<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b83649c7e80680e067732jpeg.jpg" alt="" width="3563" height="2375"/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure>Only a month ago, even prominent doctors in India were declaring that the country had defeated the <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1620014851520000&amp;usg=AFQjCNH26pr4ATCusVi4rW_jCSccSqOyNw">novel coronavirus. </a>They felt that herd immunity in cities like Delhi would protect people from infection and death. Based on a few dubious studies, they conceded that a large proportion of Indians had acquired herd immunity through mild or asymptomatic Covid-19 infections.Just like the theory that a lifetime exposure to germs would protect South Asians, herd immunity also turned out not to be true.Here in Nepal we are seeing a surge that is proportionately similar to India. The exponential rise in the number of cases, infection of younger cohorts, and the severity of the disease, bear all the hallmarks of the contagion sweeping across India.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b83679c7e80680e067733jpeg.jpg" alt="" width="1390" height="584"><figcaption> </figcaption></figure>While we try to treat the sick by increasing hospital space and ensuring oxygen supply, we must also plan for an <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGreS-S3470fwa9xi8chTwsApsL8Q">exit strategy</a> that entails acquiring more effective herd immunity through mass vaccination, and partial lockdowns enforced with all <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEgv4bMUglLS5mZDf0VcnTA8rrcwA">precautionary measures</a>.<a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFOLiROFJhRqoWS8Lm4Rrizbt_w7w">Over-preparation rather than under-preparedness </a>needs to be our mantra. Widespread vaccination is the key to get us out of this pandemic, and we have lost precious time with the delays.This means our <a href="https://www.nepalitimes.com/latest/nepal-braces-for-new-wave-with-vaccine-drive/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-braces-for-new-wave-with-vaccine-drive/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNH7Un17CIezo7XVehWgZr4IVThqzQ">vaccine diplomacy</a> has to go into top gear. If <a href="https://www.nepalitimes.com/latest/jabs-and-jab-nots/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/jabs-and-jab-nots/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEHISgu64T2PwpgpRFk_IklnxurbA">Covishield from India</a> is not available, we must lobby for as many dosages of vaccines from <a href="https://www.nepalitimes.com/latest/the-gift-of-the-jab/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/the-gift-of-the-jab/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFYyDtUVRKNT2a92xdtV6IBpGmKNQ">Chin</a>a, <a href="https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGsbwsSUqjInkvevMv3Ycj6ryTa8w">Russia</a>, or the United States, and administer them urgently.All of these vaccines are in general at least 50% effective (the ‘pass mark’ for vaccine efficacy). None of the inoculations appear to have serious adverse effects, even though there are questions about whether they provide enough protection from the new strains, and duration of immunity.We are trying to immunise the population from SARS-CoV-2, which happens to be a wily killer that exploits the human need for social interaction and mobility. Analysing this sudden and rapid spread of the virus in the Subcontinent, it looks like South Asians are more vulnerable because of <a style="letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/nepals-virus-vortex/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-virus-vortex/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFClAleG43b0LxtmN6SUTtqq0wUeA">our co-morbidities.</a>South Asians are known to be genetically more susceptible to diabetes and cardio-vascular diseases. The diet and lifestyle of people in the 40-70 age group increases the risk factor for obesity, diabetes and hypertension. Not unsurprisingly, the death toll due to Covid-19 is higher in this age cohort among South Asias than in Europe or the Americas.The other reason for the infection suddenly taking off again in our part of the world is that we let our guard down, attending festivals, religious ceremonies and political rallies.And then there is the presence in Nepal of both the UK variant of the virus ( B.1.1.7) and the B.1.617 (Indian variant) both of which are at least 20% more transmissible. The good news (at least so far) is that these variants may not be any more lethal than the standard virus. But even if they are not, we desperately need to stop transmission.And since this is a respiratory virus, the most effective way to do that is still to wear a mask, avoid crowds and use hand sanitiser.In a pandemic of this scale, the general public also needs to know what treatment works and does not. Oxygen, if available, is definitely helpful since it is a drop in oxygen level in the blood that leads to serious complications.A drug called dexamethasone saves lives, it is easily available and cheap. Tocilizumab, unavailable in Nepal, and expensive, can also be used to treat severely ill patients and should only be administered by a physician. There are web <a href="https://www.indiacovidsos.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.indiacovidsos.org/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNG9m03344ZEP5kR4-D9sw3xAz7ZjQ">links</a> with pragmatic tips that may come in handy if a hospital bed is not available, as we are now seeing in India and Nepal.There is a lot of fake news about the effectivity of treatment drugs. The following commonly used drugs for well-known illnesses do not work against Covid-19 although, even today, many are rampantly and unnecessarily prescribed in South Asia: Azithromycin, ivermectin, choloroquin, colchicine, convalescent plasma, vitamin D, zinc, lopinavir-ritonavir, favipiravir, and doxycycline.Even remdesivir, the drug that many desperate families try to acquire for their hospitalised relatives, does not save lives even though it is known to reduce hospital stay.Many of these drugs were studied for their efficacy by carrying out large randomised controlled trials by the biggest, adaptive Covid-19 tests undertaken by Oxford University’s <a href="https://www.recoverytrial.net/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.recoverytrial.net/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFWVQpxuWW8Bb9WDrI4MR584LIUww">Recovery Trial</a>.The Nepal Health Research Council was the first country set-up outside the UK that recently started collaboration with Recovery Trial as part of a global effort to in order to help find a treatment drug against Covid-19.This tragedy has exposed the inadequacy and inequity in the health care system of Nepal and South Asia. The dominant method of health care delivery in the region, especially for curative services, are private enterprises that follow the corporate health care model patterned after the United States.Nepal has also increasingly gravitated towards this system of health care, with many new private hospitals all over the country. The pandemic will force us to question this model, and ask if alternatives like the UK National Health Service would be more suitable.Despite the vested interests behind the <a href="https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGPAmj-NNRDt3JI_--ydl8p8gFc_A">medical-industrial complex</a> in Nepal, we need to plan for <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGNZppXCvCMgFPm4GVAEVi5e8MJRg">universal health care (UHC)</a>, and even consider universal basic income (UBI), if we are going to improve health care to the vast majority of Nepali people.Even President Joe Biden is trying to reform US health care with a stimulus package that has clear aspects of UBI. We need to look at a combination of UHC and UBI in Nepal because even if we survive this pandemic, there is certain to be another one sooner or later.The international media has only taken notice of the second wave in Nepal after reports of infections at <a href="https://www.nepalitimes.com/banner/mt-everest-city/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/mt-everest-city/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEXmV4I4K_YnFSjorLfpqWrs5_c0g">Mt Everest Base Camp</a> last week. But it is reassuring to know that even up there at 5,364m, Nepali specialists are doing their best to follow protocols to deal with suspected Covid-19 among climbers and support staff.This work is critical because the ubiquitous ‘Khumbu cough’ and even the life-threatening high altitude pulmonary edema (<a href="https://www.nepalitimes.com/latest/high-alert/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNHi0ktDBncK6SypHGzDbi44cBgObw">HAPE</a>) simulate the symptoms of Covid-19, and it can be difficult to tell them apart.Buddha Basnyat, MD, is a clinical researcher at the Patan Academy of Health Sciences and an <a href="https://www.nepalitimes.com/latest/sherpa-genes-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sherpa-genes-for-covid-19-treatment/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEJKfShTwfhNqAdP0GvlMmh5-IMfQ">expert in high altitude medicine</a>. He is also a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNF_WOWRO49qKaxdIzZ6QpXh6cnQpA">frequent health columnist</a> for Nepali Times.

Buddha Basnyat

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How Nepal can survive 2nd Covid wave

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110121152/636ce6409c7e80680e096759jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: RSS</figcaption></figure>The <a href="https://www.nepalitimes.com/banner/nepal-fights-infodemic-to-push-vaccine/" target="_blank" rel="noopener noreferrer">Covid-19 vaccines</a> developed by AstraZeneca, Moderna, and Pfizer–BioNTech, and others are proving effective in preventing ‘symptomatic’ disease, but it is still uncertain how well they protect people from becoming infected, or from spreading the virus to others.A small percentage of people who are fully vaccinated are still getting <a href="https://www.nepalitimes.com/latest/first-signs-of-the-second-wave/" target="_blank" rel="noopener noreferrer">Covid-19</a> if they are exposed to the virus that causes it. These are called ‘vaccine breakthrough’ cases. This means that while people who have been vaccinated are much less likely to get sick, it may still happen. Research is on-going about how common these cases are.In the United States, a country with the most vaccinated people, the Centre for Disease Control (CDC) on 15 April reported that it has identified close to 5,800 confirmed cases of Covid-19 among the fully vaccinated people. Of those infected, 396 (7%) required hospital admission and 74 (1%) died.It is important to note that asymptomatic breakthrough cases may not be reported, since routine testing may not be done among those already vaccinated. Deaths among the vaccinated population in the US as of mid-April is 0.008 percent of the total inoculated population. This is an extremely low number.The bottom line here is that vaccines work very well against the most dominant variants in the US, but such benefits are reduced with less common variants. In a cohort of 417 persons in Rockefeller University Hospital, who had received the second dose of BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) vaccine at least two weeks previously, two women with vaccine breakthrough infection were identified.In a study in Israel, 170 SARS-CoV-2 infections among health care workers between 19 December, 2020 and Jan 24, 2021, 58% reported symptoms and were designated as Covid-19 cases. Of the 170 HCWs who were infected, 52% were unvaccinated, 46% tested positive after the first dose, and 2% tested positive after the second dose.This suggests that though the risk of infection remains a small percentage of the vaccinated population, it is significantly reduced two weeks after the final dose. Even among vaccinated people who test positive, there is evidence that severity and fatality are rare.What is happening in India <a href="https://www.nepalitimes.com/editorial/the-covid-tsunami/" target="_blank" rel="noopener noreferrer">will have direct impact on us in Nepal</a>. There, the emergence of the term double mutant coincided with a massive increase of Covid-19 cases and deaths in India. It is not proven, but there is a broad consensus that these <a href="https://www.nepalitimes.com/banner/unmasking-the-second-wave/" target="_blank" rel="noopener noreferrer">new mutations are more contagious</a>, and likely cause more severe symptoms. But the most important question is whether the mutant or other unknown mutants in India are able to evade vaccine immunity.The answer is: we do not know. The Indian Council of Medical Research (ICMR) has data that shows 4,208 people who had taken the first dose of the Bharat Biotech Covaxin  tested positive for coronavirus—this 0.04% of the 9,356,436 people vaccinated.This is a clever way of presenting data as all those who are vaccinated do not have the same level of exposure. That is why there needs to be a comparison group which there is not. The ICCMR also reports that 100,302,745 people in India have received the first dose of <a href="https://www.nepalitimes.com/banner/despite-doubts-nepal-sticks-with-astrazeneca-jabs/" target="_blank" rel="noopener noreferrer">the Covishield vaccine</a>  and 17,145 have tested positive after that, which is 0.02%. That does not mean taking only one dose is better than taking two doses. Based on this data the percentage of positive cases among those who have received one dose is lower than those who have received both.There have been reports in the Indian media that 10% of the new hospitalisations there is among those who have received at least one dose of a vaccine. Being so close to India, and with many people going <a href="https://www.nepalitimes.com/latest/nepal-braces-for-its-2nd-covid-wave/" target="_blank" rel="noopener noreferrer">back and forth across the open border</a>, the vaccinated population in Nepal must take precautions: maintain distance, avoid crowds and wear a mask when out for at least a month or two.Meanwhile, AstraZeneca has sent the Serum Institute India a legal notice over delays in the vaccine supply and has threatened to cancel its production agreement. Serum Institute is planning to declare that it will not be able to meet its obligation to supply Covishield due to domestic demand.This has resulted in delays in delivery to all major countries, including Nepal which was planning to extend its <a href="https://www.nepalitimes.com/banner/nepal-begins-covid-19-vaccination-drive/" target="_blank" rel="noopener noreferrer">Covishield vaccination drive</a> through direct purchase and under the COVAX initiative.India is starting to vaccinate every one above 18 from 1 May. Currently, the Serum Institute is producing about 2 million doses a day and is likely to take a year or more just to meet Indian demand.All this means that those have been vaccinated should consider themselves extremely lucky. There will not be many (or any) vaccines available when the second wave peaks in Nepal.Data so far is actually quite encouraging about the protection that vaccines give, and the time will soon come when a sense of normalcy will return--being able to sit around and have coffee with vaccinated friends or family two weeks after the second dose.Masks, however, are going to be part of our lives for many years to come, as reaching a herd-immunity threshold is looking quite unlikely because of vaccine hesitancy, the emergence of new variants, and the delayed arrival of vaccines for children.Sushil Koirala is a public health expert with 23 years of international experience with USAID, UNDP, the Global Fund, and has worked as a technical adviser to the Nepal Ministry of Health.

Masks and vaccines to stop Nepal’s 2nd wave

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181152/636be9a79c7e80680e0878d1jpeg.jpg" alt="" width="995" height="659"/><figcaption>Photo: NEWS MEDICAL LIFE SCIENCES</figcaption></figure>As a physician, I am at the receiving end of a lot of questions from friends and relatives about the pandemic. While some want to know about their symptoms, most questions are about <a href="https://www.nepalitimes.com/here-now/why-nepals-covid-19-figures-are-deceptive/" target="_blank" rel="noopener noreferrer">whether the number of cases in Nepal is actually going down</a>.It is hard to tell. There a lack of tracing, testing is inadequate, and record keeping is unreliable. The media carries a daily tally that is based on government figures, and they show confirmed cases have now dipped to below 1,000 per day, almost half of them in Kathmandu Valley.The Ministry of Health statistics also show that there are about 250 patients in critical care, and some 50 of them require ventilator support. If these figures are to be believed, the death rate from Covid-19 does not seem to have decreased.More worrying are reports that <a href="https://www.nepalitimes.com/banner/bala-chaturdashi-and-covid/" target="_blank" rel="noopener noreferrer">Pashupatinath now sees 80 cremations daily</a> as opposed to 30 per day at this time last year. Are some of these unidentified Covid-19 ‘excess mortality’? It is all guess work, but this more than double increase in funerals needs to be accounted for.It is indeed possible that although some of the excess mortality is due to undiagnosed Covid-19, it could very well be that the <a href="https://www.nepalitimes.com/latest/covid-19-will-get-worse-before-it-gets-better/" target="_blank" rel="noopener noreferrer">winter death rate</a> has gone up this year because people with other pre-existing conditions like cancer, cardio-vascular diseases, diabetes or kidney patients needing dialysis are not visiting hospitals for treatment. These ‘indirect’ Covid-19 deaths could be a useful research project.Despite this, there are indications that young urban Nepalis are letting their guard down. The parties during the <a href="https://www.nepalitimes.com/here-now/tying-the-knot-during-covid-19/" target="_blank" rel="noopener noreferrer">wedding season</a>, unmasked crowds at Thamel’s indoor nightclubs and concerts and the throngs in Pokhara Lakeside and Sauraha show a <a href="https://www.nepalitimes.com/banner/concerts-rallies-and-crowded-malls/" target="_blank" rel="noopener noreferrer">‘what will be will be’ attitude</a>.An affordable and effective vaccine is still some way off. Wearing a mask, preferably a N95, which serves the dual purpose of protection from SARS-CoV-2 as well as Kathmandu’s air pollution, maintaining safe distance and frequent had washing with soap and water are our ‘vaccines’ for now.Japan has important lessons for us. So far, it has kept Covid-19 death rate at the lowest by far among G7 countries by strictly following guidelines including avoiding the ‘san-mitsu’ or the 3Cs: closed spaces, crowded spaces and close contact settings.<a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/">We in Nepal will be lucky</a> if a <a href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/">vaccination</a> arrives by mid-2021. Current vaccines like Pfizer and Moderna are out of the question because of their cost and the lack of capacity to maintain the very cold storage that they require.The <a href="https://www.nepalitimes.com/opinion/glimmers-of-hope-for-nepal-on-vaccine/">Oxford University Astra Zeneca vaccine</a> that the <a href="https://www.deccanherald.com/national/serum-institute-of-indias-covid-19-vaccine-not-to-get-nod-till-uk-authorises-astrazeneca-shot-931200.html">Serum Institute of India</a> is manufacturing appears to be our best bet because it is relatively inexpensive and only requires the regular 3-6o Celsius cold chain. The good news is that the Serum Institute of India is also studying other vaccines such as an <a href="https://www.livemint.com/companies/people/intra-nasal-covid-19-vaccines-will-be-far-easier-to-deliver-kiran-mazumdar-shaw-11603681291099.html">intra-nasal vaccine</a>, which can be stored at room temperature. If effective, this would be the answer for countries like Nepal.We are awaiting published results of trials of the <a href="https://www.nepalitimes.com/latest/nepal-to-test-covid-19-test-kits-from-china/">Chinese</a> vaccine, and that could also be the answer for developing countries like <a href="https://www.nepalitimes.com/latest/90-in-poor-countries-will-miss-covid-vaccinations/">like Nepal</a>. The Chinese have an impressive track record of making vaccines, and to combat infectious diseases. For example, the inexpensive <a href="https://www.nepalitimes.com/banner/mosquitoes-move-up-mountains-as-the-earth-warms/">Japanese Encephalitis</a> vaccine made in Chengdu helped control the deadly disease in rural communities throughout Asia.This Chengdu vaccine cost less than $5, in contrast to the $100 per shot encephalitis vaccines made by Western pharmaceutical companies. The Chinese <a href="https://archive.nepalitimes.com/news.php?id=18079">Hepatitis E vaccine</a> could prevent infection and save lives of pregnant women in the Subcontinent where the virus is a scourge due to poor hygiene.TherapiesAside from vaccines, research into treatment of Covid-19 is also making progress. For example, the Recovery Trial in the UK has convincingly showed that dexamethasone, a readily available and inexpensive steroid saves lives in the treatment of moderate to severe Covid-19 patients.In all this confusion regarding treatment, however, it is equally important to note what does not work. Drugs like hydroxychloroquin do not work in the treatment of this disease, despite its false efficacy touted by Donald Trump. The <a href="https://www.who.int/nepal">World Health Organisation</a>’s Solidarity research also showed that the expensive remdesivir drug that our government was at one time handing out freely to Covid-19 patients is not very helpful, either.Reliable diagnosis of Covid-19 is important, especially in countries like Nepal as there are many other infectious diseases that may at first present with fever and cough, like tuberculosis. The PCR (polymerase chain reaction) test still remains the gold standard for Covid-19, but they are expensive and may take a day or two for the results.Antigen tests are being carried out in Nepal and can give a quick diagnosis in symptomatic individuals within 30 minutes. But they are not as accurate as the PCRs. There are other commercial brands, and some may not be as accurate as others.New variantNews of the new variant of Covid-19 reported in England and South Africa and now spreading across the globe, sound alarming. It is interesting that this new variant was discovered in the UK where a great emphasis is given to finding its chemical constituents.One of UK’s prime institutions for this is the Sanger Centre near Cambridge, with whom we at Patan Hospital also collaborated to delineate a variant of typhoid organism mutation, helping establish a new treatment strategy for typhoid in the Subcontinent in 2016.The best way to handle the new Covid-19 variant is <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/">continued vigilance</a> about preventive measures, especially since the mutation gives the virus the ability to spread faster. It is best to be over-prepared than under-prepared to fight this wily virus.Masking up, safe distance and hand washing are our best course of action for us to stop the pandemic in 2021 and beyond.<a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">Buddha Basnyat</a> is a clinical researcher at Patan Academy of Health Sciences and writes Dhanvantari, a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">frequent health column</a> for Nepali Times.

Staying safe in 2021 and beyond

<figure></figure> <img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba5129c7e80680e0736a1jpeg.jpg" alt=""/><figcaption>A woman with her mask down walks by Sneha Shrestha mural in Pimbahal, Patan this week. Photo: BIKRAM RAI</figcaption> Five months after the first COVID-19 case was detected in Kathmandu, and after many experts were puzzled about why the virus was not spreading as fast as elsewhere, parts of Nepal and Kathmandu city are now in the vortex of the pandemic.Hospitals in Tarai cities are fast filling up with symptomatic cases, and doctors say patients requiring ICU treatment and ventilator support are on the rise.On Thursday, Kathmandu Valley recorded its highest daily rise of 87 positive cases. All beds are occupied in hospitals with designated wards for coronavirus patients. Overwhelmed, doctors are sending asymptomatic patients to home isolation. Some were diverted to Kathmandu Medical College’s facility in Duwakot and Ayurveda Hospital in Kirtipur.<a href="https://www.nepalitimes.com/banner/experts-caution-against-extending-nepal-lockdown/" target="_blank" style="background-color: rgb(255, 255, 255); font-size: 15px; letter-spacing: 0.01em;" rel="noopener noreferrer">Experts caution against extending lockdown</a>, Sonia Awale<a href="https://www.nepalitimes.com/editorial/lockdown-may-be-over-but-pandemic-is-not/" target="_blank" style="background-color: rgb(255, 255, 255); font-size: 15px; letter-spacing: 0.01em;" rel="noopener noreferrer">Lockdown may be over, but pandemic is not</a>, EditorialThe government has approached private hospitals to start opening COVID-19 wards, and had set the maximum treatment charge per patient. However, private hospitals are balking, they say the fees are too low for the care needed.“Self-isolation at home has worked elsewhere but in Nepal where people don’t strictly follow safety measures, patients are ostracised, and there is a lack proper rescue mechanism, it might not be the best strategy,” cautions BaburamMarasini, former head of the Epidemiology and Disease Control Division. “It would be better to move asymptomatic cases to available government training centres, non-profit institutions, and if needed even hotels and hostels.” <figure></figure> <img width="955" height="594" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba5159c7e80680e0736a2jpeg.jpg" alt=""><figcaption> </figcaption> As of Thursday, Nepal has a total of 21,750 cases with 6,296 active. So far, 65 people have lost their lives, five of them on 6 August alone. Cases in Kathmandu Valley have reached 876, mostly in the capital city (see graphs). Eight people have been infected with coronavirus at the Ministry of Internal Affairs and Law and so has minister Gyanendra Kumar Yadav in Province 2.Says public health expert Sameer Dixit: “Local governments and security personnel should be facilitating self-isolation at homes. Admitting asymptomatic cases in hospitals depletes resources, as it exposes mildly infected patients to severe cases.”There are now 66 ICU cases across Nepal with 29 just in Bagmati Province (see map) where three patients are on ventilator support. Given the steep rise in symptomatic and severe COVID-19 cases, all 1,702 ICU beds nationwide and stock of 900 ventilators could be used up.“The rate of infection in Kathmandu is increasing, and this could lead to a shortage of hospital beds, equipment and heath workers,” warned Jageshwor Gautam of the Health Ministry, appealing to the public to remain at home and follow <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">safety measures</a>. Several hundred traffic police in Kathmandu are in quarantine after the infections spread, and the Nepal Police headquarters was sealed this week after seven staff tested positive. <figure></figure> <img width="949" height="606" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba5189c7e80680e0736a3jpeg.jpg" alt=""><figcaption> </figcaption> Special attention should also be given to the fact the virus SARS-CoV-2 is airborne, which is why <a href="https://www.nepalitimes.com/banner/masks-unmasked/" target="_blank" rel="noopener noreferrer">wearing mask</a> should be mandatory, spitting prohibited and ensuring cross ventilation in workstations at all times.Finance Minister and government spokesperson Yubaraj Khatiwada says the government does not want to re-impose a nationwide lockdown, but says some restrictions may have to be put into place.District administrations of Kathmandu, Lalitpur and Bhaktapur districts met on Thursday to draw up a joint strategy for the Valley. Among the measures being discussed are: strict protocols for government offices, banks, markets, and public transport. They are worried most people are not following guidelines for masks and physical separation, and warn that they may have to resort to punitive measures and fines to enforce the rules.Health experts fault Khatiwada’s <a href="https://www.nepalitimes.com/latest/nepal-ends-covid-19-lockdown/" target="_blank" rel="noopener noreferrer">announcement on 21 July</a> in which he categorically stated that the “lockdown has been lifted” even though it had only been relaxed. They said this had given people a <a href="https://www.nepalitimes.com/editorial/lockdown-may-be-over-but-pandemic-is-not/" target="_blank" rel="noopener noreferrer">false sense of security</a>, and especially allowed Indian factory workers, vendors, barbers and drivers to stream back to Nepal <a href="https://www.nepalitimes.com/latest/heightened-covid-19-risk-at-india-nepal-border/" target="_blank" rel="noopener noreferrer">across the open border</a>. This is the reason the Tarai cities were the first to be hit, and the virus is spreading to Kathmandu from there.    The COVID-19 Crisis Management Centre (CCMC) is said to be discussing modalities for a ‘smart lockdown’, including isolating areas where there are outbreaks and stricter enforcement of mask and separation rules. It is also going to decide this weekend whether or not to re-open long distance buses, as well as regular domestic and international flights which were supposed to resume on 17 August.Says Buddha Basnyat, a physician at Patan Academy of Health Sciences: “We are seeing a worrying surge in typical COVID-19 symptoms with advanced pneumonia, unlike before when most cases were asymptomatic and had co-morbidity.” <figure></figure> <img width="516" height="655" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba51a9c7e80680e0736a4jpeg.jpg" alt=""><figcaption> </figcaption> Experts say the rise of symptomatic cases is also due to co-infection such as seasonal flu, typhoid and <a href="https://www.nepalitimes.com/opinion/the-dangers-of-the-dengue-virus/" target="_blank" rel="noopener noreferrer">dengue</a>, all infectious disease common during the monsoon. Some have pointed to high co-morbidity and delayed mass testing as  contributing factors to possible community transmission in the Tarai districts and Kathmandu.But despite the surge in symptomatic cases, health professionals have advised against re-imposing a blanket curfew, favouring a ‘<a href="https://www.nepalitimes.com/banner/experts-caution-against-extending-nepal-lockdown/" target="_blank" rel="noopener noreferrer">smart lockdown</a>’ where localities with cluster outbreaks are sealed off, and tested – while strictly enforcing masks in public places and preventing crowds.So far, shutdowns have been re-imposed in five Tarai districts, and semi-lockdowns in parts of nine others where there has been a surge in cases. <figure></figure> <img width="640" height="828" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba51d9c7e80680e0736a5jpeg.jpg" alt=""><figcaption> </figcaption> “We are already experiencing semi-lockdown of sorts because of floods and landslides. A lockdown now will cause more harm than good. The only way to fight this pandemic is <a href="https://www.nepalitimes.com/editorial/open-and-shut-case/" target="_blank" rel="noopener noreferrer">behavioural reform, surveillance and isolation</a>,” says Marasini.Indeed, most experts agree that a focus on the coronavirus should not shift attention away from more devastating conditions that can <a href="https://www.nepalitimes.com/banner/children-are-collateral-damage-in-nepal-lockdown/" target="_blank" rel="noopener noreferrer">affect people’s well-being</a> because of economic collapse.

Sonia Awale

Nepal’s virus vortex

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121116/636b8c4d9c7e80680e06b2efjpeg.jpg" alt="" width="4096" height="2730"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>With no proven <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">cure or vaccine available yet for COVID-19</a>, various treatments with no proven benefits and potential deadly side-effects are being tried out on patients.One example of a desperate treatment measure is a New York City doctor carelessly declaring on primetime tv recently that COVID-19 pneumonia was similar to <a href="https://www.nepalitimes.com/latest/high-alert/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGuDq-Ti_uWGlw-rY-q1PpyQQO54g">high altitude pulmonary edema (HAPE)</a>, and he recommended high altitude drugs like Diamox for the treatment of Covid-19.Trekkers in Nepal are familiar with <a href="http://archive.nepalitimes.com/news.php?id=19693#.Xp-oJy8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19693%23.Xp-oJy8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGSLnJg3LMR2gIcZz9LMdKOvruqJA">Diamox</a>, a pill they take to acclimatise better when hiking at higher altitudes. There is no scientific basis that the drug will work, but this idea of very low oxygen (hypoxia) and pneumonia in both afflictions was appealing.To counter this some of us in Nepal and other countries have a forthcoming Opinion in the British Medical Journalcautioning against this rash treatment strategy using high altitude medicines. In medicine, doctors have to remember the maxim, Primum non nocere (‘above all do no harm’).But there are some silver linings <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGtTkAInA3D5xIkzd65kTSfDvYESg">if Nepal escapes the worst of COVID-19</a>. <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGbOqrkOzN3uP_va7u0F-uhlxipaQ">Tuberculosis</a> rates, which are very high in South Asia (more than 400 per 100,000) could go down if people continue to use the masks since it will also mean that a tuberculosis patient will not spread the bacteria, not to mention other respiratory infections.Similarly, as more people get into the habit of washing hands with soap and water where available, the rates of diseases like typhoid and hepatitis A and E, caused by fecal oral transmission, will certainly be reduced.An average of <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHn0HGje-Tq3pDeekYbQAbhZxJOwg">230 people used to be killed every month</a> on Nepal’s highways and streets. The lockdown has now lasted a month, and that is approximately the number of lives saved due to vehicles being off the roads.The importance of public health for both the rich and poor countries has been highlighted by the pandemic. Industrialised countries had thought they had been done with infectious diseases, except perhaps the odd HIV patient. This pandemic has given great pause to that argument. Developing countries which having tried to come to grips with pre-existing epidemics have used lessons learnt in dealing with coronavirus in prevention.The Indian state of Kerala for example, has done relatively better in dealing with COVID-19 partly because it utilised prior lessons from the Nipah outbreak a year ago. Other South Asian countries with robust public health infrastructure like Sri Lanka also have a better handle on the disease.They strengthened their public health system, and it has paid rich dividends. South Korea too had an outbreak of MERS Coronavirus in 2015 which was brought by a South Korean returning from Kuwait, but they were able to effectively control the spread, and have been dealing successfully (so far) with the novel coronavirus. Singapore had been doing well, but discovered last week that it had a blind spot in the migrant workers’ dormitories. It has now announced a ‘circuit breaker’ lockdown till 1 June.South Asian countries have had more time in preparing for the contagion, while they wait for a vaccine or drugs to treat COVID-19. Treatment trials are happening all over the world even as the patients and doctors await with bated breath (pardon the pun). In all likelihood, we will soon know if chloroquin works or not before we have a vaccine.Vaccines will be a game-changer against Covid-19, and competition is heating up because whoever makes this vaccine first will be the knight-in-shining armour. China, USA, UK are probably a few of the countries engaged in developing a vaccine, and among them are researchers at Oxford University Clinical Research Unit who <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHKJgZ_d-vQIhZ5sdehQmMT7iWvHQ">collaborated closely with Patan Academy of Health Science</a> in a recent successful typhoid vaccine study.This Oxford University group lead by Professors Sarah Gilbert and Andrew Pollard are optimistic about producing a million doses of the vaccine by autumn. The vaccine will be eventually required not in the millions, but in billions of dosages. It also has to be affordable for countries like ours.For making vaccines promptly for neglected tropical illnesses, it is hard to beat the Chinese. When <a href="http://archive.nepalitimes.com/news.php?id=19220#.Xp-nMS8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19220%23.Xp-nMS8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEw-YGKhD3XomMEP736r5ileoWJ3g">Japanese Encephalitis (JE)</a> was raging in China and South Asia, it was the Chinese who tested, developed and made available the ‘Chengdu vaccine’ that revolutionised the prevention of the mosquito-borne disease. The earlier vaccine was expensive and only tourists in Nepal could afford it.Similarly, when <a href="http://archive.nepalitimes.com/news.php?id=18079#.Xp-m3S8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D18079%23.Xp-m3S8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEndZvjwlu6D0uMBXFMGO9OgvSoXg">hepatitis E</a> was a scourge in China, the Xiamen Innovax Biotech came up with a vaccine in 2012 to protect vulnerable populations. Because there is no other commercial vaccine available against hepatitis E, it will be valuable in South Asia if the virus is rampant again and affect pregnant women with a fatal outcome.Nepal clearly needs to have a strong public health infrastructure in collaboration with a prestigious institute abroad to be able to tackle COVID-19 and other infections. Just like earthquakes, there will be more pandemics in future. Humanity needs to up its game in the control of emergent infectious diseases, and Nepal can make a small contribution by helping itself, especially by strengthening public health.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">frequent health columnist</a> for Nepali Times.Prevention while searching for a cur

Prevention while searching for a cure

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How Nepal can survive 2nd Covid wave

Masks and vaccines to stop Nepal’s 2nd wave

Staying safe in 2021 and beyond

Nepal’s virus vortex

Prevention while searching for a cure