Nepal must hope for the best, prepare for the worst

In sharp contrast to Europe and the United States, the Western Pacific, South and Southeast Asia have reported relatively fewer cases of COVID-19 despite having their first cases in January itself.

As of 13 April Nepal has recorded 13 confirmed cases out of which 11 were imported infections. Despite being in the neighbourhood of the epicentre, the South Asian region have shown a relatively lower prevalence of the disease. Most of these countries have resource constraints, illiteracy, poverty, inefficient health system, and poor hygiene -- all conducive to the spread of epidemics. 

Cities like New Delhi, Karachi, Kathmandu and Dhaka are so densely populated that a virus capable of human-to-human transmission like COVID-19 would be expected to be rampant -- just as tuberculosis is. 

Tuberculosis is primarily a respiratory illness spread by droplet infection in the same manner as the novel coronavirus. On 14 April, India recorded more than 1,248 new positive cases for COVID-19- its highest figure yet- and 29 deaths. India's nationwide caseload is now at 10,815 and there have been 353 fatalities, but this is still much lower per capita than in the United States (7 cases vs >1,000 cases per million population in India and the US respectively). 

Is this lower prevalence a true picture, or is it giving us a false sense of security because we have not performed enough tests? Nepal had tested only 5,184 people till 13 April.

There is a possibility that the disease is circulating in the community, and more will be detected once testing is scaled up. However if this was true, there should have been reports of increased hospitalisation and mortality associated with some unknown and unusual pneumonia. Most of the hospitals in Nepal have set up fever clinics, but none so far have reported an increase in the number of suspected patients. 

Mathematical models are used to predict outcomes in infectious diseases. Crucially, most models predict that the exponential ‘wave’ has yet to hit our region. The lockdown may have in fact pushed the wave further back, and bought us time. It is also possible that some element in the agent-host-environment interaction, could have hindered the virus from spreading. But this could be just a feel-good hypothesis. 

Amazingly, Nepalis who are not known for following directions have taken to heart the importance of a lockdown, and the constant wearing of a mask. Nepal enforced a lockdown immediately after detection of the second case, while many countries in the West did it only after the disease exploded. 

This prompt action by the government is praiseworthy. On Tuesday, the government announced the extension of the lockdown till 27 April. We have to use the time to preparing health facilities and scaling up testing and contact tracing. Otherwise, the lockdown will have been for naught. 

Experimenting with partial lock downs in some areas may be a consideration. But how to deal with the tremendous impact of the lockdown on the livelihoods of vulnerable people and the economy is another question altogether. And if Nepal’s migrant workers are forced to return home from the Gulf and other countries the problem will only be compounded. 

Medical data from Wuhan revealed that COVID-19 patients who needed a ventilator had a very high mortality rate, from  60-97%, and that patients in intensive care required about 10 days on the ventilator. With such long durations and high mortality rates, deciding whether or not to put a patient on a ventilator will be a critical decision. 

Other seriously ill patients with other diseases like heart attacks with a potentially better outcome may be denied a ventilator due to the overwhelming number of severely ill CCOVID-19 patients. Renal failure also seems to be a prominent feature of severe COVID-19 patients, which is going to tax our limited dialysis capabilities.  

These conversations should be carried out now by Nepal’s policy makers during this relatively calm period. Because once the storm hits, it will be all hands on deck to deal with the day-to-day emergency.

Peter Horby from ISARIC (International Severe Acute Respiratory and Emerging Infection Consortium ) and his team have enrolled almost 3,000 COVID-19 patients in the UK for a randomised controlled trial to study the efficacy of both commonly prescribed drugs like azithromycin, steroids, and  medications used in hyper-inflammatory conditions. 

The UK is in a unique position to deliver large clinical trials because of its unified National Health Service (NHS). Horby’s study is the kind that could quickly make available reliable and concrete treatment strategies even as we wait for an effective vaccine.

Not for nothing is this coronavirus designated as ‘novel’. Even as our lives are dramatically transformed, the world will have to find new drugs, new vaccines, and new methods to cope with this and other future viruses. 

Buddha Basnyat, MD and Sudeep Adhikari, MBBS are both from Patan Academy of Health Science and Patan Hospital.