitoring and shortage of human resources at the ward-level.”

Local municipalities struggling with contact tracing efforts should increase their human resource capacity immediately and be strictly monitored by the province health directorate. To support contact tracing efforts, at an individual level, it is important for us to have minimal contacts during these times. In addition, if found to be infected, it is vital to actively inform the close contacts of the previous week about being tested positive and ask them to quarantine and get tested as well.

When in doubt, it is important to get tested and self-isolate, so as to prevent spreading the infection to your close and loved ones. Local municipalities who are responsible for contact tracing also need to enforce masking , discourage crowding and provide hand washing services in public spaces.

Equitable distribution of vaccines

As Covid-19 vaccine supply slowly increases, the government needs to ensure equitable vaccine distribution, and at the same time clearly communicate the importance of getting vaccinated as well as the risks associated with them. The roll out of Covid-19 vaccines in cities like Kathmandu and Biratnagar has been criticised by the public to be poorly planned with few sites and long lines.

Although the recent vaccine drives in Kathmandu saw an increase in vaccination sites with one camp in each ward, long lines and shortage of vaccines was still being reported. To ensure that the targeted population in each vaccination drive (age group, occupation, etc) gets vaccinated accordingly, screening procedures should be in place.

At the vaccination sites, staff or security personnel should screen those in queue as to whether they meet the eligibility criteria. This would prevent those not meeting the eligibility criteria for the specific vaccination drives from wasting their time and avoid misunderstanding and conflict.

While efforts are being made by the government to add new sites for distribution of vaccination proof certificates for migrant workers, it should immediately digitise this process bearing in mind that such certificates can be the passport to access public spaces and indoor activities in many countries.

Isolate safely

During the first wave, the majority of the local governments took an active role in management of Covid-19 positive individuals at the community-level institutional isolation facilities. However, the government’s decision to promote home isolation of all mild cases of Covid-19 in the second wave led to many family members being infected at the same time.

To prevent the third wave, therefore, the local government needs to ensure that every Covid-19 positive individual is safely isolating at home or institution by following appropriate guidelines. Every individual should consult the nearest healthcare providers or government Covid-19 hotline numbers on how to safely isolate at home and avoid risking other family members.

More importantly, local governments need to consider re-establishing community-level institutional isolation centres to ensure that low-income individuals who do not have access to a single-use bedroom or bathroom at their homes do not put others in the family or community at risk.

Invest in science

On the research front, more work is needed to understand the evolving nature of the virus within Nepal. Regular genomic sequencing of SARS-CoV-2 virus is now being done at the National Public Health Laboratory, which increases the national capacity to detect and monitor the type of virus circulating in the country. In addition, the ongoing nationwide Covid-19 serological survey being conducted by the Ministry of Health and Population partnered with WHO will provide an estimate of the prevalence of the infections (people who have been infected in the past and developed antibodies to the virus).

Regular large scale serological surveys should be conducted to provide a snapshot of the disease burden and track how infections progress through the population over time. India has already conducted four rounds of nationwide serological surveys within a span of little over a year.

Furthermore, under the leadership and guidance of the Ministry of Health and Population and in partnership with vaccine research experts in the country and abroad, Nepal could be a site for Covid-19 vaccine trials among the adolescent group or for research on mixing vaccines for booster shots in adults using already approved Covid-19 vaccines.

Although small, the proportion of the fully vaccinated population is growing, so it is very important to actively investigate and report the breakdown of cases and hospitalisations by vaccination status. This is important for public health experts to monitor the effectiveness of the vaccines to prevent severe illness and contribute towards the research and monitoring of ‘breakthrough’ infections among the fully vaccinated.

Such breakthrough cases are expected as no vaccine has 100% effectiveness and research has shown that breakthrough infections are possible among the fully vaccinated -- nevertheless, the vast majority of  hospitalisations and deaths seen recently in the US are still amongst the unvaccinated.

Our civic duty to stop the spread 

In order to prevent a potential third wave from happening, each of us needs to work towards stopping the spreading of the virus. Until the majority of the population nationally and globally  gets vaccinated, Covid-19 will endure.

In the meantime, we must maintain and strengthen public health measures that work: proper masking, physical distancing, frequent handwashing, respiratory and cough hygiene, ensuring good ventilation and avoiding crowded places or closed settings. The US Center for Disease Control and Prevention has recently recommended fully vaccinated people to wear a mask in indoor public settings as fully vaccinated who do become infected with the Delta variant can be infectious and can spread the virus to others.

With the Delta variant being the predominant strain spreading in Nepal, those fully vaccinated should continue to follow safety measures. Work spaces, shopping centres, gyms and restaurants/cafes should operate in a well ventilated space and with strict mask mandates. In cases where ventilation is poor the businesses should operate in half capacity.

This ensures maintaining caution as well as keeping the business and operations running for economic viability. Even small measures such as asking a person to properly wear a mask if you see it not being followed in an indoor public setting can make a difference.

It is our civic duty to follow the public health protocols and safety measures to keep ourselves and others safe. Refusal to take precautions should not be normalised unless we want to delay returning to the pre-pandemic normal. So let us work together to prevent future waves of infections by being accountable at an individual level.

In Nepal, during the peak of the second wave, the positivity rate for PCR tests reported on 11 May, which logged the highest number of reported new cases 9,483 was 44.5%. The positivity rate for Covid-19  tests (PCR and rapid antigen test) reported on 8 August is lower at 20.6%.

However, compared to neighboring India, Nepal has a higher weekly average number of new cases per million people (figure below). In addition, the reproductive rate (R) that represents the average number of new infections caused by a single infected individual is rising in Nepal and is currently at 1.15. If the rate is greater than 1, the infection is able to spread in the population and needs to be below 1 to contain re-infections.

The R has varied from a high of 2.13 during the peak of the second wave to a low of 0.63 in mid-June. The fact that the R is rising again is cause of concern with public health experts, which prompted the Ministry of Health announcing a potential third wave coming soon.

With only 9.1% of the Nepalese population fully vaccinated as of 10 August, and the highly transmissible Delta variant circulating in the country, it is critical now more than ever that each of us individually need to be accountable.

Despite our very real pandemic fatigue, now is not the time for us to let our guards down as we did after the first wave. It is even more urgent for each one of us to collectively employ all of our learning to mitigate this looming third wave.

Tsering Pema Lama, PhD, MSc - Johns Hopkins University (JHU)

Swetha Manohar, PhD – JHU

Binita Adhikari, MSPH, RN - JHU and Health Foundation Nepal

Bijay Acharya,MD, MPH FACP, America Nepal Medical Foundation, Massachusetts General Hospital and Harvard Medical School.

Molly Fitzgerald, DrPH, MPH – JHU

Angela KC, MSPH - JHU, Acumen

Dinesh Neupane, PhD, JHU

Santosh Dhakal, PhD, JHU