COVID-19 Pandemic in Pakistan

COVID-19 Outbreak in China

In December, 2019, the World Health Organization (WHO) was informed by the Chinese government about numerous cases of pneumonia with unfamiliar etiology. The outbreak began in the Hunan seafood market in the Wuhan city and quickly infected more than 50 people. The Hunan seafood market was the selling point of live animals such as frogs, bats, birds, rabbits and marmots.⁸ On January 10, 2010, the National Health Commission of China suggested it was a viral pneumonia,⁸ but this virus was later identified as novel coronavirus. Initially, it was assumed that the seafood market had infected animals and people were infected if they visited the market. Further investigation showed that some individuals were infected with the virus with no record of visiting the market. Thus, later observations revealed the human-to-human capabilities of the virus. Spreading of virus occurs due to the close contacts with an infected person, or exposure to virus-containing aerosols during sneezing, coughing, and respiration. These aerosols can penetrate to the lungs via inhalation through the nose or through the mouth.⁹ Table 1 shows the early stages of the COVID-19 outbreak.

Key Hosts of COVID-19 and Comparison with Previous Coronaviruses

Initial research concentrated on raccoon dogs and palm civets as a key reservoir of infections in the case of the first SARS-CoV.² However, only the samples isolated from the civets foods at the food market provided positive results. This suggests that the palm civets were infected at the market by other palm civets or by other infected animals.¹⁰ Later, Rhinolophus bats were found to have anti-SARS-CoV antibodies suggesting that bats are a source of viral infections following prior exposure to the virus.¹¹ Saudi Arabia faced the Middle East Respiratory Syndrome (MERS) coronavirus outbreak in 2012. A recent study shows that MERS-Coronavirus was also detected in bats and that bats were key hosts and transmitting media of the virus. Table 2 shows the key hosts of SARS-CoV-2 and its comparison with SARS-CoV.¹²

COVID-19 Outbreak in Iran

Iran reported its first confirmed cases of SARS- CoV-2 infections on February 19, 2020 in Qom. On the same day, Iran's Ministry of Health and Medical Education (MOHME) stated that both patients had died. On March 31, 2020, according to the MOHME, there had been 2,898 COVID-19 deaths in the country with 44,605 confirmed patients.¹³ As at March 31, 2020, Iran has the sixth highest number of COVID-19 deaths and coronavirus-infected cases following Italy, China, Spain, United States, and France.

It was thought that the virus may have been transported to the country by a merchant from Qom who had visited China. Iran became an epicenter of the virus in the Middle East with more than 10 countries tracing their cases back to Iran by February 28. Government actions in Iran included suspension of public events and Friday prayers, closure of schools, colleges, universities, and shopping centers as well as holy shrines, and banning of festival celebrations. Economic actions were also announced to help families and businesses. The government was reluctant to quarantine entire cities and areas, and heavy traffic between cities continued ahead of Nowruz holidays, despite the government's intention to limit travel. The government later implemented a travel ban between cities following an increase in the number of new cases.

COVID-19 Outbreak in Pakistan

Table 3 gives the COVID-19 outbreak report on a daily basis in Pakistan.

Comparing Pakistan with the world

From the data in Table 4, Khyber-Pakhtunkhwa (KPK) had the highest fatality rate followed by Sindh and Gilgit Baltistan. Punjab followed by Sindh had the highest number of infection cases. The Baluchistan had highest recovery rate. The environmental conditions of countries such as Malaysia, Indonesia, and Thailand appear not to be conducive to the prolonged survival of the virus, ostensibly due to their high tempartures.²⁰ Scientists are examining the effects of temperature and relative humidity on COVID-19. Most scientists believe that COVID-19 is not effected by temperature and humidity, but the connection between the virus and weather remains unknown. Likewise, the relationship between the immune system and how it affects infection, fatality and recovery from COVID-19 is currently unknown. Using data from Worldometer (https://www. worldometers.info/coronavirus/), we compared the number of cases reported, the number of deaths and the fatality rate in Pakistan with selected countries across the world (Table 5).

COVID-19 started in Iran nearly the same date as in Pakistan, however, as shown in Table 5, Iran has higher number of infected cases and deaths than Pakistan. In March, the United States of America reported 26,000 registered deaths compared to 40,000 in Italy and Spain combined. Some researchers say that the number of reported cases of COVID-19 is rapidly increasing in the EU/EEA and the UK.²¹ The observed trends in the cumulative incidence of COVID-19 suggest that the pandemic is progressing at a comparable speed in all countries, although the trend in Pakistan, thus far, may not have been as in other countries. This is despite countries being at different stages, variations in national public health responses, and possibly different case definitions, and different protocols for selecting patients to test for confirmation of COVID-19 disease, including catch- up testing.²² From Table 5, it appears that Pakistan has a lower fatality rate than other countries, especially countries in the EU, USA, Iran, and Indonesia (Table 5).

Weather Conditions

Although there is currently no research to support them, there are some anecdotal assertions on the relationship between weather conditions and coronavirus spread. It is widely known that in the cold days, the outdoor air is colder. For influenza, it has been shown that absolute humidity strongly affects flu transmission, with drier conditions being more favorable to the transmission of the flu than colder conditions.²³ Based on studies in Vietnam and the USA, analysts argue that SARS-Cov-2 transmission patterns are similar to those exhibited by influenza.^23,24 Notably, the Vietnam study observed influenza-like illnesses, without distinguishing influenza from other types of pathogens.²⁵ It has been argued that similar patterns observed with influenza transmission may be applicable for corona virus, but there are no specific studies examining the role of humidity for coronaviruses or other respiratory viruses besides flu. The countries with dry cold air have favorable conditions for flu transmission but for coronaviruses, the relevance of this factor is largely unknown. A study has suggested that transmission is possible in different hot and humid climates. Pointing out that Singapore, for example, which lies nearly on the equator, has had significant transmission of coronavirus.²⁶ But there are differences between Singapore in February and a temperate zone in summer. For example, there are different lengths of day light hours, ultraviolet radiation, and other unknown factors that may be important for coronavirus transmission. Further study is required to determine if the regions with hot weather like Pakistan and Saudia Arabia have less viral spread of transmission.

Indoor/Outdoor Living

In the winter, in many climates, people spend more time indoors with less ventilation and less personal space than outdoors in the summer. Schools are a place of potentially increased opportunities for infectious disease transmission. School terms have been strongly identified as periods of higher transmission for respiratory viruses including those causing flu, chicken pox, and measles.²⁷ The 2009 pandemic flu in the United States was very much reduced during the summer, and then came back rapidly in September.²⁸

Schools and Schools Closures

However, the significance of school terms is important but unknown for the SARS-CoV-2. At the beginning of the pandemic, few children were identified as cases. This was suspected to mean that they were not easily infected and did not significantly transmit the virus. It was also suspected that when they do get infected, children were less likely to exhibit severe symptoms compared to their older counterparts. Nonetheless, newer studies had indicated that children and younger-aged people were getting infected.²⁹ With the first case reported in Pakistan on February 26, 2020, the Government of Sindh announced school closure and later for the entire country. Understanding how the virus infects children is important in understanding whether school closures may help in the control of COVID-19 spread, and to anticipate how much summer vacation may potentially help in reducing viral spread.

Immune Levels

In Pakistan, the cold weather remains for a very short time, Almost the entire year the population enjoys sunny weather and the average person's immune system is generally stronger in summer than in winter. One hypothesis has focused on the role of melatonin which has some immune effects and is modulated by the photoperiod, which varies seasonally.³⁰ Another hypothesis is that of vitamin D levels, which depend, in part, on ultraviolet light exposure. According to one research paper, vitamin D supplementation reduces the incidence of acute respiratory infection.³¹ As Lipsitch argues in his paper, many people think that as the proportion of susceptible contacts declines, the epidemic peaks, and eventually declines.³²

Lipsitch presents a compelling argument on the seasonality of COVID-19, and whether the virus will be attenuated by warmer weather.³²

A recent study, nonetheless, suggests that children may be infected and shed detectable virus at about the same rate as adults, but the open question remains whether children transmit the virus as readily as adults?³³ The immediate school closure by Pakistan government as first case reported helped the country to weaken outbreak.

As indicated by the most recent figures on the COVID-19 fatalities recorded by John Hopkins, out of the 132,276 cases recorded around the world, the greater part have been from Italy, USA and Spain combined.³⁴ In the interim, just 515 individuals have died in India and Pakistan, while 20 deaths have been recorded in Nigeria and Kenya. Since its first COVID-19 case reported on Feb 26, Pakistan has recorded 107 deaths and about 6,300 cases as of April 15.

Some researchers have suggested that nations like the European Union and the United States where the Bacille Calmette Guerin (BCG) immunization, an effective immunization against tuberculosis, was not mandatory are greatly impacted by COVID-19.³⁵ Some researchers also assert that in Iran, where widespread BCG vaccination was embraced in 1984, fewer people have died from COVID-19. The nations that did not actualize the BCG immunization, which for the most part incorporate western nations, had more coronavirus infections per capita and a higher death rate.³⁶ In Pakistan, the BCG vaccination is obligatory for newborn children. Since 1949, all babies in Pakistan are given a single portion of the BCG immunization at birth.³⁷ Figure 2 shows COVID-19 deaths in the European Union and Pakistan.

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Figure 2:

Shows the comparison of COVID-19 deaths with European countries with Pakistan.³⁸

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Treatment Plans and Developments in Vaccine

At the time of submitting this paper, there were over 80 clinical trials to evaluate a diversity of potential SARS-CoV-2 treatments all over the world.³⁹ One simple but very effective treatment modality is the use of convalescent plasma therapy, or serum from patients who have recovered from the virus to treat new patients. Patients with resolved viral infection develop a specific antibody response which may be helpful in neutralizing viruses in newly- infected individuals. This treatment was successfully employed in the past.^40,41 On March 20, Pakistan's top hematologist and transplant surgeon in the state of Shamsi announced that the blood of recovered COVID-19 patients can be habituated to slow the spread of the deadly contagion which has infected and killed thousands people worldwide. It has been reported that the body of a COVID-19 patient creates antibodies against the virus.⁴²

On April 10, the national Institute of Blood Disease (NIBD), Pakistan, prepared to deliver its first plasma therapy.⁴⁸ The Drug Regulatory Agency of Pakistan (DRAP) on April 9 granted approval for a passive immunization using plasma therapy.⁴⁸ On April 13, medical experts at the Dow University of Health Sciences (DUHS), in Pakistan, claimed that they had formulated a drug to treat COVID-19 patients. Medical specialists from the DUHS claimed that intravenous immunoglobulin was a great development in the fight against novel coronavirus. The DUHS study team reported the globulin was manufactured with purified antibodies obtained from the recovered COVID-19 patients, and referred to it as a ray of hope.⁴⁴

Globally, the long-term objective of COVID-19 research is to develop an effective vaccine to produce neutralizing antibodies. Researchers at the Baylor University in Waco, Texas, and the National Institutes of Health in the United States are working on a vaccine based on what they know about the coronavirus in general, using evidence from the SARS outbreak. In addition, the recent mapping of the COVID-19 spike protein may overlay the way for quicker progress of a specific vaccine.⁴⁵ Of particular attention is the use of a relatively new vaccine technology, RNA vaccines that have the ability to cause potent immune responses against infectious diseases and definite cancers.⁴⁶ Traditional vaccines stimulate the production of antibodies via experiments with purified proteins from the pathogens, or by using whole cells (live, attenuated vaccines). While very effective, the formation of new vaccines can take years. Instead, RNA-based vaccines use mRNA that, upon entering the cells, are translated into antigenic molecules that in turn stimulate the immune system. This process has been used effectively against some cancers,⁴⁷ and clinical trials are ongoing for several other cancers. In addition, the production of RNA- based vaccines is more rapid and less-expensive than traditional vaccines, which can be a major advantage in pandemic situations. Clinical trials for an mRNA- based SARS-CoV-2 vaccine are currently underway.⁴⁸ Study participants will receive the mRNA vaccine in two doses, 28 days apart and the safety and immunogenicity will be considered. On April 18, the Federal Minister of Science and Technology, Pakistan, reported that Pakistan would be starting the first phase of clinical trial of COVID-19 vaccine and would be fully contributing to the 66 different global studies being conducted on three different approaches, including repurposed drugs, antibodies and vaccines.⁴⁹

Economic impact

According to a report by the Asian Development Bank (ADB) during the COVID-19 outbreak, Pakistan's economy could lose about $16.387 million to $4.95 billion, or about 0.01% to 1.57% of its gross domestic product, a GDP drop that will cost Pakistan's GDP by at least 1.57% and trigger 946,000 job losses.⁵⁰ The textile sector in Pakistan relies on foreign countries for the bulk of its capital goods input. Lots of foreign textile industries were closed during the pandemic which will surely affect Pakistan textile sector. Pakistan Stock Exchange (PSX) is experiencing a major downturn due to the pandemic. On March 19, the PSX fell to its lowest point in more than five years. Karachi Stock Exchange 100 index (KSE-100) has suffered several trade standstills these days to protect investors during instability and unrest.⁵¹

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