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Understanding COVID-19 in Nepal

Affiliation.

1 Sukraraj Tropical and Infectious Disease Hospital, Teku, Kathmandu, Nepal.
PMID: 32335607
DOI: 10.33314/jnhrc.v18i1.2629

The novel coronavirus COVID-19 (SARS-CoV-2) was first reported in 31 December 2019 in Wuhan City, China. The first case of COVID-19 was officially announced on 24 January, 2020, in Nepal. Nine COVID-19 cases have been reported in Nepal. We aim to describe our experiences of COVID-19 patients in Nepal. Keywords: COVID-19; experience; Nepal.

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REVIEW article

Combating the covid-19 pandemic: experiences of the first wave from nepal.

$\nBuddha Bahadur Basnet&#x;$

1 Faculty of Science, Nepal Academy of Science and Technology, Lalitpur, Nepal
2 Nepal Environment and Development Consultant Pvt. Ltd., Kathmandu, Nepal
3 Central Department of Environmental Science, Institute of Science and Technology, Tribhuvan University, Kathmandu, Nepal
4 Nepal Development Society, Bharatpur, Nepal
5 Kantipur Dental College Teaching Hospital and Research Center, Kathmandu University, Kathmandu, Nepal
6 National Disaster Risk Reduction Centre, Kathmandu, Nepal
7 Little Buddha College of Health Sciences, Kathmandu, Nepal

Unprecedented and unforeseen highly infectious Coronavirus Disease 2019 (COVID-19) has become a significant public health concern for most of the countries worldwide, including Nepal, and it is spreading rapidly. Undoubtedly, every nation has taken maximum initiative measures to break the transmission chain of the virus. This review presents a retrospective analysis of the COVID-19 pandemic in Nepal, analyzing the actions taken by the Government of Nepal (GoN) to inform future decisions. Data used in this article were extracted from relevant reports and websites of the Ministry of Health and Population (MoHP) of Nepal and the WHO. As of January 22, 2021, the highest numbers of cases were reported in the megacity of the hilly region, Kathmandu district (population = 1,744,240), and Bagmati province. The cured and death rates of the disease among the tested population are ~98.00 and ~0.74%, respectively. Higher numbers of infected cases were observed in the age group 21–30, with an overall male to female death ratio of 2.33. With suggestions and recommendations from high-level coordination committees and experts, GoN has enacted several measures: promoting universal personal protection, physical distancing, localized lockdowns, travel restrictions, isolation, and selective quarantine. In addition, GoN formulated and distributed several guidelines/protocols for managing COVID-19 patients and vaccination programs. Despite robust preventive efforts by GoN, pandemic scenario in Nepal is, yet, to be controlled completely. This review could be helpful for the current and future effective outbreak preparedness, responses, and management of the pandemic situations and prepare necessary strategies, especially in countries with similar socio-cultural and economic status.

Introduction

The unanticipated outbreak of the novel coronavirus was first reported in Wuhan, China, in December 2019; it transmits from human to human via droplets and aerosol ( 1 ). The WHO declared Coronavirus Disease 2019 (COVID-19) as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020, and a pandemic on March 11, 2020 ( 2 ). As a result, countries worldwide adopted various mitigative measures ( 3 , 4 ) and eradication strategies ( 5 ), aiming to reduce potentially enormous damage and reach zero cases, respectively. However, significant gaps in advance preparedness and the implementation of response plans resulted in the rapid spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) globally with 219 nations reporting it as of January 22, 2021 1 ( 6 ).

The Federal Democratic Republic of Nepal is a landlocked country in South Asia bordered by India in the south, east, and west, and China in the north. Its population, gross domestic product (GDP), and human development index (HDI) are 29.24 million 2 , 30.64 billion 3 , and 0.579 4 , respectively. The constitution of Nepal (2015) consists of a three-tier (federal, province, and local) governmental system. Each tier has the constitutional power to enact laws and mobilize its resources. In Nepal, the first case of COVID-19 was reported on January 23, 2020, in a 32-year-old Nepalese man who returned from Wuhan, China. Two months after the first case, the second case was diagnosed through domestic testing on March 23 in a returnee from France ( 7 ). Subsequently, the Government of Nepal (GoN) imposed early interventions approved by the WHO, including a travel ban and the Indo-Nepal and China-Nepal borders closure 5 . ( 8 ) to delay the possible onset of the detrimental effects of the outbreak across the country.

This review presents a 1-year (up to January 22, 2021) scenario of COVID-19 in Nepal, reviews the strategies employed by the GoN to control COVID-19, and provides suggestions for the prevention and control of current and future pandemics. Federal, provincial, and district-level daily cases of COVID-19 [confirmed by real-time PCR (qRT-PCR), cured, and death] in Nepal from January 23, 2020, to January 22, 2021, were obtained from the Ministry of Health and Population (MoHP), GoN 6 . Searches using the website of MoHP of Nepal, PubMed, the WHO, the worldometer official website, and Google were conducted to gather the information on the number of deaths, cured, and confirmed cases of COVID-19 and reports describing the approach taken by the government to contain COVID-19 in Nepal. The search terms included “COVID-19 in Nepal” and “Prevention and management of COVID-19 in Nepal.” Data used in this article were extracted from relevant documents and websites. The figures were constructed by using Origin 2016 and GIS 10.4.1. We did not consult any databases that are privately owned or inaccessible to the public.

Epidemic Status of COVID-19 in Nepal

The MoHP of Nepal confirmed the first and second cases of COVID-19, respectively, in January and March, in an interval of 2 months 1 ( 9 ). As of January 22, 2021, 268,948 COVID-19 positive cases were reported, with 263,546 recovered, and 1,986 death cases 6 . This data showed nearly 0.74% death and about 98% recovery rate in Nepal. The case fatality rate (CFR) was 0.5% up to March 30 in Nepal ( 9 ). The CFR in the USA, Brazil, and Russia is similar (~2%), whereas in the South Asian Association of Regional Cooperation (SAARC) countries, the CFR varied from ~0.09 to ~4.7 % ( Table 1 ). In total, 2,035,301 qRT-PCR tests were performed in Nepal, indicating about 13.47% current prevalence of COVID-19 among the qRT-PCR tested population as compared with 2.5% as of March 31, 2020 2 . As of reviewing, the prevalence of COVID-19 among the qRT-PCR tested population is higher than the neighboring countries, China (~0.055%) and India (~0.099%) ( Table 1 ). In addition, up to the third quarter of 2020, <1% of the confirmed COVID-19 cases were symptomatic across all age groups, while the proportion of symptomatic cases progressively increased beyond 55 years of age from 1.3 to 9% 7 , 8 . Unlike Nepal, higher symptomatic cases were reported from other parts of the world during the same period ( 10 ). Understandably, the scenario of the proportion of symptomatic to asymptomatic cases remains to vary between countries and care facilities. Few possible reasons for low symptomatic cases reported in the Nepalese population may be poor health-seeking behavior and utilization of tertiary health care services ( 11 ) for mild symptomatic cases, home isolation without a diagnosis, and a high rate of self-medication practices ( 12 ).

Table 1 . Prevalence and case fatality ratio (CFR) of COVID-19 of top leading countries, neighbor countries of Nepal, and SAARC as of Jan 28, 2021.

Among the provinces, Bagmati province ( n = 144,278) has the highest number of confirmed cases in Nepal, followed by province no. 1 ( n = 30,422) and Lumbini ( n = 30,308) ( Figure 1A ). As depicted in Table 2 , the confirmed cases of COVID-19 are distributed throughout the country in all the administrative districts. The total number of confirmed cases is highest in the Kathmandu district ( n = 103,523) followed by Lalitpur ( n = 16,106), Morang ( n = 13,236), and Rupandehi ( n = 9,708) districts and lowest in Manang ( n = 20), Mugu ( n = 37), Mustang ( n = 43), and Humla ( n = 44) districts ( Table 2 ).

Figure 1 . Overview of COVID-19 cases in Nepal up to January 22, 2021. (A) Province-wise distribution of total confirmed cases, recovery, and deaths; (B) Gender, age-wise distribution of COVID-19 confirmed cases; (C) Gender-age wise distribution of COVID-19 death cases; and (D) Age and gender-wise case fatality rate (CFR) in Nepal.

Table 2 . District wise distribution of confirmed cases, recoveries, and deaths due to COVID-19 and total population in Nepal.

Among 268,948 confirmed cases, 174,193 were males, and 94,755 were females, with a male-to-female sex ratio of 1.85. The largest number of infected cases was reported in the age group 21–30 years (26.92%, n = 72,396), followed by the age group of 31–40 years (26.26%, n = 70,648) ( Figure 1B ); however, the number of death cases was higher in the age group 61–70 (23%, n = 458) ( Figure 1C ). A higher death trend in old age is also observed in Europe, America, and Asian countries ( 13 , 14 ). Overall, male death was ~2.33 times the death rate of females. Reports have indicated that men are at greater risk of around two time of acquiring severe outcomes of COVID-19, including hospitalizations, intensive care unit (ICU) admissions, and deaths ( 15 ). The enhanced susceptibility of males for COVID-19 associated adverse events may be correlated with the hormonal and immunological differences between males and females ( 15 , 16 ). Among a total of 1,986 fatal cases (Male: n = 1,391; female: n = 595), over half ( n = 1,166) were observed in senior adults (≥60 years). One early study among the Nepalese children suggested that male children were more commonly infected than female children ( 17 ).

Among 1,986 fatal cases (mean age: 66.15 years), 623 (31.37%), 721 (36.30%), and 642 (32.32%) were with no report of comorbidities, with single comorbidities, and with multiple comorbidities, respectively. In cases with single comorbidities, the highest incidence was reported in respiratory disease ( n = 184) followed by hypertension ( n = 117), renal disease ( n = 107), diabetes ( n = 77), liver disease ( n = 44), and cardiovascular disease ( n = 36) ( Figure 2 ). Similar results are reported from other parts of the world ( 18 ). The detailed epidemiological trend analysis of COVID-19 in Nepal is shown in Figure 3 .

Figure 2 . Age and gender-wise distribution fatal cases with single comorbidities. (A) Age-wise distribution of leading single comorbidities among COVID-19 deaths; (B) age-wise distribution of leading single comorbidities among COVID-19 deaths in Nepal in male; and (C) age-wise distribution of leading single comorbidities among COVID-19 deaths in Nepal in female.

Figure 3 . Trend and spatial distribution of COVID-19 cases in Nepal. (A) Cumulative trend analysis of COVID-19 cases, (B) daily case wise trend analysis of COVID-19, (C–E) spatial distribution of infected, recovered, and death cases.

Geographically, Nepal is divided into three distinct ecological zones, mountain, hilly, and low-plain land from north to south. Politically, Nepal is divided into 7 provinces, 77 districts, and 753 local bodies. There were multiple peaks of active cases of COVID-19 in Nepal: active cases rapidly increased from early May to early July 2020, then increased slowly up to late July and increased at a higher rate again up to the end of December, and then decreased sharply ( Figure 3A ). The spatial distribution of COVID-19 confirmed cases, recovery, and deaths were compared ( Figures 3B–D ). Approximately, 64.84% of the total confirmed cases were reported from the hill regions, with single megacity Kathmandu contributing nearly half, 33.31% of lowland-plain areas, and 1.85% of Himalayan regions. The reported cases in the megacities are relatively higher than in the other regions. The higher number of cases in megacities may be correlated with dense populations in these areas ( 8 ). In the earlier months, the testing facilities and contact tracing were limited only to few districts, including the capital, Kathmandu, which gradually became available in other parts of the country. However, the testing frequency and testing facilities are still not homogeneous due to the lack of required technical resources and professional workforces ( 19 ) 9 .

The Response of Nepal Government to COVID-19

Nepal has adopted many readiness and response-related initiatives at the federal, provincial, and local government levels to fight against COVID-19. Initially, the government had set health desks and allocated spaces for quarantine purposes at the international airport and at the borders, crossing points of entry (PoE) with India and China 10 , to withstand the influx of many possible infected individuals from India and other countries. The open border and the politico-religious relationship with India and migrant workers returning from the Middle East, and other countries were a source of rapid transmission to Nepal 10 , 11 . The Nepal-China official border crossing points have remained closed since January 21, 2020. On March 24, 2020, the GoN imposed a complete “lockdown” of the country up to July 21, 2020. As part of the lockdown, businesses were closed, the restriction was imposed on movement within the country, workplaces were closed, travel was banned, and air transportation was halted 11 , 12 . In addition, for COVID-19 preparedness and response, the GoN developed a quarantine procedure and issued an international travel advisory notice. Closing the border was critical as Nepal and India share open borders across which citizens travel freely for business and work.

The GoN underestimated both the short and long-term impacts of border closure 11 . Around 2.8 million Nepali migrant workers work in India. Though the GoN discussed holding these workers in India with its Indian counterpart 13 , this plan did not materialize. Nepal has 1,690 km-long open borders with India, which could not keep migrant workers long despite the restrictions implemented by both governments 12 . As a consequence, the majority of COVID-19 cases were in the districts along the Indo-Nepal border. The decision of the government to lockdown the country from March 10, 2020, without sufficient preparation pushed daily wage laborers in urban areas to lose their jobs, and, hence, they were trapped without food or money. Ultimately, after a couple of days of lockdown, both migrant workers and daily wage laborers started walking the long way home due to the economic crisis.

As per the cabinet decision on March 25, 2020, Nepal established a COVID-19 response fund, developed a relief package 13 , and distributed relief to families in need through a “one door policy” 13 designed to reduce the COVID-19 impact; however, there were several gaps: the selection of families was unfair, GoN delayed the procurement of relief, relief packages did not include cash, and relief materials were inadequate and substandard 14 , 15 . The government has not adequately taken into account the impact of COVID-19 on the socio-economic sector. For instance, people participated in meetings, rallies, political demonstrations, and protests, where the virus could quickly spread among a large group of people. The government has, yet, to develop a stimulus package for social and economic recovery at the micro and macro levels. As the government has allocated $788 million for the health sector for the fiscal year (July–June 2020), a budget of 32% larger than the previous fiscal year, it should address the COVID-19 impact on the socio-economic front 16 . There is an opportunity to integrate all fragmented social protection schemes to strengthen socio-economic conditions and to emphasize more tremendous efforts, capacities, and resources to cope with the likely impacts of the COVID-19 pandemic 16 .

In addition, a minimal standard of quarantine as per the “Quarantine Operation and Management Protocol” (2076 B.S.) and “Standards for Home Quarantine” were imposed for all provinces 16 , 17 . The Sukraraj Infectious and Tropical Disease Hospital (SITDH) in Teku, Kathmandu, was designated by GoN as the primary hospital for COVID-19 cases along with Patan Hospital, the Armed Police Forces Hospital, in the Kathmandu Valley, followed by twenty-four hubs, and four satellite hospitals across the country 18 . Similarly, MoHP updated the National Public Health Laboratory (NPHL) capacity for confirmatory laboratory diagnosis of the COVID-19 from January 27, 2020, followed by the regional laboratory. The interim guideline for the establishing and operating of molecular laboratories for COVID-19 testing in Nepal was imposed to make uniformity in the test results 14 . Furthermore, the NPHL organized the training of trainers for laboratory staff in collaboration with the Medical Laboratory Association of Nepal 19 Ministry of Health and Population established two hotline numbers (1115 and 1133) to address public concerns, and prepared and disseminated regular press briefings, and improved its websites to channel appropriate information to the public. Besides, MoHP also conveyed decisions, notices, and situation updates periodically through its websites. Further, the Health Emergency Operation Centre (HEOC) of MoHP launched a “Viber communication group” to circulate updates on COVID-19 11, 13 . Early testing and timely contact tracing are crucial restrictive policies to control the spreading of the SARS-CoV-2 virus ( 20 , 21 ); however, in the earlier days of the pandemic, Nepal could not perform enough diagnostic tests and timely contact tracing; it resulted in a crucial time lag in identifying and isolating COVID-19 patients and caused delays in the ability of government to respond to the pandemic adequately. To alert and improve the testing and tracing response of the government, youth-led protests were carried out in different parts of the country 20 . Health Sector Emergency Response Plan was implemented in May 2020, focusing on the COVID-19 pandemic. This plan intends to prepare and strengthen the health system response capable of minimizing the adverse impact of the COVID-19 pandemic. Government of Nepal devised a comprehensive plan on March 27, 2020, for quarantining people who arrived in Nepal from COVID-19 affected countries. The GoN had initially airlifted 175 Nepalese from six cities across Hubei Province of China on February 15, 2020, followed by Middle East countries, Australia, and so on 13 .

Ministry of Health and Population engaged in developing, endorsing, improving, and disseminating contextualized technical guidelines, standard operating procedures (SOPs), tools, and training in all other critical aspects of the response to COVID-19, for instance, surveillance, case investigation, laboratory testing, contact tracing, case detection, isolation and management, infection prevention and control, empowering health and community volunteers, media communication and community engagement, rational use of personal protective equipment (PPE), requirements of drugs and equipment for case management and public health interventions, and continuity of essentials services 13 ( 15 ). The major contextualized technical guidelines, SOPs, tools, and training materials developed by GoN to respond to COVID-19 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 were listed in Table 3 .

Table 3 . Major contextualized technical guidelines, standard operating protocols, tools, and training materials developed by the Government of Nepal (GoN) to respond to COVID-19.

Ministry of Health and Population and supporting organizations, such as United Nations Development Program (UNDP), UNICEF, and World Vision managed crucial supplies of PPE, facemasks, gloves, and sanitizers to ensure the protection of frontline workers and supporting staffs 13 , 30 , 31 , 32 . The frontline media of the nation increased online awareness programs via the involvement of celebrities, doctors, and experts of microbiology and infectious diseases on physical distancing and the importance and use of masks and sanitizers to prevent the COVID-19 contagion. In addition, camping programs were launched by the involvement of youth volunteers of the community in central Nepal 33 .

Government of Nepal received funds from the World Bank ($29 million), the United States of America ($1.8 million), and Germany ($1.22 million) to keep people protected from COVID-19 through health systems preparedness, emergency response, and research. In addition, support from UNICEF and countries, including China, India, and the USA, in the form of emergency medical supplies and equipment were received within January 2020 to March 2020. Private companies, corporate houses, business organizations, and individuals have also contributed to the prevention, control, and treatment fund of coronavirus ($13.8 million), established by GoN to cope with COVID-19. The Prime Minister Relief Fund is also expected to be utilized. The GoN allowed international NGOs to divert 20% of their program budget to COVID-19 preparedness and response; for instance, the Social Welfare Council has allocated $226 million 31 , 33 , 34 , 35 , 36 , 37 .

The GoN has formed a committee to coordinate the preparedness and response efforts, including the MoHP, Ministry of Home Affairs, Ministry of Foreign Affairs, Ministry of Finance, Ministry of Culture, Tourism and Civil Aviation, Ministry of Urban Development, Nepal Army, Nepal Police, and Armed Police Force. The Humanitarian Country Team (HCT) includes the Red Cross Movement and civil society organizations (national and international NGOs). Under the joint leadership of the office of Resident Coordinator and the WHO, the HCT has initiated contingency planning and preparedness interventions, including the dissemination of communications materials to raise community-level awareness across the country 21 . The clusters led by the GoN and co-led by the International Astronomical Search Collaboration (IASC) cluster leads and partners are working on finalizing contingency plans, which will be consolidated into an overall joint approach with the Government and its international partners. The UN activated the provincial focal point agency system to support coordination between the international community and the GoN at the provincial level 21 .

However, despite these robust efforts implemented by GoN, few lapses existed. Examples are the following: issues of inconsistent implementation of immigration policies usually at Indo-Nepal borders 38 , 39 , 40 , shortage and misuse of crucial protective suits and other supplies in hospitals, the ease and the end of lockdown, lack of poor infrastructure facilities, and continuous spread of COVID-19 across the country ( 19 ). The GoN decided to lift the lockdown effective from July 22, 2020, completely; however, the socio-administrative and health measures with the potential for high-intensity transmission (colleges, seminars, training, workshops, cinema halls, party palaces, dance bars, swimming pools, religious places, etc.) remained closed until the following directive as of September 1, 2020. Long route bus services and domestic and international passenger flights were halted until August 1, 2020 41 . A high-level committee at the MoHP has requested all satellite hospitals (public, private, and others) to allocate 20% of their beds for COVID-19 cases. The respective hub hospitals coordinate with the HEOC and satellite hospitals to manage COVID-19 cases 42 . After lifting lockdown for 3 weeks, the federal government has given authority to local administrations to decide on restrictions and lockdown measures as COVID-19 cases continue to rise. In addition, the authority to impose necessary restrictions if COVID-19 active cases surpass the threshold of 200 was given to the Chief District Officer (CDO) 43 . Since March 2020, all the central hospitals, provincial hospitals, medical colleges, academic institutions, and hub-hospitals were designated to provide treatment care for COVID-19 cases. At this stage of operation, the major challenges for the COVID-19 response were managing quarantine facilities, lack of enough human resources, having limited laboratories for testing, and availability of limited stock of medical supplies, including PPEs 14 . To the best of our knowledge, this pandemic is the most extensive public health emergency the GoN faced in its recent history.

There is no doubt that GoN has taken major initiatives to fight the COVID-19 pandemic. The MoHP, together with associated national and international organizations are closely monitoring and evaluating the signs of outbreaks, challenges, and enforcing the plan and strategies to mitigate the possible impact; however, many challenges and difficulties, such as management of testing, hospital beds, and ventilators, quarantine centers, frontline staffs, movement of people during the lockdown, are yet to be solved 18 , 30 , 38 , 44 , 45 , 46 , 47 . Therefore, in the opinion of the authors, we recommend some steps to be implemented as soon as possible to mitigate and lessen the impacts of COVID-19 ( Table 4 ).

Table 4 . Major steps taken by GoN and way forward in the response to COVID-19 outbreak.

To strengthen its coordination mechanism, the government formed a team to monitor conditions and measures applied to control the outbreak; a COVID-19 coordination committee 11 to coordinate the overall response, and a COVID-19 crisis management center 14 to coordinate daily operations; however, these teams and committees did not function efficiently because roles and authorities were not delegated to ministries and government. A new institution was created, instead of using the National Disaster Risk Reduction and Management Authority (NDRRMA) 48 , which enhanced additional confusion. The MoHP is responsible for overall policy formulation, planning, organization, and coordination of the health sector at federal, provincial, district, and community levels during the COVID-19 pandemic situation. Allegedly, there is an opportunity to strengthen coordination among the tiers of governments by following protocols and guidance for effective preparedness and response. For example, some quarantine centers were so poorly run that, in turn, could potentially develop into breeding grounds for the COVID-19 transmission 15 .

Finally, this study only focuses on analyzing COVID-19 data extracted from the MoHP database for 1 year. Furthermore, we did not quantify the effectiveness of the strategies of GoN and the role of non-governmental organizations and authorities to combat COVID-19 in Nepal.

This study provides an insight into the impacts of the COVID-19 pandemic from the Nepalese context for the period of first-wave from January 2020 to January 2021. Despite the several initiatives taken by the GoN, the current scenario of COVID-19 in Nepal is yet to be controlled in terms of infections and mortality. A total of 268,948 confirmed cases and 1,986 deaths were reported in one year period. The maximum number of cases were reported from Bagmati province ( n = 144,278), all of the 77 districts were affected. The cases showing highly COVID-specific symptoms were low (<1%) in comparison with the reports across the globe ( 10 ), which may be because the average age of the Nepalese population is younger than many of the highly affected European countries. The other reasons may be differences in demographic characteristics, sampling bias, healthcare coverage, testing availability, and inconsistencies relating to the reporting of the data included in the current study. Both the number of infections and deaths are higher in males than in females. Despite the age, testing and positivity, hospital capacity and hospital admission criterion, demographics, and HDI index, the overall case fatality was reported to be less than in some other developed countries ( Table 1 ). Consistent with reports from other countries ( 22 , 23 ), the death rate is higher in the old age group ( Figure 1 ). Spatial distribution displayed the cases, which are majorly distributed in megacities compared with the other regions of the country.

Based on this assessment, in addition to the WHO COVID-19 infection prevention and control guidance 49 , some recommendations, such as massive contact tracing, improving bed capacity in health care settings and rapid test, proper management of isolation and quarantine facilities, and advocacy for vaccines, may be helpful for planning strategies and address the gaps to combat against the COVID-19. Notably, the recommendations provided could benefit the governmental bodies and concerned authorities to take the appropriate decisions and comprehensively assess the further spread of the virus and effective public health measures in the different provinces and districts in Nepal. In this review, we have summarized the ongoing experiences in reducing the spread of COVID-19 in Nepal. The Nepalese response is characterized by nationwide lockdown, social distancing, rapid response, a multi-sectoral approach in testing and tracing, and supported by a public health response. Overall, the broader applicability of these experiences is subject to combat the COVID-19 impacts in different socio-political environments within and across the country in the days to come.

Author Contributions

BB: Conceptualization, writing, and original draft preparation. KB, BB, and AG: data curation. BB, RP, TB, SD, NP, and DG: writing, review, and editing. All authors contributed to the article and approved the submitted version.

Conflict of Interest

KB and AG were employed by Nepal Environment and Development Consultant Pvt. Ltd., in Kathmandu, Nepal.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors are grateful to the Ministry of Health and Population (MoHP), Government of Nepal, for supporting data in this research. We are thankful to the reviewers for their meticulous comments and suggestions, which helped to improve the manuscript.

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Keywords: COVID-19, pandemic, preparedness, response, spatial distribution, public health, Nepal

Citation: Basnet BB, Bishwakarma K, Pant RR, Dhakal S, Pandey N, Gautam D, Ghimire A and Basnet TB (2021) Combating the COVID-19 Pandemic: Experiences of the First Wave From Nepal. Front. Public Health 9:613402. doi: 10.3389/fpubh.2021.613402

Received: 05 October 2020; Accepted: 11 June 2021; Published: 12 July 2021.

Reviewed by:

Copyright © 2021 Basnet, Bishwakarma, Pant, Dhakal, Pandey, Gautam, Ghimire and Basnet. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Til Bahadur Basnet, ddst19basnet@hotmail.com

† These authors have contributed equally to this work

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Open access
Published: 08 April 2021

The use of medicinal plants to prevent COVID-19 in Nepal

Dipak Khadka 1 , 2 , 3 ,
Man Kumar Dhamala 4 na1 ,
Feifei Li 5 ,
Prakash Chandra Aryal 2 , 3 ,
Pappu Rana Magar 6 ,
Sijar Bhatta 2 ,
Manju Shree Thakur 2 ,
Anup Basnet 2 ,
Dafang Cui 1 &
Shi Shi ORCID: orcid.org/0000-0002-6906-6732 1 , 7

Journal of Ethnobiology and Ethnomedicine volume 17 , Article number: 26 ( 2021 ) Cite this article

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Medicinal plants are the fundamental unit of traditional medicine system in Nepal. Nepalese people are rich in traditional medicine especially in folk medicine (ethnomedicine), and this system is gaining much attention after 1995. The use of medicinal plants has increased during the COVID-19 pandemic as a private behavior (not under the control of government). A lot of misinterpretations of the use of medicinal plants to treat or prevent COVID-19 have been spreading throughout Nepal which need to be managed proactively. In this context, a research was needed to document medicinal plants used, their priority of use in society, their cultivation status, and the source of information people follow to use them. This study aimed to document the present status of medicinal plant use and make important suggestion to the concerned authorities.

This study used a web-based survey to collect primary data related to medicinal plants used during COVID-19. A total of 774 respondents took part in the survey. The study calculated the relative frequencies of citation (RFC) for the recorded medicinal plants. The relationship between plants recorded and different covariates (age, gender education, occupation, living place, and treatment methods) was assessed using Kruskal-Wallis test and Wilcoxon test. The relationship between the information sources people follow and the respondent characteristics was assessed using chi-square test.

The study found that the use of medicinal plants has increased during COVID-19 and most of the respondents recommended medicinal plants to prevent COVID-19. This study recorded a total of 60 plants belonging to 36 families. The leaves of the plants were the most frequently used. The Zingiber officinale was the most cited species with the frequency of citation 0.398. Most of the people (45.61%) were getting medicinal plants from their home garden. The medicinal plants recorded were significantly associated with the education level, location of home, primary treatment mode, gender, and age class. The information source of plants was significantly associated with the education, gender, method of treatment, occupation, living with family, and location of home during the lockdown caused by COVID-19.

Conclusions

People were using more medicinal plants during COVID-19 claiming that they can prevent or cure COVID-19. This should be taken seriously by concerned authorities. The authorities should test the validity of these medicinal plants and control the flow of false information spread through research and awareness programs.

The new coronavirus disease (COVID-19) pandemic has caused global socioeconomic disturbances with a worrisome number of deaths and health issues, and the world has been struggling to find medicine to treat and prevent COVID-19 [ 1 ]. A number of combinations and trials have been done, but so far, they have not produced promising results [ 2 , 3 , 4 ]. The different types of misinformation related to COVID-19 have been spreading throughout the world through social media [ 5 ], including use of medicinal plant products to prevent or cure COVID-19. Due to this situation, ethnobiologists should collaborate with local people and document the medicinal plants used with caution to stop the inaccurate sharing of information [ 6 ].

There is a strong inter-relationship between people and plants according to needs [ 7 , 8 , 9 , 10 ]. People are dependent on plants for different purposes such as for food, medicine, and houses [ 11 , 12 , 13 ]. Plant species have always been a fundamental source for the discovery of drugs [ 14 ]. People had used medicinal plants to fight against pandemics in the past [ 15 , 16 , 17 ], and dependency of people on medicinal plants might have increased in these days around the world as medicinal plants can be an alternative option to prevent COVID-19 [ 18 ].

Different researchers have suggested herbal medicine as a potential option to cure or prevent COVID-19 [ 19 , 20 ]. Countries like China and India are integrating their use with western medicine to boost the immunity power of COVID-19 patients [ 21 , 22 ]. In China, traditional medicine showed encouraging results in improving symptom management and reducing the deterioration, mortality, and recurrence rates [ 23 ]. On the other hand, the World Health Organization (WHO) (2020) claims medicinal plants might be good for the health and in supporting the immune system, but not in preventing or curing COVID-19. The WHO Africa (2020) claims unscientific products to treat COVID-19 can be unsafe for people, as they may abandon self-hygienic practices, may increase self-medication, and may be a risk to patient safety.

Lifestyle, diet, age, sex, medicinal conditions, and environmental factors have been playing an important role in the personal fate towards the severity of COVID-19 [ 24 ]. The source of information, such as social media, plays an important role to combat pandemics [ 25 , 26 ]. People receive information regarding COVID-19 and other diseases from different sources including the social media, local people, national health authorities, and the WHO, based on respondent characteristics such as age and gender as well as occupation, state of their living, and primary mode of disease treatment method [ 27 ].

In Nepal, the medicinal plants are often used in the traditional medicine system, which includes Scholarly medical system (The Ayurveda, homeopathy, the Unani, and the Tibetan medicine), Folk medicine (ethnomedicine, community medicine, household medicine, and any other forms of local medicines), and Shamanistic (Dhami-jhankri, Jharphuke, Pundit-Lama-Pujari-Gurau, and Jyotish). Among them, folk medicine system is using more medicinal plants in Nepal [ 28 ]. The first scientific research published in ethnobotany is dated back to 1955 [ 29 ]. More than 80% of the people in Nepal have been using traditional medicine such as medicinal plants [ 30 , 31 ]. Medicinal plants are the primary source of healthcare for the people in Nepal and are an integral part of their culture [ 32 , 33 ]. Most of the people in Nepal have been using medicinal plants as the alternative to allopathic or western medicine [ 34 ].

It has also been playing an important role in increasing the economic level of people [ 35 ] as Nepal exports medicinal plants to different countries in the world [ 36 ]. The elder people living in rural areas have more knowledge of traditional medicine [ 37 ].

In Nepal, COVID-19 cases are increasing daily but the health care system is fragile and has a lack of infrastructure [ 38 ]. In this context, home remedies, like the use of medicinal plants supported by the relevant authorities, can serve as an alternative option to combat COVID-19. The Nepal government has also valued medicinal plants as an immunity power booster used with prescriptions [ 39 ]. But, there a considerable amount of false information spread in Nepal regarding the use of medicinal plants and people are randomly using plants which can go against the traditional methodology and make it difficult to combat COVID-19. The present study has attempted to reveal the status of medicinal plant use in Nepal during COVID-19. Specifically, this study is aimed to address the following objectives: (1) document the status and source of medicinal plants used to prevent COVID-19, (2) know the relationship between the number of plants reported and covariates, and (3) know the relationship between information sources respondents follow and respondent characteristics.

Methods of data collection

A set of questionnaire forms were prepared by Google Form developer. The Google Form was initially tested to validate and understand the response rate from respondents. We followed the code of ethics of the International Society of Ethnobiology [ 40 ]. We wrote a consent message to all the people we reached with the form and also placed clearly written consent message at the top of the form. Additionally, we asked a consent question at the beginning of the form for written consent from each respondent. The Google Form was circulated through social media (such as Facebook) and emails in our friend circles asking them to circulate the form with consent message at first as much as possible and inform us whether the form has been sent to others. From our friend circles’ help and our efforts, we reached a total of 998 people throughout the online survey in June 09, 2020, to July 18, 2020, in which a total of 774 (77.55%) people filled the form in different parts of Nepal and provided information about the different variables (Table 1 ) used for the study.

Sample population

A total of 774 respondents participated in the survey, of whom 407 (52.58%) were from the urban area and 367 (47.42%) were from the rural area. The age of the respondents varied from 16 to 76 years. Among them, 65.51% were below 30 years of age; all of the respondents were literate, and most of them (69.5%) had attended University. There were more male respondents (60.85%) than female (Table 2 ).

Data analysis

The status of medicinal plants used during COVID-19 (increase, decrease, same, and never used) and recommendation of medicinal plants (strong, moderate, low, and never) was calculated and shown in the bar graph using Microsoft Excel 2013.

The medicinal plants recorded were tabulated in the table with respective scientific, local, and English names with their family and parts (root, stem, leaves, rhizome, roots) used. The scientific names from local name identification followed the Dictionary of Nepalese plant nam e[ 41 ] and ethnomedicine study from Nepal [ 42 ], and the family assignation in this paper followed the TROPICOS [ 43 ]. Finally, we reaffirmed plant species by taxonomic experts from Tribhuvan University Nepal and collected herbarium specimens were deposited in the National Herbarium and Plant Laboratories (KATH) Godawari, Lalitpur Nepal, and specimen codes were presented in a table for each species. For all the species, frequency of citation (FC) and relative frequency of citation (RFC) were calculated following Tardio and Pardo-de-Santayana (2008) [ 44 ].

where FC = number of respondents who mentioned the use of species and N = total number of respondents took part in a survey.

The results of the RFC and the top 10 medicinal plants used are presented in the radar diagram using Microsoft Excel 2013.

The Shapiro test, Kruskal-Wallis test, Wilcoxon test, chi-square test, and related diagrams were drawn using R [ 45 ]. The Shapiro test was performed to test the normality of the data. As the data of plant number was not normally distributed, the Kruskal-Wallis test was performed to test the relationship between several plants with an occupation, education level, primary treatment mode, and age class. The Wilcoxon test was performed to see the differences in number of plants reported with gender and place of living during COVID-19 pandemic.

The relationship between information sources and respondent characteristics was shown in the graph and statistically analyzed using the chi-square test.

Status of medicinal plant use

Out of 774 respondents, 323 (42%) respondents agreed that the use of the medicinal plant has increased during COVID-19, whereas 313 (40.44%) agreed the use of medicinal plants during COVID-19 is the same as that of normal condition (Fig. 1 ).

Trend of medicinal plant use during COVID-19

Most of the respondents, 349 (45.09%), believed that information/knowledge of medicinal plants has increased during COVID-19, 333 (43.02%) believed it is the same as usual, and 93 (11.89%) considered that they are confused about the use of medicinal plants (Fig. 2 ).

The knowledge level of people on the use of medicinal plants during COVID-19

A total of 670 (86.5%) of the respondents had recommended medicinal plants to prevent COVID-19, whereas 104 (13.4%) had not recommended. Most of them had made a moderate recommendation (Fig. 3 ).

Recommendation of a medicinal plant to prevent and cure COVID-19

Medicinal plants recorded

A total of 60 species of medicinal plants from 36 families and 54 genera were documented as being perceived. Among them, the most common families were Apiaceae (6 species), Zingiberaceae (4 species), Amaryllidaceae (4 species) and Lamiaceae (4species). And most common genus were Allium (3 species), Terminalia (2 species), Mentha (2 species), Cinnamomum (2 species), and Syzygium. Likewise, the most perceived species was Zingiber officinale (39.79%) followed by Curcuma angustifolia (34.11%). The habit analysis showed that the medicinal plants belonging to herb, shrub, climber, and tree species were 56.67%, 11.67 %, 6.67%, and 25% respectively (Table 3 ). Leaves (33.68%) were the most predominantly used parts, followed by seeds (23.33%), fruits (21.67%), roots (13.33%), rhizomes (11.67%), whole plant (8.33%), bark (6.67%) stem (1.67%), and bulb (1.67%) (Fig. 4 ). The most commonly used method of preparations was to grind the parts, boil with hot water or milk, and drink.

Parts of plants used for medicinal purpose to prevent COVID-19

Relative frequency of citation

The relative frequencies of citations ranged from 0.001 to 0.398 and for ten most cited species value ranged from 0.03 to 0.398. The most cited species was Zingiber officinale (308 times cited and frequency of citation was 0.398) followed by Curcuma angustifolia (264 times cited and frequency of citation was 0.341) (Fig. 5 ).

List of top ten ranked plant species reported by respondents shown the frequency of citation

Source and cultivating conditions of medicinal plants

The respondents had mentioned that they were getting medicinal plants from home gardens (45.61%), markets (32.03%), and jungles (10.73%), and the remaining respondents were getting medicinal plants from all of the above three sources. Most of the respondents were also cultivating (47%) more medicinal plants during COVID-19 than before, and few have just started (3%) (Fig. 6 ).

The medicinal plant cultivation status during COVID-19

Number of plants reported and covariates

The number of reported plants used by individual respondents ranged from 0 to 12 (Fig. 7 ). In the occupational category, people who were engaged in agriculture and those with jobs used comparatively more medicinal plants than others, but the difference was not significant (Kruskal-Wallis, χ 2 = 7.921, df = 5, p = 0.1606). The people with university-level education were using more plant species compared to people with secondary-level and primary-level education, and the differences were statistically significant ( Kruskal-Wallis, χ 2 = 50.736, df = 2, p = < 0.0001 ). The people living in the city were using more plants than people living in the village, which was statistically significant ( W = 85818, p = 0.0002). The people whose primary method of treatment was allopathic were using a statistically significant low number of plants (Kruskal-Wallis, χ 2 = 32.524, df = 3, p = 0.0001) compared to the respondents whose primary methods of treatment were Ayurvedic and homeopathic. The female respondents were using more plants than males; the difference in the use of plants by males and females was statistically significant ( W = 77489, p = 0.03864). Age group of 20–29 and below (< 20) reported more number of species being used. The number of medicinal plant species reported was statistically significantly different among the age groups (Kruskal-Wallis, χ 2 = 25.484, df = 6, p = 0.0003).

Graphical representation of plant use as a preventive method against COVID-19 by respondents

Information sources

People are using different sources to prevent COVID-19, such as social media like Facebook Twitter, official information from the World Health Organization, the national health authorities, and local communities (Fig. 8 ). The information adopted from social media is risky but in significant proportion, more than 25% of secondary education respondents and female respondents are using social media information, and there was a statistically significant relationship between information source and gender ( χ 2 = 8.0304, p = 0.0459). The relationship between information source and education was statistically significant ( χ 2 = 34.714, p = 0.0005). The jobless people were following the local community for obtaining information (more than 50%), and the relationship between the source of information and occupation was marginally significant (χ 2 = 23.863, p = 0.0699). The people living with their families were depending more on local communities and social media for plant use information (more than 50% and 25% respectively), and the relationship between the source of information and living with the family was statistically significant ( χ 2 = 7.9621, p = 0.0445). The people who using Ayurvedic as the primary treatment were mainly following information provided by the communities (more than 50%), and there was a statistically significant association between the information source and the primary treatment method ( χ 2 = 17.406, p = 0.0095). The people living in the city and village during the lockdown of COVID-19 both followed similar sources of information, and there is no significant association between source of information and people living in lockdown ( χ 2 = 4.6375, p = 0.2054).

Graphical representation of information sources with respondent characteristics

Status and sources of medicinal plant

Medicinal plants have attracted the attention of several stakeholders around the world [ 46 ]. They have chemical diversity and can play a significant role in new drug development [ 47 ]. In this study, the majority of respondents in Nepal reported that the use of medicinal plants has increased during COVID-19 and also believed that information about the medicinal plants has increased, and most of them recommend medicinal plants to prevent COVID-19. Researchers such as Rastogi et al. (2020) and Vellingiri et al. (2020) have claimed that medicinal plant-based treatments should be beneficial to treat and prevent COVID-19 [ 20 , 48 ]. Yang et al. [ 49 ] reported that plant species traditionally used as food can help to enhance the immune system of the body and help to prevent the manifestation of COVID-19 [ 50 ]. In the past, medicinal plants were combined with western medicine to treat a similar disease, severe acute respiratory syndrome (SARS) [ 51 ].

There is no effective medicine available so far for the treatment of COVID-19; medicinal plants are being used globally that might have increased the demand for medicinal plants [ 52 ]. Some plants are useful to treat viral disease, but COVID-19 is a new disease, and the effectiveness of the medicinal plants to cure it has not been tested yet. Therefore, the excessive use of medicinal plants, however, could be problematic and is a matter of concern. Easy access to social media which often publish unreliable advertisements might have a role to play in the increasing use of medicinal plants. Moreover, local availability of medicinal plants and an incorrect belief that medicinal plants have no side effects among people might also be responsible for the same. All the stakeholders including ethnobotanists and community leaders should come together to educate people about the proper use of medicinal plants.

Medicinal plants recorded and frequency of citation

We recorded a total of 60 plant species, and most of the species were similar to the study based on a preliminary survey in five heavily affected cities, Wuhan, Milan, Madrid, New York, and Rio de Janeiro, and twelve less-affected rural areas, Appalachia, Jamaica, Bolivia, Romania, Belarus, Lithuania, Poland, Georgia, Turkey, Pakistan, Cambodia, and South Africa, which recorded 193 plant taxa from 69 families [ 53 ]. A study in Morocco had recorded a total of 23 species which include some similar species viz. Allium sativum , Allium cepa , and Zingiber officinale [ 54 ]. A study from India recorded 15 species [ 55 ]. A study from China have screened 26 medicinal plants for possible treatment of COVID-19 [ 56 ]; likewise, other studies from China have discussed about medicinal plants similar to our study [ 57 ]. A study from Bangladesh screened 149 plants from 71 families and found they have potential molecules for preparing a drug for the treatment of COVID-19 [ 58 ].

Most of the species reported in this study are locally available, home garden species, and used for daily food at home. The leaves were the most used parts of the plants corroborating the findings of other related studies in Asia [ 59 , 60 ]. The use of leaves is mainly due to the presence of active secondary metabolites [ 61 ]. Underground parts, such as roots and rhizomes, are rich in bioactive constituents [ 62 , 63 ]. However, indiscriminate use of underground parts might lead to conservation threats particularly to wild species [ 64 ]. Similarly, the use of bark in an excessive amount and the whole plant use might create problems in conservatio n[ 65 ].

The citation of species might have been influenced from social media along with the cultural, religious, and community leaders within Nepal and neighboring India. For instance, the famous Hindu Swami Ramdev of India has suggested that Tinospora cordifolia boiled in water, Curcuma angustifolia , Zanthoxylum armatum powder, and Ocimum tenuiflorum leaves can prevent COVID-19 (written in India TV News of 14 March 2020). The most cited species in this study are also the most commonly used species in Nepal, such as Zingiber officinale , C. angustifolia , and Allium sativum . These species are planted in almost every household of rural Nepal, and these species are also listed by the Nepal Ministry of Health & Population Department of Ayurveda & Alternative Medicine, Teku, Kathmandu, as an alternative medicine to boost the immunity power of people [ 66 ]. Plants like Curcuma angustifolia , Cuminum cyminum , Allium sativum , Terminalia bellirica , Z. officinale , O. tenuiflorum , Cinnamomum species, Piper nigrum , Vitis vinifera , and Citrus spp. were also recommended by the Indian Government to boost immunity power but does not claim to cure or treat COVID-19 [ 67 ]. Some of these medicinal plants used might show a placebo effect on people as treatment of diseases like COVID-19 depending on multiple factors such as psychological factor [ 68 ].

The medicinal plants reported in the study have different chemical compounds and constituents that have been proved in treating different diseases and ailments. T. bellirica, Cinnamomum species , Piper nigrum , dry Z. officinale , and raisin contain phytonutrients, chlorophyll, vitamins, minerals, eugenol, and a bioactive compound; Z. officinale contains sesquiterpenes [ 69 ].

Chemical constituents 8-Gingerol and 10-Gingerol from Z. officinale were active against COVID-19 [ 70 ]. COVID-19 patients might have a cytokine storm [ 71 , 72 ], and Curcuma species like angustifolia and caesia have the capacity to block cytokine release [ 73 ]. Allium sativum contains sulfoxide, proteins, and polyphenols like bioactive sulfur-containing compounds which are antiviral with immunostimulatory potential [ 74 , 75 ]. Tinospora cordifolia has alkaloids, glycosides, lactones, and steroids with immunomodulatory roles and can treat fever, chronic diarrhea, and asthma [ 76 , 77 ]. Citrus species contain polysaccharides and polyphenolic compounds which improve the immunity of body [ 78 ]. Ocimum species like Ocimum tenuiflorum extract contains Tulsinol (A, B, C, D, E, F, G) and dihydrodieuginol that possess immunomodulatory and Angiotensin-converting enzyme 2 (ACE II) blocking properties to inhibit replication of coronavirus [ 79 ]. Phyllanthus emblica is antioxidative and anti-inflammatory, and its extract Phyllaemblicin G7 has the potential to treat COVID-19 [ 80 ]. Azardirachta indica extracts Nimbolin A , Nimocin, and Cycloartanols (24-Methylenecycloartanol and 24-Methylenecycloartan-3-one) have shown potential to inhibit COVID-19 [ 81 ]. Mentha arvensis possess eugenol, terpenes, and flavonoids which are good antioxidants and modulators of xenobiotic enzymes which help to inhibit COVID-19 [ 82 ]. Cinnamom species like Cinnamom unverum contains antioxidant and antiviral compounds (eugenol, cinnamic acid, caryophyllene) which might help to inhibit COVID-19 [ 83 ].

The species with a lower frequency of citation are also useful in some way; Camellia sinensis has immunomodulatory properties due to the presence of epigallocatechin gallate, quercetin, and gallic acid in its leaves [ 84 ]. Euphorbia species like E uphorbia thymifolia has antioxidant and antiviral activities [ 85 ]. Functional food such as Allium cepa , Nigella sativa , Carica papayas , and other species are functional food; they possess immunomodulatory properties in several ways and help in effective health management if taken in an adequate manner [ 50 ] . However, there is no proper research and scientific evidence supporting that medicinal plants can prevent or cure COVID-19. The use of medicinal plants is traditional and has a long history with its own theory, like traditional Chinese medicines whose composition is typical and complicated. A creative evaluation system should be developed before its use to prevent or treat COVID-19 [ 86 ]. Some researchers have suggested natural products obtained from plants might be an alternative option to treat COVID-19 [ 87 , 88 ].

But at present, the use of different, unproven medicine, as well as herbal medicine, has been the only way to protect vulnerable patients and such medicines should not be overlooked, or taken without the prescription from a health personnel [ 50 ]. The effectiveness of above-mentioned medicinal plants should be tested scientifically then added to the discovery of drugs used to treat COVID-19.

Most of the respondents obtained medicinal plants from home gardens or farms. It is interesting to find that people are cultivating more medicinal plants during COVID-19, which is a positive sign for the development of gardening or farming practices in the country. This type of activity will support the sustainable conservation of medicinal plants. However, collecting medicinal plants from the jungle will cause several issues in the conservation of plants [ 89 ]. Different types of actions can be taken to conserve and for the sustainable use of such species, including assessing the conditions of plant use and their presence as well as policy formation [ 90 ]. Some people have also just started to plant medicinal plants which is a good sign for the sustainable livelihood in Nepal.

The use of medicinal plants depends on several covariates, such as occupation, education level, age, class, living condition, and treatment methods that people usually follow. The sociocultural acceptance of people vary within different places and communities [ 91 ]. People living in villages most live with their families in Nepal, and studies have found that the use of medicinal plants usually comes from families [ 92 ]. During COVID-19, well-educated people perceived more medicinal plants in Nepal, contrary to the results of other studies, which found that well-educated people often rely on modern medicine for treatment [ 93 ]. Females reported more medicinal plants than males, similar to other studies [ 94 ], probably because women are more involved in household work and invest more time in the kitchen, caring for their family, and in food and health, as well as in farm work such as cutting grasses and collecting fodder. People adopting agriculture reported a higher number of medicinal plants, which may be because they have easier access to medicinal plants. In Nepal, people with agricultural occupations and living in rural areas used more traditional methods to stay healthy [ 95 ]. The job holders also reported comparatively more number of plants.

Interestingly, the youths (age groups below 30) have reported using more medicinal plants, probably because they lived with their families and learned more about the medicinal plants from the elders. This group is also the most active group on social media. Most respondents also claimed that they were more aware of the medicinal plants during COVID-19, which is a good sign as the research by Tiwari et al. (2020) has mentioned that young people are forgetting the use of medicinal plants. However, the misunderstanding of medicinal plants is also dangerous, and the stakeholders need to think about and provide accurate information to the young people [ 96 ]. Young people should follow a reliable source to obtain information about medicinal plants. People who primarily use Ayurvedic and homeopathy remedies reported more number of medicinal plants. The use of plants and the acquisition of knowledge usually depends on the culture and primary health care system [ 97 ].

Information sources and respondent characteristics

The source of information is the key to using medicinal plants, and it is not good to follow social websites and rely on them, as the usefulness and accuracy of messages regarding COVID-19 provided by social media such as YouTube have not been tested [ 98 ]. However, in this study, a large number of respondents were found to be engaged in social media to obtain information regarding COVID-19. Most of the people were not relying on the WHO and national health authorities, similar to the study of Bhagavathula et al. [ 99 ]. Most well-educated people, female, job holders, people living with families, people who are following allopathy as a primary treatment, and people who live in the village are all following social media to obtain knowledge of prevention methods and using medicinal plant-based on the source which might be incorrect and thus harmful. This is because the frequent use of social media and the practices of using several sources of social media have caused an overload and increased people’s concerns [ 100 ].

This study recommends the use of official websites of the WHO and national health authorities to gain information regarding COVID-19. Most people also rely on the communities for the use of medicinal plants which might cause traditional malfunction. Therefore, it is unwise to adopt unscientific sources of information and use medicinal plants privately. The correct use of medicinal plants passes from generation to generation, which is usually applicable to old diseases. No valid medicine has been developed to prevent or cure COVID-19 so far. The COVID-19 pandemic has created a large crisis, and it needs large-scale behavior changes [ 101 ]. For instance, we need to change our behavior and follow valid information to use different preventive measures to be free from COVID-19. The collaboration between diverse stakeholders such as the government, volunteers, people, and other sectors is deemed necessary to transmit information and respond to crisis through improving information flow [ 102 ]. Different studies on herbal remedies are deemed necessary which would be helpful to prepare an antiviral drug against COVID-19 as well as to help prevent going against traditional methodology related to the use of medicinal plants [ 103 ]. There is an urgent need to disseminate a high level of public awareness to prevent misinformation regarding treatment and prevention measures of COVID-19 [ 104 ].

Limitation of the study

This is online survey based study. The questionnaire was mostly circulated among the educated social network colleagues of ours as they can read and understand about the issues, provide their consent, and fill the form similar to other studies from the globe. This might create some bias on the study, but during extreme condition (such as COVID-19 lockdown) this is one of the prime ways to get information and help deal with the extreme situation. Researchers have reported that well-educated people preferred to follow modern medicine, but during COVID-19 time educated people were aware about the medicinal plants as opportunistic medicine [ 105 , 106 ]. This behavior of educated people helps to increase concern of them on medicinal plants. Further, a field-based study might cover responses from all levels and classes of people with quantification of uses.

This study found that medicinal plants used and the beliefs related to them have increased during COVID-19. A total of 63 medicinal plant species used to prevent COVID-19 were investigated and recorded. The frequently used plants in the home were recorded more in comparison to other plants. The plants’ cultivation status have increased during COVID-19. The use of medicinal plants was associated with social and demographic variables. Likewise, the source of medicinal plants also varied with the demographic social factors of the respondents. This study recommends undertaking studies of medicinal plants used during COVID-19. The validity and reliability of such medicinal plants should be tested further by phytochemical and pharmacological research, and invalid information should be monitored and controlled in different social media platforms and communities. It is recommended that people follow information from authentic sources related to the COVID-19 pandemic.

Availability of data and materials

All data have already been included in the manuscript. We are willing to share the data generated and analyzed during the current study.

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Acknowledgements

We are highly indebted to all respondents who took part in the survey. We are thankful to Heather Whitefield for editing the English of our manuscript; assistant professor, Department of Botany Trichandra College, Tribhuvan University, Sanu Raja Maharjan for confirming plant names; and the Government of Nepal Ministry of Forest and Environment Department of Plant Resources National Herbarium & Plant Laboratories (KATH) Godawari, Lalitpur Nepal for deposition of herbarium specimens. We are also thankful to Dr. Shanti Timilsina and Suraj Jha of Aurveda Campus, Tribhuvan University Kirtipur, Bhuwan Parajuli of Nepal Sanskrit University Patanjali Ayurvedic Medical College and Research Center, Chandramani Aryal of Companions for Amphibians and Reptiles of Nepal ( CARON ), Sandesh Neupane, Pramananda Rajbanshi, Bishal Sharma, Deepa Karki, and Ankita Chaudhary of GoldenGate International college for helping in herbarium specimen collection and preparation.

This work was supported by the National Key Research and Development Program of China (2017YFC0506200) and the project of National Survey of Traditional Chinese Medicine Resources from National Administration of Traditional Chinese Medicine (GZY-KJS-2018-004).

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Man Kumar Dhamala is deceased. We would like to dedicate this paper in the memory of Dr. Man Kumar Dhamala who died on November 5, 2020.

Authors and Affiliations

Guangdong Key Laboratory for Innovative Development and Utilization of Forest Plant Germplasm, College of Forestry and Landscape Architecture, South China Agricultural University, Guangzhou, China

Dipak Khadka, Dafang Cui & Shi Shi

Environmental Science Program, Golden Gate International College, Battisputali, Kathmandu, Nepal

Dipak Khadka, Prakash Chandra Aryal, Sijar Bhatta, Manju Shree Thakur & Anup Basnet

Environment Protection and Study Center (ENPROSC), Baneshwor, Kathmandu, Nepal

Dipak Khadka & Prakash Chandra Aryal

Central Department of Environmental Science, Tribhuvan University, Kirtipur, Kathmandu, Nepal

Man Kumar Dhamala

State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, 100012, P.R. China

Provincial Government Ministry of Social Development, Regional Health Directorate, Dhankuta, Province 1, Nepal

Pappu Rana Magar

South China Limestone Plants Research Center, College of Forestry and Landscape Architecture, South China Agricultural University, Guangzhou, China

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DK, MKD, PRM, SS, FFL, and DFC designed the study. DK, MKD, PRM, SB MST, PCA, and AB conducted the data collection. DK and PCA analyzed the data. DK, MKD, SS, DFC, MST, SB, AB, and PRM confirmed the plants. DK and SS wrote the manuscript. MKD, PCA, FFL, SB, and DFC reviewed the manuscript. The authors read and approved the final manuscript.

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Correspondence to Dafang Cui or Shi Shi .

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Khadka, D., Dhamala, M.K., Li, F. et al. The use of medicinal plants to prevent COVID-19 in Nepal. J Ethnobiology Ethnomedicine 17 , 26 (2021). https://doi.org/10.1186/s13002-021-00449-w

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DOI : https://doi.org/10.1186/s13002-021-00449-w

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Impact of COVID-19 on tourism in Nepal

Ranjit Sah and Shailendra Sigdel equally contributed to this work.

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Ranjit Sah, Shailendra Sigdel, Akihiko Ozaki, Yasuhiro Kotera, Divya Bhandari, Priyanka Regmi, Ali A Rabaan, Rachana Mehta, Mahesh Adhikari, Namrata Roy, Kuldeep Dhama, Tetsuya Tanimoto, Alfonso J Rodríguez-Morales, Rachana Dhakal, Impact of COVID-19 on tourism in Nepal, Journal of Travel Medicine , Volume 27, Issue 6, August 2020, taaa105, https://doi.org/10.1093/jtm/taaa105

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We read the recent article by Shrestha et al ., 1 about Nepal’s first case of COVID-19 and public health response with great interest. Despite recent progress and the government’s commitment to reduce the absolute poverty rate to 16.7% from 18.7% last year, 2 the World Bank forecasts that 31.2% of Nepalis are at risk of falling into extreme poverty, primarily because of reduced remittances from overseas workers, foregone earnings of potential migrants, collapse of the tourist industry, job losses in the informal sector and increased cost of essential commodities, all as a result of COVID-19. 3

COVID-19 related deaths worldwide were approaching 400 000 as of 1 June. The effects of COVID-19 on the global economy have been and will be, catastrophic. However, the full global impact, in both economic and health terms, remains unknown. The consequences in low- and middle-income countries, such as Nepal, where national economies rely on a small number of services and industries, are deeply worrying.

Tourism is one of Nepal’s largest industries. Tourism revenue in 2018 accounted for 7.9% of the country’s Gross Domestic Product (GDP) and supported >1.05 million jobs, with the expectation of providing >1.35 million jobs by 2029. 4 Nepal hosted 1.19 million foreign tourists in 2019, and the ‘Visit Nepal 2020’ campaign, officially introduced on 1 January, aimed to attract 2 million tourists, generate $2 billion and create thousands of new jobs.

However, on 23 January, the first case of imported COVID-19 was detected in Nepal. In response to cases worldwide increasing exponentially and amid growing public concern, the government suspended the ‘Visit Nepal 2020’ initiative on 3 March. Shortly after the World Health Organization (WHO) declared COVID-19 a pandemic on 13 March, the government suspended all permissions for mountaineering expeditions and suspended all visas.

After confirmation of the second imported case on 23 March, the government locked the country down and suspended all national and international flights. Massive cancellations of hotel and tourist bookings followed, resulting in widespread unemployment, loss of income and threatened livelihoods for thousands. The collapse of international and domestic tourism followed a 2% drop in tourist arrivals in January 2020 compared to 2019. 5 Over 10 000 tourists who had entered Nepal before the lockdown was also left stranded, although many of them were eventually repatriated.

Remittances from 3.5 million Nepalese living and working abroad account for almost a quarter of the country’s GDP. Since 2009, Nepal’s Department of Foreign Employment issued over 4 million permissions to migrant Nepalis working in 110 countries. 6 When the 2015 earthquake hit Nepal, foreign remittances jumped 20%, cushioning families against the financial shock of the disaster. COVID-19 is set to have a much worse economic impact than the earthquake and the migrant worker saviours have themselves become a problem. International flights are banned, keeping job-seekers at home and stranding migrant workers abroad. On 24 March, the government’s High-Level Coordination Committee for Prevention and Control of COVID-19 informed Nepalis abroad to remain where they were and appealed to host countries to offer them protection. Many have been laid off and are unable to return home. In some countries, migrant workers are still employed but the safety and health of all are jeopardized by the pandemic. 6 The government is currently investigating the repatriation of workers stranded in COVID-19 affected countries, even though this may place extra strain on the nation’s health system.

Healthcare systems of any country depend on the economy and Nepal’s lost remittances and tourism revenues have crippled the nation’s finances. Loss of income has concomitant adverse impacts on the health of all citizens. Funding from donor countries to help Nepal’s health system, which constitutes around 50% of the health budget, 7 will probably decrease, as donors are also suffering from the pandemic, although billions of dollars have already been pledged to help Nepal’s COVID-19 response. Unfortunately, the move to federalism, work to overcome regional health disparities, and attempts to accomplish the Sustainable Development Goals and improve the nation’s poverty rate have all been set back by the pandemic.

Fortunately, Nepal has so far evaded the full impact of COVID-19. As of 31 May, there were around 1500 confirmed cases, most of which were asymptomatic, with only eight deaths. Yet Nepal has insufficient resources and manpower for the massive testing and treatment of people that may be needed. Currently, Nepal has 18 000 doctors and 35 000 nurses working in 500 public and private sector hospitals, but there are only around 1100 critical care beds and 600 ventilators for a population of 28 million. 8

Because of the high prevalence of the respiratory disease in Nepal, due to air pollution, large numbers of cigarette smokers, and widespread indoor combustion of biomass fuels, coupled with weak health care facilities, the country will likely experience a high death toll if community transmission of COVID-19 does occur. Furthermore, the country’s public health and social support systems will be put under great strain to cope with a flood of returnees from abroad, especially via the border with India. All returnees will need to be tested, quarantined, fed and sheltered.

At present, concerted efforts are being made to resolve the lack of testing kits, PPE and medical supplies. 9 Diagnostic and treatment protocols have been established. As of 30 May, the government has established RT-PCR labs in each province and testing is now available in 20 centers in Nepal and 127 hospitals have been designated as COVID-19-ready. 10 So far >60 000 RT-PCR tests have been carried out. Emergency medical deployment teams has been established in the hub hospitals and medical colleges and is planning to mobilize them as per the need of the provincial and other hospitals. All points of entries at international airport and ground crossings are strengthened with a dedicated standard health desk equipped with adequate human resources and necessary commodities.

The pandemic has already challenged Nepal’s economy and the healthcare system. The resurgence of tourism may take longer than witnessed after the 2015 earthquake and remittances may not normalize soon. The government is taking steps to invest significantly in Nepal’s agricultural sector and is planning to incentivize migrant workers to stay and work in Nepal, as a means to boost the country’s economy in the long-term. The COVID-19 pandemic has sensitized the entire population as well as central and local authorities to the need for quality in healthcare. The government has increased the health sector budget to over 6% for the coming fiscal year, although this is still well below the recommendation of WHO (10%).

The pandemic necessitates long-term extreme measures to prevent healthcare facilities from being overwhelmed. The extent of the impact will depend on COVID-19 progression and the country’s ability to cope. Thus, there is a profound need for all stakeholders to take a far-sighted view and plan how best Nepal can, in the future, offer an appropriate and affordable healthcare service to its citizens.

R.S. and S.S. drafted the concept and manuscript. A.O., Y.K., D.B., P.R., A.A.R., R.M., M.A., N.R., K.D., T.T., A.J.R.M. and R.D. review the literature, critically revised the manuscript and English content of the article. All author read and agrees for the final manuscript.

AO and TT receive personal fees from MNES Inc., outside the submitted work.

Shrestha R , Shrestha S , Khanal P , Bhuvan KC . Nepal’s first case of COVID-19 and public health response . J Travel Med 2020 . doi: 10.1093/jtm/taaa024 .

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The world Bank In Nepal ( 2020 ) https://www.worldbank.org/en/country/nepal/overview ( 1 June 2020, date last accessed ).

Prasain S . Nepal tourism generated Rs240b and supported 1m jobs last year: report t. http://kathmandupost.ekantipur.com.np/news/2019-05-26/nepal-tourism-generated-rs240b-and-supported-1m-jobs-last-year-report.html ( 1 June 2020, date last accessed ).

Visit Nepal 2020 Tourist Arrivals: 2% Drop in January . https://www.nepalisansar.com/tourism/visit-nepal-2020-tourist-arrivals-statistics/ ( 1 June 2020, date last accessed ).

Rimal S . Nepali labor migrants, Covid-19, and the state . https://asiafoundation.org/2020/04/01/nepali-labor-migrants-covid-19-and-the-state/ ( 1 June 2020, date last accessed ).

Karkee R , NGOs CJ . Foreign aid, and development in Nepal . Front Public Health 2016 ; 4 : 177 . doi: 10.3389/fpubh.2016.00177 .

Adhikari D. ( 2020 ) Coronavirus in Nepal: laborers returning home allege bias in hospitals . Anadolu Agency . https://www.aa.com.tr/en/asia-pacific/coronavirus-in-nepal-laborers-returning-home-allege-bias-in-hospitals-/1798135 ( 1 June 2020, date last accessed ).

Asim M , Sathian B , van Teijlingen E et al. Covid-19 pandemic: public health implications in Nepal . Nepal J Epidemiol 2020 ; 10 : 817 – 20 .

World Health Organization ( 2020 ). Situation update—coronavirus disease (COVID-19) . WHO Country Office for Nepal . https://www.who.int/nepal/news/detail/24-04-2020-who-nepal-situation-update ( 1 June 2020, date last accessed ).

Author notes

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Understanding COVID-19 Situation in Nepal and Implications for SARS-CoV-2 Transmission and Management

Prabin dawadi.

1 Biological Resources Unit, Nepal Academy of Science and Technology, Lalitpur, Bagmati, Nepal

2 Central Department of Microbiology, Tribhuvan University, Kathmandu, Bagmati, Nepal

Gopiram Syangtan

3 Shi-Gan International College of Science and Technology, Tribhuvan University, Kathmandu, Bagmati, Nepal

Bhupendra Lama

Sushil r. kanel.

4 Department of Chemistry, Wright State University, Dayton, OH, USA

Dev Raj Joshi

Lok r. pokhrel.

5 Department of Public Health, The Brody School of Medicine, East Carolina University, Greenville, NC, USA

Rameshwar Adhikari

6 Research Center for Applied Science and Technology, Tribhuvan University, Kathmandu, Nepal

Hem R. Joshi

7 Department of Mathematics, Xavier University, Cincinnati, OH, USA

Ioana Pavel

8 Department of Physical and Environmental Sciences, Texas A&M University at Corpus Christi, Corpus Christi, TX, USA

Background:

The pandemic of Coronavirus Disease 2019 (COVID-19), one of the most infectious diseases in the modern history, is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and has had a profound health and economic toll, globally. This paper identifies the overall health status associated with COVID-19 pandemic in all 7 provinces of Nepal, a developing country in South Asia, analyzing data from January 2020 to February 2022. It focuses on the SARS-CoV-2 prevalence, transmission through wastewater and other routes, diagnostics, treatment options, and alternative medicines, thereby offering key perspectives for its management.

Materials and Methods:

Studies regarding coronavirus spanning the 2017 to 2022 period were searched on the web, Nepalese database, and Web of Science. Refined criteria included SARS-CoV-2 in wastewater of Nepal or worldwide. Demographic data (sex, age-group, and geographic location) were also obtained from websites and relevant reports of the Ministry of Health and Population (MOHP) of Nepal, ranging from January 2020 to February 2022. Moreover, trends concerning lockdown, business, and border activities in Nepal between February 2020 and October 2020 were evaluated. The viral dissemination pathways, diagnosis, and available treatment options, including the Ayurvedic medicine, were also examined.

Aerosols generated during the hospital, industrial, recreational, and household activities were found to contribute to the propagation of SARS-CoV-2 into environmental wastewater, thereby putting the surrounding communities at risk of infection. When lockdown ended and businesses opened in October 2020, the number of active cases of COVID-19 increased exponentially. Bagmati Province had the highest number of cases (53.84%), while the remaining 6 provinces tallied 46.16%. Kathmandu district had the highest number of COVID-19 cases (138, 319 cases), while Manang district had the smallest number of infections (81 cases). The male population was found to be predominantly infected (58.7%). The most affected age groups were the 31 to 40 years old males (25.92%) and the 21 to 30 years old females (26.85%).

Conclusion:

The pandemic impacted the public health and economic growth in our study duration. SARS-CoV-2 was prevalent in the wastewater of Nepal. The Terai districts and the megacities were mostly affected by SARS-CoV-2 infections. Working-age groups and males were identified as the highest risk groups. More investigations on the therapeutic and alternative cures are recommended. These findings may guide the researchers and professionals with handling the COVID-19 challenges in developing countries such as Nepal and better prepare for future pandemics.

Emerging infectious diseases (EIDs) present one of the greatest challenges to public health in the 21 st century. An emerging virus, depending on its potential to spread among humans, may cause individual or sporadic cases, culminating in a localized outbreak requiring public health intervention, or, in the worst-case scenario, a widespread epidemic, or worldwide pandemic. 1 The novel Coronavirus Disease 2019 (COVID-19) is a new respiratory disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) that is causing worldwide public health and economic challenges and has been recognized as a pandemic by the World Health Organization. 2 The virus was first reported in Wuhan, Hubei Province, China, in December 2019. 2 , 3 SARS-CoV-2 is an enveloped and positive single-stranded RNA virus belonging to the ß-coronavirus genus. 2 - 4 SARS-CoV-2 holds high homology with SARS-CoV and targets angiotensin-converting enzyme receptor-2 (ACE2) for the viral attachment. 4 A schematic depicting SARS-CoV-2 structure and pathogenesis is presented in Figure 1 . 5 There are very few studies on the transmission of SARS-CoV-2 through treated or untreated wastewater from advanced countries; however, COVID-19 surveillance of wastewater in developing countries has not been reported adequately. 6 There is thus a need to study the presence of SARS-CoV-2 in wastewater in the developing countries like Nepal.

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Schematic depicting SARS-CoV-2 structure and its pathogenesis.

On 24 th January 2020, the first case of COVID-19 was reported in a Nepalese student, who had recently returned from China to Nepal, and the second case was identified about 2 months later in a person returning from France. 7 A complete genome sequence of SARS-CoV-2 strain from a Nepalese patient with COVID-19 showed 99.6% identity with SARS-CoV-2 reference genome and the full-genome comparison of the isolate revealed >99.99% identity with 2 previously sequenced genomes available at GenBank (MN988668 and NC045512) for SARS-CoV-2 from Wuhan, China, and >99.9% with 7 additional sequences: MN938384.1, MN975262.1, MN985325.1, MN988713.1, MN994467.1, MN994468.1, and MN997409. 8 , 9 The majority of COVID-19 cases were reported to be asymptomatic. The likelihood of COVID-19 outbreak was noticeably underestimated in Nepal during the early phase of the pandemic and there was a subsequent rise in cases over time. 10

Notably, the healthcare system in Nepal was not prepared to manage such an outbreak in terms of physical facilities in the hospitals, availability of health care professionals, and arrangement of diagnostic as well as safety materials for the frontline healthcare professionals. There were misconceptions spread in the society that the Nepalese people are resistant against the COVID-19 for some unknown reasons. They also believed that their culinary practice and traditional medicine were effective against the disease, albeit with no scientific evidence. On one hand, there has been a challenge, particularly, for healthcare professionals in tackling COVID-19 with utmost precautions and with limited resources. On the other hand, there was a challenge for the scientific community to carry out a comprehensive analysis of the trend of the disease outbreak and recommend the government for efficient strategy formulation.

The population living under the absolute poverty line is 18.7% of the total population according to the Department of Information, Nepal. The population covered by health insurance in the base year 2018/19 was reported to be 7%. 11 The present health system’s capacity to respond to COVID-19 is inadequate. According to the Ministry of Health and Population Nepal in 2020, there were 26 930 hospital beds, 1595 ICU beds, 840 ventilators, 194 hospitals with ICU facilities, 111 hospitals with COVID clinics, 13 Level-1 COVID hospitals, 12 Level II COVID hospitals, 3 Level III COVID hospitals, and 3076 isolation beds. 12 Some hospitals were designated to treat COVID-19 cases in all 7 provinces of Nepal. But there was negligence to extend strategies to trace, isolate, test, and treat since efforts were deficient to standardize testing facilities and manage isolation centers for COVID-19 patients. The panic and psychological impact regarding COVID-19 led to losses of lives by non-COVID-related diseases in the early period of the pandemic 13 as well as an increase in suicide rates. 14 Later, the deaths continued since the strategies were inadequate to manage COVID-19 and non-COVID-related diseases in those hospitalized. People feared visiting the hospital to treat minor illnesses, which might be attributed to the increased severity of COVID-19 patients with comorbidities.

Herein, this study summarizes the overall status of COVID-19 in a developing country, Nepal, with SARS-CoV-2 transmission through wastewater and other routes; disease cases in all 7 provinces; diagnostics, treatment options, and alternative medicines; and offers perspectives in managing the disease and any future pandemics. The systematic literature review was based on the search criteria consisting of keywords: “coronavirus,” “coronavirus in Nepal,” and “coronavirus in wastewater,” and the publications from 2017 to 2022 were included ( Figure 2 ), which was further refined to “coronavirus in wastewater” and “coronavirus in wastewater of Nepal”: the 2 broader categories in the Web of Science. Also, data reported from January 2020 to February 2022 from the Ministry of Health and Population, Nepal, were included to determine the impact of pandemic on different age-groups, sexes, and by geography. Moreover, data ranging from February 2020 to October 2020 were used to evaluate trends related with lockdown, business, and border activity. The data were visualized in the form of graphs (GraphPad prism 8.4.3) and tables, the conceptual figures were created in Adobe Illustrator 2020, the geographic maps were created using AcrGIS, and the statistical calculations were performed in MS-Excel 2007. The findings are novel and may guide researchers and professionals working on managing COVID-19 in a developing country Nepal for better risk assessment and management.

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Main search criteria used for the selection and categorization of published literature on coronavirus in Nepal.

SARS-CoV-2 in Wastewater

Wastewater surveillance is an approach to monitoring diseases via wastewater effluent. 15 SARS-CoV-2 can disseminate through water and wastewater, leading to potential environmental transmission as shown in Figure 3 . 16 The potential harbored by SARS-CoV-2 for transmission via fecal-oral and aerosol routes poses an imminent challenge to comprehend the survival of the virus circulating in the environment. 17 The presence and evolution of SARS-CoV-2 in waters, soils, and other environmental compartments may pose a public health risk. 18 SARS-CoV-2 enters wastewater through the residential, industrial, and quarantine (isolation) facilities with COVID-19 patients. 19

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Schematic depicting dissemination pathways of SARS-CoV-2 from household activities, hospitals, and industries to the environment.

In Nepal, SARS-CoV-2 ribonucleic acid (RNA) was found in 60% (50/84 samples) of wastewater and river water samples analyzed. 20 Different studies have documented the presence of SARS-CoV-2 RNA in wastewater from different countries. 21 - 37 In the neighboring country, India, the viral genome was detected in the wastewater system. 38 Viral shedding through the digestive route seems to last longer than the shedding through the respiratory tract. 39 The impact of lockdown on SARS-CoV-2 dynamics was assessed using viral genome quantification in Paris wastewater and a significant decrease in the number of genome units was recorded, which coincided with the expected decline in the number of new COVID-19 cases with the length of lockdown. 40 The possibility of secondary transmission via wastewater should not be overlooked, as the virus has been found in human feces and wastewater samples from many countries, with possible cases of transmission still being debated. 41 Some coronaviruses can potentially survive in the gastrointestinal tract and spread via fecal-oral route or via inhalation of contaminated wastewater droplets. 42

The design encompassing wastewater plumbing system could allow harboring pathogenic microorganisms and has been suggested to hold the potential for enabling airborne transmission of the viruses, such as SARS-CoV-2, upon aerosol generation. Further, self-isolation and official quarantine centers for infected people could serve as a hotspot for virus shedding into the system. 43 , 44 The possibility of extended duration of viral shedding in feces, for nearly 5 weeks after the patients’ respiratory samples tested negative for SARS-CoV-2 RNA and the virus remaining viable for days in feces, may contribute to fecal-oral transmission. 45 , 46 The presence of SARS-CoV-2 in the infected person’s feces and urine, even after viral clearance in the respiratory tract, as well as its presence in untreated wastewater, may elevate the likelihood of future fecal-oral transmission to potential intestinal infection. 6 , 47 However, the presence of viral genetic materials in stool does not always mean that viable infectious virions are present in feces or that the virus can or has spread by fecal-fomite, fecal-oral, or fecal-aerosol/droplet transmission. 48 , 49

Wastewater surveillance includes the concentration of SARS-CoV-2 RNA from wastewater in a catchment or sampling point and enumeration of viral RNA copies using reverse transcriptase quantitative polymerase chain reaction (RT-qPCR). 36 However, the problems associated with biomedical wastewater treatment and disposals are of public health concern, particularly in developing countries like Nepal where hazardous waste landfills are absent. 50 Longitudinal analysis of wastewater can provide population-level estimates of the burden of SARS-CoV-2 where in-person or at-home testing may not be available. 51 SARS-CoV-2 in wastewater may reflect a potential health threat to individuals and has the potential to spread through aerosol inhalation or ingestion when the virus remains infectious in wastewater. Various coronaviruses could be cultured for a few days from wastewater. 52 , 53 Also, the enteric transmission of SARS-CoV-2 may be possible. Environmental surveillance of SARS-CoV-2 could serve as a data source and indicate whether the virus is circulating in the community or not. 33 , 54

SARS-CoV-2 Transmission and Cases in Nepal

While the source of SARS-CoV-2 is still unknown, bats and pangolins have been suspected, crossing the species barrier, and rapid human-to-human airborne transmission has been established. 55 - 57 Viral transmission could also occur through other routes including fomite, fecal-oral, blood-borne, mother-to-child, and animal-to-human routes. 58 - 60

Nepal is not an exception to COVID-19 and encountered challenges to prevent the spread of infection. Nepal was under complete lockdown from March 24, 2020, for several months in an attempt to control COVID-19 and prevent its spread into the community. 61 At the same time, a large number of Nepalese citizens returned from highly infected areas like India and China through open borders and entered different parts of the country without quarantining. When the lockdown ended and people returned to their normal schedule in October 2020, the cases increased exponentially ( Figure 4 ). Gradually, COVID-19 spread all over Nepal, with an increase in the number of new cases and deaths. Among them, most of the infected patients were reported from Bagmati Province. In Nepal, research documented a possible link between COVID-19 and temperature indicators, showing increased transmission of the disease in winter. 62 This created an alarming scenario in a low-income country Nepal with an inadequate healthcare system. The data from January 2020 to February 2022 demonstrated the highest numbers of cases for Kathmandu district, while the lowest occurred in Manang district ( Table 1 ). In Nepal, the total number of cases until February 17, 2021, was 974 493. The highest total cases were found in Bagmati Province (53.84%) followed by Province 1 (13.07%), Lumbini province (11.18%), and Gandaki province (9.55%), respectively. The cases were low in Karnali Province (2.44%), Sudurpashchim Province (4.5%), and Madhesh Province (5.42%). Figure 5 shows the COVID-19 cases trend district-wise and province-wise for Nepal for the period January 24, 2020 through February 17, 2021. The Terai region, including the Kathmandu valley, had a significant number of cases. This could be linked to Nepal’s open border with India on 3 sides: east, south, and west, as well as influx from COVID-19 affected areas nearby. 61 Also, megacities may have a greater number of cases because of dense populations. 63 The gender-wise distribution of COVID-19 cases is presented in Figure 6 . Data showed that males were predominantly infected (58.7%) compared to females (41.23%) ( Figure 6 ). The age group between 31 and 40 years old males were infected the most (25.92%), while the females aged 21 to 30 years old were infected the most (26.85%) ( Figure 7 ). The reason may be these age groups belong to the active working population in Nepal. The age group 80+ were the least infected, likely due to the low number of elderly population above 80 tested. Males were more symptomatic than females. A meta-analysis further corroborated that females could present COVID-19 cases in asymptomatic form compared to males. 64

District-wise highest and lowest cases of COVID-19 in 7 provinces of Nepal (January 24, 2020 through February 17, 2022).

Provinces	Highest (number/%)	Lowest (number/%)	Total cases in provinces
Province no. 1	Morang (47 735/37.51%)	Sankhuwashaba (776/0.61%)	127 251
Madhesh province	Dhanusa (11 200/21.18%)	Bara (5618/10.62%)	52 865
Bagmati province	Kathmandu (138 319/61.41%)	Rasuwa (1334/0.26%)	524 896
Gandaki province	Kaski (44 968/48.29%)	Manang (81/0.09%)	93 133
Lumbini province	Banke (20 392/18.71%)	Rukum East (284/0.26%)	108 998
Karnali province	Surkhet (127 111/53.40%)	Humla (140/0.58%)	23 803
Sudurpashchim province	Kailali (7416/47.93%)	Bajura (244/1.96%)	14 238
			Total: 945 184

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Reported cases in all 7 provinces of Nepal concerning lockdown, and business and border activities.

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Distribution of the total number of positive cases in 7 provinces and 77 districts in Nepal (January 24, 2020 through February 17, 2021).

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Gender-wise distribution of COVID-19 cases in Nepal (January 24, 2020 through February 17, 2022).

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Gender- and age-wise distributions of COVID-19 infections in Nepal (January 24, 2020 through February 17, 2022).

The first death in Nepal was a 29-year-old new mother with an unknown mode of transmission on May 16, 2020, and by June 21, there were 23 deaths reported. Surprisingly, most of the deaths happened outside of hospitals, and COVID-19 was confirmed postmortem. 65

Laboratory Diagnosis to Detect SARS-CoV-2 in Nepal

As a low-resource country, Nepal has had suffered a profound impact on the clinical microbiology laboratories over the course of this pandemic. 66 Not only clinically, but also technologically and logistically, rapid and accurate detection of this novel virus offers considerable challenges. Before laboratory diagnosis, to categorize the suspected patients of COVID-19, the clinicians should observe the following symptoms: fever or symptoms of lower respiratory infection, such as cough or shortness of breath, fatigue, dyspnea, sore throat, headache, conjunctivitis, and/or gastrointestinal issues. 67 - 69

The gold standard for the detection of SARS-CoV-2 is the identification of the viral genome targets by nucleic acid amplification test (NAAT), such as real-time reverse transcription-polymerase chain reaction (rRT-PCR), used globally for the diagnosis of COVID-19 in the upper respiratory samples during the first week of infections. It uses the TaqMan fluorogenic probe-based chemistry and 5′-nuclease activity of Taq DNA polymerase. 70

Nonetheless, rapid diagnostic tests (RDTs), such as antigen-detecting RDTs (Ag-RDT) and antibody-detecting RDTs, virus isolation (culture method), electron microscopic examination, complete genomic sequencing technique (Meta-genomics, next-generation sequencing), and isothermal-CRISPR-based diagnostics have been used for the detection of SARS-CoV-2. 71 - 73 However, each method presents its limitations. Comparative study of different diagnostics molecular technologies has revealed that CRISPR-COVID had a 100% specificity and 40 minutes as the reaction turn-around time (TAT); RT-PCR-COVID with 90.4% specificity and 1.5 hours TAT; and NGS with 100% specificity and approximately 20 hours TAT. 71 Whereas antigen and antibody-based rapid immunoassays with a wide range of sensitivity and specificity are also available in the market. 72

In Nepal, confirmatory test for COVID-19 and/or detection of genomic material (i.e., RNA) of SARS-CoV-2 involves the rRT-PCR method. However, serology-based immunoglobulin (IgM and IgG) antibody tests and antigen tests are also being introduced as supplementary and seroprevalence tools for community surveillance. 74 PCR assays were rapidly deployed in the country during the early stages of the pandemic and have formed the cornerstone of detection. The central government agencies also rapidly deployed funding mechanisms for developing novel testing strategies. The RDTs didn’t exhibit enough reliable performance (sensitivity and specificity) and were not recommended for stand-alone use to guide decision-making in any setting. A similar response was found in her southern neighbor, India. 75

Upon meeting the national testing guidelines, specimens collected from the upper respiratory tract include nasopharyngeal (NP) swab and oropharyngeal swab: synthetic fiber swabs with plastic shafts are preferred over calcium alginate swabs or cotton-tipped swabs with wooden shafts, for molecular diagnosis. The swabs are immediately placed in sterile tubes containing 2 to 3 mL of viral transport media (VTM). However, other possible samples include bronchoalveolar lavage, tracheal aspirate, NP aspirate, nasal wash, saliva, sputum, blood/paired serum, urine, and stool for detection of the viral RNA. 76 - 79 Clinicians are advised to wear proper personal protective equipment (PPE) during specimen collection, pack the specimens in a triple packaging system, and maintain the cold chain for the transport of specimens in VTM before processing. 80 , 81 However, many affluent countries have also encountered challenges in the test delivery, specimen collection and transport, and limited testing. These challenges persisted greater in low-resource settings as in Nepal. 81 , 82

Tests are performed in designated laboratories for patients meeting the case definition of COVID-19 following clinical observations and national guidelines. Diagnosis of COVID-19 is ultimately confirmed by rRT-PCR. 83 , 84 Although RT-PCR is considered the standard laboratory test for the diagnosis of COVID-19, it may also yield a false negative/positive result in some cases. 85 In the early stage of the disease, several cases with false-negative/positive RT-PCR results were reported probably because of inadequate viral loads in the sample and/or technical issues during nucleic acid extraction. 86

Molecular tests form the basis for confirming COVID-19, whereas computed tomography (CT) scan may support the diagnosis 87 but serological tests for SARS-CoV-2 that are also widely available play an increasingly important role in understanding the epidemiology of the virus and in identifying populations at higher risk for infection. 66 , 74 , 88 , 89 In cases with typical clinical manifestations, chest CT may prove to be an invaluable asset because it may show characteristic features of the disease even when the RT-PCR screening test is negative. 90 , 91

Treatment of COVID-19 in Nepal

The antiviral therapeutics used globally against SARS-CoV-2 infection were not particularly designed to act against SARS-CoV-2. Camostatmesilate (Foipan™) and Nafamostatmesilate (Buipel™) are serine protease inhibitors, which target TMPRSS2. 92 , 93 An antimalarial drug Chloroquine phosphate (Resochin™) targets ACE2, 94 , 95 and hydroxychloroquine (Quensyl™, Plaquenil™, Hydroquin™, Dolquine™, Quinoric™) acts against endosome and pH. 95 - 97 Remdesivir is an adenine nucleotide analog targeting viral RdRp. 98 - 100 Favipiravir (Avigan™) also targets RdRp. 101 Lopinavir/Ritonavir (Kaletra™) targets viral proteases. 102 , 103 Umifenovir (Arbidol™) targets membrane fusion and clathrin-mediated endocytosis. 104 These drugs are under various phases of clinical trials against SARS-CoV-2 infection.

In Nepal, Remdesivir is the major potential drug under evaluation. Further, plasma therapy is also under trial. On 9th August 2020, the Government of Nepal granted permission to use Remdesivir in COVID-19 patients as an experimental drug. The Ministry of Health and Population (MoHP) and the Department of Drug Administration (DDA) of Nepal authorized the import and usage of Remdesivir for treating COVID-19 and delegated authority to Nepal Health Research Council (NHRC) to oversee its administration as an experimental use drug (Nepal Health Research Council). 105

However, it was found that Remdesivir use was not statistically associated with a difference in time to clinical improvement in SARS-CoV-2 infected patients but was found effective based on individuality. 106 Patients receiving Remdesivir presented complications, including hypersensitivity reactions such as anaphylactic and infusion-related reactions. 74 The drug has displayed a mixed result in COVID-19 patients and has side effects to the level of acceptance. 107

Treatment Options Against SARS-CoV-2 Infection in Nepal

Remdesivir (Veklury) was approved by the US Food and Drug Administration (FDA) for use against mild-to-severe COVID-19. 108 The median time to recovery was significantly reduced by 5 days in patients that received Veklury (10 days for the recovery for Veklury group compared to 15 days for the placebo group). The odds of clinical improvement at day-15 were also statistically significantly higher in the Veklury group compared to the placebo group. The overall 29-day mortality was 15% for the placebo group and 11% for the Veklury group; this difference was not statistically significant. 104 In a large study conducted under the SOLIDARITY trial (a World Health Organization-sponsored, open-label, randomized trial), that included 12 000 patients in 500 hospital sites in over 30 countries, the study did not find a statistically significant difference in mortality between the Veklury group and the standard-of-care group. 106 Remdesivir has been shown to speed up the recovery rate in hospitalized patients requiring supplemental oxygen but the drug alone is not adequate to solve the issues arising from the pandemic. 109

Convalescent plasma therapy

Clinical trials on the use of convalescent plasma therapy against SARS-CoV-2 infection have been conducted in Nepal. 110 Immune-based therapy consists of convalescent plasma and immunoglobulins, interleukin-1 (IL-1) inhibitors, interleukin-6 (IL-6) inhibitors, and other immuno-modulators. Blockage of IL-6 and IL-1 and inhibition of Janus Kinase (JAK) may lead to treating systemic inflammation associated with severe COVID-19. 111 Convalescent blood products consist of convalescent whole blood or convalescent plasma or convalescent serum, pooled human immunoglobulin for intravenous or intramuscular administration, high-titer human immunoglobulin, and polyclonal or monoclonal antibodies. 112 Previous studies in the United States 113 and China 114 - 117 reported plasma therapy as an option for treatment against severe COVID-19 but more clinical trials are needed to confirm its proposed efficacy. In Nepal, convalescent plasma showed beneficial effects against COVID-19, but larger, randomized controlled trials are required to confirm its efficacy. 118

Ayurveda and alternative treatments in Nepal

The Ayurvedic medical system has its origin in the Indian subcontinent. 119 Research published over the years in Ayurvedic and traditional Chinese medicine (TCM) have demonstrated that herbs and/or TCM can limit viral replication, limit virus entry and attachment to the host cell, and promote the patient immune system. For example, medicinal herbs with immuno-modulatory and antioxidant characteristics, such as ashwagandha ( Withania somnifera ), have been documented to enhance immune response and reduce viral replication. 120 Tulsi, haldi (turmeric), giloy, black pepper, ginger roots, cloves, cardamom, lemon, and ashwagandha were among the phytochemical and antiviral compounds evaluated in a recent study in the hopes of finding a cure for COVID-19. 121 To investigate the antiviral effect of phytochemical components and bioactive compounds found in herbs, researchers docked them with distinct coronavirus target proteins such as viral capsid spike and protease. The study indicated that certain phytochemicals used in traditional medicine had a high affinity for viral proteins, making them potential candidates for target drug design. 122

A research compared the Ayurvedic protocols suggested by the governments of Nepal and India. 123 There is a lot of evidence that the Ayurvedic and traditional systems of medicines offer excellent potential in dealing with COVID-19 pandemic and other epidemics that the society may encounter in the future. Altogether, during this pandemic about 60 medicinal plants belonging to 36 families were utilized in Nepal. 124 There is, thus, a need to explore and utilize the traditional Ayurvedic knowledge vis-à-vis the state-of-the-art technologies to address the ongoing pandemic and prepare for any future respiratory viral disease outbreaks.

Role of Sanitation in Public Health Protection

Inadequate hygiene, sanitation, and disinfection approaches in healthcare facilities, as well as dwellings without proper wastewater disposal and management, may expose individuals to the circulating virus particles. 6 Overuse of non-biodegradable plastics during the epidemic has exacerbated plastic pollution, posing a considerable health threat to land and aquatic ecosystems in Nepal. 125 Access to safe water, nutritious food, and lack of sanitation and hygiene remain a challenge in most rural communities and mountain regions due to geographical challenges and lack of effective people-focused programs. 126 , 127 Apparently healthy people were infected as a result of poorly handled quarantine and hospital waste across the country during the pandemic, as reported on national news media. 128

Individuals who believe they are at risk and are aware of the seriousness of COVID-19 implications are more likely to exercise caution. 129 Hand washing has been recommended as a preventative measure against the circulating and emerging SARS-CoV-2 strains. 130 The survival duration of coronavirus in water environments is highly influenced by temperature, water properties, suspended solids, and organic matter concentrations, solution pH, and disinfectant dose, with the advantage that the current drinking water disinfection process effectively inactivates most bacterial and viral pathogens present in water, including SARS-CoV-2. 131 The environmental discharge of inappropriately treated wastewater might expose public to coronavirus infection, underscoring the importance of proper wastewater treatment and management in the developing county Nepal. 132

Conclusion and Future Perspective

The pandemic has had an impact on public health and economic growth in Nepal. SARS-CoV-2 was detected in wastewater in Nepal. SARS-CoV-2 infections were particularly common in Terai areas and megacities. Working-age groups and males were identified as the most exposed groups. With limited available healthcare resources in Nepal, it has been a significant challenge managing the growing influx of COVID-19 patients. It is, thus, critical for the hospitals and clinics in all (7) provinces to pool their resources and develop a central coordination mechanism to mobilize the available resources to effectively manage and care for COVID-19 patients. Quarantine facilities should be properly managed, staffed, and surveilled ensuring the health and safety of those that are quarantined. The coordination mechanism of the hub and satellite hospitals might be an area to work on to effectively address the issues related to limited resources and capacity building in Nepal with far limited resources to address the ongoing pandemic and prepare for any future emerging infectious diseases of epidemic and pandemic potential.

Poor sanitation and mismanagement of wastewater might serve as possible environmental factors contributing to COVID-19 transmission in Nepal; however, more focused research is needed to better understand how wastewater surveillance might help predict early transmission of SARS-CoV2 in the community and help mitigate COVID-19 spread.

Acknowledgments

We would like to acknowledge the Central Department of Microbiology, Tribhuvan University, Nepal, and the Nepal Academy of Science and Technology, Lalitpur, Nepal for their support to researchers during the COVID-19 pandemic.

Funding: The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests: The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions: Dev R Joshi, Sushil R. Kanel, and Lok R. Pokhrel: conceived the study design and contributed to writing and editing the manuscript. Prabin Dawadi: contributed to study design, literature search, results interpretation, data analysis, statistical output interpretations, manuscript writing. Gopiram Syangtan: literature search, results interpretation, data analysis, manuscript writing. Bhupendra Lama: data analysis, statistical output interpretations, results interpretation, manuscript writing. Rameshwar Adhikari: Commented on the manuscript. Hem R. Joshi: Statistical trend analysis. Ioana Pavel: Commented on the manuscript.

Availability of Data and Materials: All data generated for this study are included in this article. The data are also available from the corresponding author upon reasonable request.

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PEPFAR Expands COVID-19 Vaccines In Zambia

What to know.

Zambia worked with CDC and partners to expand COVID-19 vaccination. This expansion used a new model in clinics supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) to help get COVID-19 vaccines to people living with HIV. With CDC support, the Ministry of Health (MOH) expanded vaccination to more than 1,000 sites in all 10 of Zambia's provinces as vaccines were available.

Health care worker provides vaccination to patient.

Photo essay

Photo of a man receiving a COVID-19 vaccine at a clinic.

Addressing the mental health needs of the Nepali people during the COVID-19 pandemic

The prevalence of mental disorders, such as depression and anxiety, is expected to rise since the COVID-19 pandemic . Data of Nepal Police also showed increasing deaths from suicide resulting in 16-18 persons dying due to suicide every day in 2020.

Certain groups such as persons with existing mental health conditions and psychosocial disabilities were more vulnerable to acquiring COVID-19 and stress and needed continuous care. Moreover, not everyone had access to mental health services when they required it.

Hence, the World Health Organization, Country Office for Nepal, assisted the Ministry of Health and Population in developing a COVID-19 Mental Health & Psychological Support (MHPSS) intervention framework to draw adequate attention to mental health and psychosocial support services in the national emergency response and to continue delivering essential mental health services.

A National Mental Health Strategy and Action Plan has been brought into implementation which aimed to improve access to quality essential health services.

Assessment for persons with severe mental health condition at Lele, Godawari, Province Bagmati, Nepal; Photo Credit: KOSHISH

The WHO/ International Committee of the Red Cross Guideline of Psychological First Aid was also translated and adapted to the national context in collaboration with the Nepal Association of Clinical Psychologist. This document served as a guide to adjust Nepal's unique needs in the planning phase.

WHO, Country Office for Nepal, also held regular meetings (mental health sub-cluster meetings) to co-ordinate work among partners, and as a result of concerted actions:

- more than 40,000 people received psychosocial support in some form;

- more than 20,000 children and adolescents provided essential mental health support;

- more than 3,000 health care providers reached out on their mental health needs through stress management workshops and webinars;

- more than 160 community psychosocial counsellors were trained;

- more than 500 FM radio stations across the country were engaged to disseminate messages; and

- partners also operationalized several helpline services.

Additionally, an online platform was also developed to support mental health needs of the health care providers which contained tips on mental health care, modules on stress management, webinars, audio-visual and IEC materials, self-screening tools, and appointment and follow up services.

Such services were in place to avoid various psychological issues like burnout, emotional exhaustion, or decreased sense of accomplishment, which can significantly impact competence, efficiency, and health care service delivery. This helped health service providers be capable of providing service to those who needed it.

Furthermore, WHO, Country Office for Nepal, is also partnering with KOSHISH, a national mental health self-help organization, to address mental health consequences of the COVID-19 pandemic in 5 municipalities in Nepal.

Mental health interventions have also been integrated into primary health care level as a Community Mental Health Care Package 2017 by developing necessary guidelines, training manuals, and revising the national free medicines list.

"The consequences of this health and social crisis are likely to get more pronounced among vulnerable population such as women, children, persons with disabilities resulting from both physical impairments and mental health problems. The ongoing effort to integrate mental health into primary care level will support Nepal's health systems to provide essential health service to the population. They are also bound to connect the Nepali people to quality health care services", states Dr. Rajesh Sambhajirao Pandav , WHO Representative to Nepal.

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Easy Essay about Coronavirus in Nepali कोरोना भाइरस
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Introduction

Epidemic Status of COVID-19 in Nepal

The Response of Nepal Government to COVID-19

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The use of medicinal plants to prevent COVID-19 in Nepal

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Understanding COVID-19 Situation in Nepal and Implications for SARS-CoV-2 Transmission and Management

Gopiram Syangtan

Bhupendra Lama

Dev Raj Joshi

Rameshwar Adhikari

Hem R. Joshi

Ioana Pavel

Background:

Materials and Methods:

Conclusion:

SARS-CoV-2 in Wastewater

SARS-CoV-2 Transmission and Cases in Nepal

Laboratory Diagnosis to Detect SARS-CoV-2 in Nepal

Treatment of COVID-19 in Nepal

Treatment Options Against SARS-CoV-2 Infection in Nepal

Convalescent plasma therapy

Ayurveda and alternative treatments in Nepal

Role of Sanitation in Public Health Protection

Conclusion and Future Perspective

Acknowledgments

PEPFAR Expands COVID-19 Vaccines In Zambia

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Addressing the mental health needs of the Nepali people during the COVID-19 pandemic

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