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 BS [Apr 14-May 14, 2021] 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 a 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]. We want to emphasize as we write this that this is far from over and Nepal needs to continue to remain very vigilant. All data for Nepal included in this write-up are from the Ministry of Health and Population daily updates.
Covid-19 surge comes home
Nepal was somewhat lucky to have seen a long period of a lull as Covid-19 cases remained very low for a long time following the first wave. Life was bearing the 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 largely drawn towards India’s emerging humanitarian crisis, a largely unaware Nepal was caught off guard. Nepal shares a 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.
While the world’s attention was largely drawn towards India’s emerging humanitarian crisis, a largely unaware Nepal was caught off guard.
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 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.
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 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.
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.
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 precent 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.
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
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?
Table 1 shows that weekly cases against the previous week accelerated when compared against the increase in weekly tests from April 10 – April 30. Notably, this pace of increase was somewhat stable in the last two weeks. This provided some faint glimmer of hope of a possible slowdown. During the month, average deaths per day continued to increase reaching 134/day in the last week. Apart from increasing deaths resulting from overburdened health facilities, this could partly be because of the adjusted data that now takes into account the additional bodies managed by Nepal Army. These adjustments have been made in the past several days. It is evident that the “law of the large numbers” played out in Nepal and a very rapid increase in cases resulted in an unprecedented level of deaths.
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.
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.
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.
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.
Who was being infected?
Age-specific new infections were assessed for Baisakh against the previous period (Table 4). Marginally more new infections (as proportion of the total cases) were seen among age categories above 40 years of age compared to the same groups in the previous period. Contrary to the common belief, the new infection proportions were not higher among the younger population than in the previous months. This perception might have been created by the generally higher totals for new infections. This meant that there was a relatively higher absolute number of new infections across almost all age groups.
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).
Has the vaccination have any impact so far?
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.
As the vaccine coverage so far is extremely small, it is understandable that a large proportion of the population is still unprotected. This can explain the high hospitalization and deaths the surging cases are causing. It is useful to see if the vaccination is having any positive impact among the population already vaccinated. In order to carry out a very rough indirect assessment, we looked at mortality data for the 65+ age group who were provided the first dose of Covishield vaccines in the second round of vaccination drive. This round had coverage of more than 60% of the target set and was completed on March 16th. We divided total national deaths for period before April 1 and after April 1 till date. We chose April 1 with the understanding that by then, two weeks of vaccination would had elapsed for those vaccinated in the round. So although vaccinated only with a single dose, we tried to indirectly assess if the ones vaccinated were protected more.
What we have witnessed over the past month has been both heartbreaking and extremely concerning.
There was no access to mortality figures only for the vaccinated cohort. Due to this, we looked at ag-specific mortality contributions for all age groups at the population level. We observed that after April 1, the age-specific deaths among the people 65+ years old as a percent of total deaths saw a marginal decline. (Table 5) Although not conclusive due to the absence of sound statistical analysis of this observational finding, this might still give some very early clues that vaccination may be working to reduce deaths. This should be investigated further.
Nepal, as with most low-resource settings, suffers from constraints to carry out 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 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!
The article was originally published on https://satishrajpandey.blogspot.com/