As India peaks, Covid-19 spreads rapidly in Nepal

UPDATE 29 August: Covid-19 fatality in Nepal now stands at 207. A total of 22 people are undergoing treatment with ventilator support: three in Province 1, 17 in Bagmati and two in Province 5.

Although the initial wave of coronavirus cases in Nepal were from across the border in India, public health experts now say it makes no sense to blame imported infection because the virus is now spreading in the community.

India is now the country with the third largest caseload with over 3.3 million confirmed cases, and up to 70,000 new cases every day– the highest in the world. But compared to its 1.3 billion population, this is still a low figure and India’s fatality rate of 1.87% is one of the lowest.

Yet, age-adjusted mortality rate paints an entirely different picture, which looks very similar to that of Nepal – SARS-CoV-2 is killing far higher percentages of younger people than in the developed countries.

Covid-19 similarities between India and Nepal do not end there: already poor health infrastructure in both countries are overwhelmed, there is societal stigma, health workers are infected, politicians have died, and the movement of migrant workers has affected people on both sides of the border.

What happens in India has always impacted Nepal because the two countries share an open border and this pandemic is no different, especially given Indian states bordering Nepal are some of the most affected: Uttar Pradesh, West Bengal and Bihar have 466,725 cases between them.

Nepal saw the first surge of Covid-19 cases in late March when hundreds of thousands of Nepalis working in India come back home following lockdowns in both the countries. Between 8 March and 2 July alone, an estimated 500,000 Nepalis returned from India. While they were quarantined in the first few weeks, later arrivals were allowed to go straight home to their villages for self-isolation.

“Nepal will always be at the risk because of the porous open border, even during the lockdown thousands of people managed to sneak in illegally,” says Sher Bahadur Pun of the Health Ministry. “Even if we are able to control the spread of the virus in Nepal and bring the cases down, we will never be safe until the virus spreading is not under control in India.”

The second wave of infections happened after Nepal’s lockdown was relaxed on 21 June, at a time when Covid-19 was raging across Bihar and Uttar Pradesh. Thousands of Indian workers poured across the border to rejoin jobs in factories along the Tarai industrial corridors.

The border district of Parsa, which had brought the virus under control, was suddenly hit by an outbreak that spread like wildlife. From Birganj, the virus travelled easily to Kathmandu, making the Valley the next hotspot.

As of 27 August, Nepal has registered 35,529 confirmed cases with 183 fatalities. Ten of Nepal’s 77 districts now have over 1,000 cases, Kathmandu leads with 3,455 cases, and the Valley saw a record 377 new cases on Thursday. Nationwide, the recovery rate has dropped from 73% in July to 56.7% now, since most new cases are symptomatic, or patients are serious enough to need ICU care.

It is now clear that the clusters have merged and are spreading in the community, and just like with polio Nepal will not be able to fully defeat SARS-CoV-19 until it is under control in India.

Because of this, public health experts say Nepal has no choice but to enforce distancing, mask wearing, hand-washing and other precautions. The current lockdown in Kathmandu has been extended till 2 September.

“If we can successfully implement safety measures and control the movement of the people at the border and inside the country, what is happening in India should not affect us so much,” says public health expert Sameer Mani Dixit.

Despite India’s heavy daily caseload and fatalities, the country has opened limited domestic and international flights, trains, public transport and shops.

There are also lessons to be learned from Delhi, which used to be a hotspot. The recovery rate there has surged from 55% in June to 90% this month. Delhi’s aggressive testing and tracing and home isolation are measures Nepal could easily emulate.

The ‘Kerala Model’ is also worth noting: public health authorities there prioritised early detection through extensive testing, widespread contact tracing, and 28-day quarantines for everyone infected. Despite being the first state to report a case of Covid-19, Kerala has among the lowest fatality rates in India.

“These models are particularly useful because over half of our cases are still asymptomatic, which means we need to keep up active contact tracing, mass testing and surveillance,” says Sher Bahadur Pun. “We also still need to better communicate safety measures, having a figure that the public trusts endorse masks and distancing will be very effective because lockdowns are not a long-term solution. Behavioural change is.”

Indeed, lockdowns only seem to provide a false sense of security and would have been unnecessary if the public had adopted the safety measures after 21 July. The economic cost of five months of Nepal lockdown, and the lack of treatment of existing diseases threaten to far outweigh benefits of the restrictions.

Recently, the Nepal Health Research Council decided to allow international researchers to conduct Covid-19 vaccinetrials in Nepal as part of a global effort to stop the virus. There are at least 30 vaccines in clinical trials across India.

Says Sameer Mani Dixit: “It looks like we are very close to peaking in Nepal, which is not to say there won’t be sporadic spikes, it will continue to happen until we have a vaccine. But in the meantime mandatorily wearing masks and not crowding will be the way of life into the future.”