The number of bearers of coronavirus and pneumonia has increased sharply since the beginning of summer in Kyrgyzstan. A range of activists and experts are confident that pneumonia is directly related to Covid-19. After the criticism by the public and recommendations given by the World Health Organisation (WHO), the authorities of the republic joined the statistical data and now the country tops the sad rankings of the number of cases and deaths from coronavirus.
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A 46-year-old Azimbek Muratov felt throat irritation and strange feelings in chest on June 19. Two days later, he had raised body temperature. He lost his smell and taste. He managed to call only the district doctor of the polyclinic as all hotlines of the health ministry were busy for two months already and it was almost impossible to reach them. The family medicine centre promised to send a mobile team to him, but health workers arrived just a week later, when his four-year-old son’s temperature raised.
“As far as I understood, children and old people are their priority. As soon as I reported raised temperature of my son to the paediatrician, they came the same day,” Muratov said. “They made PCR tests of all of our family members: me, my wife’s, daughter’s and son’s. A week later, they called me and said my son and I had positive tests, and my wife and daughter had negative tests. Although my wife did not have raised temperature, she lost her sense of smell. I think she had the same coronavirus, yet mild case.”
The number of references to doctors with the similar symptoms in Bishkek started to increase two weeks after the lifting the state of emergency and lockdown measures. By the end of June, the number of cases has increased so much that health workers had to open chats in social media, at their own initiative, to provide online consultations to patients. In a matter of days, the number of participants in these groups has risen up to a few dozens of thousands. On June 26, media reported that a man who had raised temperature for a few days died just in front of the National Hospital waiting for medical help.
As it was found out, the ill man and his brother were seeking medical help for 4 days. He was not admitted to a few medical facilities. At one of the facilities, according to his relative, they were kicked away when they learned the patient had raised temperature. Others did not accept them because the PCR test was negative for coronavirus. From the beginning of the pandemic, this was the key condition for hospitalisation. The news that the patient was not provided any help humbled the people. The health ministry said it would hold the internal investigation of this fact. However, two days later, two more people died near this hospital. The attempts of doctors to resuscitate them failed. According to the head doctor of the facility, the patients were in very grave condition. The cause of their death was pneumonia.
The health ministry published official data on the number of people in the republic who have or had community-acquired atypical pneumonia, as it was called by health workers, on June 29. It turned out that since March 1,145 cases of pneumonia, which tested negative for coronavirus, were registered in Kyrgyzstan. By that time, 54 people died from this disease, including 48 in the capital. Afterwards, deputy minister of health Nurbolot Usenbaev said at the briefing that “…now all patients with severe pneumonia would be hospitalised without a PCR test, and all subsequent tests would be made in hospital.”
By the beginning of July, there were hundreds of pneumonia cases per day and tens of deaths. Tough reality was obvious then – neither 6 weeks of lockdown, nor loans and grants from other countries provided to Kyrgyzstan have been useful – the country turned to be unprepared to the second wave of pandemic, even more massive. The lockdown was lifted as immediately as it was introduced. For some reason that turned fatal for many Kyrgyzstanis, the government was satisfied with one of many forecasts of repeated pandemic in autumn and failed to take any preventive measures. The peak of the disease in Kyrgyzstan, according to some “analysts”, was deemed April 20-24, after which it was thought that the worst was behind us. The forecast, according to the head of the health ministry Abdikarimov, was made based on the WHO mathematic simulation method. Three days later, the Soros Foundation issued their forecast, where they said that if economic activity resumes on May 1, the peak of the disease will fall on the end of June and approximately 6 thousand people won’t survive it. After it became clear that the worst options of events did come true, new beds became available – in the National Phthisiology Centre, railway hospital, national surgery centre; national hospital; National Surgery Centre; National Hospital; institute of health resort study; city clinical hospital No. 1 and former American Gansi base.
However, these measures turned to be insufficient. According to one of doctors of the 1st clinical hospital, on the first day, 90 patients were received against available 80 beds.
“All patients were in grave condition, I could not look at them, all of them were blue,” the doctor recalls. “We did not have time to make intravenous injections and to massage them. We were suffocating ourselves. In just one night, we lost four patients, we did not have time to take them to the intensive care, they turned blue and died. Young guys tested negative in PCR, so they were not taken into account. Ambulances queued in front of the hospital, they brought more patients, but they were nowhere to take. The situation was catastrophic.”
The number of calls to ambulance crews reached 5 thousand calls a day. Sometimes, it took health workers a few hours to get to a patient. In addition to the shortage of health workers, according to the head of the intensive care service of the emergency medicine of Bishkek, Egor Borisov, it was the key issue – there were no places to take patients to.
“Out of these five thousand, there were many seriously ill patients, sometimes hundreds of them. This is too many. We did all our best, but they should have been hospitalised and hospitals were overcrowded. After this wave of patients, now the headquarters informs us about available places in hospitals, and we hospitalise them. If there are no places in hospitals, we give consultations and leave them at home. Then they are consulted by doctors of family medicine centres,” Egor Borisov said.
Given the clueless and almost paralysed government, volunteers came to help who started to feed health workers at their cost, buy PPE, medications and oxygen concentrators and help doctors save seriously ill patients. Private hotels and restaurants provided their facilities as medical observatories. With the help of entrepreneurs, day hospitals were opened on July 4 in all four districts of the city. Now there are 15 of them. 50 thousand people have received medical aid so far. 10 patients died.
The highest record of confirmed covid-19 cases was set on July 12 – 719 cases, including 500 in Bishkek. A bit earlier, over 500 cases were registered every day a few times in the whole republic. 7 people have died from the laboratory-confirmed coronavirus. Community-acquired pneumonia caused 41 deaths on the same day. 612 deaths caused by pneumonia have been registered from March to July 16 compared to 167 deaths caused by coronavirus. This statistics shows the official data. The real number of cases and deaths, according to health workers, exceeds this figure many times. For example, not more than 5 per cent of population has flu every year according to official data, while up to 15 per cent of Kyrgyzstanis, if not more so, really get sick, according to health workers.
“Covid-19 and pneumonia are not the same”
The ministry of health cannot say explicitly whether pneumonia is the same coronavirus now. The agency maintained statistical data of covid-19 and pneumonia cases and deaths separately until recently. Deputy minister of health Madamin Karataev thinks they cannot say they are the same until there are no results of studies.
“To those who say that coronavirus and pneumonia are the same I’d say, what is the level of alveoli? Bronchi? Is there a bronchiectasis or not? Only lay people can say so, these are different things,” Karataev said. “There may be concurrent conditions. Pneumonia-caused deaths were before coronavirus. Now the rates are different.”
However, Karataev does not rule it out that this incidence rates was provoked by Covid-19. The official suggested that the increase in the number of lethal cases was caused by the age of patients in addition to concomitant diseases. To the question of the cause of deaths of young people, he said “it could be a new strain or something else. I cannot say it without evidentiary basis and deep analysis,” the official said.
The deputy minister added that a group of doctors of the health ministry carries out a research by regions, whose results will be known in August. The official did not explain what the health ministry are trying to find out. The head of the republican research and practical centre for virus infection control of the health ministry, Zuridin Nurmatov, who is now in Batken with this group, also thinks that Covid-19 and pneumonia are not the same. According to him, only some cases can be directly related to coronavirus.
“Pneumonia is caused by various agents, bacteria, viruses, but coronavirus,” Nurmatov said. “Usually, a wave of pneumonia comes after seasonal flu and ARVI in 15-20 days. It is a usual phenomenon, every year, with a sharp rise three-four times. We had this situation before coronavirus. But we have never seen such a rise as we have seen from June and now. As this outburst is not typical for this season, I conclude that this is related to coronavirus and other infections. We’ll find out the answer after we collect and analyse the data. Previously, we used to do this once a year.”
Meanwhile, Bermet Baryktabasova, an expert in evidence-based medicine, said that no special studies are needed as this is definitely Covid-19. It is sufficient to compare the disease pattern. The mess around diagnosis can be explained, according to her, by errors in tests, untimely collection of samples, as well as common inability to collect them properly.
“We’ve been put on the wrong track by saying that only PCR test confirms Covid-19,” Baryktabasova said. “This is the recommendation by WHO. They also recommended hospitalising all confirmed cases. Because of that, patients without symptoms occupied 80 per cent of beds. If this situation continued, there would have been much more deaths, patients would have no place to go. There are several reasons why PCR test can give false results. The most important one is that samples are taken from nose. However, if they collected bronchopulmonary secretion, sputum, we’d see that this is coronavirus. The test was taken untimely, and the infection went further. The rapid test made on finger has even more errors. It looks for virus fragments in blood. However, it all makes some sense when the organism has time to meet infection, sees it and starts to produce antibodies. It can be seen only one week after the exposure.”
According to the health worker, there are four methods of diagnostics of one or another disease. The most important one is the disease pattern. 80 per cent of diagnosis, according to Baryktabasova, is the clinical examination. If a doctor is not sure about the diagnosis, he or she involves laboratory blood test, urinalysis, etc. If these tests fail, the patient takes an X-ray, computer tomography or MRI. If the diagnosis is still unclear, post-mortem examination will make final diagnosis.
According to Valentina Pakhman, the head of the thanatology department of the Republican Anatomic Pathology Bureau, those patients who died from pneumonia and whose PCR tests were negative found Covid-19 during histological section of lung tissue.
“We took some corpses for virology analysis in cases when PCR tests were negative in live patients, and our post-mortem analysis found coronavirus in lung tissues. It seems that those tests were taken improperly. However, we don’t have the legal right to state it unless this fact is confirmed by virological analysis. Now we cannot do this because doctors have many patients and they don’t have time to provide us with data for our analysis. Moreover, the virology centre of the Public Health Authority has been closed for quarantine for one week already,” Pakhman said.
On July 17, it became known that the health ministry included community-acquired pneumonia cases into the Covid-19 statistics. Thus, by July 19 the number of confirmed cases from the beginning of the pandemic exceeded 26.6 thousand people. The death toll of coronavirus patients exceeded one thousand people. Officials said they would possibly consolidate statistical data on July 8, but it happened only after the open message to the agency a week after the scientific and advisory committee took place. The message said the existing approach leads to tragic consequences. According to health workers, the algorithms of management and treatment of Covid-19 and community-acquired pneumonia cases differ dramatically. In their opinion, it is the incorrect diagnosis and treatment that lead to rapid spread of the disease and its complications, including lethal ones.
Clinical protocol
In early July, the agency approved the 3rd provisional guidelines for coronavirus treatment. It excluded all trial anti-viral medications that proved inefficient.
“This is rather pneumopathy than pneumonia,” one of methodologists of the document, Baryktabasova, said. “Because the lung tissue is not inflamed, but full of blood clots. What happens then? Blood stops flowing, it is destroyed. The virus somehow affects haemoglobin in red blood cells. It is a transporter of oxygen around the body. When the process is disturbed, we have the tissue hypoxia, i.e. oxygen deficiency. The brain is in panic mode, it tells you to breathe. How can you breathe when your lungs and not only lungs are full of blood clots? When haemoglobin breaks down, it releases iron that attacks the tissue. This is evidenced by frosted glass pattern on X-ray or CT. This is not the process of inflamed lungs, but clogging. The blood is clogged, and the medications must thin the blood,” Baryktabasova said.
One of the simplest blood thinners – the main medication against thrombosis – is aspirin. However, the expert warns that overdose of these medications can lead to failed blood coagulation, including internal haemorrhage. Stronger medications must be administered under the care of doctors. However, the biggest disaster now, according to health workers, is the lack of any experience in the medicine of Kyrgyzstan to strictly observe approved treatment protocols, especially at the primary level. According to them, local doctors use bonus drugs, even veterinary ones. The health ministry does not have any experience in controlling the process of observation of the guidelines locally and in seeking feedback. New vice prime minister Ismailova tried to make health workers keep to the guidelines by threatening to bring them to account. The speed with which medical officials can now seek feedback might depend on how many more Kyrgyzstanis will fall the victims of system gaps in public health sphere, doctors said.
So far, according to the global summary statistics of the spread of disease as of July 22, Kyrgyzstan tops the list of 20 states by death toll per capita leaving behind even Brazil, which had the highest death toll that day – about 13 persons per one million people – and this indicator is higher than the Brazil’s twofold, the United States’ fourfold. It should be added that this list contains only Moldova in addition to Kyrgyzstan among all CIS states.
This article was prepared as part of the Giving Voice, Driving Change – from the Borderland to the Steppes Project implemented with the financial support of the Foreign Ministry of Norway.