Q&A with Dr. Jos Vandelaer (pictured right), WHO Representative to Nepal
WHO HQ recently announced a new guideline regarding mask uses. Could you please shed some light on that in the Nepalese context?
Recently, WHO has changed its advice on the use of masks in the prevention of Covid-19. The reason that the WHO HQ in Geneva has changed the guidance is that science has changed. COVID-19 is a new disease, and as we go forward, we also learn about how this virus behaves, which measures work better and which do not work so well. Initially, the way the virus operated led the WHO to conclude that you need a medical mask if you are a patient so that you do not infect others and you do not cough out the virus. You need a medical mask when you take care of the patients—be it health workers or at home. But there was no evidence that masks in other situations would play a role. Several studies that have since been carried out now indicate thatwearing a mask, even a cloth mask in situations of wide community transmission where physical distancing cannot be maintained. can create a physical barrier to the virus if you cough. Therefore, given this new science outcome, the WHO is now recommending that cloth masks can have a role in situations where it's difficult for people to keep a physical distance.
I see that in Nepal, even before that advice from the WHO, many people already started using masks. I would say to everybody: continue doing that. But at the same time, continue to keep a distance. The mask will help to protect you, but will not fully protect you or your contacts. The best thing is to keep distance; the best thing is also that you wash your hands regularly and do not cough in the direction of other people. So the advice would be to wear a mask, especially if you are in a more crowded place.
Also, the people will need to keep in their minds that while the surgical masks are technically better, there's a global shortage of these masks. The people who need these masks are the health workers, nurses, doctors, people working in hospitals and those caring for COVID patients. They are also needed for people visiting hospitals. We must make sure that there are enough of these masks for the people working in hospitals with patients so that they can protect themselves also. If there are not enough masks then they are the first ones who won't be protected. So for that reason, the WHO is saying to use cloth masks for the people who do not think they are infected but have to be in crowded places and have difficulties in keeping distance.
What is the present status of the development of a COVID-19 vaccine? There are concerns among developing countries like Nepal about access to the vaccine once it is developed? What is the WHO doing to allay these concerns?
Several actions are being taken, both regarding the development of a vaccine and of drugs for the treatment. On the vaccine side, many vaccines are being developed, and the WHO is trying to coordinate that. The WHO is coordinating the vaccine development so that we mainly know where we are in terms of vaccine development; so that there's no duplication being done; so that one study can learn from another study; etc. Typically, it takes many years to develop a vaccine. Hopefully, for COVID-19 it goes faster, not because it's a simpler vaccine but because there's a willingness to do several steps already in parallel, that under normal circumstances would be done one after another. Therefore, you can gain time.
The issue of who can use the vaccine once we have a vaccine is indeed an important one. The WHO is building coalitions with countries and partners to ensure that when there's a vaccine, it does not just go to the highest bidder but instead that there is a funded mechanism in place that ensures that every country has access to these vaccines. Needless to say this builds very much not only on the goodwill of countries and partners, but also on the convening efforts of the WHO.
The government has come up with a guideline that COVID-19 patients with mild symptoms will be asked to stay at home. How do you look at this guideline?
Right now, there are very few people in Nepal who have symptoms. We need first to keep that in mind! When COVID-19 starts to occur in the general population (and no longer mainly among returnees), we know from other countries that eighty per cent of the people will present with mild symptoms; fifteen per cent moderate symptoms and may need oxygen and therefore need hospitalisation, and another five per cent or so have severe symptoms and need the ICU. But the vast majority, the 80 per cent of those who have mild symptoms, do not require hospitalisation. If you have a large number of cases, it is evident that you need to rationalise the use of the hospital beds that you have because you will not be able to put everybody to hospital beds. There's no need to put people with mild symptoms in hospital beds because they do not need medical attention; they do not need oxygen. The patient will feel like when he/she is suffering from a cold or a mild flu or even less. So these people can do perfectly well by staying at home. There's nothing wrong in that. However, it is critical that when they are at home, they are away from the rest of the family so that they do not infect them.
So we come back to what I said earlier—the importance of wearing masks by the patients or anyone in close contact with the patients, and these should be medical masks. Keep distance—the patient should have a separate room, should not eat with their fellow housemates, should ideally also have a separate toilet and wash their hands regularly, etc.
Once the epidemic starts peaking, you can no longer put everybody in the hospital because there are too many cases. So it will be important that measures be taken to offload all the asymptomatic and mild cases from the hospitals. Then the hospitals can focus on more severe cases.
Has the WHO done any study or estimation as to when Nepal is going to hit the peak or how's the peak going to look like?
It is tough to say when Nepal is going to hit the peak of COVID-19. What we have seen in the last month or so, a large number of people have come back from India. Upon arrival, they have been placed in quarantine for at least 14 days. And by and large, new cases are being detected at quarantine sites, and not in villages. Quarantining possibly infected people and isolating those who are infected is key to slowing down any further spread of the virus in the population. At what point the infections will start going into the broader population and how quickly will that be, is very hard to say. So I do not want to make any predictions here because there are so many factors that come into play.
Quarantine facilities have been a matter of huge concern when it comes to their operation and management. What is the WHO's perspective on this?
What has happened is that a lot of people have returned to Nepal from India. In any situation, it's going to be a challenge to handle this number. Several quarantine sites are indeed in poor conditions, and are not up to the standard they should be. We have also heard problems around sanitation, water and hygiene. Ideally, in a quarantine site, you would have a situation where there's enough space between the people; where there is limited opportunity to mingle; where people wash hands very regularly; where there's enough food being provided, etc. Because of the massive influx, local authorities and people in charge of quarantine sites have been overwhelmed. In some sites, the number of people being kept is more than what the facility can ideally accommodate. That certainly needs to be improved. But we also hear the news that in several places there are already improvements.
What would be your observations around the number of testing being done and the testing supplies?
Most of the RT PCR tests have been done among the returnees, particularly those returning from India, and that's where most of the positive cases are being found. Because so many people have come back, it has created a substantial burden on the testing capacity. The government has increased the number of labs from initially one to now 21. But the number of people coming in is so large that there's a backlog in testing samples . It also means that in the near future, we are going to see more positive cases because it's the same population that is still being tested.
So far, the supplies have by and large been okay in Nepal. There have been in some areas temporary stoppage of certain parts of the testing chain. We have occasionally seen some shortages, but they have been filled pretty quickly. But we also need to keep in mind that at the global level, the number of tests is limited. So we also need to be more rational about the use of the tests. Also, the lab capacity should be increased in the near future. At the same time, the test kits that need to be brought in from outside need to be purchased and ordered in time, before supplies run out. We must ensure that they keep flowing in in the context of a global shortage. It is essential to look at the testing strategy regularly. There's no hard and fast rule here, but the priority should always be testing the people who have symptoms as well as their contacts. You need to know if somebody is showing the symptoms is positive; you should isolate the person and limit the spread of the disease.