Sample collection

What went wrong in Phuentsholing

56 confirmed to test positive for antibodies of 10,282 samples

43 are DANTAK cases

Phuentsholing is staring at a massive COVID-19 problem as of Monday with 41 Mini Dry Port (MDP) linked local transmission cases and  community survelliance cases.

Of the 62 community survelliance cases 43 are Dantak and 1 is IMTRAT showing the DANTAK camp to have the largest cluster of cases.

More cases are expected in the coming days as while around 25,000 samples have been collected testing is still going on for them with additional sample collection and contact tracing.

The problem was first spotted in the MDP on 12th August when a 25-year-old loader tested positive sending alarm bells.

Subsequent contact tracing and testing showed a total of 41 MDP linked cases of which around half were loaders and the rest were non loaders and consisted of people who mainly work at the MDP itself and their immediate family members.

However, the question now is how was there a massive spread in the MDP when the standard operating procedures put in place by revenue and customs at the MDP was to clearly avoid any contact with Indian drivers.

Here, a health official who is part of the testing team in Phuentsholing said he had heard that due to the summer heat some of the loaders may not have been in masks and gloves as mandated.

This could have been a crucial mistake that may have allowed the initial entry of the virus into the MDP.

Also, while the SOP was in place, there are already question marks on how strictly it was complied with and implemented.

During the MoH contact tracing the MDP staff claimed that they did not move out of their residence, however, here again, in the absence of strong monitoring it is difficult to know if none of them moved out.

Officials have already said that while the MDP loaders say they did not move out the possibility of a few of them moving out cannot be discounted.

The MDP later became a cluster of contacts, and MoH found out there were a little over 1,000 people interlinked to each other. Most of them were loaders and their immediate family members.   

Some of the contacts moved out after their contract term was over or after resigning from MDP. The contacts reached 12 different Dzongkhags leading to 5 cases in Paro.

The rest of all the first contacts of which around the maximum came to Thimphu at around 5,000 all tested negative.

The official said that going forward Bhutan will still have to import essentials through the MDP and so measures must be put in place and the SOP enhanced to prevent another transmission via the MDP.

However, more worrying than the MDP cases are the 62 community surveillance cases in Phuentsholing which started with 5 cases that jumped to 6 cases and then rapidly to 23 cases  to 25 cases and now 62 within a short span of time.

When asked about the source of infection for the community survelliance cases so far, while there are approximate ideas and links on where people went or stayed there is no definitive answer yet.

The MoH said, “People working in different places or where they visited does not guarantee the source of infection. MOH is still trying to find out the source of infection, whether it was imported or was already prevalent in the community.”

The MoH official who is with the testing teams in Phuentsholing said, “The community surveillance shows that there were hidden cases in the community.”

Giving a broad probable cause of the spread he said, “People did not follow public health measures like keeping social distance and wearing face masks despite repeated table top awareness campaigns.”

Given that Phuentsholing was always a high risk area it is a matter of concern that facemasks were not made mandatory in the area a long while ago.

However, coming to facemasks the approach of the government itself has been quite lukewarm to facemasks.

After the first case struck Bhutan in March large numbers of Bhutanese wore face masks but then following WHO advice the government at the time said that it should only be used by medical staff and those who have symptoms.

The concern at the time was driven by the WHO messaging to prevent a shortage of masks for medical staff though in the case of Bhutan the facemasks of medical staff were imported from government procurement and is not linked to private supply in medical shops.

Literature and articles including by this paper on the importance and effectiveness of using facemasks to prevent community transmission were dismissed.

An ambivalent attitude prevailed towards face masks for months and this combined with a growing sense of general complacency saw the usage of masks became a rarity when this time could have been used to build a mask wearing and social distancing culture.

Many people even questioned the need to wear face masks until community transmission is detected.

The result was that when the government started bringing in restrictive measures including recommendations on wearing face masks it was mostly not followed by the people and even the government itself. On 19th June the Prime Minister as part of these measures recommended the use of face masks in gatherings. However, ministers and senior officials themselves did not wear masks in gatherings.

On 9th July a circular of the MoH said that that wearing of face masks in gatherings is mandatory due to the WHO finally saying COVID-19 transmission can possibly happen through the airborne route.

However, the ambivalence to wearing masks was again seen when even large government gatherings with ministers and senior executives saw the majority turning up without masks.

Like masks, despite reminders and even orders, people did not practice social distancing. Large numbers of youth could be seen hanging together in big groups.

Ultimately the lack of a facemask wearing culture and effective social distancing may have contributed to the large number of MDP and community surveillance cases in Phuentsholing.

Apart from the community surveillance cases another indication that the virus had been circulating in Phuentsholing is the number of those who tested positive for Immunoglobulin M (IgM) and Immunoglobin G (IgG) antibodies on the Rapid Diagnostic Test (RDT) kits. 

The above antibodies are produced in reaction to the body fighting COVID-19 with IgM being the first to emerge and the IgG coming later but lasting for a longer time.

Initial tests picked up a large number of people testing positive antibodies. For example, two samples of around 3,630 people saw 66 testing positive on the RDT. However, when this 66 and another 11 at a total of 77 were sent for confirmatory testing for antibodies in RCDC, called the ELISA test, only 11 were confirmed to have antibodies.

Similarly, of the 10,282 samples from 15th to 21st August there were a large number of initial RDT positive cases. Once these were sent to RCDC for the ELISA test only 56 were confirmed to have antibodies. The majority of these antibodies were the IgG which usually takes 14 to 21 days to appear as compared to IgM which takes 7 to 14 days to appear.

The 56, however, were not active COVID-19 cases as they tested negative on the RT-PCR.

On Friday a new element entered the picture when the health minister revealed that of the 25 community transmission cases in Phuentsholing 16 were from Dantak and 1 was from IMTRAT.

This means that only 8 cases were local Bhutanese in Phuentsholing until then.

Then Saturday morning this 25 jumped to 33 with 8 new community surveillance cases.

Sunday saw 27 DANTAK cases taking it to 60 and then two frontline workers on Monday morning who came in touch  taking it to 62.

So, of the 62 cases only 18 are locals.

Though the health minister said the DANTAK case is a contained cluster there are already questions on if it played a role in spreading the virus in Phuentsholing. 

There are a lot of Bhutanese voices on social media now blaming DANTAK for bringing in COVID-19 into Phuentsholing though the MoH has not confimed this.

However, everything is also not as bleak as it appears as the mass testing in Phuentsholing may have just come in the nick of time.

The health official said that on the bright side from the results so far the transmission in Phuentsholing has been detected at a relatively early stage and it is not widespread.

He said the virus must have entered Phuentsholing a week or two before the national lockdown and the lockdown in that sense has been very helpful in containing the spread.

He said that the large sero-survelliance of 16,450 samples focused mainly in the south also showed that there was no large scale national transmission.

Also given that 25,000 samples were taken and more than half the test results have come, the positive cases so far represent only a fraction of the total cases which again shows that it is not widespread.

In effect the sealing of the border and various early measures held off the virus for a long period that allowed Bhutan to prepare and even when it came, it could be detected, traced and contained with no human casualty so far.

By comparison and to put things into perspective a recent sero-survey in Delhi showed that 29 percent of the people had got exposed to the virus.

The prevalence rate in Phuentsholing is currently 0.4 percent of 25,000 samples collected even if all the MDP and Community Surveillance cases are added up. 

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