Staying safe in 2021 and beyond

As a physician, I am at the receiving end of a lot of questions from friends and relatives about the pandemic. While some want to know about their symptoms, most questions are about whether the number of cases in Nepal is actually going down.

It is hard to tell. There a lack of tracing, testing is inadequate, and record keeping is unreliable. The media carries a daily tally that is based on government figures, and they show confirmed cases have now dipped to below 1,000 per day, almost half of them in Kathmandu Valley.

The Ministry of Health statistics also show that there are about 250 patients in critical care, and some 50 of them require ventilator support. If these figures are to be believed, the death rate from Covid-19 does not seem to have decreased.

More worrying are reports that Pashupatinath now sees 80 cremations daily as opposed to 30 per day at this time last year. Are some of these unidentified Covid-19 ‘excess mortality’? It is all guess work, but this more than double increase in funerals needs to be accounted for.

It is indeed possible that although some of the excess mortality is due to undiagnosed Covid-19, it could very well be that the winter death rate has gone up this year because people with other pre-existing conditions like cancer, cardio-vascular diseases, diabetes or kidney patients needing dialysis are not visiting hospitals for treatment. These ‘indirect’ Covid-19 deaths could be a useful research project.

Despite this, there are indications that young urban Nepalis are letting their guard down. The parties during the wedding season, unmasked crowds at Thamel’s indoor nightclubs and concerts and the throngs in Pokhara Lakeside and Sauraha show a ‘what will be will be’ attitude.

An affordable and effective vaccine is still some way off. Wearing a mask, preferably a N95, which serves the dual purpose of protection from SARS-CoV-2 as well as Kathmandu’s air pollution, maintaining safe distance and frequent had washing with soap and water are our ‘vaccines’ for now.

Japan has important lessons for us. So far, it has kept Covid-19 death rate at the lowest by far among G7 countries by strictly following guidelines including avoiding the ‘san-mitsu’ or the 3Cs: closed spaces, crowded spaces and close contact settings.

We in Nepal will be lucky if a vaccination arrives by mid-2021. Current vaccines like Pfizer and Moderna are out of the question because of their cost and the lack of capacity to maintain the very cold storage that they require.

The Oxford University Astra Zeneca vaccine that the Serum Institute of India is manufacturing appears to be our best bet because it is relatively inexpensive and only requires the regular 3-6^o Celsius cold chain. The good news is that the Serum Institute of India is also studying other vaccines such as an intra-nasal vaccine, which can be stored at room temperature. If effective, this would be the answer for countries like Nepal.

We are awaiting published results of trials of the Chinese vaccine, and that could also be the answer for developing countries like like Nepal. The Chinese have an impressive track record of making vaccines, and to combat infectious diseases. For example, the inexpensive Japanese Encephalitis vaccine made in Chengdu helped control the deadly disease in rural communities throughout Asia.

This Chengdu vaccine cost less than $5, in contrast to the $100 per shot encephalitis vaccines made by Western pharmaceutical companies. The Chinese Hepatitis E vaccine could prevent infection and save lives of pregnant women in the Subcontinent where the virus is a scourge due to poor hygiene.

Therapies

Aside from vaccines, research into treatment of Covid-19 is also making progress. For example, the Recovery Trial in the UK has convincingly showed that dexamethasone, a readily available and inexpensive steroid saves lives in the treatment of moderate to severe Covid-19 patients.

In all this confusion regarding treatment, however, it is equally important to note what does not work. Drugs like hydroxychloroquin do not work in the treatment of this disease, despite its false efficacy touted by Donald Trump. The World Health Organisation’s Solidarity research also showed that the expensive remdesivir drug that our government was at one time handing out freely to Covid-19 patients is not very helpful, either.

Reliable diagnosis of Covid-19 is important, especially in countries like Nepal as there are many other infectious diseases that may at first present with fever and cough, like tuberculosis. The PCR (polymerase chain reaction) test still remains the gold standard for Covid-19, but they are expensive and may take a day or two for the results.

Antigen tests are being carried out in Nepal and can give a quick diagnosis in symptomatic individuals within 30 minutes. But they are not as accurate as the PCRs. There are other commercial brands, and some may not be as accurate as others.

New variant

News of the new variant of Covid-19 reported in England and South Africa and now spreading across the globe, sound alarming. It is interesting that this new variant was discovered in the UK where a great emphasis is given to finding its chemical constituents.

One of UK’s prime institutions for this is the Sanger Centre near Cambridge, with whom we at Patan Hospital also collaborated to delineate a variant of typhoid organism mutation, helping establish a new treatment strategy for typhoid in the Subcontinent in 2016.

The best way to handle the new Covid-19 variant is continued vigilance about preventive measures, especially since the mutation gives the virus the ability to spread faster. It is best to be over-prepared than under-prepared to fight this wily virus.

Masking up, safe distance and hand washing are our best course of action for us to stop the pandemic in 2021 and beyond.

Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and writes Dhanvantari, a frequent health column for Nepali Times.