Lyonchhen Dr Lotay Tshering at COVID-19 Press Briefing

Partner tests positive 14 days into quarantine, 19 days into entering Bhutan and 28 days after 1st contact with index case

Guide and driver who tested negative to continue the quarantine

One major problem of the COVID-19 virus is that given that it is a new virus there is still no clear global understanding on how it behaves or when it shows up in tests.

The common wisdom was that some symptoms would manifest itself within two weeks and this is why a two-week quarantine period was kept.

However, the unpredictable nature of the virus made itself known when the partner of the index case, in the form of the American tourist, tested positive on Friday after three earlier tests showed her to be negative. The test came positive on her last day of quarantine when she was supposed to be released.

The lady was in quarantine in Paro but after the test she was moved to the isolation section of the JDWNRH.

This case now throws up some questions, issues and challenges for the government and Bhutanese at large.

This is because the travel history of the index patient and his female partner, who now tested positive, show that they had met each other on 22nd February 2020 a full 28 days up to today.

The index case had taken a flight from Mumbai to Kolkata on 21st February and his partner had taken a flight from Delhi to Kolkata on the same day. On the 22nd  they reached Assam by flight and from there on the 23rd they took a 7-day river cruise on the Brahmaputra to reach Guwahati on 1st March.

The travel history shows that the index case and his partner landed in Bhutan on 2nd March and he showed symptoms of a bloated abdomen (dyspeptic symptoms) and nausea on the evening of the same day and had to go for a OPD visit in JDWNRH.

This is a full 19 days up to the lady testing positive.

On 5th March he returned from Punakha and had to be hospitalized after which he tested positive for COVID-19.

With the partner testing negative thrice before and showing a positive result only on the 14th day of quarantine; 19th day of coming to Bhutan and the index patient showing symptoms; and 28th day of first major contact in Assam with the index patient there are now questions on how long the virus takes to show on tests given an international report in Hubei province of a delayed incubation period of 27 days.

Of the 62 in quarantine around 40 have finished their quarantine and have tested negative for the fourth time before their release.

Travel of the lady

The lady, unlike the index case, had no symptoms and so she moved around freely. As per the first press briefing on 6th March by the Health Minister while the index case was not well and stayed in the room on 2nd March, the lady moved around a bit in Thimphu and went to Ziluka Anim Dratshang and the Handicraft market.

On 3rd March the lady undertook a Cheri hike, visited Buddha Point and went to Changlimithang.

On the 4th the lady went to Punakha and while in Punakha on the 5th  of March she visited the Punakha Dromchoe and then she came back to Thimphu on the 5th and did not move around much.

A person in the tourism industry said those people who went to these places on the same day and around the same time should do self-quarantine. He said that he is particularly concerned with the proximity of the partner to the packed crowds in the Punakha Dromchoe and also in Thimphu.

Here, the Health Minister Lyonpo Dechen Wangmo clarified that 29 people who were in immediate contact with the lady are already in quarantine.

She said as to those people in the Dromchoe, Buddha Point or Changlimithang they would have only been exposed to her if they were within a range of one meter from her for a prolonged period of around 15 minutes. She also said that it will be impossible to trace such contacts even if they were there.

She said that she does not recommend self quarantine for people who were there on that day, but she can only offer general advice like calling if people have symptoms and then based on the risks a test can be done. She asked people to observe the general medical advice like hand washing, cough etiquette and avoiding big gatherings.

Since the partner of the American tourist who tested positive had visited the Zilukha Anim Dratshang and also the handicraft bazar in Thimphu and spent some time there, the MoH said that it is in constant touch with the people there who got in touch with the lady to check for symptoms or any other developments.

However, the MoH is also taking into account the fact that the woman tested negative three times and positive on the 14th day of quarantine which means her viral load was very low and so the chances of transmission were low.

Transmission requires a high viral load.

The other factor was that the woman, was asymptomatic, until recently which means she would not have been coughing or sneezing to spread the virus through those means.

The Foreign Minister said the guide and driver testing negative itself is an indication.

PM clarifies

The Prime Minister announced that the quarantine period of the partner, guide and driver finished on Friday and they were due for release which is why a final test was done.

However, in the report that came the partner tested positive while the driver and guide tested negative.

The PM said that there is no reason for worry as the lady is not showing any symptoms and that from the day the index patient tested positive she was put in quarantine.

Lyonchhen said that if the woman had tested negative then preparations had been made to send her home but now as per the protocol this cannot happen and she has to stay back and undergo symptomatic treatment unless she is negative.

The PM initially announced that since the guide and driver had tested negative for the fourth time they have the option of going for home quarantine and reporting any symptoms or continue using the current facility at Royal Institute of Tourism and Hospitality (RITH). However, an hour later the PMO said, “After thorough review and consideration of international best practices, it has been decided that the guide and the driver will continue to stay at the quarantine facility in Mothithang.”

The PM said that so far 40 of them who were released all tested negative except for the partner. The PM said that the test of the partner had been rechecked.

Lyonchhen clarified that the lady’s case is not a new case that has come to Bhutan but it was there from earlier and there is no risk to Bhutan from her case.

The PM also clarified the difference in earlier and current results of the lady is not due to the test kits and machines.

Lyonchhen said that the lady will now be shifted from the quarantine center to the isolation ward in the hospital and she will be monitored for her symptoms and treated accordingly as there is no medicine which can cure the virus.

He said that it is not like a new case has come into Bhutan as she has been in quarantine and the only people in touch with her are the health staff and they wear protective clothing. He said that the medical team who treated the index case are all in quarantine.

The PM said that with the lady testing positive a medical team will have to be identified who will take care of them and even they will undergo quarantine.

The PM said that the country is still in the preventative stage to stop the entry of COVID-19 into the country.

On doubts over the veracity of the test the PM said that in such a case the people’s faith in the test should be strengthened more because it said negative three times and then tested positive when the virus showed up in her system.

Lyonchhen said that those who were in touch with her like the guide and driver are still negative today. He said, however, he does not know for sure that if they will remain negative because while checking it is not due to the testing equipment or the skills of the ones doing the test but it is the nature of the test.

“No test is 100 percent specific but this test is highly highly sensitive,” said the PM. He said that it is not a 100 percent test but is highly sensitive which is also the international practice.

He said that once a test comes positive then it is reconfirmed once but if it comes negative then it is tested again and again.

The PM said that the testing and the results is routine and it is nothing to worry about or panic about as it is as routine as having three meals a day.

Responding to a question on if Bhutan would shift from the orange to the red zone the Prime Minister said that there will be no change in the status.

He said that an important aspect is that all the people who had first contact with the lady are already in quarantine and so there is no need to do additional work on this.

He said this is not a new COVID-19 case coming into the country and so the risks have not changed.

He said the risk to the country remains the same and he said that instead the biggest danger is the worsening international situation and as it reaches closer to Bhutan’s borders and the danger of it crossing into Bhutan.

He said that Bhutan is still in a preventive mode and one step the government. Lyonchhen clarified if the virus comes into the country then the strategy will shift from prevention to containment and stopping the cases from spreading within the country. He said since Bhutan is in the prevention stage this is why the schools have been shut and movement from outside the country into Bhutan has been restricted.

The PM also said that while in quarantine the lady was treated like she had the virus and so there were no lapses on the part of health officials in dealing with her. “Those who are in quarantine must be considered positive unless proven otherwise and so there is no worry,” said the PM.

The PM said that if the tour guide and the driver do not show any symptoms in the coming days then it can be considered that they are negative.

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