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As of Monday morning there are a total of 40 local transmission cases originating from Phuentsholing which includes 28 cases linked to the 25-year-old index case found on August 12th in the Mini Dry Port after he had symptoms and got tested.
Of the 40 cases above, five cases in Paro are either primary or secondary contacts of the Phuentsholing case. There is one primary contact in Thimphu who has tested positive too.
However, a more worrying number is that of the 40 cases it now includes 6 cases caught from community surveillance in Phuentsholing who have had no direct contact with the MDP cases.
Another worrying number is that of the 76 people detected with antibodies in Phuentsholing a more accurate ELISA test was run and around 11 came back positive which means that they were probably exposed to the COVID-19 virus and recovered.
In addition to this of the 2,203 samples collected on 18th August another 21 have tested positive for antibodies, but they are yet to be retested for ELISA to eliminate possible false positives.
The Rapid Diagnostic Test (RDT) kit results for antibodies of the 2,654 samples collected on 19th August are yet to come.
The Prime Minister and Health Minister have already acknowledged community transmission in Phuentsholing.
However, an important context is that as of Thursday evening around 11,704 RT-PCR tests have been done as part of the community surveillance and only six have come positive which shows that while there is community transmission in Phuentsholing it is not as widespread as initially thought.
The first big question is how the virus entered Phuentsholing in the first place and when did it come in.
A member of the Technical Advisory Group (TAG) currently based in Phuentsholing said that it can be conclusively said for now that the cases came mainly from transshipment areas where goods were loaded from Indian trucks and put on Bhutanese ones.
He said that the majority of the cases are from the MDP or its contacts. The member said that even of the 6 community surveillance cases two had gone to the RRCO and spent two hours there when the lights went out.
A third one who was detected in the flu clinic lived near the MDP area and another two were from a private warehouse.
The TAG member said that it is clear that the virus is in people in and around those connected to the transshipment of goods. He said these transshipment areas acted as a bridge for the virus to come in.
A mystery case is the sixth positive case from the community surveillance in the form of a 36-year-old man detected on 20th August. Here the TAG member said that if the case is related in some way to the MDP, RRCO or even the private ware house then there is not much cause for worry, but if this sixth case has got the infection from a new source then it would be cause for worry and MoH would have to investigate.
So far all those who have tested positive in the MDP case are loaders and their contacts.
As to how specifically the virus came in he said that while the 25-year-old loader is the index case he is not the primary case or the source which is likely to be an Indian driver.
He said that the loaders must have come in touch with an infected driver and it could have been transmitted through a cough or the sharing of small items like tobacco and the non washing of hands.
The TAG member said that the it is highly unlikely that the loader was infected through the goods.
He said that as per international medical literature including by the CDC of the USA surface food contamination is very minimal and it can only happen if there are a large number of touching a door knob in a conference and people do not wash their hands.
He said even in the case of the food there are only rare cases with one being COVID-19 traces found on a salmon chopping board and another in the case of New Zealand where an outbreak after a long pause was blamed on import of frozen food.
However, in the New Zealand case the frozen food theory has been ruled out by authorities.
China, however, recently reported COVID-19 traces on frozen chicken wings from Brazil. But tests of those who came in contact with the wings showed everyone to be negative.
Once the virus reached the loaders the initial claims that all of them had stayed on their base and did not move out is not true.
While doing contact tracing the MoH teams found that a couple of them had left the camp but then again they tested RDT negative.
The quarantine system for the loaders was not a very strict one and so more may have moved out into the main population and had some interactions as they are mostly young.
The other question is on how recent are the cases that came to Phuentsholing.
Here the TAG member said that going by the testing so far and the MDP cases the probable date of entry of the virus may not be before 1st August 2020. He said that the MDP cases also did not have antibodies to show an earlier entry of the virus.
He said that the IgM antibodies would show up between 7 to 14 days and IgG antibodies from 14 to 21 days in general.
While the MDP cases and the 6 surveillance cases support the theory of the recent entry of the virus what is puzzling are the large number of cases that tested positive for antibodies in the community surveillance.
So far around 97 have tested positive for antibodies on the RDT test kits while testing negative for COVID-19.
The RCDC ran a more accurate ELISA test to rule out cross reactivity with other types of antibodies or errors on the 76 tests and the ELISA tests now show that 11 of the 76 have confirmed antibodies.
However, the 76 testing positive are from earlier samples and the 21 RDT positive from the 18th August is yet to undergo ELISA tests while the RDT results from the 19th and 20th August samples are awaited given how busy the labs are
The TAG member explaining why a large number of the 76 cases failed the ELISA test said they were false positive tests as the same people may have been exposed to Dengue.
He said that even for the 11 who have been confirmed to have antibodies specific to COVID he said though the makers of ELISA claim a high degree of accuracy it cannot be considered to be 100 percent accurate.
He said that the only 11 of the antibodies test coming out as positive through ELISA and a limited number of community surveillance cases (6) coming out positive so far is good news, though more has to be known about the origins of the sixth community surveillance case.
Even the sole woman who had tested positive for IgG in the RDT mass surveillance test from 30 July to 4th August (of 16,450 samples) came out negative when her result was run through the ELISA test.
He said that the above shows the virus is not widespread and it has come in relatively recently. He said that final outcome would depend on the mass testing right now which in the first phase will test two members of every household.
He pointed out that the lockdown had come at the right time starting from 11th August as it had frozen movement and restricted the spread of the virus.
The TAG official said that testing the entire Phuentsholing population will take another 10 to 15 days.
There are twenty teams with each team consisting of 5 people who are 2 lab technicians dressed in full PPE who collect the samples, 2 Dessups in N-95 masks and PPE for the head and 1 driver which is a total of 100 people going around Phuentsholing collecting samples.
The TAG member said that the challenge is not only in sample collection but also in testing as it takes time for the RT-PCR results to come with such a large number of tests.
He said that the staff at the RCDC and Phuentsholing Hospital have been working around the clock.
The Phuentsholing hospital focuses on testing the primary contacts of the Phuentsholing cases while RCDC in Thimphu are testing the community surveillance tests.
The TAG member said that despite workload, risk and the long hours the staff collecting the samples and doing the tests are very idealistic and energetic in doing their work.
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