Thimphu City

Main worry is for unexposed and high density Thimphu as most Bhutanese are likely to get infected in coming months

Phuentsholing is not a concern given that around 60 to 70% are estimated to have been infected over time

Bhutan opening now to take advantage of highest vaccine and booster efficacy of 10 weeks

Countries who controlled COVID-19 like Bhutan are now seeing record cases and deaths as they open up

The Prime Minister in a blunt and frank press conference on Monday 14 March made it clear most of the 700,000 Bhutanese will be infected with Omicron (see story on page 3).

The Foreign Minister Lyonpo Dr Tandi Dorji said that after vaccination and without restrictions the R number (spreading power) of Omicron is around 7 to 10 which means it may double every 7 or 10 days.

The minister said that once the lockdown is lifted completely, in the worse case scenario of restrictions not being followed, the majority of Thimphu could be infected within 14 days.  It would be longer with restrictions, but most residents would anyhow be infected.

Lyonpo said that for the other parts of the country it would depend area wise as exact predictions cannot be given since there are different gewogs and villages which are different.

The minister, however, said that within the next two to three months, if there are no restrictions then the majority of the Bhutanese population would be infected.

He said in Thimphu from the current numbers of around 100 plus a day it would first jump to 500 to 600 cases a day and then after that thousands per day once all relaxations happen and people can move across mega zones.

Already the virus has reached 18 Dzongkhags in this outbreak with cases yet to be detected from Trashigang and Gasa only.

The Technical Advisory Group had earlier given a projection of either a very conservative national infection rate of 5 percent which is 29,573 more Bhutanese being infected, 143 cases requiring hospitalization, 10 Intensive unit Care cases and 8 more deaths or around 15 percent on the higher side which is 88,500 infected Bhutanese, 715 hospitalized and 24 more deaths.

However, even this figure by the TAG was debated within the National COVID-19 Taskforce as many senior government officials feel the actual infection rates will be much higher.

Here the Technical Advisory Group (TAG) member Dr Tshokey said that if people go around not wearing masks, not maintaining social distancing and crowding then the virus would infect Thimphu rapidly as pointed out by the Foreign Minister.

He said Omicron is 33 to 34 times more transmissible than Delta and they have found that the secondary attack rate of Omicron in families is 100 percent meaning that 100 percent of the family turns positive.

He says only in instances where the primary index case is caught early then only one to two family members are spared with the attack rate being around 90 percent.

Thimphu is a worry

Lyonpo said that of all the places the main worry is for Thimphu and the expectation is that if things go well in Thimphu then it will be the same for other Dzongkhags too.

He said Thimphu is a worry given the large size of the population here which comes to 120,000 to 130,000. He said that the capital also has a large population of elderly people and co morbid people who are here in the capital since the medical facilities are here.

A major reason for worry for Thimphu is that its population is mainly a naïve population or one that has not encountered the virus before and so do not have the hybrid immunity of both an infection and the vaccine.

Lyonpo said there is similar concern for other northern population areas like Paro etc where there has been not much contact with the virus.

Dr Tshokey said they are worried about Thimphu given the close density of a large population. He said there are many parts of the city where people live in camps or shared bathrooms and here the virus really spreads and it is not possible to isolate a family member.

He said Thimphu is risky since the JDWNRH is here and so there are all types of patients from those getting chemotherapy for cancer to other co morbidities.

Why we should worry less about Phuentsholing and Southern areas

By contrast the government is not as worried for the southern areas like Phuentsholing which is why the restrictions are also being lifted faster there. Lyonpo said that in Phuentsholing by now around 70 percent of the city must have been infected, with many not even knowing they got the virus.

The other issue of Phuentsholing is it saw the highest rate of infections in past outbreaks and so has developed a certain natural immunity.

Dr Tshokey giving an example of Phuentsholing and Samdrupjongkhar said that at at least around 60 to 70 percent of the people there are infected. He said one can make this out as when 100 people are called with one from every household then around 60 to 70 percent test positive and so it can be assumed that the rest of the family are also all positive since Omicron is very transmissible.

How Omicron is behaving in countries that adopted Bhutan like measures

A point of concern for Bhutan would be to see how countries or territories that, like Bhutan, had low infection rates in the past and high vaccination rates like New Zealand, South Korea, Singapore and Hong Kong are doing.

Dr Vincent Rajkumar, the Editor-in-Chief of the Blood Cancer Journal and Professor of Mayo Clinic pointed out that South Korea was very successful in curbing cases and deaths in the last two years with 75% vaccination.

However, he points out that when Omicron enters a country that has not had high infections before, as in the case of South Korea, both the cases and deaths are soaring to record levels.

South Korea had a 7-day average of 2,205 cases and 16 deaths every day in 8 November 2021, but on 16 March it had a 7-day average of 387,377 cases and 262 deaths every day.

He says Omicron is not mild as even in a well vaccinated population like South Korea, it is causing deaths.

Vincent says Omicron is deceptive because when a lot of vulnerable people have already died over the two years and a large proportion of the population had prior COVID, then Omicron appears mild.

He says, “You see its true face when an immunologically naïve population meets it. As we do now in South Korea.” He says prior infection provides protection which is why populations like South Korea, China and New Zealand are more vulnerable.

He points out that high vaccination rates and booster rates help keep serious disease, hospitalization and deaths lower, but as seen in South Korea despites vaccination there are vulnerable people, especially the elderly, immunocompromised and children who have not been vaccinated.

According to Dr Vincent cases and deaths go up when relaxations are removed. However, the Doctor also puts in two important qualifiers.

He says that while vaccines are less effective in preventing infection they have a huge protective effect in preventing deaths and hospitalizations.

The second point is that countries like South Korea and others have prevented far more deaths and illness than others like USA and UK in the last two years due to controlling COVID’s many waves.

Singapore on 29 December 2021 had a 7-day average of 290 cases and 1 death everyday and as of 16 march it has 12,859 cases and 9 deaths everyday.

New Zealand as of 29 January 2022 had a 7-day average of 105 cases and no death everyday and on 16 March it was 21,675 cases and 10 deaths per day.

Hong Kong on 24 January 2022 had a 7-day average of 40 cases every day and no deaths and on 16 March it was 15,836 cases and 283 deaths every day.

The territory despite having a high vaccination rate has seen much higher deaths due to the majority of the elderly above 80 there not being vaccinated. Also, Hong Kong had not had earlier waves and had largely kept the virus out.

In terms of the risk to Children between 5 and 12 recently, 375 children from the ages of 0 to 5 were hospitalized in the UK which is a 58% jump in a week.

Denmark is well known for removing restrictions. On 30th October 2021 it had a 7-day average of 1,598 cases with 2 deaths per day and on 16 March it has 9,901 cases with 36 deaths per day.

Denmark’s still continues to see a lot of excess deaths even 6 weeks after it declared ‘Freedom Day’ lifting restrictions. Its CDC has also been criticized for trying to hide or undeplay excess deaths.

Deaths in South Africa which declared itself as having overcome Omicron is also rising again.

In addition to the above, there is a global surge of COVID-19 due to the BA.2 variant.

Bhutan opening up to take advantage of maximum vaccine efficiency period

Lyonpo Tandi said that in the case of Bhutan an advantage is that the vaccination rate is very high including among the elderly and co morbid. He also said that the highest level of protection after a booster dose is for 10 weeks and so Bhutan is opening up at the right time.

He said the vaccines which came in on Saturday can be given to the elderly and vulnerable as the fourth dose. He pointed that most countries have not even given the fourth dose and many countries have not even given the third dose.

He said the mistake in some places was that the elderly people were not vaccinated adequately while in other places they took too long to open after the booster dose.

Children from 5 to 11 are expected to get their second dose soon while those from 12 to 18 are getting their booster doses.

COVID protocols to continue

The minister said Bhutan is not ‘living with the virus,’ and so to protect the co morbid and elderly apart from the fourth booster dose the various restrictions like mask mandates and preventing gatherings would continue.

He said that most deaths in COVID happened due to complications arising from infections, heart failure, and respiratory failure so the government had procured drugs to deal with this.

The minister also stressed on the importance of good ventilation in offices and other places.

He said for remote rural areas, medical teams have been deployed across the country and the helicopter services will also be used.

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