The numbers game

Any new arrival to Nepal might believe that Covid-19 has been all but banished from the country. All preventive measures have been lifted and life is back to normal across the country. Schools have reopened and so have theatres. Clubs are packed with partygoers and two recent political rallies have gathered thousands in one place. But the coronavirus is by no means gone and by all indications, Nepal should be awash in Covid-19 cases. And yet, it is not. 

New Covid-19 cases have fallen dramatically in recent weeks, going from thousands per day to less than a thousand per week. From a peak of 5,743 new infections in a single day on October 21, Nepal on Monday, February 8, reported just 130 new infections. On Sunday, there were 119 new cases and on Saturday, 99. Given that the government appears to have opted for a hands-off approach to the pandemic while citizens too seem to have largely stopped taking precautions, these numbers are astounding. There have been attempts to explain this dramatic fall in the face of contradictory behaviours but no conclusive answer yet. For public health experts, the numbers remain a mystery but they believe that the corresponding dramatic fall in testing could provide some answers. 

At the height of the pandemic, Nepal was conducting between 12,000 to 13,000 polymerase chain reaction (PCR) tests a day, estimated Dr Anup Bastola, chief consultant in tropical medicine at the Sukraraj Tropical and Infectious Disease Hospital. Currently, only around 2,000 PCR tests are being conducted daily. However, Bastola believes that the current testing is adequate.

“Even if people are not testing, they are certain to visit the hospital when they get to a critical stage. But the number of critical cases has declined in parallel, which indicates that Nepal has combated the first wave of the coronavirus,” he told The Record. 

Not everyone shares his belief. According to Dr Anup Subedee, an infectious disease specialist, Nepal is not testing nearly enough. 

“It is imperative to conduct tests on representative samples to know if the number of cases are actually declining or rising,” Subedee said. 

According to the Health Ministry, as of February 8, over 2 million PCR tests have been conducted so far. However, this number does not reflect the actual number of people tested as it only enumerates the number of tests given. In many cases, tests have been conducted multiple times because of a failure to obtain accurate results. Individuals who need to travel frequently also need to get tested before they leave each destination.  Sarita Chalise, a 26-year-old banker, told The Record that she alone had been tested three times while travelling to Nepalgunj from Kathmandu by bus. 

“Because of travel restrictions, the number of tests conducted per head remains lopsided. There actually isn’t any true data on this,” said Subedee. 

This need to test frequently has even led to many individuals faking their test results as PCR tests can get expensive and are only valid for 24 hours. The average cost of a PCR test at private hospitals is about Rs 3,000. The government provides PCR tests free-of-cost but they are only available at designated hospitals and there is usually a long wait.  

According to Dr Lhamo Sherpa, an epidemiologist, one way to ramp up testing would be for the government to subsidise all tests as many refused to be tested because they cannot bear the cost or afford to lose hours or even a day to testing. Sherpa also pointed out that the large-scale mobilisation of frontline health workers during the height of the pandemic has died down and areas outside of the large cities lack trained health care personnel to administer the tests and collect swabs.  

Read also: Prepare, don’t panic

The literature, however, is still inconclusive on whether testing has a direct positive correlation with a rise in cases. For instance, in the US, increased testing was not the sole reason the number of cases were rising -- tests just revealed the extent of a raging pandemic. Increased testing will also not reveal more cases when there are no cases to be found.   

But experts insist that Nepal is in no position to scale down testing as there is no conclusive evidence that the country has gotten over the worst of the pandemic. With new more virulent strains of the coronavirus being discovered -- and entering the country itself -- Nepal needs to exercise more caution, especially given the state of its healthcare infrastructure and its numerous other constraints, including in finances and human resource. 

“It is imperative to conduct tests because it not only distinguishes whether the infection is from the coronavirus or the common flu but also shows the rate at which the virus has affected the body,” said virologist Dr Sher Bahadur Pun.

But Nepal is not the only country in the region with declining numbers. India’s dramatic fall in daily cases has baffled experts around the world, with a number of theories being floated, including ones that had once found purchase in Nepal. Heat and humidity, along with an immune system that is used to combating a variety of diseases, have been posited but there is little peer-reviewed literature to support these assertions. A more palatable reason could be India’s demographics, which is similar to Nepal’s. In India, just 6 percent of the population is above 65 years of age while in Nepal, that proportion is 5.69 percent of the population. Symptoms are less likely to develop in younger people.

“The virus has already infected a large number of the population, so perhaps most of the vulnerable population has already been infected. This could be the reason why the numbers are declining,” said Dr Subedee.

Subedee, however, believes that the exact cause of the fall in coronavirus cases in Nepal will remain unsolved until the government conducts a seroprevalence study, where random samples of the population are tested for antibodies. India has already conducted a number of these studies while Nepal conducted one in September and refused to release it publicly. According to Subedee, the study had discovered a seroprevalence rate of 13 percent, or that one in eight people surveyed were found to have coronavirus antibodies.  

“Even if 5 to 10 percent of the population is infected, it still is a significant number that is enough to start an epidemic in itself,” he said.

The arrival of Covid-19 vaccines and the beginning of the government’s vaccination drive has led many to breathe a sigh of relief but vaccines alone will not eradicate the coronavirus. Public health experts estimate that more than 70 percent of the population will need to get vaccinated if Nepal is to achieve herd immunity and that means Nepal needs to acquire vaccine doses for 20 million people. 

Read more: Everything you need to know about the vaccines arriving Thursday

“Nepal has been receiving vaccines in installment. We are not ready to get back to normal and it is vital we remain cautious or else we might invite a second wave,” said Dr Pun. 

With nationwide federal elections planned for the spring, and political rallies galore, there will be numerous opportunities for superspreader events to take place. And although a casual walk down the streets of Kathmandu might intimate that the virus is gone, precautions still need to be adopted and that includes masks, social distancing, handwashing, and avoiding large gatherings. 

“Those who are not cautious will likely be infected and will likely be spreaders too,” said Dr Bastola.

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