Hon’ble Mr. Bhanu Bhakta Dhakal
Minister, Ministry of Health and Population
Ramshahpath, Kathmandu, Nepal
Dr. Jos Vandelaer,
WHO Representative WHO Country Office UN House,
We, Nepali public health professionals, would like to express our gratitude to the Government of Nepal, particularly Ministry of Health and Population (MoHP), provincial and local governments, WHO, partner organizations, and most importantly, all frontline health workers and security forces for their ongoing effort to curb the outbreak of COVID-19 in Nepal. We applaud the decisive role the government played in enforcing the on-going lockdown in a very timely manner. We acknowledge the limits of our knowledge, mainly on the transmissibility of the virus and the most effective management of the confirmed cases. Nevertheless, we have learned in the past two months that countries that are open to learning, quickly adapting to the new information, and re-strategizing as they go are the ones that give themselves a much better chance to more successfully managing this pandemic.
Based on the available science, we believe that the current testing strategy adopted by MoHP is restrictive in breaking the chain of possible transmission and might be a hindrance to subsequently contain the spread early. As more RT PCR test kits become available in Nepal, we believe that MoHP, in coordination with its technical partners such as WHO, should broaden the eligibility criteria for testing. It is imperative that the government immediately expand the case finding beyond health care settings, and pursue active community-based surveillance and also expand the testing criteria following active and aggressive contact tracing. We believe that this provides a crucial window of opportunity to detect and isolate the cases early, thereby increasing the likelihood of containing the outbreak. In this regard, we urge MoHP and WHO to consider the following recommendations:
- Revise the test eligibility criteria to include people who have travelled from abroad in the past 14 days, showing either one of the three main COVID-19 symptoms (fever, cough, shortness of breath.)
- Trace and test all close contacts, especially the immediate family members who live in close proximity, of the confirmed COVID-19 case, regardless of the presence of symptoms. The contacts that have tested negative but show either one of the three main symptoms should be re-tested after two days.
- Make testing services available across major population centres of the country. Nepal Public Health Laboratory (NPHL) should enforce quality control measures, ensure the safety of laboratory workers, develop mechanisms for unified reporting of testing to the public and reconfirm the positive results. Capable private sector labs that meet the required standard should be allowed to test following a MOHP-led assessment; incremental improvements to the facilities can take place while the tests are being offered.
- Ensure that people with suspected and confirmed COVID-19 cases are protected from stigma and harm. The government needs to take firm steps to curb any possible steps that can lead to stigmatization of the suspected cases or people returning from areas where there is an ongoing outbreak of COVID-19. We are aware that the above recommendations might, at times, conflict with the current WHO guideline for testing of suspected cases as well as contact tracing, but they are in line with the WHO’s repeated assertion of using the lockdown period to look for new cases aggressively in order to make the best use of the lockdown period and the sacrifices made by all. We believe this is even more paramount for Nepal, where a more proactive effort upfront to test and isolate cases early significantly lessens the burden of large-scale mitigation at a later stage. We have seen that government’s leadership and the cooperation extended by the people and other well-wishers have thus far kept the number of identified cases to a minimum and we firmly believe that the country will be able to manage the future situations better through the implementation of the above recommendations together with other measures that the government is planning to implement. We remain committed to providing any help and support needed.
Satish Raj Pandey
[i] Available science suggests that 41% to 79% of the transmissions may have happened while people are asymptomatic or pre-symptomatic (Hiroshi N et al.). It is now also widely accepted that asymptomatic transmission may have been higher than what was previously believed. With the infection estimated to have an incubation period of 2–14 days with a basic reproduction number of 2.24–3.58 (Chih-Cheng L. et al), we believe delayed testing is not only insufficient in detecting cases early but presents a high risk for community transmission in Nepal.
[ii] While it is unclear how many cases actually develop two out of the main ARI symptom, it is most likely to be low. Chih-Cheng L. et al. show that 92.8% of the symptomatic cases develop fever, 69.8% develop cough but only 34.5% show dyspnoea and 27.7% develop myalgia. In light of this, we think the current protocol used for diagnosis of COVID-19 in Nepal is narrow and likely to miss out on many asymptomatic and mildly symptomatic cases.