essay on impact of covid 19 in nepal

COVID-19 impact on Nepal’s economy hits hardest informal sector

Smart policies for informal workers key for recovery

KATHMANDU, October 8, 2020— Nepal’s economy is projected to grow by only 0.6 percent in 2021, inching up from an estimated 0.2 percent in 2020 as lockdowns caused by COVID-19 disrupt economic activity, especially tourism, says the World Bank’s latest South Asia Economic Focus Beaten or Broken? .

Released today, the twice-a-year-regional update notes that South Asia is set to plunge this year into its worst-ever recession as the devastating impacts of the pandemic on the region’s economies linger on, taking a disproportionate toll on informal workers and pushing millions of South Asians into extreme poverty.

The report forecasts a sharper than expected economic slump across the region, with regional growth expected to contract by 7.7 percent in 2020, after topping 6 percent annually in the past five years. Regional growth is projected to rebound to 4.5 percent in 2021. Factoring in population growth, however, income-per-capita in the region will remain 6 percent below 2019 estimates, indicating that the expected rebound will not offset the lasting economic damage caused by the pandemic.

In previous recessions, falling investment and exports led the downturn. This time is different as private consumption, traditionally the backbone of demand in South Asia and a core indicator of economic welfare, will decline by more than 10 percent, further spiking poverty rates. A decline in remittances is also expected to accelerate loss of livelihoods for the poorest in some countries.

“The economic consequences of the pandemic and impact on livelihoods across Nepal is expected to be the most acute for informal workers or those without social security or assistance, who are more at risk of falling into extreme poverty,” stated Faris Hadad-Zervos, World Bank Country Director for Maldives, Nepal and Sri Lanka . “Swift action is needed to provide incomes, social protection, and employment to support them. This includes key investment climate reforms to promote physical infrastructure and access to finance for the informal sector to shorten the transition to recovery.”

Informal businesses make up around 50 percent of enterprises in Nepal and are the main source of income for most of the labor force. Within this group, urban informal sector workers and self-employed households in urban areas are more vulnerable than rural households who can fall back on subsistence farming. Most informal firms operate with limited savings, and owners may face the difficult choice of staying home and facing starvation during the lockdown or running their business and risking infection. These scenarios accentuate financial difficulties as well as the spread of COVID-19.

The report urges governments to design universal social protection as well as policies that support greater productivity, skills development, and human capital. In that effort, securing international and domestic financing will help governments fund crucial programs to speed up recovery. In the long-term, digital technologies can play an essential role in creating new opportunities for informal workers, making South Asia more competitive and better integrated into markets—if countries improve digital access and support workers to take advantage of online platforms.

“COVID-19 will profoundly transform Nepal and the rest of South Asia for years to come and leave lasting scars in its economies. But there is a silver lining toward resilient recovery: the pandemic could spur innovations that improve South Asia’s future participation in global value chains, as its comparative advantage in tech services and niche tourism will likely be in higher demand as the global economy becomes more digital,” said Hans Timmer, World Bank Chief Economist for the South Asia Region.

The  World Bank Group , one of the largest sources of funding and knowledge for developing countries, is taking  broad, fast action  to help developing countries strengthen their pandemic response. We are supporting public health interventions, working to ensure the flow of critical supplies and equipment, and helping the private sector continue to operate and sustain jobs. We will be deploying up to $160 billion in financial support over 15 months to help more than 100 countries protect the poor and vulnerable, develop human capital, support businesses, and bolster economic recovery. This includes $50 billion of new IDA resources through grants and highly concessional loans.

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Article Contents

Authors’ contributions, acknowledgments, conflicts of interest.

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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.

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An Overview of the Impact of COVID-19 on Nepal’s International Tourism Industry

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• Asmod Karki   ORCID: orcid.org/0000-0003-2270-0545 5 ,
• Nama Raj Budhathoki   ORCID: orcid.org/0000-0002-2041-4986 6 , 7 &
• Deepak Raj Joshi   ORCID: orcid.org/0000-0001-5620-7025 8  

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COVID-19 severely impacted Nepal’s economy. The tourism industry, a major contributor to Nepal’s gross domestic product (GDP), has been one of the major sectors to bear the secondary impact due to COVID-19. This chapter provides an overview of the economic and non-economic impact of COVID-19 on the tourism sector. The discussion centers around two major stakeholders: businesses and workers. It also elaborates on the major stakeholders’ expectations on the government to withstand and recover from the economic shock.

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Acknowledgements

This book chapter would not have been possible without the exceptional work by a number of people at Kathmandu Living Labs (KLL). We are grateful, in particular, to:

Sazal Sthapit

Arogya Koirala

Aishworya Shrestha

Roshan Poudel

Manoj Thapa

Our special thanks to Dr. Melinda Laituri for her constant encouragement to write this chapter as well as for her constructive feedback on our earlier draft. This research was possible thanks to the Cities’ COVID Mitigation Mapping (C2M2) Program, developed by the U.S. Department of State’s Humanitarian Information Unit and the American Association of Geographers (AAG).

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Correspondence to Nama Raj Budhathoki .

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Karki, A., Budhathoki, N.R., Joshi, D.R. (2022). An Overview of the Impact of COVID-19 on Nepal’s International Tourism Industry. In: Laituri, M., Richardson, R.B., Kim, J. (eds) The Geographies of COVID-19. Global Perspectives on Health Geography. Springer, Cham. https://doi.org/10.1007/978-3-031-11775-6_10

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REVIEW article

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

• 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.

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Medical Education in Nepal: Impact and Challenges of the COVID-19 Pandemic

Affiliations.

• 1 S. Sigdel is assistant professor, Department of Cardiothoracic and Vascular Anesthesiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal; ORCID: https://orcid.org/0000-0001-5357-1083 .
• 2 A. Ozaki is attending physician, Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki, Fukushima, Japan.
• 3 R. Dhakal is assistant professor, Department of Pathology, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.
• 4 B. Pradhan is professor, Department of Cardiothoracic and Vascular Anesthesiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
• 5 T. Tanimoto is researcher, Medical Governance Research Institute, Shinagawa, Tokyo, Japan.
• PMID: 33332910
• DOI: 10.1097/ACM.0000000000003888

During the COVID-19 pandemic, there has been a global shift toward online distance learning due to travel limitations and physical distancing requirements as well as medical school and university closures. In low- and middle-income countries like Nepal, where medical education faces a range of challenges-such as lack of infrastructure, well-trained educators, and advanced technologies-the abrupt changes in methodologies without adequate preparation are more challenging than in higher-income countries. In this article, the authors discuss the COVID-19-related changes and challenges in Nepal that may have a drastic impact on the career progression of current medical students. Outside the major cities, Nepal lacks dependable Internet services to support medical education, which frequently requires access to and transmission of large files and audiovisual material. Thus, students who are poor, who are physically disadvantaged, and who do not have a home situation conducive to online study may be affected disproportionately. Further, the majority of teachers and students do not have sufficient logistical experience and knowledge to conduct or participate in online classes. Moreover, students and teachers are unsatisfied with the digital methodologies, which will ultimately hamper the quality of education. Students' clinical skills development, research activities, and live and intimate interactions with other individuals are being affected. Even though Nepal's medical education system is struggling to adapt to the transformation of teaching methodologies in the wake of the pandemic, it is important not to postpone the education of current medical students and future physicians during this crisis. Looking ahead, medical schools in Nepal should ensure that mechanisms are proactively put into place to embrace new educational opportunities and technologies to guarantee a regular supply of high-quality physicians capable of both responding effectively to any future pandemic and satisfying the nation's future health care needs.

Copyright © 2020 by the Association of American Medical Colleges.

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• Karki DB, Dixit H. An overview of undergraduate and postgraduate medical education in Nepal and elsewhere. Kathmandu Univ Med J (KUMJ). 2004; 2:69–74
• Uprety A, Leppold C, Shrestha D, Higuchi A, Tanimoto T. Hunger strike and health system reformation in Nepal. Lancet. 2016; 388:1982–1983
• Adhikari B, Mishra SR. Urgent need for reform in Nepal’s medical education. Lancet. 2016; 388:2739–2740
• Magar A. Need of medical education system reform in Nepal. JNMA J Nepal Med Assoc. 2013; 52:I–II
• Gupta RP, Ghimire J, Mahato RK, et al. Human resource for health production capacity in Nepal: A glance. J Nepal Health Res Counc. 2013; 11:144–148
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Open Access

Peer-reviewed

Research Article

Household preparedness for emergencies during COVID-19 pandemic among the general population of Nepal

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft

Affiliation Center of Research for Environment, Energy and Water, Kathmandu Nepal

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliations Center of Research for Environment, Energy and Water, Kathmandu Nepal, Interdisciplinary Center for River Basin Environment, University of Yamanashi, Yamanashi, Japan

Roles Conceptualization, Investigation, Methodology, Project administration, Supervision

Affiliation Nepal Red Cross Society, Head Office, Kathmandu, Nepal

Roles Conceptualization, Supervision, Writing – review & editing

Affiliation Institute of Medicine, Research Directorate, Tribhuvan University, Kathmandu, Nepal

• Salina Shrestha, 
• Rabin Malla, 
• Sadhana Shrestha, 
• Pallavi Singh, 
• Jeevan B. Sherchand

• Published: September 12, 2024
• https://doi.org/10.1371/journal.pgph.0003475
• Reader Comments

The COVID-19 pandemic has negatively impacted the global economy affecting numerous people’s livelihoods. Despite preventive behaviors and advancements of vaccination, the risk of infection still exists due to the emergence of new variants of concern and the changing behavior of the SARS CoV-2 virus. Therefore, preparedness measures are crucial for any emergency. In such situations, it is important to understand preparedness behavior at the household level, as it aids in reducing the risk of transmission and the severity of the disease before accessing any external support. Our study aimed to evaluate household preparedness level for emergencies during the COVID-19 pandemic and its relationship with socio-demographic characteristics among the general population of Nepal. Data was collected through a questionnaire survey. Descriptive statistics, a Chi-square test, and logistic regression model were used for analysis. The study demonstrated that 59.2% had a good preparedness level. Good preparedness was observed among the respondents living in urban areas, those who were married, had white-collar occupations, high-education with graduate and above and high-income levels with monthly income >NPR 20,000, and were young-aged. The study findings underscore the need to develop tailored programs on preparedness prioritizing vulnerable population. It further highlights the importance of proper and consistent information flow, resources distribution, capacitating human resources and better health surveillance.

Citation: Shrestha S, Malla R, Shrestha S, Singh P, Sherchand JB (2024) Household preparedness for emergencies during COVID-19 pandemic among the general population of Nepal. PLOS Glob Public Health 4(9): e0003475. https://doi.org/10.1371/journal.pgph.0003475

Editor: Michele Nguyen, Nanyang Technological University, SINGAPORE

Received: March 23, 2024; Accepted: July 23, 2024; Published: September 12, 2024

Copyright: © 2024 Shrestha et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are available in the Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The sudden onset of emergencies has resulted in a vivid increase in damage to life and property over the last few decades, leading to severe health impacts [ 1 ]. Coronavirus disease 2019 (COVID-19) has become one of the major public health issues globally and was declared a pandemic on 11 March 2020. It transmitted rapidly to almost all the countries of the world compared to the previous coronavirus epidemics such as SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome) over the past three years [ 2 ]. The pandemic has affected the global economy and affected the livelihoods of many people [ 3 ]. As of 24 December 2023, the total number of confirmed COVID-19 cases worldwide was around 773,119,173 with a death toll of 6,990,067 [ 4 ]. In Nepal, there were a total of 1,003,450 reported confirmed COVID-19 cases and 12,031 deaths [ 5 ].

Recently, the World Health Organization (WHO) lifted the declaration of the public health emergency of international concern due to diminishing waves of COVID-19. However, experts have made it clear that the threat still exists, and the pandemic is not over. The disease remains and people must learn to live with it, as in the case of influenza, cholera etc. where the virus cannot be eradicated [ 6 , 7 ]. Hundreds of thousands of cases, along with numerous deaths, are still occurring [ 8 ]. A considerable number of people are suffering from long COVID-19 [ 9 ], and higher risks exist among individuals with chronic diseases [ 10 ]. At this moment, the major concern is the changing nature of the virus possessing uncertainties and more variants are still expected to evolve with no inevitability about changes in severity. This chaotic situation underscores the necessity of always being in a state of readiness. During this phase, WHO advises countries not to let down its guard and to maintain systems built during the challenging times of the pandemic. The Global Strategic Preparedness, Readiness and Response Plan for the period 2023–2025 [ 11 ], updated by WHO, further suggests incorporating and continuing to monitor COVID-19 cases through community-based surveillance in national programs. It strongly emphasizes data collection and reporting in various aspects of this matter to reduce infection.

The crucial matters to be considered for inquest to control the disease are, firstly, measures followed by non-infected individuals for prevention; secondly, preparedness measures required prior to getting infected. Despite awareness, adherence of preventive practices, and the advancements in vaccinations, the risk of emergencies, such as the possibility of any family members getting infected by COVID-19, still exists. In such situations, compliance with preparedness measures is crucial and plays a special role in lessening the deleterious impact of resurging COVID-19. For example, huge loss of life and property can be prevented through strong preparation before the onset of emergencies in the family [ 12 ]. Therefore, studying preparedness is crucial.

Preparedness is usually considered as the ‘knowledge and capacities to effectively anticipate, respond and recover from the impact of hazard events’ [ 13 ]. It should be addressed at different levels, including household, community, and government levels. Household preparedness is especially important in such situations, as it involves the preparation for self-rescue measures that need to be conducted immediately and appropriately before accessing other external support [ 14 ]. These measures comprise hygiene, proper isolation, effective communication, and storage of items including medicine, food, water, hygiene material, etc. during emergencies [ 15 – 17 ]. The proper home quarantine of family members taking care of the infected person, should also be preferred [ 18 , 19 ]. A lack of preparedness prior to the onset of any emergency usually makes people anxious and distressed due to fear of the unknown, that negatively influences their ability to make decisions and causes difficulties in taking the right actions during emergencies [ 20 – 23 ]. Therefore, awareness of the household-level preparation is crucial to ease the panic and lessen the severity of the crisis. Understanding of preparedness among the people is indispensable for this reason.

Household preparedness is crucial and needs to be prioritized, especially in developing countries like Nepal, to reduce the burden on health institutions with inadequate resources [ 24 – 26 ]. Additionally, it helps to enhance the adequate management of crisis within households. Numerous awareness programs for prevention from COVID-19 are conducted by many organizations [ 27 , 28 ]. However, the dissemination of information on several aspects of household preparedness for emergencies is comparatively less frequent. Moreover, the inequality in access to information, and required resources regarding the adversity of emergencies is ubiquitous in relation to variation in socio-demographic status such as geographical location, marital status, gender, education, income, occupation [ 29 – 33 ]. This further diminishes the perceived severity of emergencies among the people with limited access and exhibits the possibility of variation in preparedness behavior with respect to socio-demographic characteristics. Nevertheless, it is imperative to increase the perceived severity to motivate people to act at any time with careful measures that determine preparedness behavior [ 34 ].

Previous studies on household preparedness for emergencies in different countries have revealed diverse information that aids in comprehending the status of preparedness behavior, its influencing factors and provides the guidelines for policy recommendations [ 14 , 19 , 35 – 40 ]. Nonetheless, the lack of detailed studies on household preparedness for emergencies in the context of Nepal accentuates the importance of this study. We assumed differences in compliance with household preparedness measures among the general population with reference to socio-demographic status. Therefore, this paper intends to assess the situation of household preparedness for emergencies during COVID-19 pandemic at the household level and its relationship with socio-demographic characteristics. The study results will provide empirical evidence that can help to revise the existing plan and policies, apportion the required resources as well as its efficient use during emergencies to improve preparedness. Additionally, understanding the variation in preparedness according to social and demographic factors in society will give a clear picture of the vulnerable population.

Study area and sampling

A cross-sectional study was conducted in eight of seventy-seven districts of Nepal which were the most affected districts during the COVID-19 pandemic—Kathmandu, Bhaktapur, Lalitpur, Morang, Sunsari, Rupandehi, Chitwan, and Kaski ( Fig 1 ). Eight districts were chosen to include 10% of the total districts of the countries. The study considered the general population above the age of 18 years who could give consent to participate in the survey. During the period of the pandemic, due to the difficulties of conducting probability sampling, a convenient non-probability sampling method was considered for data collection. The total sample size was 702.

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[The darkest grey thick lines covering the grey area represents the country boundary of Nepal and the soft grey lines inside the country boundary represent the administrative boundaries of Nepal separating different districts. The location of selected districts for the study is presented by rectangles. Country boundary and administrative boundaries shape files of Nepal, retrieved from Administrative Boundaries Reference (view layer) of FAO ( https://data-in-emergencies.fao.org/datasets/hqfao::administrative-boundaries-reference-view-layer/explore?layer=0 ), under an open license (CC BY 4.0): https://data-in-emergencies.fao.org/datasets/hqfao::administrative-boundaries-reference-view-layer/about?layer=0 . Figure created with QGIS software version 3.28, an open source Geographic Information System (GIS) licensed under the GNU General Public License ( https://bit.ly/2BSPB2F )]. Source: Shrestha et al. 2023 [ 41 ].

https://doi.org/10.1371/journal.pgph.0003475.g001

For each selected district, the sample size was determined according to the population proportion of the total population of eight districts. The populations of the selected districts are as follows; Kathmandu—1,744,240, Bhaktapur—304,651, Lalitpur—468,132, Morang—965,370, Sunsari- 763,487, Rupandehi—880,196, Chitwan—579,984, and Kaski—492,098 [ 42 ].

Hence, the numbers of participants selected in each district were as follows: Kathmandu—197, Bhaktapur—35, Lalitpur– 54, Morang—107, Sunsari—88, Rupandehi—99, Chitwan—66, and Kaski—56.

The study was conducted from 21 March 2021 to 12 April 2021. The same survey population was also considered to analyze the knowledge, attitude and practices on COVID-19 [ 41 ].

Ethical concern

The Ethical Review Board, Nepal Health Research Council approved the study, and the ethical approval number is Ref No. 2240. The interviewers explained the study details, including its objectives and significance. They assured respondents that their identities would remain confidential and emphasized their freedom to stop participating in the survey at any time, as participation was voluntary. Informed consent was obtained from all the respondents before the survey began. Verbal informed consent was obtained from respondents who contributed via telephone survey and included as recording, and written informed consent was obtained from those who contributed via face-to-face survey.

Measurements

Preparedness..

Eight binary (yes/no) questions were used to measure the household preparedness level of the general population for emergencies during the COVID-19 pandemic. The questions included: (1) confidence in coping with any situation during the pandemic, (2) availability of sufficient space for isolation, (3) availability of a well-ventilated room, (4) good knowledge of daily safety measures, (5) management of sufficient food and money to cope with any situation, (6) preparation of a list of contact numbers for the police, ambulance, and hospital in case of any emergency, (7) trust among friends, neighbors, and relatives for their cooperation if any family member gets infected, and (8) taking care of the mental health of family members. The total score of preparedness ranged from 0–8, with a cut-off value of 7 (median). The score values of 0–6 were categorized as poor preparedness and 7 to 8 were categorized as good preparedness.

Socio-demographic characteristics.

The information on socio-demographic characteristics of households was collected using a structured questionnaire that included the following variables: geographical location (rural municipality, urban municipality), gender (male, female), age (<20 years, 20–30 years, 31–40 years, 41–50 years, >50 years), marital status (married, unmarried), education (no education, literate, basic education, secondary education, undergraduate, graduate and above), income (<NPR 5000, NPR 5000–10,000, NPR 10,000–15,000, NPR 15,000–20,000, NPR >20,000) (USD 1 = NPR 133.12), occupation of the respondent (white-collar occupation—service, business, house rent; blue-collar occupation—agriculture, labor; and others—self-employed, remittance and others).

The questionnaire on preparedness was developed after reviewing prior studies from Hong Kong [ 37 ], and various other relevant sources [ 15 – 17 , 43 , 44 ]. Experts translated the questionnaire, which was developed in English language initially, translated into Nepali language and then back translated it to English. A pre-test of the questionnaire was conducted among 30 respondents before the administration of the final version. The questionnaire was finalized after including the suggestions received from the pre-test, ensuring clear vocabulary and simple sentence structure.

Statistical analysis

Descriptive statistics were utilized to calculate the frequency, proportion and median. The Chi-square test was employed to assess the differences in household preparedness levels in relation to socio-demographic status. Binary logistic regression was used to predict the relationship between household preparedness level (dependent variable) and socio-demographic variables (independent variables). Cronbach’s Alpha (α) was used to measure the reliability of the preparedness questionnaire. The significance level for all the statistical analysis was set at 5%. Statistical analyses were conducted using Statistical Package for the Social Sciences V.20 (SPSS Inc, Chicago, Illinois, USA).

Preparedness

The study revealed that, 95.1% (662) of respondents had taken care of the mental health of their family members, 91.7% (640) were confident about their coping ability with any situation during the pandemic, 88.7% (618) had well-ventilated room, 85.7% (598) were aware on daily safety measures to be considered and 83.8% (585) were confident in receiving help from friends, neighbors and relatives. On the other hand, only 72.5% (506) had managed sufficient food and money for emergency situations, 67.9% (474) had sufficient space for isolation and 63.2% (441) had prepared a list of contact numbers for emergencies ( Table 1 ). Among the total respondents, 59.2% (411) had good preparedness and 40.8% (283) had poor preparedness.

https://doi.org/10.1371/journal.pgph.0003475.t001

Relationship of preparedness and socio-demographic characteristics

The α value of the questionnaire for measuring preparedness on COVID-19 was 0.76. Our study illustrated that proportion of respondents with good preparedness was significantly higher among respondents residing in urban areas, at 61.3% (383), compared to those residing in rural areas, at 38.1% (24) (p<0.001). Unmarried respondents also exhibited significantly higher levels of good preparedness, at 71.8% (155), compared to married respondents, at 53.6% (255) (p<0.001). Similarly, the higher proportion of respondents with white-collar occupations demonstrated good preparedness, at 69.6% (289), compared to those with blue-collar occupations, at 30% (36), and other occupations, at 53.2% (66) (p<0.001). Regarding the relationship with education, an increasing educational level showed an increase in preparedness. Respondents with high-education level of graduate and above had significantly good preparedness level, at 87% (60), compared to other respondents (p<0.001). Additionally, the high-income group, with a monthly income of >NPR 20,000, demonstrated significantly good preparedness, at 76.4% (343), compared to those with other low-income groups (p<0.001). In the same way, the proportion of respondents with good preparedness was significantly higher among the younger age group of <20 years, at 81.8% (27), compared to other age groups (p = 0.01) ( Table 2 ).

https://doi.org/10.1371/journal.pgph.0003475.t002

The logistic regression analysis showed that the respondents with education level of graduate and above (OR: 10.06, 95% CI 3.08 to 32.91), undergraduate (OR: 5.97, 95% CI 2.22 to 16.05) and secondary education (OR: 4.61, 95% CI 1.80 to 11.77) had higher odds of having good preparedness compared to non-educated respondents. Additionally, respondents with high-income (>NRs 20,000) were 10.33 times more likely to have good preparedness (95% CI 3.05 to 34.91) than those with low-income. Regarding the age groups, respondents aged 20–30 years (OR: 0.20, 95% CI 0.06 to 0.71), 31–40 years (OR: 0.20, 95% CI 0.05 to 0.78) and 41–50 years (OR: 0.21, 95% CI 0.05 to 0.84) had lower odds of having good preparedness compared to young-aged respondents (<20 years) ( Table 3 ).

https://doi.org/10.1371/journal.pgph.0003475.t003

Our study assessed the preparedness of the general population for emergencies during the COVID-19 pandemic and its association with socio-demographic characteristics.

The findings revealed that many of the respondents were still not considerate about good household preparedness measures. Studies conducted in three provinces [ 35 ] and four regions [ 14 ] of China also showed a lower proportion of study population, with only 28% and 9.9% adhering to household preparedness measures, respectively. Similarly, 59.2% of total respondents in Hong Kong adhered to good household preparedness during an emergency, indicating that many are still at risk [ 37 ].

Our study uncovered the fact that a substantial proportion of respondents had well-ventilated rooms in their houses. Previous studies conducted in Spain [ 45 ], China [ 46 ], United Kingdom and Italy [ 47 ] also revealed access to improved ventilation in households among people after the pandemic started. In the indoor household setting, the aerosols containing SARS COV-2 virus generated by sneezing, coughing and talking by infected persons can increase the risk of transmission. Proper ventilation allows the fresh air to move in and quickly remove the virus from the room, reducing the risk [ 48 ]. However, the lack of sufficient space for isolation among the respondents in our study can further increase the threat. The aforementioned study also reported the dearth of space in many of the households for isolation [ 49 ]. Small households usually face more difficulties in managing separate spaces for isolation [ 50 ]. Despite the large number of infected people who stayed in home isolation [ 49 ], adherence to safety measures cannot be assured and is not monitored regularly [ 51 ]. The virus shedding, frequently touched surfaces, and deposition of respiratory droplets in the room of an infected person pose a risk of fomite transmission [ 52 ]. Therefore, it is necessary to avoid the crowded environment in the room and allocate a room for isolation to reduce the infection risk. The establishment of isolation centers in every locality can help address such issues.

The study found that a significant number of respondents were knowledgeable about the daily safety measures required for the prevention of COVID-19 transmission. This knowledge is especially important in the closed environment of the household setting, where frequent contact occurs. The household setting possesses a higher risk of secondary transmission attributable to the survival duration of the virus in aerosols and fomites compared to non-household settings [ 53 – 55 ]. The importance of good knowledge and practices for safety measures and prevention was also highlighted in the prior studies [ 14 , 56 , 57 ]. Key safety measures, such as physical distancing, proper use and disposal of personal protective equipment (PPE), hand hygiene, cleanliness of contaminated surfaces and other necessary stuffs, use of dedicated utensils for the infected person etc. inside the home are imperative for breaking the chain of transmission of SARS CoV-2 and play a key role in reducing the spread of the disease [ 43 , 44 , 58 ]. Compliance with safety measures requires adequate facilities of Water, Sanitation and Hygiene (WASH) [ 59 – 61 ] and easy access to PPE at affordable prices [ 62 ].

A considerable number of respondents in our research had managed food and money for emergencies compared to the aforementioned studies. For instance, only 6.7% of the study population in four regions of China (Beijing, Guangdong, Heilongjiang and Sichuan) [ 4 ] and 31.1% in three provinces of China (Heilongjiang, Guangdong and Sichuan) [ 35 ] had managed food and money for emergencies. Similarly, in Hong Kong 57.3% of the population reported having sufficient food items [ 63 ]. Food is a life saver and the most important item required for preparedness during emergencies. Almost everyone should store preferably non-perishable food for emergencies. Moreover, saving money for emergencies help protect against financial crisis arising from several unexpected circumstances such as extra expenses for frequent hospital visits and treatments, loss of income, and job etc. Savings can help manage crisis, increase resilience, and provide support to easily bounce back from such difficult situations.

Our study demonstrated that a significant proportion of respondents had not prepared a list of contact numbers of the police, ambulance, and hospital in case of emergencies. Although several hotline numbers have been made available by concerned organizations to inquire about COVID-19 during emergencies [ 44 ], a considerable portion of study population were unaware of using these numbers. Conversely, a similar study conducted in Saudi Arabia revealed the contrasting results, showing increased awareness and the number of emergency calls among the people during the pandemic [ 64 ]. The health condition of COVID-19 patients can further worsen, increasing the risk of death, if they are kept at home during the sudden onset of severe symptoms. The situation is further aggravated if the person possesses other chronic illnesses [ 10 ]. In such situations, immediate calls for ambulance, hospital or police are important for timely treatment and reducing risk. Improving familiarity with existing hotline numbers and understanding the significance of using them is crucial.

On the other hand, among the total respondents, the majority were more confident about receiving support from friends, neighbors, and relatives, indicating that a substantial number had good social capital in terms of a social network. A study conducted in China also revealed the similar result, with a significant proportion of study population having high social support during COVID-19 pandemic [ 65 ]. Social capital is underscored as the strongest factor of preparedness, which helps to control the spread of disease and maintain the mental and physical health of people [ 66 , 67 ]. Social capital, in relation to the social network, such as the presence of trustworthy friends and relatives, also increases the confidence in dealing with difficult situations during emergencies, especially regarding financial and physical help [ 39 , 68 , 69 ]. Therefore, preparing a list of contact numbers of appropriate family and friends should be prioritized. The use of digital media is one of the most effective ways to improve social networks even in times of crisis.

The study showed that a significant proportion of respondents were confident about their ability to cope with any situation during the pandemic, and majority of them were observed to be conscious about taking care of the mental health of their family members. The key point to note is that mental health problems are prevalent globally [ 70 ], including in Nepal during the pandemic [ 71 , 72 ]. The earlier studies also highlighted that a substantial number of people staying with family members who receive care and support are comparatively less susceptible to mental health problems such as stress and depressive disorders etc. further supporting our study findings [ 72 , 73 ].

Our study also disclosed that the preparedness of the general population was associated with socio-demographic characteristics. The study population from rural areas was observed to be less prepared compared to those from urban areas, which resembles the study conducted in China [ 14 ]. The lack of resources and weak communication channels in rural areas, which hamper the adequate and timely flow of information, might be the possible reason for poor preparedness [ 30 , 74 ]. This fact was justified by a study conducted in Thailand, which showed 1.35 times increase in the preparation for emergencies with the addition of each source of information [ 75 ]. Similarly, a lower proportion of married respondents had good preparedness compared to unmarried respondents, though this became statistically insignificant under a 5% significance level in the logistic regression when conditioned on other variables. Our study further illustrated that respondents with higher education were more prepared for emergencies. Study conducted in Hong Kong [ 37 ], Serbia [ 40 ], and Thailand [ 75 ] also revealed an association of good preparedness with high educational background. Generally, educated people acquire more knowledge and are more frequently updated. Their better intellectual ability, processing of acquired knowledge, and propensity for learning equip them to understand the severity of risks and make them aware to comply with preparedness measures. Accordingly, they can properly allocate resources and plan for future emergencies [ 75 ]. The preparedness for emergencies was higher among respondents with white-collar occupations, which bears a resemblance to the study conducted in Hong Kong [ 37 ]. Regarding income level, a significant proportion of respondents with high-income had good preparedness and were more likely to practice the necessary measures. Our finding aligns with the study conducted in Hong Kong [ 37 ]. The reason might be that people with high incomes and white-collar occupations feel more secure, have sufficient resources, and have access to necessary items required for preparedness. Concerning age, youngest respondents showed good preparedness compared to old respondents. Additionally, the decline in statistical significance for Age > 50 noted from univariate to multivariate logistic regression could be because of the lower education levels amongst the older generation i.e. a potential confounding effect. A previous study showed that most with older age are illiterate or less educated due to lack of opportunities and family obligations in earlier days [ 76 ]. The higher use of internet and social media among the young-aged people might be one of the possible reasons for their good preparedness. Online platforms and social media are usually considered powerful mediums for rapid flow of information from different parts of the world, aiding in awareness and behavioral change [ 77 ]. Nonetheless, contrasting results were observed in a study conducted in Texas, USA, which showed good preparedness among older aged people [ 78 ]. The mixed results of different studies regarding the age factor underscore the necessity of detailed studies on the underlying reasons for in-depth understanding.

Enhancing the adherence of preparedness measures for health emergencies among the community people is paramount, especially during a health crisis. Prompt reporting of sickness if any family member becomes infected is of utmost importance to reduce both the severity of the disease and its transmission. However, fear of stigmatization often inhibits the disclosure of sickness to the concerned authorities [ 79 ].

Several policy implications are listed below in Table 4 .

https://doi.org/10.1371/journal.pgph.0003475.t004

There are several limitations in the study. The study is cross-sectional, that gives only a snapshot of the characteristics of the population. In addition, telephone surveys were also conducted in some areas that were difficult to reach during pandemic for face-to-face survey. The association of social norms, ethnicity, religious and cultural diversity with preparedness behavior among the general population were not included in the study. A future study considering these factors during health crisis is critical for comprehensive understanding. Moreover, detailed investigations on the hurdles in following preparedness measures and identifying motivating factors for positive behavior change is crucial.

The study put forward a comprehensive analysis of household preparedness during the COVID-19 pandemic among the general population and its influencing factors. A significant proportion of respondents demonstrated poor preparedness at the household level for emergencies. Many lacked sufficient space for isolation in their homes, did not prepare a list of contact numbers of the police, ambulance and hospital and did not manage sufficient food and money to cope with the crisis. Good household preparedness levels were mostly observed among the respondents living in urban areas, married individuals, those with white-collar occupations, young, aged groups, high-education level with graduate and above and high-income level with monthly income >NPR 20,000.

To address this issue, a tailored program on household preparedness for the pandemic, emphasizing vulnerable groups, is crucial. Consistent and timely flow of information through various communication channels regarding the possible severity of the disease, importance of household preparedness measures along with better health surveillance aids in dealing with the health crisis. Additionally, building trust in the government is essential to ameliorate the people’s self-discipline in adhering to adequate measures.

Supporting information

S1 questionnaire..

https://doi.org/10.1371/journal.pgph.0003475.s001

https://doi.org/10.1371/journal.pgph.0003475.s002

S1 Table. Characteristics of the study population.

https://doi.org/10.1371/journal.pgph.0003475.s003

Acknowledgments

The authors express gratitude to all the volunteers affiliated with Nepal Red Cross Society (NRCS) district chapters for their contribution to the questionnaire survey and valued suggestions during the survey. Additionally, we extend our appreciation to all the survey respondents.

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A Review of the Scientific Contributions of Nepal on COVID-19

Rupesh raut.

1 King Edward Medical University, Mayo Hospital, Lahore, Pakistan

2 Tribhuvan University Institute of Medicine, Kathmandu, Nepal

3 National Public Health Laboratory, Kathmandu, 44600 Nepal

Kritika Dixit

4 Birat Nepal Medical Trust, Biratnagar, Nepal

Alfonso J. Rodriguez-Morales

5 Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de Las Américas, Pereira, Risaralda Colombia

6 Latin American Network of COVID-19 Research, Pereira, Risaralda Colombia

7 Universidad Cientifica del Sur, Lima, Peru

Zenteno Marco

8 Instituto Nacional de Neurología Y Neurocirugía, Mexico City, Mexico

Kuldeep Dhama

9 Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, 243122 Bareilly, Uttar Pradesh India

Yashpal Singh Malik

10 Division of Biological Standardization, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh 243122 India

Ruchi Tiwari

11 Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, UP Pandit Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan (DUVASU), Mathura, 281001 India

D. Katterine Bonilla-Aldana

12 Semillero de Investigación en Zoonosis (SIZOO), Grupo de Investigación BIOECOS, Fundacion Universitaria Autónoma de Las Americas, Pereira, Risralda Colombia

13 Comisión Coordinadora de Institutos Nacionales de Salud Mexico, Mexico City, Mexico

Purpose of Review

There has been a high influx of publications on the SARS-CoV-2 and COVID-19 worldwide in the recent few months as very little was known about them. Nepal too had a substantial number of publications on the same, and there was a need to track the most relevant and impactful to the scientific community through bibliometric analysis.

Recent Findings

A total of 72 publications were analyzed. Bagmati Pradesh (88%) and its district, Kathmandu (77%), was with the most publications. There were no publications from Gandaki and Karnali Province. Most of the publications were in the international medical journals (82%), 53% chose European journals to publish, and 15.27% were related to and published in psychology journals. The majority were original articles (39%) and mostly related to public health (20.83%). 59.7% of the papers had Nepalese as the first author. Most of them were affiliated with Tribhuvan University Teaching Hospital and Patan Academy of Health Sciences.

Our analysis suggests a need to shift the type of studies from observational studies to studies oriented more towards the therapeutic and clinical trials of available medicines and patient care management. Similarly, the bibliometric analysis gives an overall picture of Nepali medical research’s publication status around the globe.

Introduction

Coronavirus disease 2019 (COVID-19) has changed almost every aspect of life. The coronavirus is a zoonotic disease that is believed to have emerged from the Wuhan City of Hubei Province in China in late December of 2019 and has later taken a form of a worldwide pandemic. By April 6, 2021, the total confirmed cases worldwide are 132.28 million cases and 2.87 million deaths with more than 200 countries affected, and in Nepal alone, there are 278,470 cases confirmed and 3,036 deaths. [ 1 ] Nepal had its first COVID-19 case on January 13, 2020. The index case was a student studying in Wuhan and had returned to Nepal for his winter vacation. [ 2 ]

Initially, little was known about this SARS-CoV-2; several research articles were written around the world to learn and share any new information with the rest of the world. The number of research articles published on COVID-19 within the past few months is as many as the ones on Dengue since the last century. With such a high influx of papers from all over the world, there is a need to track the most relevant and impactful ones. Globally, as the submission of research papers on COVID-19 increased exponentially, multiple scholarly journals too accelerated time to publication. [ 3 ] Several other journals issued special COVID-19 themed issues. [ 4 ] COVID-19 preprints were often shorter and were reviewed faster. [ 5 ]

Compared to the rest of the world, we have a limited number of publications on COVID-19. However, there is a need for a bibliometric analysis to qualitatively and quantitatively analyze these publications. The bibliometric study provides a cross-sectional view at a given time and also the current state of the research in the same field. It accentuates the impact of the articles they can have on the universe of COVID-19 knowledge. Several literature databases are used to do bibliometric analysis, among which, the most commonly used are the Web of Science and Scopus currently [ 6 ]; the latter has been used in this study.

We analyzed the 72 publications on COVID-19 from Nepalese researchers which have been categorized according to the districts and provinces of research done, the journal they have been published in, the impact factors, and number of citations, and help answer the evolution of research on this field within the nation.

Articles were retrieved from PubMed using these search terms: Covid-19, COVID-19 virus, coronavirus 2019, and SARS-CoV-2. Their citations in Scopus were recorded on July 17, 2020. Duplicate papers and the ones containing no information about COVID-19 were eliminated. The analysis of only those citations was made, which were found in Scopus.

We recorded the following: article title, journal, journal impact factor [IF, Journal Citation Reports], journal country, type of article, article category, language, and affiliation center (of Nepali and other authors). VOSviewer software was used for visualization mapping.

We classified the articles into the following ten categories: original article, review, commentary, editorial, letter, news, report, viewpoint, guidelines & consensus, and others.

Publications were also categorized into the following ten types according to the investigation they had mainly shown in their articles: diagnosis, epidemiology, pathophysiology, prevention, prognosis, public health, social issues, special populations, treatment, and others.

Findings Related to COVID-19 Research in Nepal

While searching for the publications, the number increased as each month passed by. By July 17, we had a total of 75 papers. The publisher withdrew one of the documents upon the author’s request, and two had no information about COVID-19 or Nepal. Researchers were also not from Nepal, and their affiliated institution was also not from Nepal. Thus, we were left with a total of 72 articles for analysis. Out of these, 69% were open access and 31% were paid.

Out of the available 72 publications, 43 (59.7%) had Nepalese researchers working in an institution in Nepal as the first author and 29 publications had the first author as a foreigner followed by one or more Nepalese co-authors. Among Nepalese as the first author, the maximum number of articles in COVID-19 by Nepalese as the first author was from Tribhuvan University Teaching Hospital (TUTH) and Patan Academy of Health Sciences (PAHS), five each. Universidad Tecnológica de Pereira from Colombia and ICAR-Indian Veterinary Research Institute from India also had published five each. When all the Nepali authors were considered (first and co-author), TUTH had the most significant number of contributions (21), followed by PAHS (14). A total of 26 (36%) publications were single-center studies, and 46 (64%) were multi-center studies.

Authors from 5 different states were present, out of seven. Previously, states were only numbered from 1 to 7. At the time of writing, only 4 out of 7 provincial governments gave official names to their respective states, and Province No. 1, 2, and 5 are still numbered as such. While scrutinizing the first and co-authors from these 72 articles, 96 were from different Nepali institutes, including two who did not disclose their affiliated institute and only mentioned that they were private practitioners. The majority of studies (88%) were from Bagmati Pradesh (Province No. 3), followed by Province No. 2 and Province No. 5 (4% each) and by Province No. 1 and Sudurpaschim Pradesh (Province No. 7) (2% each). There were no publications from Gandaki Pradesh and Karnali Pradesh (Fig.  1 ).

Affiliation of Nepali authors to institutions in different states of Nepal

Out of 77 districts, researchers were affiliated to the institutions from 11 districts only, most of which came from the Kathmandu District (77%), followed by Lalitpur (6%). The third highest number of research was from the institutions in Morang and Rupandehi (3% each). Bhaktapur, Kavrepalanchok, Parsa, and Kailali comprised 2%; Chitwan, Palpa, and Jhapa comprised only 1% of the total contributions in COVID-19 research (Fig.  2 ).

Number of publications according to districts

We found 39 journals in which these articles were published. The median impact factor (IF) of the journals was 2.093. The highest impact factor was the British Medical Journal (30.223), and the lowest was that of the journal Pathophysiology (0.073). Most of the authors chose international journals to publish their work (~ 82%). Among them, 53% were published in European journals, followed by 22% in South Asia, 18% in North American, 4% in South-East Asia, and the remaining 3% in Latin American Journals. All of the articles (100%) were in the English language, and so were the publishing journals (Fig.  3 ).

Number of publications according to different regions

Of the total of papers, 18 (25%) of these were published in journals from the UK, 13 (18%) each in journals from the USA and Nepal, 12 (16.6%) in journals from the Netherlands, 4 (5.5%) in journals from Italy, 3 (4.16%) in journals from Malaysia, 2 (2.78%) in the journal from Pakistan and Mexico, and 1 (1.38%) each in journals from Switzerland, Scotland, Poland, India, and Germany (Fig.  4 ).

Number of publications categorized according to country of publication, collaboration

The journal with most Nepalese publications, the Journal of Nepal Health Research Council , had seven papers (9.72%), followed by 6 (8.33%) each in the Journal of the Nepal Medical Association and the Asian Journal of Psychiatry . A total of 11 (15.27%) articles were published in several International Psychology Journals. Five (6.94%) were published in Travel Medicine and Infectious Disease .

Out of 72 articles, 41 were not cited yet. Thirty-one articles were cited 324 times to date. The paper with the most number of citations was 140 times by Rodriguez-Morales et al. and was published in Travel Medicine and Infectious Disease (IF 4.589). This was followed by the article by Phua et al., in the journal The Lancet Respiratory Medicine (IF 25.09). This article was cited 64 times to date.

Article Category

In decreasing order, the categories were as follows: public health: 15 (20.8%), treatment: 12 (16.67%), special populations: 8 (11.11%) and pathophysiology 8 (11.11%), prevention 6 (8.33%), diagnosis 6 (8.33%), social issues: 6 (8.33%) and other topics (clinical investigation, ethics, rehabilitation) 6 (8.33%) and finally, epidemiology 5 (6.94%) (Fig.  5 ).

Focus of the COVID-19 articles (number of articles)

Article Type

The majority of papers, 28 (39%), were original articles, 28 (31%) were letters to the editor, 13 (18%) were review articles, 5 (7%) were editorials, and 4 (5%) were notes (Fig.  6 ).

Types of publications on COVID-19 from Nepal

The national collaborations between Nepal authors seem to be limited based on network visualization maps at Scopus and PubMed databases (Figs.  7 and ​ and8 8 ).

Network analysis for authors of Nepal on COVID-19 at Scopus. Analyzed with VOSviewer

Network analysis for authors of Nepal on COVID-19 at PubMed. Analyzed with VOSviewer

COVID-19 has been the main focus of scientific researchers around the globe this year. Since very little was known about this SARS-CoV-2 initially, there was indeed a boom in the number of observational studies initially and recently in experimental trials. [ 7 ] Our search was done on July 17, 2020, using the Scopus database with relevant search equations. Compared to neighboring countries like India and Pakistan, we have a limited number of publications on this topic. Moreover, we did not come across any journal with the bibliometric analysis of the publication on COVID-19 in Nepal.

The number of COVID-19-related publications was highest during the first 10 days of February, and majority of them were from China [ 8 , 9 ], a quarter of which was published in Chinese language. [ 10 ] Second most publications was from the USA during the initial days. [ 11 , 12 ] The idea of bibliometric analysis of publications in Nepal has not been explored to its full potential yet. We can only find a handful of journals with such an analysis. [ 13 , 14 ] Our analysis represents the overall estimates of health research being carried out in Nepal and published in national and international PubMed indexed journals. As with any developing country, there is an underrepresentation of health research studies in Nepal and its publication in international literature. [ 14 ] A majority of the publications belong to the descriptive type of studies as there is a paucity in the clinical trials being conducted in developing countries like Nepal. Common reasons being limited human and other resource capacities, lack of funding, ethical and regulatory issues, poor data collection, and administrative matters. [ 15 ] The inclination of Nepali researchers to focus on descriptive and qualitative studies is similar. Our research saw more than 60% of the publications consisted of letters, review articles, editorials, and notes combined. Only 39% were original articles. Gianola et al. in their bibliometric analysis also reported that letters and case reports had a greater share of publications. [ 16 ].

Major popular international journals tend to reject the studies right away if it is coming from developing countries. [ 17 ] In contrast to this, we saw publications in both low- and high-impact-factor journals worldwide. Nepal got its first medical journal, the Journal of Nepal Medical Association , in 1963. Over 100 journals are being published from Nepal, out of which 25 are medical journals. [ 18 ] To date, there are 10 PubMed indexed medical journals in Nepal. Our analysis shows that COVID-19-related information is published in only two of these, the Journal of Nepal Health Research Council and Journal of Nepal Medical Association . Our study shows that only 18% of articles were published in Nepali Journals, a vast majority prioritizing international journal. Globally, the Journal of Medical Virology had the most publications on COVID-19, closely followed by CUREUS. [ 19 ] None of the research papers included on our review was published in any of these journals. Research on COVID-19 is not equally spread across the nation. Most of the research was being done in the Kathmandu district (77%) and ten other districts. Sixty-six districts had no participation at all. Our finding was similar to Simkhada’s (2010) conclusion that most health research was being carried out in the capital and a few other urban cities with teaching hospitals and universities. [ 14 ].

The worldwide bibliometric analysis of COVID-19 publications showed that English was the major language of the articles. The second common was in Chinese, followed by French, Spanish, and others. [ 20 , 21 ] All the medical journals of Nepal are in the English language, and Nepali researchers prefer to write in English. Our study shows that 100% of the articles are written and published in English. In another worldwide bibliometric analysis of the COVID-19 publication, the majority were articles (48.0%), followed by letters (22.0%), reviews (9.4%), editorials (9.2%), and notes (9.1%). [ 22 ] Our analysis also showed the majority of original articles followed by other categories in the same sequence.

Aristovnik et al., in their study, mentioned that the typical research topics on COVID-19 roamed around virology, epidemiology, clinical presentations, investigations, diagnosis, and treatment. [ 23 ] We found in our research that the issues of interest in the articles published revolved around these parameters, too, the majority of which fall under the public health category, followed by treatment. According to the bibliometric analysis of publications from the Arab countries, majority of the publications were related to public health and epidemiology too. [ 24 ] While 16.6% of the publications were regarding the treatment protocol, none had discussed about the vaccine. Similar was the finding in another study where only 14% of the publications were related to the treatment. [ 25 ] One article by Ahmad et al. was among the first ones to have bibliometric analysis of publications on COVID-19 vaccine. [ 26 ] Numerous clinical trials have been registered across the globe since the onset of the pandemic. [ 27 ] COVID-19 has become the research hotspot of coronavirus research, and the key to defeating this pandemic is also the clinical research on the same. [ 28 ] There is an urgent need for cooperation between governments and scientific researchers globally to combat this pandemic. [ 29 , 30 ].

Limitations

Our review has several limitations. We used only PubMed indexed journals to search for the articles on COVID-19 by Nepali authors. Other publications in other databases were not included. We were dependent on the indexing of the databases used. That might have potentially avoided any articles yet to be published (those accepted but not published previously).

As the COVID-19 outbreak quickly infected several countries and took the form of a pandemic, many research publications also escalated in Nepal and abroad. We believe that our results guide the research centers that most of Nepal’s publications are qualitative type and there is a need to shift our study towards the therapeutic and clinical trials of available antivirals and other medications and find a new solution to this rapidly spreading pandemic. We want to invite the country’s scientific community to contribute by publishing their findings with maximal transparency.

Author Contribution

RR, RS, KD, AJRM, JM, and AL processed data, implemented techniques, analyzed results, and drafted the initial version of the manuscript. YSM, RT, DKBA, and KD joined the discussions and provided constructive suggestions on editing the manuscript.

Declarations

The authors declare no competing interests.

This article is part of the Topical Collection on COVID-19 in the Tropics: Impact and Solutions

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rupesh Raut and Ranjit Sah contributed equally.

Contributor Information

Ranjit Sah, Email: pn.ude.moi@hastijnar .

Alfonso J. Rodriguez-Morales, Email: oc.ude.ptu@mzeugirdora .

Impact of Post-Covid Syndrome on Quality of Life and Mental Health Among Covid-19 Survivors: A Study from a Tertiary Care Center in Lebanon

20 Pages Posted: 13 Sep 2024

Hisham Bou Fakhreddine

affiliation not provided to SSRN

Salah Zeineldine

Independent

Hassan Itani

Jawad abdul sater, pierre boukhalil, bassem al harfani.

American University of Beirut

Imad BouAkl

Background and Aim: Post-COVID Syndrome (PCS) significantly impacts morbidity, impairing quality of life (QoL) and mental health. This study assesses PCS symptom prevalence, the impact of COVID-19 severity on QoL and mental health, and identifies predictors of impaired QoL among COVID-19 survivors in Lebanon.Methodology: The study included adult COVID-19 survivors who recovered at least 4 weeks before enrollment. Participants completed symptom questionnaires, 36-Item Short Form Health Survey (SF-36), and Hospital Anxiety Depression Scale (HADS) at enrollment and during follow-up visits. PCS symptoms prevalence, SF-36 and HADS scores were compared across infection severity groups. Multivariate linear regressions identified predictors of lower SF-36 scores.Results: The study included 417 patients, with 50.1% being male and an average age of 48 years. Most patients (78%) had mild COVID-19 and presented within 3 months of recovery (83%). The most commonly reported symptoms were fatigue (54.3%), dyspnea (47.5%), cough (38.8%), and palpitations (38.4%). Dyspnea was more prevalent in severe cases (71.4%) than in mild and moderate ones. Severe COVID-19 patients had significantly lower scores in physical function, role limitations due to physical health, and body pain compared to the mild group. Mild cases had higher abnormal HADS anxiety scores than moderate and severe cases, with no differences in HADS depression scores. The main independent predictors of impaired physical functioning and role limitations were severe COVID-19, fatigue, and dyspnea.Conclusion: PCS severely impacts QoL and mental health, with impairment directly linked to the severity of acute infection and the persistence of symptoms.

Note: Funding Information: This research did not receive any specific grant from funding agencies in the public, commercial, or not for-profit sectors. Declaration of Interests: The authors declared no conflicts of interest. Ethical Approval Statement: The study was approved by the Institutional Review Board (IRB) at the American University of Beirut (AUB) (IRB ID: BIO 2021-0078). Verbal consent was obtained from participants as the documentation of informed consent was waived by the IRB.

Keywords: COVID-19, Post-COVID Syndrome, Quality of life, Mental health, Short Form -36 (SF-36) Questionnaire, Hospital Anxiety Depression Scale (HADS)

Suggested Citation: Suggested Citation

affiliation not provided to SSRN ( email )

No Address Available

Independent ( email )

American university of beirut ( email ).

Beirut, 0236 Lebanon

Imad BouAkl (Contact Author)

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Scaling up suicide prevention in Nepal: a collaborative effort

The COVID-19 pandemic had a profound impact on mental health worldwide, with evidence pointing to an increase in anxiety and depression. In response to concerns around increased risk of suicide, Nepal has intensified its suicide prevention efforts. The Parliamentary Committee on Women and Social Affairs met to accelerate suicide prevention efforts, and a national mandate has since paved the way for the development of  a national suicide prevention strategy and the establishment of a dedicated  mental health and suicide prevention office.

“We are in a critical moment for mental health and suicide prevention, there is momentum, there is will and commitment from the grass roots level to national authorities” said Dr Rajesh Sambhajirao Pandav, WHO Representative to Nepal.

National leadership and strategic action

The government of Nepal, with support from the World Health Organization (WHO), the United Nations Development Programme (UNDP)and local NGOs, has taken critical steps to address suicide. A national suicide prevention action plan is being developed, led by the National Planning Commission in Nepal. This plan aims to ensure coordinated efforts among key stakeholders, accountability and sustained political commitment to suicide prevention.

Nepal is working to move beyond the often fragmented and one-size-fits-all approaches to suicide prevention.  Guided by WHO’s LIVE LIFE initiative , Nepal has adopted a multifaceted strategic approach to suicide prevention that acknowledges the complex nature of suicide and engages relevant stakeholders. The Ministry of Health and Population (MoHP) Nepal, in collaboration with WHO,  convened a series of policy dialogues to engage municipal representatives, including mayors,  local administration officers, and health section chiefs, in the implementation of comprehensive and community-based approaches to mental health and suicide prevention.

Limiting access to highly hazardous pesticides

Phasing out highly hazardous pesticides is a critical intervention in suicide prevention. Through collaborations with the health and research sectors, data on self-poisoning incidents were used by authorities within the agricultural sector to advocate for stricter regulation. Since 2019, Nepal has banned  26 highly hazardous pesticides. These bans, supported by research showing no negative impact on agriculture, are expected to significantly reduce suicides by pesticide poisoning, as has been the case in other countries in the region enacting bans.

Media personnel participate in training on responsible reporting of suicide in Nepal. @ WHO Nepal

Supporting responsible media reporting on suicide  

Responsible media reporting can increase awareness about mental health and suicide, challenge stigma and misconceptions, as well as  promote help-seeking behaviours. Sensationalized reporting can, however, inadvertently increase the risk of imitative suicidal behaviours. Recognizing the critical role of the media in suicide prevention, WHO Nepal, in collaboration with the National Health Education Information and Communication Centre (NHEICC), has trained 293 journalists on responsible media reporting practices, using WHO’s resource for media professionals which has been endorsed by the Department of Health Services.

Prioritizing early interventions and follow-up support

The Government of Nepal is prioritizing early identification of suicidal behaviors and follow-up support through capacity building for primary care workers and gatekeepers (people likely to come into contact with at-risk individuals). Local adaptation of WHO’s Mental Health Gap Action Programme (mhGAP)  has led to the development of a National Mental Health Care Program 2022. A capacity building program, endorsed by the Government, has also been developed for school nurses, counselors and teachers in collaboration with WHO and UNICEF. Moreover, MoHP and WHO, using mhGAP resources, are working towards a national protocol for assessment and management of people with suicidal behaviour  to provide focused guidance to assess suicide risk at health facilities as well as  tailored  support.

A 24/7 suicide prevention helpline, supported by WHO and a local NGO, has been established by the MoHP. Extensive and coordinated awareness raising campaigns promote the helpline and suicide prevention included walkathons, cycle rallies, and drama performances. The helpline has already provided ongoing counseling to over 700 individuals.

Cycle rally to raise awareness for suicide prevention and the crisis helpline. @ WHO Nepal

Strengthening surveillance for targeted intervention

To effectively address suicide, Nepal has also prioritized the development of a suicide and self-harm case registry. This tool, which is currently being piloted in two districts, will help monitor trends in suicidal behaviour, identify at-risk groups, and guide future interventions and service provision, ensuring that efforts are both targeted and effective.

Dr Pandav  reflects on the significant progress made in Nepal, stating "Nepal's comprehensive approach to suicide prevention is laying a solid foundation for lasting change. Continued monitoring and collaboration will be crucial to sustaining this momentum.” With coordinated actions like pesticide bans, media training, and community support, Nepal is making bold strides to reduce suicide and create a healthier future for all.