Nepal | July 05, 2020

Nepal’s response to COVID-19: Initiatives, challenges, future pathways

Prof Sujan B Marahatta
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The COVID-19 pandemic has challenged the social, economic and political integrity of the world. Though the global community is doing its best to understand the virus and seek the best way to mitigate its effect, the infection continues to rise, claiming a significant toll of human lives. By April 27, there has already been above 3 million cases and above 200,000 deaths due to COVID-19. While WHO was consistently warning against the pandemic potential since the beginning of the epidemic in Wuhan, China, many countries did not fully capitalise on the warnings and failed to prepare for the disaster.

In Nepal, there have been 54 confirmed cases of COVID-19, of which 16 have recovered, and no death has been recorded so far. In the initial phase, Nepal failed to capture the significance of this global problem as not much was done to prevent it. But with the increase in the number of cases, Nepal is trying its best to combat COVID-19 through different measures, which began with international travel restrictions, ban on public gatherings, border closure and finally a long country-wide closure.

Lockdown, as a draconian measure, has been practised that spares the straining of the health system, although at the high cost of economic consequences. Intensifying quarantine facilities and proactive screening via testing and tracing, followed by isolation and case management, have been some of the cornerstones for flattening the epidemic curve. How effectively these measures have been implemented needs further evaluation to ensure proper mitigation approaches.

Unfortunately, these measures have not been implemented homogenously across the country and have been correlated with the uneven distribution of the epidemiology of COVID-19. The focus on social distancing has been an effective strategy to control the rate of infection from an economic and social point of view, but confinement measures are not sustainable in the long run. In fact, a sustained economic slump will create negative health consequences, from deaths of despair to pressures on public-health budgets, which might create more non–COVID-19- related deaths than confinement would save from this disease.

There is also a challenge in extending testing and other public health and medical interventions, too. Timely action, testing, tracing, tracking, treating and togetherness have been seen as the most effective strategies to combat the disease. However, the health system of the country is struggling to first screen a large number of community cases proactively, second diagnose the suspected cases at the health centres, and third provide care to the patients.

Lack of adequate diagnostics at the hospitals, coupled with limited facilities to confirm COVID-19 cripples early detection and treatment. Detecting and managing the cases in the peripheral parts of the country are far-fetched. The hospitals in Nepal are largely unprepared due to lack of resources (availability of ICU facilities, isolation wards and human resources) for the management of an expected wave of infections due to COVID-19 in the imminent future. More crucially, health workers, including doctors, in Nepal are poorly prepared due to lack of personal protective equipment (PPE).

Strict social distancing measures, i.e., lockdowns, have been practised to reduce the overall transmission in the country so that the health facility can cope with the fewer number of patients. It is expected to offer a window period for the health system to prepare and arrange the logistics and streamline the healthcare system. This build-up will obviously offer security for possible future waves of the disease. Meanwhile, in line with these efforts, proactive diagnostic capacity needs to be scaled up to detect the virus and scrutinise the immune people.

Test, Test and Test have been applauded as the best strategy to address COVID-19. Learning from the SARS epidemic of 2003, South Korea took proactive measures to test hundreds of thousands of people for infection and track the potential carriers. Similarly, learning from South Korea, Germany has increased its testing facilities by conducting huge numbers of tests.

rRT-PCR is the best feature to anticipate or rule out the likelihood of the SARS-CoV-2 infection. Technologically, it’s hard to run this test in a low care setting because it also demands sophisticated technology and hands-on skills to deal right from sample collection, sample processing and conducting the test adhering to the strict Standard Operating Procedure (SOP). Though WHO provided guidance for laboratory testing among suspected human cases for COVID-19 on March 2, how well the procedure is being followed remains questionable.

The country is trying to establish the tests in a better way to make the best possible prediction. Our fundamental challenge here is how to adopt the best quality test to realise our strategy. The currently used rapid diagnostic kits are of two types: one based on detection of SARS-CoV-2 viral protein in respiratory samples, such as in the sputum and throat swabs, and second is the detection of human antibodies generated in response to the SARS-CoV-2 infection in the blood or serum.

Studies suggest that the antibodies are produced only in the second week after the onset of symptoms in majority of cases. The strength of the antibodies produced depends on several factors, such as age, severity of infection, use of certain medications and presence or absence of comorbidities, which suppress immune systems. Due to this reason, through this method, the diagnosis of COVID-19 infection is only possible in the recovery phase when the patient’s immune system starts to fight against the infection, and by this period the infection could have already spread among the population. In addition to this, it should also be noted that these serological tests just measure the level of antibodies, and there is no evidence to suggest that serological tests will reveal if the individual is immune or protected from reinfection.

Another rapid diagnostic test available is the detection of the presence of viral proteins or antigens in respiratory samples. For this test to function, the antigen should be present in sufficient concentrations so it could bind with the specific antibodies fixed to a paper strip. There are several factors which influence credibility of these tests, such as duration of the onset of illness, concentration of viral antigen in the specimen, the precise formulation of reagent in the test kits and the quality of specimen collection and processing. Due to these reasons and limited information available regarding the test, WHO does not currently recommend using this antigen-based RDT for patient care. However, there is great stress for its use in research to understand its performance and potential diagnostic utility.

The global nature of this pandemic and the fact that countries are at different pandemic levels suggest that the pandemic crisis could be long. In addition, social tensions linked to severe prolonged confinement, which negatively affects people quite differently, financially as well as non-financially, may get out of hand. With all the confusion and crisis going around due to the COVID-19 outbreak, it is certain to provoke social stigma and discriminatory behaviours against people of certain ethnic backgrounds as well as anyone perceived to have been in contact with the virus.

The presence of stigma can contribute to more spread of infection as it can undermine social cohesion and prompt possible social isolation of groups, making it difficult to control the outbreaks. Stigma can drive people to hide their illness for fear of discrimination, which can come as a barrier for seeking health care immediately and limit the adoption of healthy behaviours, worsening the situation. So the whole society needs restructuring and remodeling to best cater to the demands created by the nasty virus. How the world will cope and move forward in this extraordinary situation determines our existence and sustainability. It is a critical time to think about the communication strategies to be adopted to support and enable communities to take effective action to combat the disease as well as avoid fueling fear and stigma.

If we look at the global scenario, currently most of the countries are practising certain social-distancing measures, either in the name of complete lockdown, physical distancing or home quarantine. Disruption in mobility, disturbed socialisation alongside confusion, rising fear, uncertainty and economic constraints have brought frustration and panic among the global population. This has been seen in different forms of anti-lockdown protests, rallies and actions, violating the government’s measures against COVID-19.

To control such civil unrest and prevent the risk of outbreaks, there is a need to create an environment, in which the disease and its impact can be discussed and addressed openly, honestly and effectively. Due to the increasing cases of infection and deaths, it has triggered disruption to social and mental wellbeing of global citizens. The confusion and uncertainty are fueling misinformation, stigma and discrimination, which are negatively impacting the prevention strategies adopted by different nations. There is a need for proper communication strategies and community engagement alongside the togetherness of all concerned entities fighting against this wicked virus globally. Citizen ownership will be essential to ensure that solidarity prevails over discrimination.

The infection cannot be controlled or contained only by scientific communities, healthcare workforce and/or political strategies. There is a need for community engagement alongside the togetherness of all concerned entities fighting against this wicked virus. The most important step for Nepal now is to immediately start proactive community testing. The more tests we do, the more we know about the cases to be isolated, which can help us to prevent community transmission. For the general public, cooperation with regard to the government measures is absolutely vital. It is important to strictly adhere to the social distancing strategy in addition to helping the community to identify the suspected cases, and endorsing testing and self-quarantine for anyone with symptoms to combat the wicked virus.

Prof Marahatta is an epidemiologist and public health expert

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