May 21, Friday
Binod Dangal(MD), Sanju Sapkota (MD), Rajkumar Dangal (MD), Arun Bhattarai (MD), Khusbu Jha (MD), Sujan Pandey (MD), Himshail Kdhaka (MBBS), Sanjeet Shrestha (IT Officer)
Along with the surge of second wave, the recent global pandemic COVID-19 is increasingly alarming. Although the initial increase of cases was gradual. A recent drastic surge in the number of cases reflects the speed of transmission from person to person. Because of the uncontrollable increase in COVID-19 cases, and because we are not prepared enough for immediate management of a huge number of people with a potentially lethal disease with our inadequate budget allocation, a prompt and effective response to a apparently unknown overwhelming pandemic is very challenging and dubious. We are giving context of how Dolakha district is handling second stage of COVID-19 with preparedness strategy and responses.
Dolakha, is one of the seventy seven districts of Nepal. It covers 2,191 square kilometer area and has a population of 186,557 (2011 census). It is a district of strong religious affiliation and beautiful touristic places. It is 133km away from Kathmandu towards eastern part of the country in Himalayan region.
With a rise of COVID-19 cases in the country, Dolakha entered into second stage of COVID outbreak with community transmission. There were around 1800 cases in 2020 with the first stage of transmission, however there are already 400 plus active cases in the second week of May 2021. Second stage of transmission shows rapid transmission, moderate to severely affected individuals including children, and significant numbers of young deaths. This is creating havoc of COVID-19 around the district.
Provincial Health Unit located at Hetauda activated health emergency response by allocating emergency funds to each provincial hospitals. They have organized virtual training for capacity building of health care workers in emergency and critical care management of COVID patients, supported supply chain (Essential medicine, dead body bags, ventilators, ICU beds, PPEs) for COVID response. They also helped in installing PCR labs in few hospitals and developing protocol to manage COVID -19 based on severity at the hospital and at home isolation.
District Crisis Management Committee (DCMC)- (PIC 1) is functional since the rise of COVID-19 cases and is led by Chief District Officer (CDO) with the memberships of Mayor (Bhimeshwor municipality), District superintendent of Police (DSP), District Health Officer (DHO), Medical superintendent of Charikot Hospital, Chief of Army, Chairperson of Dolakha Chamber of Commerce and Industry, Chairperson of Dolakha Journalism Center, Chairpersons of 7 rural municipalities and 2 municipalities, Chairperson of district coordination committee and few invited members depending on the discussion to manage any crisis. DCMC discusses on current issues, decides on main agendas and directs for implementation in different levels of care especially during crisis period. This committee is also addressing issues related to COVID-19 in current days.
District wide lockdown was initiated with rising cases. Charikot Hospital has installed PCR lab (PIC 2) with the support of Bhimeshowr Municipality with the significant contribution from district members of parliament. Fig 2 shows 1702 RT-PCR tests performed within 2 weeks of instillation and with 627 (37%) of positive rates. There was rapid increase in admission rates and 5 notable deaths.
Charikot Hospital is a recently upgraded provincial level hospital with 50 bed capacity. It is the only public hospital in the district with free health care strategy and electronic health record system. It is a referral CEONC site for safe motherhood program. It is managing 200-300 patients per day with complicated surgeries of different specialties, running robust mental health program, managing residency program of NAMS and KMC Teaching hospitals, running CME to uplift skills of Mid-Level Practitioners (MLP) and managing all levels of government’s vertical programs.
Management of COVID-19 cases at Charikot Hospital
Management of COVID-19 has become the major concern in the district. Charikot Hospital expanded bed capacity up to 43 beds with oxygen therapy and other supportive care. Charikot Hospital has prepared protocol for COVID-19 management, and treating moderate to severe cases in HDU and in general wards (PIC 3). Other rural municipality level hospitals has also established COVID isolation wards.
With increasing case load at Charikot Hospital, there was crisis in nursing staffing in caring COVID cases those who are admitted at Charikot Hospital. Seven school health nurses managed under the management of Province are utilized for COVID response at Charikot Hospital. And, with the support of district police office and other private hospital namely Dolakha Community hospital and Tshorolpa Hospital, almost 50 big oxygen cylinders (PIC 4) were managed for direct patient care at Charikot Hospital.
COVID relief fund was activated with the contribution of two hundred thousand rupees from each municipality with the basis of its utilization in managing COVID cases within the district. Similarly, four COVID dedicated ambulance were defined for patient transfer, referral and discharge.
Contact tracing was found to be the major steps towards case identification (PIC 5). Each municipality have started contact tracing at their municipality level hospitals and collected swabs were sent to Charikot Hospital for reporting.
After initial increase in COVID deaths at the district, Nepal Police and Nepal Army based in Dolakha (Taradal Gan) and Armed Police Force (APF) of district supported in disposing dead bodies from the hospital.
Dolakha Chambers and industry, Dolakha Guthi, Lali Gurash youth club and Dolakha water consumer committee have supported basic food (two times a day) for COVID dedicated hospital staff, COVID infected patients and their visitors. This has added motivation to all COVID dedicated staff of Charikot Hospital (PIC 6).
Coordination with Dolakha Hospital- Dhulikhel Hospital
Dolakha Hospital, managed by Dhulikhel hospital has been managing majority of referred NON-COVID patients as per the co-operation and understanding reached in DCMC meeting along with other stakeholders to make it a dedicated NON-COVID hospital for the time being. It is providing specialist’s quality health care services to all varieties of patients including Gynecology & Obstetrics, Orthopedics, General surgery and other general medical patients at low costs (PIC 7), which has made the diversion and management of NON-COVID patients inside the district easier. It has been actively working for triaging, detecting and appropriate referral of COVID patients as well (PIC 8 )
It has built capacity of COVID antigen testing which has detected more than a dozen of COVID patients and referred for either hospital admission or home isolation (PIC 9). It has been working to strengthen the home isolation services as well in at least 4 municipalities, by deploying the community health workers (CHWs) and using dedicated help line phone number. It has been actively performing public awareness and education activities through pamphlets and direct counselling to the patients and their accompanying people.
Support of NGOs/INGOs/Locals for COVID management:
There are few organizations who have supported to combat COVID-19 cases for the district. Health Partnership Nepal (HPN), UK charity organization have supported PPEs, and basic medicines and consumables for Charikot Hospital. Dolakha Redcross society have supported dead body bags, masks and sanitizers for Charikot Hospital.
One Heart has focused MNH (Maternal and Neonatal Health) helpline to support maternal and neonatal care by strengthening health worker’s capacity and direct advice in phone calls.
Caritas Nepal, Suahara Dolakha and local people supportive movements are approaching to help for COVID care within the district. Individuals and group of people have supported medicines/cash contributions for COVID relief fund of the district. A group of business people living in Japan namely Gaurishankar Business Group of Dolaha have made contributions in essential medicines for COVID care of Charikot Hospital.
Bhimeshwor municipality has faced major responsibilities in combating COVID-19 in Dolakha. Dolakha has responded quite well with the current existing resources available, however with the limited resources and other basic procedures, Dolakha has following major challenging tasks:
- Unavailability of Intensive Care Units to manage critical COVID patients.
- Lack of Oxygen plants in the major hospitals of Dolakha.
- Lack of adequate human resources to take care of critical patients.
- Patient visitors management in isolation COVID wards.
- Unavailability of vaccines for general population.
- Inadequate PPEs in health facilities.
- Inadequate oxygen cylinders and oxygen therapy.
- Lack of critical care capacity with unavailability of major lab tests for critical COVID-19.
- Difficulties in controlling migrants from other districts and from India.
- Inadequate planning and management of isolation centers at different municipalities.
- Inadequate numbers of COVID antigen kits.
- People are unemployed and having difficulties to have basic need for many workers.
- Low levels of sanitation, health negligence and unemployment all leading to many health issues.
- Dead body management.
- Health Care Worker’s security and safety.
- Non COVD case management at Hospitals and their safety.
One of the biggest challenge is Health Care Worker’s (HCW) safety and security. Most of the HCWs of the district are not insured for COVID care. What happens if front line health workers are affected with COVID-19?
At this level, We are not in the stage of answering this question because of limited human resources at all health facility notably COVID dedicated hospital like Charikot Hospital.