PCR testing services need to be expanded in the rural areas as such facilities are disproportionately higher in Bagmati province and urban areas. It has been a year and a half since the start of the pandemic, and yet PCR lab services have not reached all districts.
If not PCR, at the least rapid antigen testing services should be made continuously available in every district until such PCR labs can be set up to prepare for a potential third wave. Data from testing is vital to understand the epidemiology of the virus and its transmission – person, place and time are the data points required consistently to track this virus.
Along with expansion of testing services, it is essential to address testing hesitancy that is driving individuals with Covid-19 like symptoms to stay home without being tested. More than 100 laboratories that are equipped with PCR equipment remain under-utilised. Addressing the social stigma associated with Covid-19 positive status via trusted members of the community can help reduce testing hesitancy.
Clear, consistent and enforced travel regulations
Although the government has increased quarantine measures for unvaccinated travelers entering through international flights, its enforcement remains an issue. Monitoring air travelers, and not allowing for exceptions is important.
While ongoing efforts are in place to increase the number of health desks at Indian border entry points, we recommend these efforts continue and expand across the border region. Increased screening for cases using rapid antigen tests and implementation of quality isolation facilities for a nominal or no fee near the border crossings for those presenting with symptoms and/or testing positive are also key.
A collective sense of responsibility by citizens and travelers to be accountable and follow government protocols is equally imperative. Evading entry points without providing proof of vaccination or having gone through screening is no longer acceptable. We have to put forth the larger health and well-being of our communities and societies that we will enter post travel.
Case contact tracing
Just as important are case contact tracing efforts which the local level wards are given the responsibility to implement and oversee. Sharada Magar, a registered nurse who supported contact tracing efforts during the second wave in Gulmi district, told us: “The effectiveness of contact tracing effort remains questionable due to poor monitoring and shortage of human resources at the ward-level.”
Local municipalities struggling with contact tracing efforts should increase their human resource capacity immediately and be strictly monitored by the province health directorate. To support contact tracing efforts, at an individual level, it is important for us to have minimal contacts during these times. In addition, if found to be infected, it is vital to actively inform the close contacts of the previous week about being tested positive and ask them to quarantine and get tested as well.
When in doubt, it is important to get tested and self-isolate, so as to prevent spreading the infection to your close and loved ones. Local municipalities who are responsible for contact tracing also need to enforce masking , discourage crowding and provide hand washing services in public spaces.
Equitable distribution of vaccines
As Covid-19 vaccine supply slowly increases, the government needs to ensure equitable vaccine distribution, and at the same time clearly communicate the importance of getting vaccinated as well as the risks associated with them. The roll out of Covid-19 vaccines in cities like Kathmandu and Biratnagar has been criticised by the public to be poorly planned with few sites and long lines.
Although the recent vaccine drives in Kathmandu saw an increase in vaccination sites with one camp in each ward, long lines and shortage of vaccines was still being reported. To ensure that the targeted population in each vaccination drive (age group, occupation, etc) gets vaccinated accordingly, screening procedures should be in place.
At the vaccination sites, staff or security personnel should screen those in queue as to whether they meet the eligibility criteria. This would prevent those not meeting the eligibility criteria for the specific vaccination drives from wasting their time and avoid misunderstanding and conflict.
While efforts are being made by the government to add new sites for distribution of vaccination proof certificates for migrant workers, it should immediately digitise this process bearing in mind that such certificates can be the passport to access public spaces and indoor activities in many countries.
During the first wave, the majority of the local governments took an active role in management of Covid-19 positive individuals at the community-level institutional isolation facilities. However, the government’s decision to promote home isolation of all mild cases of Covid-19 in the second wave led to many family members being infected at the same time.
To prevent the third wave, therefore, the local government needs to ensure that every Covid-19 positive individual is safely isolating at home or institution by following appropriate guidelines. Every individual should consult the nearest healthcare providers or government Covid-19 hotline numbers on how to safely isolate at home and avoid risking other family members.
More importantly, local governments need to consider re-establishing community-level institutional isolation centres to ensure that low-income individuals who do not have access to a single-use bedroom or bathroom at their homes do not put others in the family or community at risk.
Invest in science
On the research front, more work is needed to understand the evolving nature of the virus within Nepal. Regular genomic sequencing of SARS-CoV-2 virus is now being done at the National Public Health Laboratory, which increases the national capacity to detect and monitor the type of virus circulating in the country. In addition, the ongoing nationwide Covid-19 serological survey being conducted by the Ministry of Health and Population partnered with WHO will provide an estimate of the prevalence of the infections (people who have been infected in the past and developed antibodies to the virus).
Regular large scale serological surveys should be conducted to provide a snapshot of the disease burden and track how infections progress through the population over time. India has already conducted four rounds of nationwide serological surveys within a span of little over a year.
Furthermore, under the leadership and guidance of the Ministry of Health and Population and in partnership with vaccine research experts in the country and abroad, Nepal could be a site for Covid-19 vaccine trials among the adolescent group or for research on mixing vaccines for booster shots in adults using already approved Covid-19 vaccines.
Although small, the proportion of the fully vaccinated population is growing, so it is very important to actively investigate and report the breakdown of cases and hospitalisations by vaccination status. This is important for public health experts to monitor the effectiveness of the vaccines to prevent severe illness and contribute towards the research and monitoring of ‘breakthrough’ infections among the fully vaccinated.
Such breakthrough cases are expected as no vaccine has 100% effectiveness and research has shown that breakthrough infections are possible among the fully vaccinated — nevertheless, the vast majority of hospitalisations and deaths seen recently in the US are still amongst the unvaccinated.
Our civic duty to stop the spread
In order to prevent a potential third wave from happening, each of us needs to work towards stopping the spreading of the virus. Until the majority of the population nationally and globally gets vaccinated, Covid-19 will endure.
In the meantime, we must maintain and strengthen public health measures that work: proper masking, physical distancing, frequent handwashing, respiratory and cough hygiene, ensuring good ventilation and avoiding crowded places or closed settings. The US Center for Disease Control and Prevention has recently recommended fully vaccinated people to wear a mask in indoor public settings as fully vaccinated who do become infected with the Delta variant can be infectious and can spread the virus to others.
With the Delta variant being the predominant strain spreading in Nepal, those fully vaccinated should continue to follow safety measures. Work spaces, shopping centres, gyms and restaurants/cafes should operate in a well ventilated space and with strict mask mandates. In cases where ventilation is poor the businesses should operate in half capacity.
This ensures maintaining caution as well as keeping the business and operations running for economic viability. Even small measures such as asking a person to properly wear a mask if you see it not being followed in an indoor public setting can make a difference.
It is our civic duty to follow the public health protocols and safety measures to keep ourselves and others safe. Refusal to take precautions should not be normalised unless we want to delay returning to the pre-pandemic normal. So let us work together to prevent future waves of infections by being accountable at an individual level.
In Nepal, during the peak of the second wave, the positivity rate for PCR tests reported on 11 May, which logged the highest number of reported new cases 9,483 was 44.5%. The positivity rate for Covid-19 tests (PCR and rapid antigen test) reported on 8 August is lower at 20.6%.
However, compared to neighboring India, Nepal has a higher weekly average number of new cases per million people (figure below). In addition, the reproductive rate (R) that represents the average number of new infections caused by a single infected individual is rising in Nepal and is currently at 1.15. If the rate is greater than 1, the infection is able to spread in the population and needs to be below 1 to contain re-infections.