How complacency and lax protocols led to the nation’s second COVID-19 outbreak

A big question mark with the massive second COVID-19 outbreak in Thimphu and Paro is on its source and how it spread, despite the various precautions taken.

An infectious flight and a driver

It all started with a 27^th November flight from Kolkata carrying 52 passengers and 6 crew with a total of 58 on board. The passengers were mainly composed of medical referral patients coming back from Kolkata and also some custom officials coming back.

This was the most infectious flight ever as more than 60 percent of the passengers eventually turned positive. Even the pilot in that flight also tested positive later.

A health official said that apart from a high number turning positive in that flight the laxity seems to have appeared in transporting the patients from the airport to the quarantine center. The bus driver who transported some of the passengers from this group was found to be positive during contact tracing on 24^th December 2020.

The bus driver had taken a group of passengers who were mainly custom officials from the same flight to a local hotel in Paro. Many of these officials were later found to be positive.

A different Khangkhu school bus driver had taken some of the passengers from the flight to the Thimphu quarantine facility but he was found to be negative.

According to government officials as per the protocol the driver was supposed to stay in a containment facility and undergo testing, but in a reflection of the lax monitoring the driver instead went home carrying his then unknown infection with him.

What did not help was that the driver was a bus driver of Shabha school and health officials suspect that he must have been the source of infection in the school. Shabha High School saw 16 cases in its school mainly among students and many cases outside the school in Paro was also linked back to it.

The driver said that on 22^nd and 23^rd November he had ferried some students from the school for counseling.

The test on the driver showed that his COVID-19 infection was earlier than most others and he even had some antibodies in his blood.

A health official said that the driver had the virus for a few weeks and must have got infected due to the 27^th November flight. Along with a driver a few of the students also showed some antibodies in the blood showing how Shabha High School was an early source of the outbreak.

The outbreak in Shabha school was detected when a staff who stayed in the school had some cough and she took her mother and daughter for a test and her mother and daughter tested positive first and a few days later even she tested positive.

This staff and her family within the school compound stayed close to where the driver parked his bus and the families knew each other.

The cases were not only in the school but many people in the locality where the driver lived in Bara, Shabha had also turned positive.

While the school and the locals were blissfully unaware of the infection spreading within it and around it there were several archery matches held at a local archery range not far from the school and the general area.

Even family members of students who had turned positive and others who were later found to be positive themselves also took part in the archery matches and events.

The archery matches in an area of active infection led to the virus spreading further. The result is that a primarily rural and spread out gewog of Shabha has had 45 cases till date mainly focused around the school.

Then there was a major archery tournament involving many teams going on in Dechencholing, Thimphu where positive cases from Paro headed there to take part in the tournament.

Health officials could draw this link as a lot of positive and first contact cases took part in the same archery tournament.

Dechencholing, Dangrena saw Thimphu’s biggest outbreak and according to the Health Minister Dasho Dechen Wangmo it was from here where the virus spread to the rest of Thimphu.

A health official said that the mistake on their part was designating places like Phuentsholing, Gelephu and other places in the south as high risk areas with more enforcement, but the same level of risk and enforcement was not applied in Paro.

Paro airport for all purposes was like a dry port on its own bringing in far more positive cases than any of the entry points in the south, but after the initial vigilance there was a major slacking in the transportation of the passengers to quarantine centers and especially on the protocol around drivers driving these patients.

The health official said that contact tracing of cases showed that the outbreak was quite recent given that many cases did not have antibodies.

Measures in the airport

A government official on the condition of anonymity said that while the Department of Air Transport was responsible for the protocol and safety inside the airport the Prime Minister’s Office (PMO) was responsible for logistics like organizing the buses to pick up the patients and also managing the quarantine centers or the hotels.

The Ministry of Health (MoH) was responsible for the medical aspects like the protocol and safety measures in dealing with these passengers.

In terms of the protocol within the airport the official said that as soon as the passengers come out they are given new facemasks and the old masks were put in dustbins.

The passengers had to maintain social distance and line up and temperatures are taken and other tests done.

The passengers then move to immigration where there is a plexiglass to protect the immigration officer who is in facemasks, gloves and a face shield.

In the mean time the luggage coming out of the aircraft are all sprayed and sanitized along with the conveyor belt.

No airport staff is allowed to help passengers with their luggage. The passengers pick up their luggage and go through customs who also wear masks, face shields and gloves.

After that the passengers have to exit the airport and then head into buses headed for the quarantine centers.  

The airport has 152 staff comprising of civil aviation, customs, BAFRA, Druk Air and Bhutan Airlines staff and all of them do a 12-day shift and stay in the premises and go home only after testing. There has also been no outbreak in the airport premises as such.

The official said that initially bus drivers would be quite afraid but after a while when there were not many cases coming some degree of laxity must have come in.

The official said it could also be a coordination issue when there are too many agencies and authorities involved.

Logistics and coordination

The health official said that the government is working on coming up with modalities looking at the protocol lapses. He said that there needs to be better communication as the PMO and MoH need to talk to each other on the logistics issues and there needs to be better coordination in general.

He said that they have to rework the teams in terms of manning quarantine centers and there needs to be more briefings when teams take over a quarantine center and stricter security.

When asked if the 27^th November flight had brought in a more infectious strain of COVID-19 the health official said that it is difficult to prove that without gene sequencing.

However, he said that in earlier outbreaks in a family of five there could be two cases but the rest would remain negative, but now virtually everyone was turning positive. He said a factor could also be the winter weather and everyone sleeping with windows shut and spending time around a Bukhari.

In the Dechencholing, Dangrena the health official said that apart from the many archery matches the community up there is quite tight knit with a lot of family relatives connected to each other or close contact among households where a lot of mixing had taken place.

Health Minister points to Paro

The Health Minister Dasho Dechen Wangmo said that with the index case in Thimphu being from the south they had initially thought the case may have come from the south and so thousands of tests were done there but not a single case came up there. She said that

based on a rough estimation the case spread from the arrivals in Paro.

She said that based on their investigations they found that most of the cases came towards the end of November and first week of December. This is also the same time as the 27^th November flight.

She said it came from Paro and was spread to Dechencholing, Dangrena where there were archery tournaments and holidays and so from there it spread to Norzin Wom cluster and from there to the Terma Linca cluster, Olakha cluster and then to the Debsi cluster.

Lyonpo said that in Paro the spread was from Shabha but it could not spread much due to a smaller population, less crowd and less movement than Thimphu.

She said that in Thimphu the Norzin Wom area had many people coming there due to Sabzi Bazar, Centenary Farmers Market and it spread from there.

She said that the extent of the spread could have been disastrous if not for the use of facemasks and washing of hands.

Righting the lapses

The minister said that the process of getting patients from Paro has very strong protocols but it is very important to investigate and find out where there were lapses.

She said that around two weeks ago the National COVID-19 Taskforce decided that the lapses in getting patients from Paro need to be looked into to bring about future improvements. She said it is not about appropriating blame but improving the system and preventing future lapses by putting in place new plans and policies.

The Paro Dzongda and Incident Commander of the Dzongkhag Tenzin Thinley said that the bus driver was supposed to stay in a quarantine center along with testing but apparently he had not done so and had gone home which is located near Shabha school. The Dzongda said that measures have been geared up know and everyone is supposed to stay in designated places including the task force in Paro itself, which is currently staying in a hotel.

A senior staff from the Khangkhu school who later tested positive had gone to his wife’s village in Shabha for three days and celebrated Lomba there which included archery matches. The senior staff tested positive along with his two children and wife. His source of infection is suspected to be in Shabha during the archery matches.

The Cabinet Secretary Sangay Duba said that they are working on coming up with various measures.

He said one proposal is to use dedicated buses instead of the Thromde buses and also school buses in Paro to transport aircraft passengers. He said that safety measures will be enhanced for the bus drivers and there will also be some improvement on disinfecting the buses.

The Cabinet Secretary said that the plan is to have dedicated management teams to manage the quarantine centers fulltime as the current practice is to keep changing the teams who have to be briefed again.

He said that as per the protocol the bus drivers are supposed to stay in a containment center and undergo weekly testing which was done but he said in the last couple of cycles this fell through. He said that as per the protocol a driver is not supposed to mix with the public and has to drive without stopping between the airport and the quarantine center. He said that as per the advice of the Technical Advisory Group (TAG) the drivers were given facemasks and face shields.

He said that there is now discussion to construct a barrier between the passengers and driver.

The cabinet secretary said that while the PMO is in charge of the overall logistics and guidance when it comes to an area like Paro there is a team headed by the Dzongda as the Incident Commander to implement measures within the Dzongkhag.

The Shabha Driver speaks

The Bhutanese had tried to contact the driver last week but could not do so as he was in quarantine. The paper managed to get through to him via phone on Sunday afternoon before publishing this article online.

Contradicting the Cabinet Secretary, the Paro Dzongda and health officials the driver said that it is not true that there was any quarantine or containment facility for drivers.

He said that he has been serving since March 2020 to December 22^nd 2020 transporting passengers from the airport and the only time he was put in a containment facility was in August 2020 during the national lockdown when they stayed for a month in a hotel, but he was subsequently released back to the school by the Dzongkhag saying they would use him as and when flights came in.

He also said that in the whole month of November and December he had not even been tested even once far from any claims of weekly testing.

He denied that he is the source of the infection in Shabha school or elsewhere and instead said that the students very well could have been infected by the parents or from elsewhere.

The driver also said that even his infection may be either while ferrying passengers or even possibly while moving around in town.

The driver said that while he had initially tested negative on a test in 22^nd December his wife had turned positive on the same day. He said he underwent another test on 24^th December when he came out positive.

The driver said that he suspects even his wife’s positive case may have been gotten from Thimphu as she had travelled there around 11^th December 2020 to get the flu shot and she had also visited the clock tower area.

However, while the above incidents and facts show how the virus entered Paro and then Thimphu the Health Minister herself said that it is an estimation based on contact tracing and not thoroughly established.

As new cases come forward everyday either through contact tracing, mass testing or flu clinics the MoH is learning new things everyday on the spread of the virus.

There are also the puzzle or mystery cases which are not linked to any contact tracing. The Ministry is expected to come with a report on the issue in due time.

Editor’s Note: The story has been updated with new and additional information and updates before publishing it online.

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