COVID19 in Nepal: Now that the world “has” vaccines, are we safe?

 

COVID19 in Nepal: Now that the world “has” vaccines, are we safe?

Satish Raj Pandey, Shashi Dev Shah

 

Almost 11 months after @promed_mail sent this email (below) alerting the world about “pneumonia of unknown cause” in Wuhan, China, the world has recorded, by the time we write this, close to 57 million known infections out of which nearly 1.4 million (2.4%) have died due to COVID19 pandemic (JHU Coronavirus Update Center). While this pandemic has been highly politicized and has been extremely polarizing, these numbers, which look to continue to grow for the foreseeable future, can't be brushed off as not significant.  The mental shock, personal trauma, and economic devastation this has caused are of such magnitude and wide-ranging that they simply can't be ignored.

The past few days have brought us very mixed news regarding the future of the pandemic. On one hand, the world recorded, for the first time, more than half a million daily cases, moving swiftly on to more than 600,000 daily cases coupled with daily deaths exceeding 10,000 (Worldometers). Many countries, including very affluent ones, are under the scourge of a new surge of cases and deaths. It had momentarily looked like deaths were coming under control only for the overwhelmed health facilities to again record rising cases of deaths. This paints a very sobering picture of the time we are living in. However, this is not to say that all is gloomy. We have had some really exciting news coming out of the several candidate vaccines showing very promising results from their Phase 2 and/or Phase 3 trials. 

It is very heartening to see that, for this extraordinary plight faced by the world, scientists around the world have worked at breakneck, unprecedented speed, oftentimes even competing against each other, to present to the world a bright prospect of vaccines being available (soon) to fight the pandemic. From the recent results seen, it is increasingly looking like the existence of a vaccine is no longer a matter of if but now a matter of when, and more importantly, immediately for whom. This light at the end of a very depressing tunnel has brought much-awaited cheers to many. While making the vaccine might end up being the easy part of getting everyone vaccinated, we still need to celebrate these moments because the bright scientists of this world have put us all on the path of being able to win this war in the long run. 

 While the world was waking up to exciting breaking news about these candidate vaccines and their high efficacy, WHO Director-General, Tedros Adhanom Ghebreyesus was warning the world that “A vaccine alone will not end this pandemic.” The point he was trying to make, as he should, was that, due to limited supplies, the initial supply of the vaccines will be prioritized (rightly) for those most-at-risk to reduce the deaths. This means that the rest of the world will have to wait. He emphasized that as we wait, all of those tools that we know to work such as surveillance, testing, isolating, early treatment, contact tracing, and community mobilization, to name a few, need to be continued. This is not a time to let our guard down. 

This means that each country needs to be focused on what is best to contain the spread of the virus until its population, at least the critical mass to begin with, has access to the vaccine. For this to be effective, experts need to be engaged so that we can understand better where the epidemic is going within the country and what kind of initiatives will give the most bang for the buck until vaccines are available for everyone.

This article makes an effort to outline some critical data regarding the current situation of COVID in Nepal. We are trying to do this because during the Dashain and Tihar festivals the daily reported cases have seemingly gone down. This, along with this euphoric news about vaccine breakthroughs, can give a false sense of security to the people and make them let their guards down. We have to realize this pandemic is far from over and in fact, has entered into a very dangerous phase and will remain as that until vaccines are more widely available. The only word we can repeat for people is caution, caution, caution. 

So let us see what our COVID19 situation looks like. Some of the tables presented here will have testing and new case data segregated for Kathmandu valley and outside Kathmandu valley.  This is done because, as you can see from the data, the cases and testing seem to be evenly divided between the valley and the rest of the country. We hope that this will help understand the situation better and will prevent dilution of the national figures by Kathmandu valley related data.  Please also take note that while some graphs use daily numbers others use a seven-day average. This distinction is necessary to understand the data better.  All data for Nepal shown in this article is taken from the Ministry of Health and Population daily updates. 

 

Where are we with testing and positive percent?

Testing is the backbone of the COVID19 response. We have to admit that after a slow start, thanks to the Nepal government's efforts, testing (RT-PCR) did get scaled up rather well through most of October. The seven-day average even crossed the 16,000 mark during this month. While it falls short of the government's claim that the country can carry out more than 22,000 tests per day, this increase has enabled us to identify cases both in and outside the Kathmandu valley. We can see (Chart 1) that testing in Kathmandu valley surpassed the testing done in the rest of the country around the third week of September and has since remained above the rest of Nepal level.  Testing in Kathmandu hit a high of more than 9000 (seven-day average) in the middle of October but since then has dropped to below 5,000. Similarly, testing outside the valley exceeded 7,000 in the third week of October but has now dropped to below 3,000. We can see that the slump is mostly related to the festival season and can hope that it will increase again now that the festivals are over.

 

Chart 1: Seven-day moving average test and yield -National, Kathmandu Valley, and out of Valley.

We can see (Chart 1) that the overall percent positive (also known as yield) for Nepal had hovered above 20% since the second week of October. This is very alarming. In the past two weeks, yield in Kathmandu valley has constantly remained above that of the rest of the country. What gives some ray of hope is that the yield in the rest of the country seems to be moving towards the 20% mark from a high of 25% at the end of October.

 

Who is doing these tests?

We looked at the RT-PCT tests by government and private facilities for both Kathmandu valley and out of the valley. What we see from these charts is the tests from government facilities are constantly going down. We can observe (Chart 2) that almost all of the increase in testing mentioned earlier for October happened in privately-run labs in Kathmandu valley. The majority of the tests being done out the valley are still done by the government-run labs, and the share of private labs have remained mostly constant through October and November. The entire nation has seen a massive slump in testing during the festival season. The drop is more pronounced in the government-run labs. This is very concerning because most people who need support to get tested rely on these government labs and these dwindling numbers can only mean that their tests are vastly delayed or never take place.  There is an urgent need for the government labs to start testing close to their capacity and let the number of tests to continue to slide.

 

Chart 2:RT-PCT tests in  Kathmandu Valley and tests positive, by government and private labs

 

 

Chart 3: RT-PCT tests out of Kathmandu Valley and tests positive, by government and private labs

 

What are we finding from these tests?

We have said that the overall tests in the valley and the yield from the tests have remained above the rest of the country. This, naturally, has caused the new case numbers in the valley to be above the rest of the country. The new cases found were on an increasing trend in both Kathmandu valley and outside the valley (Chart 4). One notable observation from Chart 1-4 is that the only time both yield and number of cases seemed to be going down, despite the number of tests remaining constant, is the short period around 2-3 weeks after the lockdown. This gives a hint that the lockdown might have been somewhat bringing the spread under control despite the economic hardships it caused. We can see from the high yields and high number of new cases the spread becoming uncontrolled following that short period. 

During the festivals, the drop in new cases is seen to commensurate with the drop in testing indicating a slightly more stable yield (albeit still above 20%) for both these geographical regions.  The drop in the COVID19 new cases during the festival should be seen strictly as a drop in overall testing. As mentioned before, there are some bright spots that the drop in cases outside the Kathmandu valley seems to be slightly steeper than the fall in testing. We need to observe testing results from after the festivals to see if these are real drops and if we are rounding a corner there.

Chart 4: Seven-day moving average of new cases and RT-PCT tests done (Kathmandu valley and outside

 

Chart 5: Daily new cases in three Kathmandu valley districts and the rest of Nepal

 

What does the overall testing yield and cases found to tell us?

WHO sets standards to know if the spread of the virus in a country is in control. It is desirable that for countries with adequate testing that the overall daily tests/positive case found remains above 10, or better still, even above 20.  It may be true that the initial spread of the virus in Nepal mostly took place among returnee migrants, either infected before they arrived or presumably infected due to poor conditions of the quarantine facilities. It is clear (Chart 6) that around the end of August the spread had established deeper roots through the local transmission. The experts had raised the red flag several times about this which was mostly ignored. The spread in the community, therefore, continued unabated causing the tests done to find each positive case to drop below 10 and even below 5 since 7th Oct (with very few exception).  Again, this is an area of grave concern.   

Chart 6: Daily tests carried out per new positive case found

Who is being infected?

The above theory about increasing local transmission can be seconded by an alarming reality that the proportion of older people among the newly infected was growing every day.  This population is presumed to be less mobile and mostly confined to their homes. It appears that they are being infected by the younger members of the family who bring the virus home. The share of the 60+ population among all newly infected increased by more than double to 8.1% by Nov 19 compared to 3.9% by Aug 27 (Chart 7). The number of 60+ age group in this period increased 14 times compared to 5.7 times in the younger population.  For a disease known to affect the elderly disproportionately more (from severity of the disease and mortality perspectives), this shift is again an area of major concern.

Chart 7: Shift in proportion of COVI19 cases by age groups

 

But are people dying?

Yes, people are dying. This is a short answer to the question. The long answer is that the overall deaths have started to grow considerably since around the beginning of September and have gone worse in the second half of October and November. We are constantly losing (officially) more than 15 people at a minimum almost every day. This coincides with the shift of the infection in the older age group.  Protecting our older population has to be a priority as they are more vulnerable to succumbing to this virus. We can see that most growth in new cases were seen between Oct 9-Oct 29^th and the deaths have started to increase around two weeks after this period. This lag time in deaths increase is very common.

It is also to be noted that the government had revised its guidelines to stop requiring COVID19 testing on the deceased if the status was unknown before the death even though they are highly suspected and symptomatic to COVID19 . If we assess this in the backdrop of the widespread practice of home isolation, it can be safely assumed that a significant number of COVID19 related deaths might be being missed. We tried to corroborate this by assessing what proportion of deaths before the change in the guidelines was tested positive after the person's demise and we found that until Sept 2, 23% of the total people who died were diagnosed AFTER their death. The recent news articles that mention a much higher number of bodies 'managed' by the Nepal Army's dead body management team also support this notion that COVID19 related deaths in Nepal are now vastly under-reported.

Chart 8: COVID19 Daily Deaths (National)

 

But isn’t our case fatality ratio very low?

Our case fatality ratio (CFR), based on new cases and mortality figures shared by the Ministry of Health and Population stands at 0.6%. This is much lower than the global average mentioned at the start of the article. As with most averages, a more granular look at these deaths will give us a different picture. As many as 30 districts and 3 provinces now have CFR higher than the national average.  This tells us the dangers of having this virus freely circulated in the general population. A large number of people can still die if the spread is not checked on time.

 

Chart 9: COVID19 Case fatality Ratio, by district, province and National

 

What should we be looking at?

We have seen from around the world that when the health care system can't cope with the increasing load of the cases, people die and die at higher rates. This has been witnessed even in the most affluent of counties. This is the reason countries keep a very close eye on hospitalization rates and doubling time of ICU enrollments. Patients on the ventilators is another indicator countries look at to understand if they are approaching capacity or not. The entire idea is to prevent the hospitalizations to overwhelm the system so that lives can be saved. We looked at the number of patients in ICU and on ventilator support in both Kathmandu valley and nationally. The overall number of patients in ICU has grown through November till this day. The patients on ventilator support were seen to be alarmingly going up until the second week of November and for now, have remained at a relatively lower level. We can't help but notice that this may be inching back up as we emerge from the festivals.

Chart 10: COVID19 patients in ICU or under ventilator support

 

Conclusion

The spread of COVID19 is far from over, globally, and in Nepal. This is not the time for any complacency. The COVID case increase in Nepal hasn't relented. It is still spreading fast. Deaths are also not abating and as the increasing number of the older population get infected, the country is sitting on a time bomb poised for a higher level of deaths if left unchecked. Pinning hopes solely now on a vaccine that is still going to remain out of reach for months can have catastrophic consequences. The country needs to continue to fight against the virus. 

People should avoid indoor crowded spaces, need to use a mask at all times, stop holding gatherings of all sizes (dinners, parties, and the likes), remain within your bubble and not overlap as much as possible, maintain social distancing, ventilate your rooms well, isolate responsibly if you are in close contact of the infected, buy a Pulse Oximeter or donate one to those that can't afford, seek treatment from a professional promptly and stop stigmatizing those that have presumably tested positive. 

In the meantime, the government should channel its energy to prepare the country for the vaccines. They should work with the GAVI COVAX Advance Market Commitment (AMC) to ensure that vaccines are secured for the country to the level the mechanism allows. The country should ensure that our share of financing for the vaccines is worked out ahead of time. Finally, while the vaccines are being produced, the country should immediately start putting measures in place, working closely with international/national experts, to develop the protocols,  infrastructure, and distribution mechanisms in place so that the vaccines can be rolled out in a timely and equitable manner as soon as they become available.

This is a fast spreading virus. It has been infecting the world at a very rapid rate. Even if vaccines become available quickly, no one is safe until everyone is safe. The safety of the world lies of how quickly and how widely the vaccination is applied while other safety non pharmacological intervention measures are continued to be used to compliment. Nepal can’t be looking at its recent seemingly reducing COVID19 cases as it is confounded by the festivals and resultant low testing. It should focus all its energy on keeping it population safe until the vaccines become available and then, distribute the vaccine among its population in a speedy and equitable manner. Only this will make Nepali safer.  Until then, we aren’t safe, not just as yet.