Photo Courtesy: Ministry of Health

As Bhutan hits 172 cases on day 9 high numbers from flu clinics, mass screening and community surveillance heightens Community Transmission challenge

Of 172 cases on day six 20 cases are from flu clinics, 62 from mass screening and 32 from community surveillance with 58 close contact cases

Within the last nine days of the lockdown that first started in Thimphu there has been a total of 172 local transmission cases averaging at the rate of 19 cases a day. Bhutan now also has 178 active cases with 623 total cases.

Day six of the lockdown on 25th December saw the biggest spike in cases with a record 38 cases of which 29 cases were in Thimphu.

Mass screening cases

Around 10,000 have been tested in Thimphu for the mass screening and so far 62 cases have come up in Dechencholing, Changangkha, Chang Jalu, Motithang, Kabesa, Upper Dechencholing, Debsi and Nyinzergang.

The Health Minister Dasho Dechen Wangmo earlier said that a sweep was also done to test everyone in Dechencholing given the high cases there.

She tried to assuage concerns saying that of the many mass testing cases quite a few had some form of interaction with earlier positive cases.

However, such a high number of mass screening cases spread all over Thimphu with and no direct link to positive cases shows that Thimphu has a significant level of Community Transmission.

Community Transmission

The magnitude of the problem was reflected in a statement by the Prime Minister on day five of the lockdown. He said, “Until now, our focus was to prevent COVID-19 from entering into the country. After almost nine months, it is now here in our communities. Rampant local transmission of coronavirus is evident.”

The Health Minister on the same day said that epidemiologically the current Thimphu and past Phuentsholing outbreaks are different.

She said in Phuentsholing the virus originated from the Mini Dry Port and since the workers were staying together it spread from there.

In the case of Thimphu it is community transmission as cases are coming from the community.

She said the danger in Thimphu is more as it is the capital city and has a large population with a lot of travel and interaction. She said it is easier for the virus to spread in Thimphu.

In response to questions by The Bhutanese the Technical Advisory Group (TAG) of the MoH said, “Our initial assessment is that the disease is at its acute state of transmission. However, it is difficult to say since it’s been only a few days since the declaration of lockdown. 

Until day two of the lockdown the original 25-year-old girl and her family in Chubachu and their close contacts and those tested in the surrounding community comprised of 21 local cases and the term being used for them was a cluster infection meaning an infection within a small area.

However, the Prime Minister on day three of the lockdown on 22nd December announced a national lockdown when it became clear that there were cases coming up which had no link to the Chubachu cases.

The Prime Minister announced the national lockdown on day 3 citing the cases from flu clinics with Thimphu reporting 5 cases from flu clinics, Paro saw 3 flu clinic cases and Lhamoizingkha in Dagana saw 1 case from a flu clinic.

He said these cases show the presence of local transmission and the lockdown will enable the authorities to find out the extent of transmission with the community.

The detection of these flu clinic cases was significant in two ways.

Firstly, it showed that since these cases have no link to the Chubachu cluster there could be other hotspots in Thimphu and secondly cases coming up in flu clinics outside Thimphu showed the presence of the virus in other Dzongkhags.

Flu clinic cases like mass screening cases are significant as in they are not the result of any contact tracing or even community surveillance by the MoH in a suspected area, but are people simply turning up at the flu clinic randomly.

This means that flu clinic cases are outside the radar of the MoH and indicates a wider spread of the virus and could end up revealing up a lot more cases.

To get an idea of how potent a flu clinic case is, the first case that started the whole lockdown and discovery of several other cases was from a flu clinic.

Secondly, the Paro flu clinic case of a mother and daughter in Shabha high school lead to 15 more cases being discovered in the same school.

However, the situation continued to get worse as on a day after the national lockdown was announced on day 4 there were three more flu clinic cases in Thimphu and 1 flu clinic case all the way in Bumthang showing the virus had already travelled all the way to central Bhutan.

As of day 5 of the lockdown 5 cases came up from the flu clinic in Thimphu, a development which would have sent an inward groan within the contact and tracing teams of the MoH.

 Of the 172 local cases so far there are 20 cases from flu clinics with 15 from Thimphu, 3 from Paro, 1 from Bumthang and 1 from Lhamoizingkha.

The challenge of flu cases can be seen in the Phuentsholing outbreak in August this year when the MoH was okay as long as it could connect the large number of cases either to the Mini Dry Port or even the DANTAK camp but there would be a tizzy when even a single flu clinic case would come up. Even in the case of one lady who was found through a flu case the MoH then said it may have to do with the fact that she stayed near the MDP.

However, the big challenge now is that just within day nine of the lockdown there are 20 flu clinic cases mainly in Thimphu but also spread across a wide geographical area of Lhamoizingkha in the south, Bumthang in the west and also neighboring Paro.

Beyond that close contact cases have been detected now in Punakha, Haa, Trongsa and Wangdue too making it an 8 Dzongkhag affair.

As of Saturday 9,526 patients were screened at Flu clinics across the country.

Lyonpo said that in flu clinics most of the visitors are from Thimphu while the number is lower in other Dzongkhags.

The Prime Minister said that one comfort in the flu clinic cases is that most of them could be somehow linked to the active cases (though not directly and conclusively).

Community Surveillance cases and Close Contacts

However, apart from mass screening and flu clinics cases the other category that is worrying is community surveillance cases. A community surveillance is the MoH doing a survey of all the people in a particular area where a case has emerged.

Till date Bhutan has 32 cases from community surveillance of which 17 are in Thimphu and 15 are in Paro.

  The final category are the close contacts or those people who came into direct contact with the positive cases and these are 58 in number.

Lyonpo said that people must be getting scared with the numbers going up like this but she said that they are doing a lot of tests and so the numbers are high. She said the figures will keep increasing in the next 7 to 8 days as more tests are done.

“However, if we strictly observe the lockdown then the numbers will not go up much after 14 days except for one or two cases. But if the lockdown is not observed well then the numbers will keep going up after day 14 too. We can break the transmission by following the lockdown well,” said Lyonpo. 

The assessment of the MoH right now is that the outbreak or community transmission is within Thimphu and Paro with the few cases in the other Dzongkhags being linked to either Thimphu or Paro.

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