Challenges of COVID‐19 pandemic: Dermatologist’s perspective from Nepal

Series of cases with ‘pneumonia of unknown etiology’ since December 2019, in the Wuhan city of China, marked the beginning of coronavirus disease 2019 (COVID‐19). In a meeting on January 30, 2020, per the International Health Regulations (2005), WHO declared it a Public Health Emergency of International Concern. ¹ Till August 25, 2020, worldwide 23,518,343 people are infected with 810,492 deaths. South‐East Asia (SEA) has now become the 3rd most affected continent with 3,666,425 cases to date. India is the most affected country in Southeast Asia (SEA) with 3,167,323 confirmed cases and 58,390 deaths. ² The first case of COVID‐19 in Nepal was confirmed on January 23, 2020, in a student coming from Wuhan, and the second case was diagnosed on March 22, 2020. ³ Nepal is a small, low income developing country sandwiched between India, the most affected country in SEA at present, and China, the country of COVID‐19 origin. We are dependent on neighboring countries for the trade and two way flows for employment. However, because of the open border and returning of uncountable infected workers back to Nepal, it has put Nepal into the danger zone. To date, we have 32,678 confirmed cases with 157 deaths. ² They are rising rapidly in the last 3 months. Lockdown and social distancing are the only way out to suppress and mitigate the situation. Nepal government has announced lockdown since March 24, 2020, and has extended it phase‐wise to date. Though it might play a role in reducing the number of cases, there are lots of impacts; so is the field of dermatology in Nepal. Some of them include:

Challenges in patient care

Because of lockdown & unavailability of public transportation, patients are unable to travel to healthcare centers. There are around 200 dermatologists with eight postgraduate training institutes in Nepal. However, the healthcare systems are centralized to bigger cities with a huge shortage of dermatologists in suburbs, hills, and mountains. Because of limited movements, patients are unable to consult the dermatologist. Hence, their skin diseases are worsening day by day. The chronic dermatological problems like immunoblistering diseases (mainly pemphigus vulgaris & bullous pemphigoid), psoriasis, eczema, etc., are becoming much worse, and the patients are ending up with more severe disease and disease complications. The mainstays of treatment for these chronic immune‐mediated diseases are immunosuppressive drugs. However, most expert opinion recommends postponing these drugs in the COVID‐19 pandemic. ⁴ Hence, we are confused about how to proceed with patient management. In our part, over‐the‐counter (OTC) treatments are easily available. Since COVID has increased the misuse of drugs with a narrow therapeutic index like methotrexate, chronic dermatology patients may end up with life‐threatening adverse effects in the future. Similarly, in our communities, the homemade topical paste of Azadirachta indica (Neem), Allium sativum (Garlic), Artemisia vulgaris (Mugwort), etc., are commonly misused for many skin diseases. This may further increase and worsen skin disease in the communities. Since we were not at all prepared for this type of pandemic with infrastructure and electronic record‐keeping systems, it has become very difficult even to trace out our previous patients for inquiry and follow‐up. Similarly, leprosy is one of the common chronic infectious diseases in Nepal with a 0.99/10,000 national prevalence rate, which is rising for the last four years. ⁵ Because of COVID‐19 lockdown and other impacts, even leprosy patients are presenting very late with higher bacillary load and frequent leprosy reactions. Hence, it may be alarming that we may not sustain “leprosy elimination” in the coming days.

Challenges in education

COVID‐19 has directly affected the education of both postgraduate and undergraduate students. The sudden transition from face‐to‐face classes to online classes has brought challenges both for teachers and students. Internet connectivity is one of the major issues, and our teaching/learning (T‐L) system is not well‐prepared for online modalities. We do not have adequate gadgets, and we are not very familiar with online T‐L platforms. Though some amount of theory syllabus is being covered by online platforms, it is impossible to fulfill the objectives of practical classes at current status. There are no systems of simulation laboratory for skill‐building. Hence, there has been a serious impact on undergraduate education. So this is the high time to invest in the necessary infrastructure for upgrading our T‐L system. Although postgraduates are getting some patient exposure, it is not at all up to the mark in comparison to normal situations. Our patient flow has reduced to less than 1/6^th of normal. Hence residents are not getting enough exposures. As only malignancies and infections are intervened on a priority basis, dermatosurgery exposure has also reduced markedly. In this crisis, we are not focusing on aesthetics, thus residents are not having exposure in this subspecialty. However, there have been tremendous improvements in teleconsultation. After the pandemic, its use has increased like never before. Many practitioners and the general public have become aware of the program and becoming ready to use it. However, we need to upgrade many technical aspects before opting for it for future use. Since visual assessment can give maximum clue for the diagnosis, dermatologists are lucky enough to use teledermatology more easily as compared to other specialties. Store and forward is the most adopted modality in our context as it is easy to adopt on minimal investment and without much technical expertise. However, at the same time, we are unable to use all our clinical acumen. We cannot palpate the lesion. We are unable to perform diascopy, Wood's lamp examination, dermoscopy, etc. We are unable to visualize the 3D view of the lesion. Similarly, we are not able to take optimal care of the psychological aspect of the patients as efficiently as in face‐to‐face consultation. Videoconferencing, however, would have solved the problem to some extent, but we are unable to choose this modality because of the lack of preparedness in terms of infrastructure and expertise. The present COVID‐19 pandemic has reflected that there is a need to remodel our T‐L system with investment in infrastructure and enrich the capacity of the practitioners in the changing context.

Challenges in healthcare worker’s safety

Healthcare workers in dermatology are also directly influenced by the COVID‐19 pandemic. Psychological insecurity for occupationally acquired infection is the biggest issue. Likewise, hand dermatitis because of frequent handwashing and alcohol‐based sanitizer use, folliculitis, and frictional dermatitis because of prolonged occlusion by personal protective equipment, etc., are very common.

Conclusion

There are lots of challenges in the dermatologist's life because of the COVID‐19 pandemic. It would have been minimized to a greater extent by prior preparedness for this type of pandemic. Unlike many developed countries, we do not have such preparation in Nepal, but all challenges come with opportunity. It is high time to invest in the digitalizing healthcare system, strengthening teledermatology, virtual classroom, and skilled labs. Likewise, we should also develop a proper pharmacy policy to minimize over‐the‐counter medications.