Ensure effective contact tracing and place symptomatic patients in hospitals, doctors sayGiven lack of facilities at home for self-isolation for a majority of Nepalis, encouraging them to stay home after testing positive for Covid-19 could spell a disaster.
A man from Gyankunja Tole of Bhaktapur Municipality died of Covid-19 on Sunday.
He was 65. He was among the 14 people who succumbed to the coronavirus in the last 24 hours. The man, however, did not die in hospital. He had been in home isolation for the last six days. He had tested positive for the virus on August 25.
The death during home isolation, according to doctors, puts spotlight on the concerns that have been raised for quite some time that many people might die without getting treatment.
“Health workers deployed for contact tracing had tracked the infected man on August 27,” Shyam Krishna Khatri, chief of Ward No. 1 of Bhaktapur Municipality, told the Post. “Our health workers allowed the patient to stay in home isolation at the request of the family members.”
He was said to have other underlying conditions as well–he was suffering from high blood pressure, diabetes and Parkinson’s disease.
Ward chief Khatri conceded that even after tracking the patient, no one from the authorities reached his home to monitor his health condition.
“We were unaware of his other health conditions,” said Khatri. “We were informed only after the patient’s death.”
Even after the man was found to be infected, health workers deployed for contact tracing had not taken swab samples of the people who had come in close contact with the deceased.
Khatri said that there are five other people–three from the family and two who live on rent in the same house–who could have come in contact with the deceased.
Swab samples of the five people were collected only after the patient died.
Amid arguments that people in Nepal are dying of pre-existing and underlying health conditions rather than the coronavirus, doctors say there are now concerns if negligence and lack of facilities will kill more people than Covid-19.
“It looks like instead of Covid-19, the man died due to the negligence of the authorities concerned,” Dr GD Thakur, former director at the Epidemiology and Disease Control Division, told the Post. “The authorities’ responsibility is not over after they have tracked the infected people.”
If the officials were to follow the protocol, after tracking an infected person, they have to assess if there is sufficient facility at the person’s home for self-isolation. They need to then ensure that health workers monitor the infected person’s health condition every day. An ambulance also needs to be ready, should the infected person’s health deteriorate.
Nepal on Sunday reported the highest number of deaths as well as highest new cases for a single day.
The country’s Covid-19 infection tally has reached 38,561.
The Health Ministry said on Sunday, 1,221 people tested positive for the virus in the last 24 hours, with 429 in Kathmandu Valley, both highest daily records till date. There are over 500 active cases in 11 districts, including Kathmandu and Lalitpur of the Valley. The Covid-19 death toll has reached 221.
With the cases rising at an alarming rate, health facilities are already getting overwhelmed, and the government has been encouraging people to practise self-isolation, which public health experts have for long warned could spell a disaster.
According to the Ministry of Health, there were 6,906 people in home isolation on Sunday, with 1,950 in Bagmati Province, and most of them in Kathmandu Valley.
Dr Sushil Nath Pyakurel, former director general of the Department of Health Services, said home isolation is not something that should not be practised, but the government should take into consideration multiple factors.
“Allowing symptomatic Covid-19 patients to stay in home isolation is too risky, as many in the country may not have a separate room and separate bathrooms, which are necessary if a person is to be isolated,” said Pyakurel. “Keeping a serious patient at home, without considering the risk of transmission to family members is a blunder.”
The major risk of home isolation is the entire family could easily get infected, according to him.
“And this is how the virus easily spreads in the community,” said Pyakurel.
Even as the cases are rising, the government authorities are not saying exactly what they are doing to contain the virus spread, except issuing prohibitory orders.
Over half of the 77 districts of the country, including Kathmandu, Lalitpur and Bhakatpur of the Valley, are currently under prohibitory orders, which mean a ban on public and vehicular movements as well as opening of shops and businesses. The government has refused to pay heed to public health experts’ calls that a prohibitory order or a lockdown is not a solution to the pandemic. Allowing essential services for limited hours creates more crowds, increasing the risk of the virus spread, according to them.
The government recently made two decisions though–establishing five-bed hospitals in each local level and reducing the cost of PCR tests from Rs 5,500 to 4,400. Doctors say hospitals–big or small–are required, but building them from the scratch takes time, hence some existing ones should be converted into dedicated Covid-19 health facilities. Reducing PCR testing cost is a good move, but until effective contact tracing is ensured, cases will continue to rise, according to them.
According to Thakur, only asymptomatic infected people, who have separate facilities at home, can stay in home isolation.
“Authorities need to assess the facilities before allowing infected people to stay in home isolation,” said Thakur. “All symptomatic cases should be taken to institutional isolations and serious cases should be admitted to hospitals that have intensive care and ventilator facilities.”
Dr Sameer Kumar Adhikari, joint spokesperson for the Health Ministry, however, said that he was not aware of Bhaktapur case.
“We have never said that an infected person having pre-existing medical conditions can be left at home,” Adhikari told the Post. “If the patient was allowed to stay at home despite his underlying health conditions, it was a mistake.”
He said that he can inquire about the incident only on Monday.
Public health experts say there continues to be a lack of communication, which is reflected in what the ministry official is saying. Even months into the pandemic, the government has not yet introduced a risk communication strategy. Public service announcements are few and far between.
Doctors say the three Ts–test, trace and treat–while are technical parts, the authorities should also ensure the fourth T–trust–in the fight against this pandemic. The government should be able to give a sense of security to the people so that they can trust the authorities.
Setting up isolation facilities, increasing the number of intensive care unit beds and ventilators and informing the people about the preparations being made to save their lives are necessary, according to Pyakurel.
“The authorities must stop stressing home isolation,” Pyakurel told the Post. “Building community isolation centres, keeping ambulances on standby and ensuring isolation beds and ventilators to transfer patients if their health condition deteriorates are a must.”
Currently, five ambulances of Nepal Ambulance Service are being used to transport Covid-19 patients to isolation facilities and hospitals.
According to Amit Joshi, chief executive officer of Nepal Ambulance Service, infected patients have to wait for hours for the ambulances to take them to the isolation facilities and hospitals.
“Hospitals take a long time to take in the patients as they are already overwhelmed,” Joshi told the Post. “Our ambulances have to wait for hours even after reaching the hospital with the infected patients.”