Early Epidemiological Features of COVID-19 in Nepal and Public Health Response

Knowledge and attitude regarding the COVID-19 pandemic among undergraduate health science students of Nepal: An online survey

Objectives

This study aims to assess health science students' knowledge and attitude about COVID-19 epidemiology, management, and prevention; and the association of knowledge and attitude with various sociodemographic characteristics.

Methods

An online survey was done among 524 undergraduate health science students using a pre-tested questionnaire across 19 health science institutions in Nepal from 30 June to 11 August 2021. All subjects were enrolled in the study after informed consent. Outcomes were Knowledge level, attitude level, and predictors of knowledge level and attitude level. Bivariate analysis was done to determine the association between variables.

Results

Of 524 students, 42.9% were male, and 57.1% were female. More than half (54.6%) and the majority (85.1%) participants had good knowledge and attitude, respectively. Approximately three-fifths (59.4%) of the participants were from the B. P. Koirala Institute of Health Sciences (BPKIHS). Students in BPKIHS (odds ratio = 1.774; 95% confidence interval = 1.243-2.533), junior years (odds ratio = 8.892; 95% confidence interval = 5.814-13.599), age less than 23 years (odds ratio = 2.985; 95% confidence interval = 2.089-4.266) were more likely to have good knowledge. Students under 23 years (odds ratio = 24.160; 95% confidence interval: 9.570-60.992) and those in junior years (odds ratio = 4.460; 95% confidence interval = 3.753-5.300) were likely to have a good attitude level. Students in BPKIHS (odds ratio = 0.443; 95% confidence interval = 0.272-0.722) were less likely to have a good attitude.

Conclusions

Overall, health science students had adequate knowledge and a good attitude regarding COVID-19. However, students lacked knowledge regarding infectiousness, transmission, post-vaccination observation period, remdesivir use, convalescent plasma therapy, and awake-prone positioning. Knowledge and attitude scores were associated with age, stream, and study institution.

A systematic review of strategies adopted to scale up COVID-19 testing in low-, middle- and high-income countries

OBJECTIVE

We undertook a systematic review of strategies adopted to scale up COVID-19 testing in countries across income levels to identify successful approaches and facilitate learning.

METHODS

Scholarly articles in English from PubMed, Google scholar and Google search engine describing strategies used to increase COVID-19 testing in countries were reviewed. Deductive analysis to allocate relevant text from the reviewed publications/reports to the a priori themes was done.

MAIN RESULTS

The review covered 32 countries, including 11 high-income, 2 upper-middle-income, 13 lower-middle-income and 6 low-income countries. Most low- and middle-income countries (LMICs) increased the number of laboratories available for testing and deployed sample collection and shipment to the available laboratories. The high-income countries (HICs) that is, South Korea, Germany, Singapore and USA developed molecular diagnostics with accompanying regulatory and legislative framework adjustments to ensure the rapid development and use of the tests. HICs like South Korea leveraged existing manufacturing systems to develop tests, while the LMICs leveraged existing national disease control programmes (HIV, tuberculosis, malaria) to increase testing. Continent-wide, African Centres for Disease Control and Prevention-led collaborations increased testing across most African countries through building capacity by providing testing kits and training.

CONCLUSION

Strategies taken appear to reflect the existing systems or economies of scale that a particular country could leverage. LMICs, for example, drew on the infectious disease control programmes already in place to harness expertise and laboratory capacity for COVID-19 testing. There however might have been strategies adopted by other countries but were never published and thus did not appear anywhere in the searched databases.

Evaluation of prognostic markers in patients infected with SARS-CoV-2

Prognostic markers are the biomarkers used to measure the disease progression and patient outcome regardless of treatment in coronavirus disease 2019 (COVID-19). This study aimed to analyze laboratory parameters as prognostic markers for the early identification of disease severity. In this study, 165 patients attending Sukraraj Tropical and Infectious Disease Hospital with COVID-19 were enrolled and divided into severe and non-severe groups. The demographic data, underlying co-morbidities, and laboratory findings were analyzed and compared between severe and non-severe cases. The correlation between the disease criticality and laboratory parameters was analyzed. Cut-off values of parameters for severe patients were speculated through the receiver operating characteristics (ROC) curve, and regression analysis was performed to determine the risk factors. Patients with severe COVID-19 infection had significantly higher absolute neutrophil count, neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), ferritin, positive carbohydrate reactive protein (CRP), glucose, urea, creatinine, and aspartate aminotransferase, while lower absolute lymphocyte count, absolute eosinophil count (AEC), and red blood cell count in comparison to non-severe infection. ROC analysis gave a cut-off value (sensitivity, specificity) of age, AEC, NLR, PLR, and ferritin as 47.5 years (70.2, 64.7%), 335 cells/mm3 (74, 67%) 3.3 (68.4, 63.7%), 129 (77.2, 51%), and 241 ng/mL (74.0%, 65.0%) respectively. Risk factor analysis showed higher age, low AEC, high ferritin, and positive CRP as independent risk factors associated with severe COVID-19 infection. Hematological and inflammatory markers, including novel NLR and PLR, should be assessed to aid clinicians in the early identification of severe cases, prioritization of cases, and effective management to decrease the mortality of COVID-19 patients.

How an Outbreak of COVID-19 Circulated Widely in Nepal: A Chronological Analysis of the National Response to an Unprecedented Pandemic

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first COVID-19 case was reported in Wuhan, China, in December 2019. In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. The first COVID-19 case in Nepal was reported in January 2020 in a Nepalese man who had returned from Wuhan to Nepal. This study aims to evaluate the government of Nepal’s (GoN) response to the COVID-19 pandemic and explore ways to prevent COVID-19 and other pandemic diseases in the future. As of May 2022, a total of 979,140 cases and 11,951 deaths associated with COVID-19 have been reported in Nepal. To prevent the spread of the virus, the GoN initiated various preventive and control measures, including lockdown strategies. The effects of COVID-19 are expected to persist for many years; the best strategies a resource-limited country such as Nepal can implement to control pandemic diseases such as COVID-19 in the pre-vaccine stage are to increase testing, tracing, and isolation capacity.

Abnormal Chest Computed Tomography Findings among Admitted Symptomatic COVID-19 Patients in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

COVID-19 has emerged as a pandemic and has varied clinical presentation. Computed Tomography scans of the chest play an important role in evaluating the lung parenchymal changes and aids in better planning the management of COVID-19 patients. The purpose of this study was to find the prevalence of abnormal chest computed tomography findings among admitted symptomatic COVID-19 patients in a tertiary care centre.

Methods

This descriptive cross-sectional study was conducted from 25 October 2020 to January 2021 in a tertiary care hospital. Ethical approval was taken from the Institutional Review Committee (Registration number: 348). Convenience sampling method was used. Chest computed tomography findings of the admitted symptomatic COVID-19 patients were evaluated for abnormal findings. Point estimate and 95% Confidence Interval were calculated.

Results

Among 153 patients, abnormal chest computed tomography findings were seen in 147 (96.07%) (92.99-99.15, 95% Confidence Interval). The findings of ground-glass opacities with consolidations were seen in 78 (53.06%) patients.

Conclusions

The prevalence of abnormal chest findings among symptomatic COVID-19 patients in our study was similar to the studies done in other countries in similar settings. Majority of the symptomatic COVID-19 patients showed abnormal chest computed tomography scan findings in the form of ground glass opacities and consolidations.

Keywords

COVID-19; Nepal; pneumonia; prevalence.

Understanding COVID-19 Situation in Nepal and Implications for SARS-CoV-2 Transmission and Management

BACKGROUND

The pandemic of Coronavirus Disease 2019 (COVID-19), one of the most infectious diseases in the modern history, is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and has had a profound health and economic toll, globally. This paper identifies the overall health status associated with COVID-19 pandemic in all 7 provinces of Nepal, a developing country in South Asia, analyzing data from January 2020 to February 2022. It focuses on the SARS-CoV-2 prevalence, transmission through wastewater and other routes, diagnostics, treatment options, and alternative medicines, thereby offering key perspectives for its management.

MATERIALS AND METHODS

Studies regarding coronavirus spanning the 2017 to 2022 period were searched on the web, Nepalese database, and Web of Science. Refined criteria included SARS-CoV-2 in wastewater of Nepal or worldwide. Demographic data (sex, age-group, and geographic location) were also obtained from websites and relevant reports of the Ministry of Health and Population (MOHP) of Nepal, ranging from January 2020 to February 2022. Moreover, trends concerning lockdown, business, and border activities in Nepal between February 2020 and October 2020 were evaluated. The viral dissemination pathways, diagnosis, and available treatment options, including the Ayurvedic medicine, were also examined.

RESULTS

Aerosols generated during the hospital, industrial, recreational, and household activities were found to contribute to the propagation of SARS-CoV-2 into environmental wastewater, thereby putting the surrounding communities at risk of infection. When lockdown ended and businesses opened in October 2020, the number of active cases of COVID-19 increased exponentially. Bagmati Province had the highest number of cases (53.84%), while the remaining 6 provinces tallied 46.16%. Kathmandu district had the highest number of COVID-19 cases (138, 319 cases), while Manang district had the smallest number of infections (81 cases). The male population was found to be predominantly infected (58.7%). The most affected age groups were the 31 to 40 years old males (25.92%) and the 21 to 30 years old females (26.85%).

CONCLUSION

The pandemic impacted the public health and economic growth in our study duration. SARS-CoV-2 was prevalent in the wastewater of Nepal. The Terai districts and the megacities were mostly affected by SARS-CoV-2 infections. Working-age groups and males were identified as the highest risk groups. More investigations on the therapeutic and alternative cures are recommended. These findings may guide the researchers and professionals with handling the COVID-19 challenges in developing countries such as Nepal and better prepare for future pandemics.

Diagnostic Performance of SARS-CoV-2 Rapid Antigen Test in relation to RT-PCR Cq Value

Background

Early detection of the SARS-CoV-2 is crucial for both the improvement of turnaround time and limiting the spread of the virus in the community. Thus, this study aims to establish rapid antigen tests as an effective diagnostic tool to improve the testing strategies of COVID-19 diagnosis.

Methods

A laboratory based cross-sectional study was performed on the patients that visited Sukraraj Tropical and Infectious Disease Hospital (STIDH) in Kathmandu, Nepal, from November 2020 to January 2021. A total of 213 nasopharyngeal swabs were collected from both symptomatic and asymptomatic patients for rapid antigen test, followed by RT-PCR assay as reference test for confirmation of COVID-19. A standard questionnaire was administered to collect other information from patients. Data were collected and analyzed using SPSS version 20.

Results

Out of 213 individuals, 75 tested positive in Ag-RDT test, while 118 tested positive for SARS-CoV-2 RNA genome via Real time PCR assay. The overall diagnostic performance of Ag-RDT showed 63.6% sensitivity and 97.9% specificity. The diagnostic accuracy of Ag- RDT was 78.9% with κ value 0.590, showing moderate agreement with RT-PCR. Significant difference (p value <0.001) was observed between Ag- RDT⁺ and Ag- RDT⁻ results when compared to C_q values obtained from RT- PCR.

Conclusion

The promising performance of Ag-RDT renders it useful as screening tool alongside RT-PCR to reduce transmission via improving contact tracing, implementation of local mitigation strategies, and refining existing testing protocol for diagnosis of COVID-19.

Ethnomedicinal landscape: distribution of used medicinal plant species in Nepal

BACKGROUND

The risk of losing traditional knowledge of medicinal plants and their use and conservation is very high. Documenting knowledge on distribution and use of medicinal plants by different ethnic groups and at spatial scale on a single platform is important from a conservation planning and management perspective. The sustainable use, continuous practice, and safeguarding of traditional knowledge are essential. Communication of such knowledge among scientists and policy makers at local and global level is equally important, as the available information at present is limited and scattered in Nepal.

METHODS

In this paper, we aimed to address these shortcomings by cataloguing medicinal plants used by indigenous ethnic groups in Nepal through a systematic review of over 275 pertinent publications published between 1975 and July 2021. The review was complemented by field visits made in 21 districts. We determined the ethnomedicinal plants hotspots across the country and depicted them in heatmaps.

RESULTS

The heatmaps show spatial hotspots and sites of poor ethnomedicinal plant use documentation, which is useful for evaluating the interaction of geographical and ethnobotanical variables. Mid-hills and mountainous areas of Nepal hold the highest number of medicinal plant species in use, which could be possibly associated with the presence of higher human population and diverse ethnic groups in these areas.

CONCLUSION

Given the increasing concern about losing medicinal plants due to changing ecological, social, and climatic conditions, the results of this paper may be important for better understanding of how medicinal plants in use are distributed across the country and often linked to specific ethnic groups.

Transmission Dynamics and Short-Term Forecasts of COVID-19: Nepal 2020/2021

Nepal was hard hit by a second wave of COVID-19 from April-May 2021. We investigated the transmission dynamics of COVID-19 at the national and provincial levels by using data on laboratory-confirmed RT-PCR positive cases from the official national situation reports. We performed 8 week-to-week sequential forecasts of 10-days and 20-days at national level using three dynamic phenomenological growth models from 5 March 2021-22 May 2021. We also estimated effective and instantaneous reproduction numbers at national and provincial levels using established methods and evaluated the mobility trends using Google's mobility data. Our forecast estimates indicated a declining trend of COVID-19 cases in Nepal as of June 2021. Sub-epidemic and Richards models provided reasonable short-term projections of COVID-19 cases based on standard performance metrics. There was a linear pattern in the trajectory of COVID-19 incidence during the first wave (deceleration of growth parameter (p) = 0.41-0.43, reproduction number (Rt) at 1.1 (95% CI: 1.1, 1.2)), and a sub-exponential growth pattern in the second wave (p = 0.61 (95% CI: 0.58, 0.64)) and Rt at 1.3 (95% CI: 1.3, 1.3)). Across provinces, Rt ranged from 1.2 to 1.5 during the early growth phase of the second wave. The instantaneous Rt fluctuated around 1.0 since January 2021 indicating well sustained transmission. The peak in mobility across different areas coincided with an increasing incidence trend of COVID-19. In conclusion, we found that the sub-epidemic and Richards models yielded reasonable short-terms projections of the COVID-19 trajectory in Nepal, which are useful for healthcare utilization planning.

Perceptions towards COVID-19 Vaccines and Willingness to Vaccinate in Nepal

Vaccination is the most effective preventive measure of COVID-19 available at present, but its success depends on the global accessibility of vaccines and the willingness of people to be vaccinated. As the vaccination rollouts are increasing worldwide, it is important to assess public perception and willingness towards vaccination, so that the aim of mass vaccination will be successful. This study aimed to understand public perception towards COVID-19 vaccines and their willingness to get vaccinated in Nepal. This cross-sectional online survey was conducted among 1196 residents of Nepal in August 2021; most of the participants of this online survey were young adults (18–47 years) with university-level education. A total of 64.5% (771/1196) of the participants perceived COVID-19 vaccines to be safe and risk-free, while 68.6% (820/1196) agreed that vaccination would be efficient in the fight against this pandemic. Most of the participants (841/1196, 70.3%) disagreed that people are getting COVID-19 vaccines easily in Nepal, while they agree with the prioritization of older adults and healthcare workers for vaccination. A total of 61.1% (731/1196) of the participants had received at least one dose of the vaccine. Among the unvaccinated, 93.3% (434/465) were willing to get vaccinated when their turn came. The higher confidence of younger adults in vaccines and the vaccination process is encouraging, as that can help educate others who are hesitant or are not positive towards the idea of receiving vaccines. Dissemination of correct and current information, acquisition of enough doses of vaccines, and equitable distribution of vaccines will be required to achieve successful completion of the COVID-19 vaccination campaign in Nepal.

The role of airborne particles and environmental considerations in the transmission of SARS-CoV-2

Corona Virus Disease 2019 (COVID-19) caused by the novel coronavirus, results in an acute respiratory condition coronavirus 2 (SARS-CoV-2) and is highly infectious. The recent spread of this virus has caused a global pandemic. Currently, the transmission routes of SARS-CoV-2 are being established, especially the role of environmental transmission. Here we review the environmental transmission routes and persistence of SARS-CoV-2. Recent studies have established that the transmission of this virus may occur, amongst others, in the air, water, soil, cold-chain, biota, and surface contact. It has also been found that the survival potential of the SARS-CoV-2 virus is dependent on different environmental conditions and pollution. Potentially important pathways include aerosol and fecal matter. Particulate matter may also be a carrier for SARS-CoV-2. Since microscopic particles can be easily absorbed by humans, more attention must be focused on the dissemination of these particles. These considerations are required to evolve a theoretical platform for epidemic control and to minimize the global threat from future epidemics.

Local response to the COVID-19 pandemic: The case of Nepal

Outbreak of the coronavirus pandemic is testing governments' capacity. Generally, considerable attention is paid to the capacity and response of the central or national governments; however, COVID-19 pandemic is local in nature. Although central authorities have important roles to play in COVID-19 response, local governments, being closer to people, are best-positioned to form the first line of defense.

Combating the COVID-19 Pandemic: Experiences of the First Wave From Nepal

Unprecedented and unforeseen highly infectious Coronavirus Disease 2019 (COVID-19) has become a significant public health concern for most of the countries worldwide, including Nepal, and it is spreading rapidly. Undoubtedly, every nation has taken maximum initiative measures to break the transmission chain of the virus. This review presents a retrospective analysis of the COVID-19 pandemic in Nepal, analyzing the actions taken by the Government of Nepal (GoN) to inform future decisions. Data used in this article were extracted from relevant reports and websites of the Ministry of Health and Population (MoHP) of Nepal and the WHO. As of January 22, 2021, the highest numbers of cases were reported in the megacity of the hilly region, Kathmandu district (population = 1,744,240), and Bagmati province. The cured and death rates of the disease among the tested population are ~98.00 and ~0.74%, respectively. Higher numbers of infected cases were observed in the age group 21–30, with an overall male to female death ratio of 2.33. With suggestions and recommendations from high-level coordination committees and experts, GoN has enacted several measures: promoting universal personal protection, physical distancing, localized lockdowns, travel restrictions, isolation, and selective quarantine. In addition, GoN formulated and distributed several guidelines/protocols for managing COVID-19 patients and vaccination programs. Despite robust preventive efforts by GoN, pandemic scenario in Nepal is, yet, to be controlled completely. This review could be helpful for the current and future effective outbreak preparedness, responses, and management of the pandemic situations and prepare necessary strategies, especially in countries with similar socio-cultural and economic status.

COVID-19 vaccination campaign in Nepal, emerging UK variant and futuristic vaccination strategies to combat the ongoing pandemic

With the emergence of the new variants of concern (VOC) of the SARS-CoV-2, the efficacy of certain vaccines against them requires further research and considerations for future scenarios of COVID-19 vaccination. The vaccines' lack of efficacy against VOC will pose at risk to the vaccinated population and is a public health threat. In this commentary, we discuss Nepal's recent experiences and expectations regarding the confirmation of VOC B.1.1.7 from the United Kingdom in the country.

Road traffic injuries in Nepal during COVID-19 lockdown

Background: As the world is busy addressing COVID-19, road traffic injuries, another major cause of death is continuously killing people on the roads. In Nepal, there were frequent media reports of occurrences of road crashes, injuries, and deaths despite nationwide lockdown. This paper aims to describe the situation of road traffic crashes and casualties during the period of complete lockdown. Methods: This study used secondary data from two sources: Nepal Police and media reports between 24 March and 14 June 2020 (because the government lifted the nationwide lockdown from 15 June 2020). Available details of crashes, deaths, and injuries for this period were extracted from media reports and the summary data that was obtained from the Police.  We have included data from both sources in the results. Results: Nepal Police recorded 1,801 incidents of road crashes during the 82 days of the COVID-19 lockdown with 256 deaths (on average 3.1 deaths daily) and 1,824 injuries (on average 22.2 injuries daily). Motorcycles comprised over 21% of all vehicles involved in crashes. Ambulances and other vehicles for essential services were also found to be involved in crashes. Speeding itself was the cause for almost a quarter of the incidents during the lockdown. Conclusions: Although a reduction in the number of road crashes and related injuries and fatalities was observed, this reduction was not as substantial as anticipated during the heavy restrictions on vehicular movement imposed during the lockdown. Media reports were mainly found to be reporting the crashes where deaths occurred, but police records also included nonfatal injuries. The incidence of crashes in this period shows that it is important to work for road safety to save lives from road traffic crashes in Nepal.

Road traffic injuries in Nepal during COVID-19 lockdown

Background: As the world is busy addressing COVID-19, road traffic injuries, another major cause of deaths is continuously killing people on the roads. In Nepal, there were frequent media reports of occurrences of road crashes, injuries, and deaths despite nationwide lockdown. This paper aims to describe the situation of road traffic crashes and casualties during the period of complete lockdown. Methods: This study used secondary data from two sources: Nepal Police and media reports between 24 March and 14 June 2020 (because the government lifted the nationwide lockdown from 15 June 2020). Available details of crashes, deaths, and injuries for this period were extracted from media reports and the summary data that was obtained from the Police.  We have included data from both sources in the results. Results: Nepal Police recorded 1,801 incidents of road crashes during the 82 days of the COVID-19 lockdown with 256 deaths (on average 3.1 deaths daily) and 1,824 injuries (on average 22.2 injuries daily). Motorcycles comprised over 21% of all vehicles involved in crashes. Ambulances and other vehicles for essential services were also found to be involved in crashes. Speeding itself was the cause for almost a quarter of the incidents during the lockdown. Conclusions: Even when the movement restrictions were imposed in Nepal, the number of road crashes was not substantially reduced. Media reports were mainly found to be reporting the crashes where deaths occurred, but police records also included nonfatal injuries. The incidence of crashes in this period shows that it is important to work for road safety to save lives from road traffic crashes in Nepal.