Image of the quarantine facility (left) with 102 positive cases & community cases nearby

How COVID positive foreign workers, a more infectious variant and laxity caused the Wangdue outbreak

The big question of the month is, how did the recent second outbreak in ‘low risk’ Wangduephodrang occur?

There is no official explanation for the outbreak yet, but it was caused due to a combination of pressure factors, like getting on with hydro project works, and situational issues, like laxity and the entry of Omicron positive labourers in large numbers.

Foreign workers, PHPA-II quarantine center in Wangdue and Omicron

In the second national outbreak, from 20 December 2020 to January 2021, the likely source was found to be a 27 November 2020 flight, where out of the 55 passengers, 34 of them tested positive including the flight pilot. Mainly medical referral patients and some customs officials had boarded the flight. 

It may not be a matter of coincidence that the outbreak in Wangdue was reported after, out of the 106 expatriate workers in the PHPA-II quarantine center in Rurichu, 91 tested positive and another 11 frontline workers posted there also tested positive, over a period of six days.

On 6 January 2022, the country only had 14 active cases in quarantine, consisting of mainly Bhutanese coming back from abroad.

However, that changed on 7 January 2022 when there were 66 imported quarantine cases in Wangdue, followed by 2 imported cases on 9 January, and 12 imported cases on 10 January, 1 case on 11 January and 21 cases on 13 January. Bringing a total of 102 positive cases in the P-II quarantine camp in Wangdue.

The Ministry of Health (MoH) on 13 January 2022 had already announced that the gene sequencing of quarantine cases in Wangduephodrang, Phuentsholing, Thimphu and Paro, and the then sole community case in Phuentsholing, were all found to be the infectious Omicron variant.

An official, said that given the shortage of workers and also quarantine sites, it was decided early in 2021 that a quarantine site should be set up in the current site in Wangdue, which was formerly a Jaiprakash Associates camp for its workers able to accommodate 300 to 350 workers.

Since it was a quarantine facility, JP modified the camp to have a separate bathroom for each room and so the camp could now contain up to 120 workers at a time.

A combination of DeSuups, RBP and PHPA security was placed as security in the camp in containment mode which means even they would not be allowed out.

The first batch of 58 workers was brought via Phuentsholing on 17 April 2021, where health checks were done and then they were brought directly for quarantine to Wangdue. The workers all tested negative, and things went smoothly.

However, the subsequent outbreak and lockdowns in the south, and especially Phuentsholing from late April 2021 to August 2021, hampered labour movement.

The second batch of 102 workers came in on 28 November 2021, again via Phuentsholing, and even this group all tested negative, and the quarantine in Wangdue went smoothly.

However, by the time of third batch coming in on 31 December 2021, three crucial changes had occurred.

The first was that after first being discovered in South Africa in November 2021, the Omicron variant had made its way to India and was spreading rapidly with COVID-19 cases going up.

The second change was that it had been decided that hydropower workers would no longer be sent via the old route of Phuentsholing, which would be kept for workers to regions like Thimphu, Paro, Haa, Chukha, etc., and instead they would all be sent via Gelephu, which would be for Wangdue, Punakha, Tsirang and Dagana.

So the earlier health and document checks, which happened in Phuentsholing, would now happen in Gelephu.

The third change was that two batches of these labourers were not subject to antigen tests in Gelephu and were sent to Wangdue in a ‘bubble mode.’

The third batch of 52 hydropower workers came into Gelephu on 31 December, and did their health checks, and were sent to Wangdue. The fourth batch of 39 workers came in on 1 January 2022, and did the same and the fifth batch of 15 or so workers came in on 4 January.

This meant that of the 106 or so workers who came in, around 91 had tested positive, which is a staggering number.

However, the index case in Wangdue was the water tanker driver who supplies water to a-200 strong Hindustan Construction Company (HCC) camp and HCC workers working for P-I. Most of the positive cases in Wangdue have been from this HCC camp, so far.

The big mystery is the link between the P-I HCC camp and the P-II quarantine center located around 1 km away with its own security.

Here, a PHPA-I official pointed out that a separate P-I HCC fabrication camp where Bhutanese and Indian workers worked, and a small mini-HCC camp they stayed in, is right next to the isolation unit. This camp saw seven Bhutanese workers there testing positive, and around 15 more Indian workers testing positive.

The official said it is possible that the virus may somehow have leaked out of the P-II quarantine camp located close to this fabrication unit and the mini-HCC labour camp, and from there spread to the main HCC camp and other places.

He said that the water tanker driver had to supply drinking water to all HCC workers from morning (6.30 am) to evening (7.30 pm) by giving water from the tank into the bottles of the workers. This meant the worker had close contact with all the HCC workers at various camps, including the Serithang camp workers right next to the quarantine unit.

Though there is no official sequence of events of spread of the virus, this is the most probable sequence of events of spread, currently.

What makes this theory even more probable is the fact that the P-1 project, where the virus spread the most, did not import any workers recently. It only imported a total of around 18 workers in November and December 2020, and all of them completed their quarantine in Phuentsholing.

P-1 has only around 400 workers in total, as work has mainly come to a standstill due to no decision yet on building the barrage.

Another important factor is that in the P-II JP quarantine camp, there were three labourers to every room, which meant that if one had the virus the other two could get it too.

Moreover, if someone tested positive, there was no separate isolation building, but the person testing positive was shifted to a separate room in the same facility. This may lead to questions on why this was done for a virus that is established to be airborne, and a highly infectious variant.

A MoH official and Technical Advisory Group (TAG) member said that Wangdue had become a high-risk zone, like Phuentsholing and Gelephu, the moment it started quarantining workers there. He said in such a scenario, it is difficult to say if all the protocols had been followed strictly at all times. He said the most likely scenario is some kind of leak from the quarantine center.

Another important clue is that 40 workers for P-II were not allowed up from Gelephu on 31 October in the third batch as their vaccine status was suspect, and so they had to quarantine in Gelephu, itself. However, from this group of 40, only 2 have tested positive so far.

As mentioned above, 52 of their fully vaccinated colleagues from the same group were allowed up to Wangdue, and most were later found to be positive.

This could very well mean that the virus either spread in an enclosed bus to Wangdue or that the nature of quarantine facility in Wangdue allowed the spread to happen widely among the workers.

Denials

However, a PHPA-II official denied that the leak would have happened from the P-II quarantine facility. He said the buses from Gelephu were accompanied and not allowed to stop on the way, and they would reach P-II around 2.30 am or 3.30 am in the morning. He said the camp had its own security.

The Incident Commander and Head of the COVID-19 Taskforce for Wangduephodrang is the Wangdue Dzongda, Sonam Jamtsho.

In an interview with the paper when asked about the COVID protocol at the site, he said the quarantine center was located 300 meters below the Wangdue-Tsirang highway by the Punatsangchu riverbank, away from any human settlement.

He said no individuals visit the vicinity, except for the identified meal delivery people who drop the meals in disposable foils at a sanitized table outside the security gate and go back. After a few minutes, the Desuups on duty, in full PPE, deliver and place the meals on the tables positioned at the doors of every individual room.

The Dzongda said the security, at the time, consisted of 3 RBP personnel, 3 PHPA security personnel and 4 Desuups complete with barbwire fencing, a watchtower and CCTV.

The Dzongda said that people were kept for 21 days in quarantine there, but a TAG member whom the paper talked to last week said it was 14 days for those who are fully vaccinated.

A Wangduephodrang hospital official also does not feel the outbreak happened from the P-II quarantine camp. He said there was tight security around the quarantine camp with barbwires and it was like a jail.

He has instead pointed to the HCC labour camp, and said since the maximum cases were from there it could be possible something went wrong there. He said the quarantine center was separated from the fabrication unit by a tall structure.

Wangdue Hospital

One question is if the outbreak in Wangdue could have been caught earlier. In JDWNRH, Thimphu anyone with flu-like symptoms or even a temperature is not allowed to enter the hospital, and is sent straight to the flu clinic.

However, this was not the case in Wangdue hospital, as many people with flu-like symptoms, which included large numbers of PHPA workers, were allowed in directly into the hospital.

One such person was Pema (name changed) who visited her parents in Punakha and developed flu-like symptoms of fever, cough, runny nose and weakness.  She visited the Wangdue hospital on 4 January, and saw many PHPA workers also with similar symptoms lining up in large numbers, but nobody was asked to take a COVID test, like in Thimphu, according to Pema.

Pema did not have to take a COVID negative test to meet the doctor, and was prescribed paracetamol and other medicines after being seen by the doctor. If that was not enough, Pema’s sister joined the family a few days later, and also had flu-like symptoms, and she too did not have to undergo a COVID test while going to the hospital.

Pema has since tested herself for COVID-19 twice, and she came out negative both times. She said, “The current lockdown may not have happened if Wangdue hospital did a little more.”

Pema has a Wangdue hospital OPD prescription signed by a doctor listing her symptoms and giving medicines, as evidence. 

The Wangdue hospital health official claimed that, as per the protocol, people are supposed to get a test at a flu clinic if they have flu-like symptoms, and it is understood that those coming to the hospital do not have flu symptoms. He said the Desuups on guard cannot be expected to ask everyone entering if they have flu symptoms, and even when they do, some may even lie to avoid the COVID-19 test.

A total of three health workers tested positive from the Wangdue hospital.

TAG, Cabinet, MoH and Omicron

The Wangdue hospital official said that the TAG team had visited the Wangdue P-II quarantine center twice, and had certified it.

Last week, a TAG member had told the paper that TAG had recommended to the National COVID-19 Task Force to bring in a manageable number of workers, since stopping all workers would lead to an economic crisis.

The TAG member, before the outbreak, had said that with the highest imported cases in Wangdue in the quarantine facilities, TAG had conducted assessment and put in place all necessary measures in coordination with the Dzongkhag.

He had said quarantine management team comprising the Cabinet Secretariat, MoH, RBP and DeSuups are working together on strengthening the quarantine management.

However, the above measures were obviously not enough to check the massive out break in Wangdue.

As the top technical body, it is not clear why TAG did not recommend to the National COVID-19 Task Force to temporarily halt the import of workers due to the spread of the highly transmissible Omicron in India.

This was, especially when Omicron led COVID-19 cases were surging in India and around the world, including in the neighboring states of West Bengal and Assam.

While Bhutan’s quarantine centers and system were ready for the Delta variant, it obviously had a much tougher time with Omicron, which is twice as more transmissible as Delta, evident in the large numbers of frontline workers testing positive.

While on the ground, the Wangdue Dzongkhag, P-II, RBP and DeSuups were responsible under the overall leadership of the Dzongda, with technical advice form TAG at the national level, the Cabinet Secretariat broadly oversaw quarantine centers.

During the second lockdown, the Cabinet Secretariat had formed a team that would go around inspecting or auditing quarantine protocols and standards, but this team had been disbanded when the second national lockdown was over.

It was clear that none of the stakeholders above were prepared for the Omicron human wave, which started coming in from the end of December 2021 onwards.

TAG member Dr Tshokey said the virus had somehow leaked out of the quarantine facility.

The Cabinet Secretary, Sangay Duba, said they still do not have the full picture on how the outbreak happened, but it may become clearer in a few days’ time.

The Cabinet Secretary said that while the P-II project is responsible for the infrastructure in setting up the quarantine, RBP and DeSuups are involved in the security aspect along with P-II too, TAG and MoH provides technical advice and the Dzongkhag Administration has oversight over it. 

He said the SOPs and protocols had been strengthened since the last lockdown.

Hydro pressure

In hydropower, the much delayed P-II project, which was around 90 percent complete needed around 1,500 workers more to finish the power house, where the main work was left, with some finishing work on the dam and the Head Race Tunnel.

A big concern for the government was the piling delay costs in the form of arrears for contractors, idling charges, loan interest during construction, and establishment costs. As a result, from around February 2021, the government started allowing in foreign workers for the hydro projects. 

The Cabinet Secretary said the country had to bring in a few thousand workers for hydro projects and various construction projects, and since Phuentsholing and Gelephu did not have enough space, they had to construct the quarantine center in Wangdue for the hydropower workers.

He said another reason that the quarantine center had to come up was because many quarantine centers in Phuentsholing and Gelephu were occupied by those doing the 7-day quarantine to go to low risk areas.

When the P-II project required workers, they would write to the Ministry of Economic Affairs who would process the request. Lyonpo Loknath Sharma said they can’t help but get workers for the project, and the foreign workers had to be quarantined in Wangdue, as there was no space in Gelephu.

He said it is still not known how the virus leaked out from the quarantine center, but the water tanker driver could be a key link.

The Prime Minister Dasho (Dr) Lotay Tshering said that despite the measures at the P-II quarantine center the government is not denying that there was some breach.

He said with the large number of the workers turning positive, it also lead to the frontline workers there turning positive probably due to the high viral load in the facility.

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