Children are collateral damage in Nepal lockdown

On Friday, it will be four months since Nepal closed the country down to prevent the spread of  SARS-CoV-2, the virus strain that causes COVID-19. Of the 40 who have died of the infection in Nepal, two are children below 5.

But many more children have died during the four months of lockdown compared to the same period last year because of lack of access to health care due to the restriction on mobility, interrupted vaccination campaigns and the lack of medicines.

However, the coronavirus grabs all the headlines. Mortality due to non-COVID-19 causes does not make the news – even though it is clear that a lockdown enforced to control one disease has caused far more deaths from other prevalent diseases, and threatens to undermine Nepal’s progress in infant and child survival over the past four decades.

“The COVID-19 crisis and lockdown have pushed many families into poverty, many have lost their sources of income, leading to malnourishment among children,” says Jhalak Gautam of the Child Health Division at the Health Ministry. “Increased malnutrition means children are more susceptible not only to COVID-19 but to many other infectious diseases such as measles and diphtheria.”

Under-5 child mortality rate in Nepal had declined substantially from 271 deaths per 1,000 live births in 1969 to 32 in 2018. Government figures show that since 17 July 2018-16 July 2019, a total of 1,357 children under 5 died of various infectious diseases all over the country. Preliminary figures for the same period 2019-2020 is 1,263 – even though only 78% of the data has been collected.

Initial government figures also show that a total of 204 children under 5 have died across the country during the lockdown between 14 March-14 June. This number was at a much lower 151 during the same period last year.

This data clearly show that the total child death numbers collected by Female Health Care Volunteers is higher this year — meaning they died at home. The number of those who have died at hospital in the same three months this year is lower than last year probably because parents are not taking children to hospital when they are sick during the lockdown.

An expert at the Health Information Management System says when all the data for this year comes in, it is bound to be much higher than last year. This means the lockdown has pushed Nepal back in meeting its health targets under the United Nations’ SDGs (Sustainable Development Goals).

Under the SDG target, Nepal is supposed to bring child mortality down further to 25 deaths per 1,000 live births by 2030. Persistent childhood malnutrition is a major reason for infant and child mortality remaining high despite dramatic progress in the 1990s. Figures for stunting, wasting and anaemia in Nepal have plateaued in the last decade  Now, the lockdown has added to the challenge.

Says Elke Wisch, UNICEF Representative to Nepal: “Progress made on children’s nutrition in the last decade is at risk of being reversed as rising numbers of children are facing malnutrition due to loss of household income and resulting food insecurity. The social and economic loss for Nepal resulting from the deterioration in children’s nutrition status will be felt long after the COVID 19 crisis is over.”

The lockdown has also disrupted vaccination campaigns across the country, leading to measles outbreaks in Dhading and Gorkha in April. Although regular immunisation services have now been restored in health facilities in all 77 districts, parents have been unable to take their children for shots because of restrictions on transportation and also because of the fear of COVID-19 transmission in health posts.

In fact, the WHO and UNICEF earlier this week stated that preliminary data for the first four months of 2020 points to a substantial drop in the number of children completing three doses of the vaccine against diphtheria, tetanus and pertussis (DTP3), first time in 28 years. Moreover, at least 30 measles vaccination campaigns were or are at risk of being cancelled, which could result in further outbreaks in 2020 and beyond.

“Vaccines are one of the most powerful tools in the history of public health, and more children are now being immunised than ever before,” said Tedros Adhanom Ghebreyesus, WHO Director-General. “But the pandemic has put those gains at risk. The avoidable suffering and death caused by children missing out on routine immunizations could be far greater than COVID-19 itself.”

With schools closed for the past four months, children in many schools are also not getting their lunches. Domestic violence has also seen a spike during the lockdown, with many of the victims children. There is also evidence of a rise in child marriage  anxiety, stress and mental disorder

Nepal appears to be on track to proving correct the grim prediction in May by the Johns Hopkins Bloomberg School of Public Health that 1.2 million children worldwide could die from pre-existing diseases like malaria, pneumonia or diarrhoea in the next six months due to the disruption to health services and food supplies due to the lockdown. That makes 6,000 fatalities a day – a whopping 45% rise in child mortality.

“Under a worst-case scenario, the global number of children dying before their fifth birthdays could increase for the first time in decades,” UNICEF Executive Director Henrietta Fore warned. “We must not let mothers and children become collateral damage in the fight against the virus. And we must not let decades of progress on reducing preventable child and maternal deaths be lost.”

Another aspect of the pandemic that Nepal has to be careful about is that while worldwide data show that children are relatively safe from contracting SARC CoV-2 which has mainly affected people above 70 years, in Nepal children also seem vulnerable.

Health Ministry data show that the rate of infection among children below 5 is 2.2% and increasing – much higher than the global average. The infection rate among young children was at just 1% a month and a half ago.

Many of the infected children belong to families who returned from India in the past three months, but children have also been infected by people who flouted lockdown rules and safety measures. This is why Far-west Province has the highest coronavirus infection rate among children at 5%.

Nepal has also seen a disproportionate number of COVID-19 infections and mortality among a younger population  Experts say this is mainly due to young returnee migrant workers from India, Malaysia and the Gulf, who make for the majority of the coronavirus cases in the country. Moreover, testing across the country so far has focused on returnees.

“Unlike elsewhere, in Nepal people with co-morbidity have a higher risk of dying regardless of the age group, and this is worrying,” says epidemiologist Sher Bahadur Pun of the Health Ministry. “But we must widen our testing to come to a concrete conclusion about this. So, until we have a vaccine we must wear masks, maintain physical distance and follow hand hygiene. This includes children.”