PIVOTING PAKISTAN RESPONSE TO COVID-19
Though it is too early but there is hope for countries located proximate to the equator like Pakistan, India, and Bangladesh by analyzing striking variation in mortality rates in comparison with countries in the Northern hemisphere. Following factors seem to be playing a favorable role in the lower mortality numbers during Covid-19 Pandemic in Pakistan. It is hoped that Corona pandemic will probably not follow the trends like US, Italy and Spain.
1) African and South Asians have better immunity due to infections like Ebola, Dengue, Typhoid, Chicken Pox, Malaria etc. Past exposure to microbial load and various pathogens like parasites, bacteria and viruses have generated improved immunity due to broad specific memory T-cells and boosted its readiness to attack new foreign invaders. Over the passage of time, this microbial load must have added and increased genetic diversity and presence of novel HLA (human leucocyte antigen) in comparison with other ethnic groups like Itlay, Spain or US. According to latest clinical Covid-19 studies recovery depends on T-cell rapid response while infection progress in case there is less functional diversity of T cells in peripheral blood. Extensive past use of chloroquine and hydroxychloroquine drugs at the community level seems to be playing favorable and beneficial in controlling mortality rate. It is in line and support ongoing debate and research on positive role of chloroquine and hydroxychloroquine in treating Covaid 19 patients.
2) Pakistan risk factor is less due to better and young population composition as compared to Spain, Italy, China and US. Total number of death is publicly available in Pakistan but further details are not easily available due to poor reporting standards and bureaucratic misalignment at multiple level. Indian data till 2nd April, 2020 is interesting. Out of the first 46 Covid-19 deaths in India, 34 had comorbidities (one or more pre-existing medical conditions). Out of total deaths, 36 were men, a pattern observed in Spain and Italy. Average age was 61 years and it would have been much higher if two young deaths are discarded; 25 years old having liver condition and 38-year-old, with kidney failure. A couple 80+ years old has successfully recovered. Only 6 cases needed ventilator support and remaining cases did not had any problem in breathing. It is likely because our immune systems degrade as we age. It’s the same reason that humans see increased cancer rates as we age— as we grow older, our immune systems, which normally find and destroy cancers in our bodies, become overwhelmed, exhausted, depleted.
3) Temperature zone, environment and living culture seems to be in action in prevalent pandemic. Most of the cities affected by Corona have temperature range less than 18 degree on average. Closed and high rise apartment buildings must have an important role in rapid transmission of infections. Studies have shown in other coronaviruses seasonal pattern, with peaks occurring during winter and disappearing in spring. By contrast, only small amounts of coronavirus appear to be transmitted in the summer. Even if high temperature does not affect the behavior of a virus. Initial studies of seasonal variation gives some clues to changes in the human immune system just like daily rhythm. According to studies at Surrey & Columbia Universities suggest a subset of white blood cells, a key player in the immune system appear to be elevated at certain times of day. For example, B cells that produce antibodies have been found to be elevated at night.
4) Pak health system is of course neither better nor developed than European or American but from our health system perils emerge strength needed in existing pandemic. Our health system and health care providers are proving better and resilient in coping like Corona pandemic due to following factors:-
a) Pak do not have strict protocols like Europe or US hence our healthcare provider enjoys flexibility and free hand to deal with patients, the way they feel appropriate in emergency situation and changing circumstances. In a sense emergency is a norm for our healthcare providers. Hence they are better equipped to apply their knowledge and experiences during this pandemic.
b) Our healthcare providers are adapt in dealing load of patients. As an example 150+ OPD and 10+ emergencies per physician / surgeon is not abnormal in our teaching and territory health units. While it is a week and month work load of a physician or surgeon in US or EU.
c) Various provincial Govts (Sindh, KPK and Punjab) have announced to induct thousands of Drs. It’s not possible in countries like US and EU to ramp a vital human resource like Drs on such short notice. It will take years for countries like EU and US to arrange and hire so many Drs.
Mortality rate of Covid-19 is comparable with other diseases / infections like diarrhea in children, seasonal flu, smoking etc. Most importantly, bankruptcy due to lock down will kill more than Corona Virus. We cannot allow the tap to run dry for the essential care of millions of sick people who need their medicines and surgeries, without creating another health crisis.
Pakistan approach to extend lockdown beyond April 15, mainly based on the Chinese model does not seem to appropriate, feasible, possible and counterproductive. Instead of locking down 95 % population, it would be efficient and effective to go other way around. For optimal results, during lockdown, we need to scale up testing tenfold from the current levels, and rigorously implementing the mantra — test-isolate-safeguard-treat-trace vulnerable among 5 % high risk population. This will be much cheaper than what Pakistan is paying in terms of economic and social costs. The lockdown itself has limited value. Even if all 220 million stayed home for next 30 days, the virus will be down, but not out. Most importantly in long run it’s not lock down, which is going to save us rather natural herd immunity.
In this regard, Antibody tests have certain downsides like insensitive however it is important and can be started immediately in order to track individual and herd immunity level for Covid-19 particularly in highly affected areas, high risk population and health workers. Whilst RT-PCR tests look directly for current signs of infection, those to detect antibodies will also be able to identify those who have had infections in the past and may now be immune. In the short term, this will be important because it will permit the authorities to identify who may return to their jobs without risk of infecting others. That is particularly valuable in the cases of doctors, nurses and the numerous other health-care workers needed to look after those who are seriously ill. And in the long run, antibody tests will reveal how far the virus has spread through a population, and thus whether or not herd immunity is likely to have built up. It is efficient, cost effective and can be easily performed in most of the pathology laboratories, while RT-PCR is expensive, time consuming and needs a special instrument, which many labs do not have. The same practice is used for viral screening of Hepatitis.
Hence instead of focusing only on ventilators and lockdown, we may consider following : -
1) Pakistan need to identify, target, isolate and safeguard vulnerable and high risk among all those of age 50+ years or having underlying medical conditions like hyper tension, uncontrolled diabetes, lungs (TB), transplant surgeries etc.
2) All such cases must be restricted and quarantined if required / needed and efforts should be focused on all such cases.
3) Antibody tests must be started immediately in order to track individual and herd immunity level for Covid-19 particularly in highly affected areas, high risk population and health workers.
4) Under Digital Pakistan Initiative, now is the time to digitize all health businesses, function, process, products, services or methods. Health bureaucracy must figure out how to digitize health completely. So all health channels and platform for sharing data must be instant, real time, streamlined, online and improved between bureaucracy at different level from district to provincial and federal level. As an example prevalence of Covid-19 infection, mortality, fatality, recovery, presenting sign / symptoms, presence of co-morbidly in critical patients and resulting morbidity are documented but not formally shared in meaningful standardized way in spite of the fact this information in real-time is vital for preparing national response in any pandemics.
5) Even a few days into the pandemic, there was crisis brewing at all levels of health and major fault lines were exposed. As an example there are no functional ICU even in teaching hospitals. Because health bureaucracy and academia has remained in paralyses for too long during past three decades. The capacity of health bureaucracy and academia need immediate improvement for quick response, data analysis and informed decision making. The list of issues that demand attention, and decisive action, grows longer by the day.
There are many other pressing concerns that reflect both deep-seated issues of power, influence and authority held by those among health bureaucracy. It is being magnified by Covid-19 and flaws in the immediate response. But more than anything else – in part because it illuminates the silver lining in this unprecedented crisis — it is necessary to call attention to those who are front and center of the effort to save lives in our hospitals, along with the many other essential workers whose virtually invisible labour is proving to be more important than anything else in this country’s arsenal.
Syed Fida Marvat & Dr Beenish Fida