The Bhutanese Leading the way.
More details have emerged on the various factors contributing to the second outbreak and its spread.
Government officials still regard the most probable source of the second outbreak as being the 27th November 2020 flight, mentioned by The Bhutanese last week, where 33 to 34 of the 52 to 55 passengers including the pilot tested positive (52 and 33 are figures of the Paro hospital while 55 and 34 are from the Foreign Minister).
The Foreign Minister Dr Tandi Dorji said, “The flight that came on 27th November from Kolkata where many of the passengers and the pilot turned positive is seen as the most likely source of the current outbreak,” though he qualified it saying it cannot be said with 100 percent surety.
After the outbreak in Thimphu followed by the Shabha bus driver and many students testing positive in Paro, the foreign minister and the Chief Election Commissioner (CEC) Dasho Sonam Tobgay were tasked by the National COVID-19 Taskforce to go to Paro and do a review of the SOPs and problems there.
However, before they could go to Paro Dzongkhag for the review the Dzongkhag came under a lockdown and so a review could not be carried out.
Some of the main points from the story
The flight
Regarding the 27th November flight a senior health official based in Paro who is also involved in the airport said that one probability is that there may have been a couple of passengers with very high viral load and that it may have transmitted to others on the plane.
A factor that may have contributed to this happening was simple airline economics. It was not economically feasible for the two airlines to operate flights with only minimal passengers as it was mainly going empty one way and so most of its flights only operated when a certain quota of paying passengers where met from anywhere in the world.
Some of these passengers carried the virus with them.
The Foreign Minister, however, does not believe that they were infected while on the flight as he said there were several packed flights in the past and there were never as many cases as the Kolkata flight.
The minister opined that the Kolkata flight had been delayed by two hours, and so the passengers were given lunch at the airport and had removed their masks and somehow a large number of them may have become infected at that time. He, however, said the real cause of the high positive numbers on the flight needs to be looked into and it may never be ascertained.
A passenger on the flight, however, said that no lunch was served at the airport but some snacks was given in the aircraft during which they had removed their masks to eat it.
Drivers and buses
The riskiest component of getting the passengers from the airport was the dozens of school and city buses from Paro and Thimphu used in ferrying passengers.
However, ironically, this weakest link in the chain got the least attention.
The Bhutanese has learnt that from Thimphu school buses from Motithang Higher Secondary School, Yangchenphu Higher Secondary School, Dechencholing Higher Secondary School, Changangkha Middle Secondary School and a school from Changjiji were used twice to ferry passengers from Paro airport to quarantine centers in Thimphu. The drivers of these buses were not placed in quarantine.
Paro Dzongkhag which does not have city buses made extensive of school buses from six schools which are Shabha High School, Khangkhu Middle Secondary School, Bitekha Middle Secondary School, Wanakha Central School, Drugyel Secondary School and Lango Middle Secondary school.
Buses from Wanakha, Drugyel and Bitekha served from March till 8th October while buses from Shabha, Lango and Khangkhu continue to serve till date.
Again except for a quarantine period from August to 8th October 2020 the drivers were not in quarantine.
The Shabha driver said that the Paro bus drivers along with city bus drivers from Thimphu had requested a senior visiting health official in Paro airport to get them tested but, despite assurances to pass on the request, nothing happened.
Apart from the Shabha driver who tested positive on 24th December 2020, a Thimphu city bus driver tested positive on 3rd January 2021, showing the extent of the risk.
This city bus driver had not taken passengers from the infectious 27th November flight but his last two trips to Paro airport was on 23rd November and then on 7th December. The city bus driver talking to, The Bhutanese, over the phone from his quarantine center said he remembered taking patients to Terma Linca a couple of times among other places.
The city bus driver said he was only discovered to be positive as he got the hospital duty in JDWNRH to transport doctors from the hospital to the quarantine center for medical staff and back. Only drivers on this duty are tested on a weekly basis which was when his status was known.
The driver said they took a nasal swab for the RT-PCR test which was not conclusive and they came back for a blood sample and then only after the blood result came he was sent for quarantine. RT-PCR test is for an active infection while a blood test is to check for antibodies after a duration of infection.
The city bus driver’s first contacts who are his wife and children, however, are negative.
Another city bus driver Tshering Dawa said around 80 city city bus drivers had ferried passengers from March 2020 till December 2020. He said 10 buses had been kept on standby for duty.
However, when there were multiple flights up to 24 city buses were sent. Drivers were also sent on rotation.
Another city bus driver Passang Tshering said that from early on there were issues as there was no partition between the driver and passengers and drivers on their own initiative either placed a rope or some plastic to ensure there was separation between the passengers and the driver.
He said in the early days no meals were arranged for the drivers and they frequently went hungry. When some of them, in the early months, stopped for a meal in Shabha the police were called by a local person.
After that the MoIC arranged packed meals for them.
Passang pointed out that most of the bus drivers had not even been tested. He said once around 10 of his colleagues had been tested and that is all that he remembers. The rest took comfort in the fact that none of the 10 were positive.
The large number of city bus drivers who carried passengers from Paro to quarantine centers in Thimphu were not placed in quarantine.
It was only during the first lockdown when these drivers worked from a garage where they ate and slept.
It was also not uncommon for a city bus driver to be doing airport duty one day and then carrying people around in Thimphu on the same bus the next day after it had been disinfected by BAFRA.
The August outbreak distraction and handing over to an under capacitated PMO
Until the August outbreak in Phuentsholing followed by localized outbreaks in Paro, Haa and later Gelephu and Samdrupjongkhar the focus was strongly on managing the Paro airport cases well.
However, the combination of increasing number of people coming back into quarantine centers and outbreaks in the south meant that the MoH, which had essentially been running the show along with the Dzongkhag administration around the Paro airport, was getting stretched thin.
With the need to deploy several teams for testing, tracing and surveillance in Phuentsholing and other affected areas in the south, the MoH started handing over more responsibilities of logistics and also overall management of the quarantine centers to the PMO.
The Cabinet Secretary Sangay Duba said initially the PMO only identified the hotels and handed it over to the health who did everything. However, later as the PMO took over the health people trained Dessups to manage some of their roles to free up some health staff.
As part of this handing over a crucial change took place when the MoH also handed over its lead role in the Paro airport along with the Dzongkhag administration to the PMO.
A senior Paro Dzongkhag official told the paper that they had been verbally told that the PMO is taking over. The official said that from September on there were lesser flights and so maybe that is why the PMO took over and maybe wanted the Dzongkhag to focus on its normal developmental activities.
However, the PMO had nowhere near the manpower and technical expertise of the MoH or the ground presence of the Dzongkhag.
Though the PMO is the highest executive office in the country with an important cross cutting function, it is understaffed even on a normal day and lacks the depth, expertise and institutional strength that ministries carry with them.
The PMO team under the Cabinet Secretary consisted of only around 10 officers spread out in 4 locations in the Tashichhodzong, below the National Assembly and two offices in town.
Of the 10, five were fully engaged in data punching of passengers coming in.
Though the officers had access to focal officers in various Dzongkhag task forces and other agencies it was not the same as being on the ground. Their role was also mainly information and coordination.
A PMO official admitted that they only went to the airport for data punching and that too if the passengers were numbering 50 or above, but if the passengers numbered around 20 or 30 then they would ask the Paro Dzongkhag data punchers to manage. The MoH and Dzongkhag were still involved in the airport but not in a lead way.
The situation outside the airport eventually became one where everybody was in charge in some way or the other and yet no one was also really in charge at the same time.
Airport officials, Dzongkhag officials and even bus drivers noticed a visible slacking after the August transition.
The city bus driver who tested positive, over the phone, said that earlier it was very strict at the airport as officials and Dessups would be there monitoring and give very clear instructions on where to go. Then while reaching the hotel in Thimphu, again Dessups and officials would come out even before the bus stopped and take charge.
He said from around September onwards he saw it had become much laxer at both the airport and also while dropping passengers at the quarantine hotels whereby officials would mainly still be in the hotel even as the bus came in.
An airport official also noticed this change and he said earlier under the MoH and Dzongkhag the drivers would be careful to stay in their buses. But later once the PMO took over and monitoring became lax, and as they came only infrequently, the drivers would come out and be mixing around.
Another factor was growing overall complacency as until then there had been no cases outside quarantine centers through the airport, and as the flights lessened everybody assumed things were coming under control.
To add to this, after the first lockdown ended and the unlocking happened, government offices went back to normal and much delayed works and economic activities were also on full swing.
A PMO official said that the 10 officers in the PMO ended up doing normal and demanding office work from 9 am to 5 pm and then doing the COVID-19 work from 5 pm onwards. Five of the 10 members who were data punchers ended up staying until 12 at midnight in the office frequently.
Even the school bus drivers in Paro who had been in quarantine from August to 8th October were tested and released back to the schools and informed that they would be called as and when the occasional flight came in.
All of the above conditions were laying the ground for the perfect COVID-19 storm to happen and the storm did come when the most dangerous and heavily infectious flight KB 211 landed on 27th November 2020.
The Shabha driver had dropped some of these passengers, many of whom turned out to be positive, to a hotel in Paro and he tested positive on 24th December 2020 two days after his wife. A senior Technical Advisory Group (TAG) member of the MoH had informed The Bhutanese about the 27th November flight and the Shabha driver.
The driver strongly refuted that he was the possible source of the spread in Shabha school or elsewhere and said the students and others must have got the virus from elsewhere. He suspects his own wife must have been infected during her trip to Thimphu.
He also said he has log books and movement orders to show he was never meant to be in any containment facility after 8th October as claimed by some senior officials.
Aircrew and airport staff quarantine
With aircrew from both airlines required to fly planes, the two airlines divided their air staff into teams and put them on a two-week rotation so that if one of the team members became positive and a team is quarantined than the other teams are available. As mentioned above, a pilot on the 27th November flight tested positive.
In these two weeks of duty a team would be on ‘Restricted Position’ where they cannot go home and would have to stay in a resort in Paro.
Here, while both the airlines claimed it was strict and with a dessups on duty an airport official, on the condition of anonymity, said the aircrew were more free to mix around than those in normal quarantine.
After two weeks the air crew would do one more week of quarantine and go home after tests. However, if they flew a passenger plan then they would have to stay for the 21-day MoH mandated quarantine.
The 422 strong Paro airport staff was divided into two teams early on and they worked in stretches to again ensure that if one team got hit another is there to take over. These people who also consisted of frontline people were normally allowed to go home after work and it was only until recently with the second lockdown that the teams have to stay at the airport itself. However, so far despite tests none of the airport staff have tested positive.
The Foreign Minister said that the fact that there were no cases until the recent outbreak in December showed that the protocols around Paro Airport there worked for a long time.
Cluster links and an outlier mystery
The Foreign Minister said who is the first patient is not important, but it is important to know how the virus has spread and then prevent it in the future.
The minister said that there are three clusters with one being the archers at Dechencholing, the cluster of students and others in Shabha and then a third cluster among some painters and Zorig Chusum people.
He said a common factor to all these clusters was the taxi driver or the uncle of the index case who tested positive at Norzin Wom in the Sabzi Bazar area. Lyonpo said he has a link to the archers in Dechencholing archery ground, archers in Paro and he was there in Sabzi Bazar.
To be clear, the minister did not blame him for the outbreak or spreading it but showed his common link to all three clusters.
While the minister said that the 27th November flight is the most likely source of the current outbreak Lyonpo said that he and the CEC were also supposed to review the Lhamoizingkha case which is an outlier.
The Lhamoizingkha case is a lady who is a hotel owner who tested positive in a flu clinic. It was later found that a person who came from Thimphu and stayed at the hotel had also tested positive.
Lyonpo said there was a breach in protocol here as the person from Thimphu did not stay in the identified quarantine hotel but stayed in that hotel.
He said the question now is if the woman infected the man or vice versa and if it was the woman then a question arises on how she got the virus as the border is not very far away.
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