Recently, a 34-year-old male with a two-day history of fever, nausea, weakness and body aches was admitted to the emergency department of Sukraraj Tropical and Infectious Disease Hospital in Kathmandu. His oxygen saturation (SpO2) was 95 percent on room air, and he tested positive for Covid-19.

Covid-like illness is rising in the community, especially since the beginning of the monsoon season. It indicates that the disease itself might be circulating in Nepal. In fact, as per the World Health Organization (WHO) data, Nepal has observed a drastic increase in the SARS-CoV-2 virus, from 5.56 percent (week 28) to 13.68 percent (week 31) in a three week-interval (i.e., between July 8-14 and July 29-August 4). The variant responsible for the rapid increase of Covid infection rate in the community is unknown. Hence, it has been termed “monsoon covid” here.

By the end of May 2024, Nepal had confirmed several Omicron sub-variants, including KP.1, KP.2, KP.3 and KP.4, also known as KP or “FLiRT” subvariants. Dozens of patients diagnosed with Covid-19 have been admitted to Sukraraj Tropical and Infectious Disease Hospital since the beginning of March 2024. Most of the patients were aged 65 and above and required the intensive care unit. Until now, there is no evidence of an increase in hospitalisations due to monsoon covid. Nonetheless, it cannot be definitively ruled out that it may become severe in the upcoming days in Nepal.

In the past, Nepal has typically experienced waves of Covid-19 following outbreaks in neighbouring India due to their shared border. Thus, we usually predict that when a Covid-19 outbreak occurs in India, Nepal will inevitably see a wave of Covid-19 after a couple of weeks or months. Nevertheless, this time, Nepal is observing monsoon covid before India, and it currently has the highest SARS-CoV-2 infection rate in the Southeast-Asian region. As per the WHO data, India has maintained a constant rate of SARS-CoV-2 infection over the past four weeks (between week-28 and week-31), and in fact, even decreasing trend to 0.73 percent (i.e., July 29- August 4) from 3.26 percent (week-28, i.e., July 8-14). It is uncertain whether the monsoon covid will hit India in the coming days, but it is not impossible.

Fever, cough and shortness of breath are the main symptoms of Covid-19. However, the symptoms have varied over multiple waves with people exhibiting atypical symptoms like silent or happy hypoxia, loss of taste and smell and flu-like illness. Notably, the patient who visited STIDH did not have a cough and shortness of breath but exhibited a low platelet count, which is unusual in patients with Covid-19. Such a changing pattern of clinical symptoms of Covid-19 over the period is not surprising. The absence of cough, shortness of breath and the presence of thrombocytopenia (a low platelet count, i.e., 70,000 per microliter of blood) is a rare phenomenon and thus worthwhile to study further. More cases, however, are needed to fully comprehend the monsoon covid and its evolving symptoms.

Viruses evolve over time, and become more or less severe. We can, therefore, expect Covid-19 to continue to evolve with more genetic mutations in the coming days. Unfortunately, are unaware of the increasing trends of monsoon covid in Nepal and its reasons. It is wise to identify mutations or analyse genetic sequencing to understand the resurgence of monsoon covid.

As of now, the seasonality of Covid-19 is not well established in Nepal. However, there have always been peaks (small or big) of Covid-19 cases during or around August in the past. Based on past data, we can assume that Covid-19 can reappear during the monsoon season every year in Nepal. Then, the question arises: Can we consider Covid-19 a seasonal virus like the influenza virus in Nepal?

It is unknown whether monsoon covid will cause an increase in hospitalisations in the coming days, as seen in March 2024, owing to KP or “FLiRT” subvariants. However, such a scenario should not be underestimated. Although vaccines against the virus are available, people are not interested in getting jabbed. Preventive measures also help to avoid it, but vaccines are still important. Continuous surveillance, genetic analysis and vaccination should be prioritised.