The Prime Minister Dasho Dr Lotay Tshering said the relaxations are being done gradually to avoid a large surge in cases over a short period which will lead to a rush of cases to hospitals, the system being overrun and deaths.
The Prime Minister said that preventable deaths must be avoided at all costs and every death should be explained as something that could not be prevented.
Lyonchhen said that the so far the fight has manly been led by the frontline workers and the case load in hospitals have been low so far.
He said now the real war by the health staff will start as the ball is now in the court of the clinicians who have to manage cases that come to them.
Technical Advisory Group (TAG) member Dr Tshokey said, that under the instructions of His Majesty they are all preparing for this phase and the main worry is if there is big surge of cases right after the relaxations and a large number of severe cases which can lead to deaths.
Dr Tshokey said that the relaxations are in such a way that the hospital beds and ICUs are not overflowing and people are not dying in the corridors and crematoriums are not full.
He said government is looking at between 50 to 70 percent of COVID bed capacity to be filled to initiate a two-week lockdown, though there is no final decision yet.
Controlling the Spread
On measures to control the spread after the relaxations, National COVID-19 Task Force Lyonpo Dr Tandi Dorji said that to avoid a big surge and spread they are easing relaxations in a cautious manner. He said they will keep testing people moving from high to low risk areas and transporters will also be tested.
To keep the numbers low, inter mingling will not be allowed and even those moving from Thimphu have been tested and even asked to home quarantine when they reach their destination.
The minister said there will be a renewed focus on awareness and education of the people and it is not about ‘living with the virus’. He said the focus is about going back to a normal life as far as possible but still protecting against and preventing serious cases.
Lyonpo said the opening is not an all out one where suddenly discotheques can open and people can start partying or there can be mass gatherings. He said that mass gatherings events like Tshechus and Dromchoes will still be restricted.
He said there will be a spread but they want to avoid one big surge at one time. He said the main concern is not about the spread itself but the spread should not lead to an increase in moderate and severe diseases.
He said what is happening in Phuentsholing is a good sign as the virus is spreading, but there are no severe cases. Lyonpo said the combination of vaccine immunity and the natural immunity gained from infections have a long lasting effect and many experts believe that after that even booster doses may not be required.
TAG says don’t panic
As the country goes in for Phase two relaxations from April with no lockdowns even if there are community cases, the National COVID-19 Task Force and the TAG will be closely observing what happens for for some time to see how things go.
Dr Tshokey said“In that time period we need to understand and see the numbers of critical cases, total numbers or positivity rates and also the reaction of the public.”
He said if things go well here with not too may getting infected at the same time, or only a limited number of serious cases then only things can cool down and there could be more relaxations.
One key barometer that will also be watched is public reaction and panic to the cases that come up at the time.
Dr Tshokey said that while people say that Omicron is ‘mild’ or like the ‘flu’ it is quite another matter when people get infected. He said at that time two reactions are very common. The first is that infected person, even if they are young and fully vaccinated, start panicking and keep calling the health team to come pick him or her up.
The other reaction is from the neighbors who also call the health team and ask why they are not picking up the positive case.
Dr Tshokey said with the above situation, a key concern is that there should be advocacy among the people so that people should know it is okay to be positive as long as one is not critically ill or showing signs like shortness of breath etc.
He said the main thing is to avoid panic if one tests positive unless one has shortness of breath. He said people should remain at home and even if a neighbor tests positive there is no additional risk as long as you avoid them.
He said they have faced cases of neighbors and even landlords almost fighting with health staff and getting aggressive asking why positive cases have not been picked up. He said there are cases where landlords have even nearly kicked out tenants for testing positive.
He said those facing medical issues should call the medical helpline and help will be provided.
Deploying to remote areas
Under His Majesty’s instructions the preparation is also to ensure that if the virus spreads to remote areas due to travels and relaxations then there should be doctors and medical care available for those who need it.
The Foreign Minister and National COVID-19 Taskforce member Dr Tandi Dorji said under His Majesty’s instructions to improve the manpower Desuups will be given one week to 10 days training on health aspects so that they can do testing and basic things.
He said retired doctors are also being recruited.
The MoH is also working out a plan to deploy the limited numbers of doctors and medical staff across the country in this critical one and a half month to two-month period to see which areas need more attention.
The country has 185 BHUs and most of them do not have doctors.
Dr Tshokey said the plan here is to redistribute doctors and medical staff as some areas for example, like the BHU in Shabha, Paro or certain Gewogs in Thimphu do not need doctors in the BHU due to the close access to the Paro Hospital or Thimphu. The priority will be given to areas very far away or which are difficult to reach.
113 general doctors and allied health professionals, supported by medically trained Desuup plus personnel are deployed across the country.
The medical teams there for now will provide medical services until COVID cases show up and then they will take part in the COVID response.
Dr Tshokey said that after this two-month period or so if things go well then they can scale down.
Positive cases can isolate at home
In terms of isolation the government has already come up with three categories which is already being implemented in Thimphu since one week.
The first category is a young patient with no comorbidities who can stay in home isolation for 7 to 10 days. The second is a 60-year-old who has some symptoms like fever and cough and that person will be taken to an isolation hotel where there will be a nurse to monitor him.
The third category is those with more sever symptoms like breathlessness who will be directly taken to the Taba National COVID-19 Hospital.
The Prime Minister said that the relaxations are already in effect as since last week people who test positive are being allowed to quarantine at home unless the family wants them to quarantine in a hotel.
He said that there are already red apartments instead of red buildings and there would only be red buildings if multiple families are infected in a building.
COVID Hospitals and medicine
The National COVID Hospital in Taba is specifically to cater to Thimphu’s large population. It has around 250 beds. It includes ICU and other support.
In the districts similar arrangements have been made like RIGSS and DGPC in Phuentsholing (268 beds) and COVID hospitals in Gelephu near the airport and hospital ward (210 beds), in Mongar at the MCH Hospital (75 beds) and one upcoming one in Trashigang with 150 beds. Routine hospitals have 1,200 beds as a back up. Dr Tshokey said while Thimphu can cater to the western region, the southern regions can be looked after by Phuentsholing and Gelephu and Mongar would be for the eastern region.
Dr Tshokey said that in case a COVID patient has other non COVID medical issues like a burst appendicitis, road accident etc then the COVID isolation facility near JDWNRH will be used for those.
In terms of anti-viral drugs, he said that till now they have been giving Remdesivir injections, but they are also in the process of buying new oral ones like Paxlovid by Pfizer and Molnupiravir by Merck. The Pfizer one can be used for 12 to 18 too.
Steroids can also be used to prevent serious illness.
5-day home quarantine
Starting April 25, domestic travellers from high to low-risk areas will have to undergo five days of “home quarantine” and produce RT-PCR negative result. High risk places are the areas with high concentration of positive cases and or areas of outbreak.
Signs to watch for
He said that the important data they are looking at, which will also decide future moves, is the reinfection rate of Omicron and so far they have not come across any reinfection cases of Omicron.
One big factor to watch will be the schools reopening tentatively by 25 April and how they do at the time.
Dr Tshokey said they will have to be really vigilant then.
Reduced Testing
On testing Dr Tshokey confirmed that it will be reduced as there will not be contact tracing like before, but the positive person will be asked to stay in isolation at home.
He also said the cluster testing and whole city testing that used to happen before will also not happen. He said when there will be no lockdowns then it does not make sense to do mass testing as that is a strategy to reopen.
Research done for relaxation
On the research done so far for relaxation, Dr Tshokey said that they have looked at the examples of many countries trying to open up and while some have gone well others have not done as well.
He said the opening strategy is reliant around Omicron being mild and highly transmissible and this also comes up in the local data.
He said people as old as 103 and in their 90s have tested positive including even young babies.
Lyonpo Tandi said that they have looked at the studies and experience of other countries and advice from expert bodies like CDC and WHO. “We know more about Omicron and also know that vaccines are very effective in preventing severe cases and deaths.”
He said there are also medicines which can be given.
Children below 5
On the fear of parents who have children below 5 who will not be vaccinated when the opening happens Dr Tshokey said that even in the case of young babies there were a couple of cases of diarrhea and dehydration which was treated.
He said around 22 cases were critical in total and of them only five or six needed oxygen and that too not due to pneumonia caused by COVID but due to pre-existing conditions.
High Omicron deaths in HK and USA
On high Omicron deaths in Hong Kong and USA he said that in the case of Hong Kong the vaccination rate among the elderly is only around 20 percent, and there has been an outbreak among them including in old age homes.
In the case of USA, he said it is due to the large spread of Omicron there, and it is also mainly the unvaccinated who are dying there.
Protecting the vulnerable
On the measures to protect vulnerable people Dr Tshokey said that His Majesty instructed the TAG to not read just one or two sources and make decisions, but to read multiple accredited sources before making a decision.
He said that they have a list of the vulnerable from the beginning of the Pandemic, but that list has not been revised yet which is being done as some may have died or others may have moved their location.
He said the vulnerable are all above the age of 60, those with comorbidity and everyone below five.
“Firstly we should prevent infection for them and when they do get infected there should be a daily monitoring system and prompt action in case of any signs and symptoms,” he added.
Lyonpo Tandi said that firstly they will be giving the second booster dose to the vulnerable and secondly under His Majesty’s program if a household has positive cases then they will ask if any of the vulnerable people would like to be isolated separately.
Lyonpo said His Majesty’s program of giving vitamins like Vitamin D and Zinc to the elderly will also continue.
He said health workers will also be accessible to people in remote areas.
Long COVID
One concern of getting infected is long COVID or the long term health implications of even mild COVID from organs like the Lung to the brain.
Here, Dr Tshokey there is a lot of literature on the subject even though the time duration of the virus has only been two years and what is known is that it can affect various organs like brain and lungs and there are even cases of severe lung damage for life, dementia etc.
He said Bhutan had gone all out to prevent infection so far as they did not want a small population being an unfit population as the impacts of the disease became clearer five or 10 years down the line.
He said that this time apart from the vaccination, Omicron is milder.
LyonpoTandi said that Bhutan has launched its own study on long COVID by talking to people who had COVID around a year ago.
On an Oxford University study that that even mild cases resulted in long COVID by damaging a portion of the brain. Lyonpo claimed that such studies have not been verified yet with randomized clinical trials.
Foreign arrivals
Starting April 25, quarantine period for international travellers who are fully vaccinated, with RT-PCR negative certificate will be reduced to five days. Those who are unvaccinated will have to undergo quarantine for 10 days.
Not given up the fight
Dr Tshokey stressed that they are not opening up because they have given up the fight, but they are simply adjusting to the situation and try and balance it with what is required in the society.
He said many countries have reopened successfully.
On schools
The Foreign Minister said that WHO is not against opening up shops and schools and WHO itself has said that lockdowns are not effective. Lyonpo said that WHO advice like Non Pharmaceutical Interventions like mask wearing, hand washing and avoiding mass gatherings will be followed.
He said there is other damages from lockdowns like mental health and depriving children of education etc.
He said Bhutan has a high vaccination rate which should help with the opening up.
Schools are to open on 25 April and not 18 April as announced earlier to enable 5 to 11 year old school students to develop stronger immunity.
Opening timeline
Thimphu and other districts opening timeline was given by the PMO. From March 13 to March 20 movement within zones without cards card timing. Other districts without zone system are to maintain the practice at chiwog and gewog levels.
In addition to the existing businesses, most businesses can open provided owners reside in the same zone until 7pm. Constructions activities can take place, within the zone.
From March 21 to March 27 movement allowed within mega-zones. Take-away restaurants can operate. Routine specialist health clinics to be established at mega-zones.
From March 28 to April 3 taxis are allowed to ferry people of the same cohort. Identified government, corporate and private employees will be allowed to attend from their offices. Except for entertainment centres, all other business entities can open.
From April 4 to April 10 mega-zone movement restrictions are lifted. Movement of private cars will be allowed. They will start opening up routine services at JDWNRH. On April 11 all offices are to be fully operational.
On April 25 businesses can operate until 9pm.The business timing will be maintained and studied for a month, and if the situation doesn’t worsen, it will be lifted along with consideration of opening of all entertainment centres thereafter.
All sporting activities will be allowed without spectators.