COVID-19 in Nepal – the surge in Baisakh
COVID-19 in Nepal – the surge in Baisakh
Satish Raj Pandey, Shashi
Dev Shah
The new year generally brings new
hope for everyone. There is an air of optimism when the calendar page is
turned. Wishes are exchanged for long life and success. This time, what
happened in the 31 days of the first month of the Nepali New Year 2078 has been
shocking and heartbreaking. The country is reeling under a devastating surge of
COVID-19 cases spread far and wide causing havoc. In a situation akin to health
system collapse, the underprepared health facilities were largely unable to
meet the rapidly increasing demand. Very unfortunately, valuable lives were lost due to the overwhelmed hospitals
that were overrun by the swelling number of patients with severe symptoms. People were suffocating to death due to lack
of oxygen. In this write up, we try to quantify this surge and make an effort
to provide some details on how the outbreak has unfolded during the month of Baisakh
(April 14-May 14, 2021). We want to emphasize as we write this that this is far
from over and Nepal needs to continue to remain very vigilant.
COVID-19 surge comes home
Nepal was somewhat lucky to have seen a long period of lull as COVID-19 cases remained very low for a long time following the first wave. Life was bearing resemblance of some normalcy. Businesses were starting to feel confident again. Around the beginning of March, in next door India, a hint of a rise in cases started to surface. Before anyone could figure out what was happening the cases surged in an unprecedented manner, and by the end of March, it was already getting very close to the highs of their first wave. In early April, India started to post a record number of cases which continued relentlessly throughout that month, spilling into May.
While the world’s attention was large drawn towards India’s emerging humanitarian crisis, a largely unaware Nepal was caught off guard. Nepal shares porous border with India. It was a tall order to escape this new wave that was rampaging through India. Add to this the complacency instilled in the government who thought the “battle was already won” and the people who thought that they have already “overcome COVID-19”. It was business as usual in Nepal, opening up possibilities of many super-spreader events, some political, others social. Some of these were even sponsored by the Government and leading political parties. There was poor preparations widely for any crisis that might be waiting in the wings. This created a perfect recipe for a disaster opening up a great opportunity for this fast and easily spreading virus to make inroads. As a result, Nepal was hit very hard in Baisakh, and the assault by the virus still continues on.
As a humanitarian disaster started to unfold in Nepal, it finally caught the attention of the international media. Several leading media outlets and houses such as The Diplomat, National Geographic, The Guardian (at least two write-ups) , The New York Times, BBC, and CNN, to name a few, covered the devastation. As the problem spiraled out of control, it forced Nepal’s Prime Minister Mr. KP Oli to resort to writing an opinion piece in The Guardian which included an appeal to help. Covid Alliance for Nepal developed a petition and popularized #vaccine4Nepal to draw the world’s attention to the plight of the Nepali people. As the situation became direr and people were suffocating to death with widespread shortages of oxygen supply, #NepalNeedsOxygen started to trend on social media.
What kind of
increase in cases and deaths did Nepal experience in Baisakh vis-a-vis
India?
Let us first look at the spread of COVID-19 in India and Nepal. Figure 1 shows that Nepal’s new cases (per 100,000 population) and % positive (of the tests done) saw a meteoric rise, quickly closing the gap with India in May. While Nepal reached 1 case per 100,000 population only on April 11, 2021, India had touched that level much earlier on Feb 25th. Moving on, Nepal witnessed 10 new cases per 100,000 population on April 27, while India had reached it on April 13th. However, Nepal rapidly surpassed India by May 10th. This is doubly concerning if we take into account that Nepal has been testing less than 50% the level of India. (comparing daily tests/100,000 population). Nepal’s 7-day % positive has though Baisakh, remained remarkably higher than India’s as the graph illustrates.
Figure: 1
This surge had a direct
adverse impact on mortality. As seen in Figure 2, through April, India’s
death/million people was 4-5 times larger than Nepal's (death/million people).
Around May 5th, this gap was closed to a half of that and by
May 12th, Nepal had already nudged ahead of India with 3 deaths per million
population. By May 14th, Nepal’s
deaths per million populations stood at 5.5. This demonstrates how overwhelmed the
health care system was resulting in a unusually high number of deaths.
Figure: 2
How does
Nepal look isolation for Baisakh?
Figure 3 shows Nepal’s exponential growth of new cases and deaths in Baisakh. In one month, Nepal identified 159, 960 new cases from 411,260 tests (RT-PCR) conducted. This gives a monthly yield of 38%. The consistently high yields show that the virus was widely spread and that the testing was largely inadequate. At the beginning of the month, the cases per million population was only 19 cases/million but by the end of it had swiftly moved to 284 cases/million. To compare with the first wave, the high for 30-day new cases was 95,160 between Oct 7-Nov 5, 2020.
Figure: 3
Nepal carried out 21,161 Antigen
tests in Baisakh out of which 2,812 tested positive. This write-up, however,
doesn’t include data related to Antigen testing. This was done to make it
comparable with the previous wave and to ensure the percent positive calculation
is consistent.
Nepal registered its highest single-day percent positive (50.2%) on May 10th. Of all the cases identified in Nepal from the start of the pandemic, 36.3% of the cases were identified in this one month alone. This month registered 15.4% of the total tests carried out to-date. In the last week of Baishak alone, 5.1% of the total cumulative tests so far was done and 14.2% of the total cumulative cases were identified.
Sadly, 1,611 lives were lost in Baisakh. This is 34.5% of the total cumulative deaths. The last week of the month accounted for 23.3% of the total cumulative deaths thus far. As a comparison, November had recorded the highest 571 monthly deaths during the first wave. This explosion of deaths shows that Nepal is facing urgent humanitarian situation right now.
How does
week on week data look?
What about testing?
For most of Baisakh, the increase in testing came from the private labs and from tests within the Kathmandu valley although cases were surging across the country (Figure 4). It was only in the last two days of the month that the seven-day average of tests from the government labs surpassed the private labs. For the first week of the month, testing level in the government labs was around half of the private labs. This reached around 70% by May 1st. Looking at it another way, we can summarize that at the beginning of the month, the government labs were doing only around 37% of total daily tests nationally. This increased to 40% by May 1st and only by May 13th the government-run labs were doing 50% of the national daily tests. This is important because tests from the government-run labs have no cost barriers as they are all free while the private labs charge at least Rs 2000 per test.
Figure: 4
Similarly, at the beginning
of the month, 72% of the total national tests was being done only in the Kathmandu
valley. By May 1st, this dropped to 63% and reached parity by May 13th as tests
were finally increased up outside the Kathmandu valley. As the percent
positivity was extremely high outside Kathmandu valley, the ramping up of tests
outside Kathmandu valley was slower than required. (Figure 4)
Table 2 shows the 7-day average for percent positive for the labs within the Kathmandu valley and outside. The percent positive outside the valley had started to go up two weeks before Baisakh. In the week of April 6, the % positivity average had already reached 11%. This was a sign of the development of a serious situation. The average quickly spiraled out of control and remained above 45% for the last three weeks of the month.
Table: 2
In Kathmandu valley, the %
positivity average reached above 10% around the first week of Baisakh (week of
April 13) and reached 40% by the third week of the month. Although, the
situation was worsening both within and outside Kathmandu valley, tests were
relatively ramped up only in Kathmandu valley for most of Baisakh.
The testing level in some provinces were far from required level despite the Provinces carrying the potential to be hot-spots for new cases.
Figure: 5
As demonstrated in Figure 5,
Province 2 and Lumbini, constantly recorded much lower than the national
average for tests/100,000 population. Their ratio remained very low throughout
the month and the increase was woefully slow. This might have been a big missed opportunity
because as shown by Table 3, the percent positive province was already in
double digits as early as four weeks before Baisakh in Lumbini and three weeks
before Baisakh in Province 2. Gandaki, Karnali, and Sudurpaschim provinces, too,
had consistently shown >10% positivity three weeks before Baisakh but still
had very low levels of testing. This shows a disproportionate burden of percent
positivity and relatively low level of testing outside the Kathmandu valley.
Table: 3
Who was
being infected?
Impact on
the health care system
The rapid increase of new cases caused a higher number of hospitalizations need in a very short time. As a result, hospitals were suddenly seeing overwhelming number of cases requiring the care for moderate to severe symptoms. Active cases nationally swelled by more than 26 times in just one month moving from 4000+ at the beginning of Baisakh to more than 100,000 by the end of it. By the accounts of the Ministry of Health and Population, Nepal, people in ICU care and on ventilator increased by more than 15 times within the month. As a result of this exponential growth, there were 371 people on ventilator care by end of Baisakh (Figure 6).
Figure: 6
Did vaccination have any impact?
At the time of writing this, through two rounds of Covishield roll out and one round of Vero Cell (Sinopharm), Nepal had administered single doses to nearly 5.7% of the population. Those that had received Covishield vaccines in the first round, mostly healthcare and other frontline workers, have also received their second dose. As a result, around 1.2% of the population is now fully vaccinated. The second dose for Vero Cell vaccine is being provided from May 16, 2021.
Moving ahead
Nepal, as with most low-resource settings, suffers from constraints to carry out the adequate crucial genome sequencing to study the presence of different variants. As we have seen in the UK and parts of India, variant B.1.617 can muscle out other variants to be the dominant one in circulation in a very quick time. This is the reason WHO recently categorized B1.617 as a variant of concern (VoC). Using proxies from India, we can hypothesize that currently, the dominant variant in Nepal might be also be B 1.617.2. This is supported to some extent by Nature in its May 14, 2021 article which states the following:
In early
May, (Dibesh) Karmacharya’s team sequenced 12 samples from people recently
infected in the Kathmandu valley — including himself. Eleven of the sequences
were of B.1.617, and one was of B.1.1.7. The results are only a tiny snapshot
of what is circulating, but are still “a little scary”, says Karmacharya.
We
have seen the havoc caused in India with the variants in circulation. Due to
the nature of B1.617 variant, many countries including the UK have shown a very
high concern. Regardless of which variant, we can be assured that the variant
(s) circulating in Nepal is (are) also spreading aggressively. This can be due
to the high infectiousness of the variant that thrives in the environment with
poor exposure population level behavior. Some experts have speculated the
R(nought) number for the variant B1.617 to be very high. Even societies of high
vaccine coverage have opened up with a lot of caution. We need to remain
mindful of this possible high transmissibility and should remain very vigilant.
The
restrictions/lockdown are currently imposed in 74 out of 77 districts of Nepal.
The slowdown of growth (not a marked decline yet though) in new cases we are
witnessing might be because the lockdowns have been in place for more than two
weeks. If non-pharmaceutical interventions are not implemented during and post
lockdown, the surge can easily bounce back as soon as the restrictions are
lifted. Our vaccination coverage is very
low and new tranche of vaccines might not arrive soon enough to counter the
current wave. Those vaccines might only be handy to face the next wave which
experts have predicted to be inevitable.
In the meantime, preventive measures are crucial to stem the spread of the virus. It is also essential for the Covid-19 response in Nepal to ramp up of testing, especially from the government facilities for areas outside the Kathmandu valley. This will make testing more accessible to a wider population. In addition, the government should reduce the cost of testing from the private labs.
What we have witnessed over the past month has been both heartbreaking and extremely concerning. This is still far from over and we shouldn’t let our guards down. All forces should continue to join hands in raising the voice in the international area for more support, particularly for items such as testing supplies, oxygen supply related support and anything that aids to further ramp up hospital capacity in an urgent manner. We should continue to appreciate the work of the health care workers and others who have tirelessly helped and saved lives in this distressful time. Let us hope that Nepal will be able to prevent further rise in the number of deaths and also dramatically reduce the new cases to a manageable level by the end of the next month, Jestha, Baisakh has surely been a month to forget. We shouldn’t, however, forget what got us in the terrible position to begin with. Let us have the resolve to not repeat those mistakes.
Stay safe, Nepal!
Good job. Interesting and comprehensive analysis.
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DeleteIt was a great effort to understand the issue. Now, it's also a suitable time to read more about new variant 🙏
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