2020: How Pakistan's response to the pandemic surprised the world

Pakistan did better than its equal and advanced global partners in containing the spread and mortality rate in the initial spike of the Coronavirus Disease 2019 (COVID-19).

The World Health Organisation’s Covid-19 dashboard on Nov 21 reported 11.6m cases and 250,000 deaths in the United States. In neighboring India, 9.05m people have contracted the deadly disease and 132,726 people have lost lives in the period.

In Pakistan, 368,665 cases were reported till that date and 7,561 people have died since March. It was definitely a surprise performance from a poor country like Pakistan having its healthcare sector in bad shape. An unexplainable success, which requires thorough scientific work to explain.

The virus was confirmed to have reached Pakistan on 26 February 2020, when two cases were recorded (a student in Karachi who had just returned from Iran and another person in Islamabad, also recently returned from the same country).

On 18 March, cases had been registered in all four provinces, Azad Kashmir, Gilgit Baltistan and Islamabad Capital Territory and by 17 June, each district in Pakistan had recorded at least one confirmed case of COVID-19.

Pakistan’s initial response to the rising cases of highly contagious disease could be termed as ‘haphazard’ at the best. Pakistani citizens returning from other countries mostly allowed entry without much ado. The flights from other countries were landing at national airports carrying Pakistani passengers, which were being allowed entry without test and quarantine.

The camps set up at Pakistan’s border with Iran were also a mismanaged affair, which caused the spread of the virus rapidly. The first two cases reported in the port city of Karachi and Capital Islamabad on the same date, February 26, had Iranian connection. Later, local transmission of the virus overcame the cases coming from foreign lands.

Pakistani authorities after initial bickering over the rising cases, regrouped and made an organized and concerted effort to contain the epidemic with lockdowns and other precautionary measures under an umbrella body representing all stakeholders in the country.

On 15 June, daily new confirmed case numbers reached their peak in Pakistan, with 6825 new cases on that day, but since then, daily cases and the percentage of people testing positive plunged downwards. In late June, the number of active cases in Pakistan stabilized and in July, started showing a significant decrease.

The pandemic after reaching its climax in mid of June, showed a slide in the number of daily cases in the months of July, August and September creating a false general impression that the country has overcome the contagious.

Claims of Herd Immunity

As the curve of coronavirus cases flattened in Pakistan, several experts suggested scores of reasons behind the slide in the cases of the disease including immunity to the deadly virus. Some surveys suggested that coronavirus has infected so many people, in some countries, that immunity to the deadly virus has been developed. But experts remained sceptical.

Herd immunity is described as a situation wherein a large part of the population has already been infected with a virus, making its further spread difficult. Researchers primarily look for antibodies, the molecular fighting mechanism in human bodies, to see if a patient has been infected. Epidemiologists at a leading institute in Karachi took samples from 1,675 people between May and July to figure out why the pandemic was tapering off in the country.

“The intensity of infections in the developed world was very different from ours. Obviously, we were having infections but we were not having that high case fatality rate and high mortality,” said an author of the study.

The research team found that around 36 percent of the surveyed people had developed immunity, which basically means the human body has become equipped to fight a pathogen. In one subset of the sample consisting of employees of a pharmaceutical company, they found seroprevalence, which is the number of people infected, to be around 50 percent. The weak point of this survey was its small number of samples,which was too small to reflect the reality of a large city or a country.

Some other surveys and opinions of experts also speculated about the strong immunity of the people in Pakistan, which in their view helped to contain COVID-19 in the country.

Experts have yet to agree on what size a given population has to become immune to go on to qualify for herd immunity, but it is generally understood to be between 60 to 70 percent. In any case, some leading experts were sceptical about the whole idea.

Developing immunity via natural selection means authorities are willing to let the pandemic run wild, killing tens of thousands, before it stops spreading. When viewed in the context of sheer numbers, the concept of herd immunity appears terrifying. For poor and developing countries lacking the resources to deal with the pandemic, such a strategy could be devastating.

The second spike of the coronavirus cases in Pakistan since November has proved that the speculations about herd immunity have no substantial ground. The second wave is being called more lethal with a rising curve of deaths. Test Positivity Ratio (TPR) has reached around seven in Pakistan, while Karachi, the largest city of the country continues to remain above 20 in positivity ratio for many days.

There are also questions about how long the immunity against the virus lasts. Multiple reports have shown that immunity can disappear within a few months. There are also verified examples of coronavirus re-infection.

Cross infections and vaccination

In Pakistan, some experts say, doctors have observed a milder form of Covid-19. “We are not sure why that is. But it could be because of cross-infections as people have already been infected with other diseases and acquired immunity.

The prevalence of dengue fever is also being touted as another reason, according to an expert. Vaccination drives against polio, measles and other infections play a similar role in building up immunity, some experts opine. Moreover, vaccination of BCG given at birth to protect against tuberculosis (TB) in Pakistan also have some role in boosting immunity against the virus.

Some experts believe that high temperature and humidity during summer also helped slow down the spread of the virus in the initial wave. In western countries people at old age homes were the most vulnerable target of COVID-19. The worst-hit countries have a high mortality rate in the old-age population due to the virus’ spread in old-age homes.

In contrast, Pakistan has a young population and a social construct that vetoes placing elderly at old-age homes, protecting the old people from exposure to the disease. It is not astounding, then, that a study found seropositivity more common in young adults and significantly less in children and older adults. It was also more prevalent in urban areas than rural.

The quality or state of being seropositive means having blood serum that tests positive for a given pathogen. “The youth steps out to work so they found positive due to exposure to the virus, ” an expert said.

A study found antibodies in 7% of Pakistanis

A seroprevalence study in Pakistan in November confirmed that seven percent of citizens have developed antibodies for the virus.

The prevalence study was carried out to determine how many people in Pakistan have developed antibodies after exposure to the virus, said health ministry spokesperson.The second round of study was conducted by the Health Services Academy in collaboration with the World Health Organisation (WHO) in 10 districts of the country.

Antibodies are blood proteins produced by the immune system to fight foreign invaders like viruses, and may help to ward off future attacks by those same invaders. According to the results of the study, people who are infected with coronavirus but show no symptoms probably account for most virus transmission. The researchers found that coronavirus is rising rapidly in urban areas as compared to rural areas of the country.

The cause behind flattened curve

The scientist-recommended strategy to contain the spread of virus has been lockdowns, testing, and contact tracing. But it is nearly impossible to get a developing country like Pakistan where two-thirds of the population relies on daily wages, to stay at home.

“There is a universal acknowledgement that the virus’ spread can be slowed down through behavioral change in the society,” said a top official leading Pakistan’s drive against the virus. “It can be voluntary with the masses informed of the risk and how to save themselves or it can be administratively enforced. We chose to do both.”

He explained Pakistan’s strategy: “Media played an important role in creating awareness, which was backed by our testing, contact tracing, and quarantine program. We managed to increase testing capacity in a very short period and applied a sophisticated tracking system that ran through the ground to apex level.

“At one point, we had over 10,000 contract workers and more than 3,000 contact tracing teams. It became an integral part of our strategy coupled with smart lockdowns in high-risk areas and hotspots and SOP compliance. Those in violation were fined or sealed.” “For the first three months, we saw a significant change in behavior. People wore masks and maintained social distancing. Once the cases slowed down, we saw less adherence to the SOPs,” he said. “This was followed by Eid-ul Adha celebrations. The curve, however, continued on a downward trajectory,” he added.

What The World Health Organization said

Dr Palitha Mahipala, the World Health Organization (WHO) Representative and Head of Mission pointed out the same fact in an interview. He said Pakistan with the support of the WHO laid a network earlier for combatting other diseases, which proved a decisive factor in limiting the severity of the COVID-19 outbreak.

From the beginning of the crisis, polio staff carried out surveillance and provided training to frontline health workers. “The polio infrastructure and related campaigns were fully utilized for COVID-19,” said Dr Mahipala.

WHO Director-General Dr Tedros Adhanom Ghebreyesus had previously commended how Pakistan capitalized on its previous work on polio: “Pakistan deployed the infrastructure built up over many years for polio to combat COVID-19. Community health workers who have been trained to go door-to-door vaccinating children have been utilized for surveillance, contact tracing and care.”

The Second Wave

Pakistan, which seemed to have flattened its Covid-19 curve in September, recorded a second spike of the virus infections from November with soaring numbers of infections and deaths.

The country had witnessed a record high in infections in a day — 6,825 cases on 14 June. Then, around July, it recorded an average of over 2,000 to 3,000 cases daily. Between August and October, it continued to record a decline in infections, wherein less than 1,000 infections were recorded daily.

However, since November, the country has been recording an increase in cases. In a span of a month, the daily cases in Pakistan more than doubled. On 12 October, 531 cases were recorded while 2,304 cases were reported on 12 November, and as many as 3795 cases on 06 December.

To detect these cases, Pakistan has so far conducted a total of 61,36,799 Covid tests. The number of tests have consistently gone up since July. While an average of 20,000-25,000 tests were done daily in July and August, the number went up to 30,000 in October. On 16 December, 38,028 tests were conducted.

As 105 more people succumbed to the disease on Dec 16 overall death toll by COVID-19 reached 9,010. The test positivity rate of COVID-19 cases also going up and has been recorded above 7 per cent.

What Doctors say on the Second Spike

Dr Abdul Bari, CEO, Indus Hospital in Karachi and member of the Sindh Health Task Force, said people’s complacency was a primary factor behind the increase in infections in the country.

“I think people’s complacency is the biggest reason behind the surge in infections, along with the weather change, now that it has become colder,” he said. He also termed opening schools as a misstep by the government. “I think the mistake on the government’s part was that they opened schools, then wedding halls and restaurants.

“All their attention was focused towards schools and colleges where they were testing people.”Meanwhile, a large number of people were gathering in wedding halls and restaurants, which went unnoticed. According to Dr Bari, many of them did not wear masks and were not following other Covid-related protocols.

“People took false impression of the initial success against the virus as they think that the deadly virus has vanished and therefore, precautionary measures are being ignored, ” another doctor said. “The political rallies have also contributed to the surge in infections,” he added.

Doctors have also expressed concern over the rising test positivity rate (TPR), which has now come up to above 7 per cent.

Dr Bari, however, said that the people have now “learnt how to live” alongside with Covid-19 and weren’t rushing to hospitals with more than half a year spent living under pandemic conditions. People have learnt to live with Covid. First people were going to hospitals even with minor symptoms, but now they’re opting for home isolation.”

The ‘Second Wave’ of the virus is raging across the country, especially in big cities and every new day brings a soaring number of infections and grim figures of deaths.

Govt Plan for Vaccine Procurement

Scores of drug companies have achieved the milestone to produce a Covid-19 vaccine as Oxford University-AstraZeneca, Pfizer, Moderna, Russia’s Sputnik V, and Chinese Sinovac and Sinopharm vaccines have reached in the phase to be used for broader public vaccination.

The UK, United States, Canada and some other countries have given approval to the vaccines and started vaccination drives.

The government of Pakistan has also recently announced that Covid vaccine will be available in Pakistan next year in February or March 2021. However, it was not disclosed which vaccine maker will be contacted for procurement.

Dr Faisal Sultan, Prime Minister’s Aide on Health said that a coronavirus vaccine would be available in Pakistan next year in February or March and it would be free for all the citizens.

He assured that the vaccine will be procured keeping in view its safety, efficacy and effectiveness.

“The government has initiated working on multiple aspects related to purchase of the vaccine,” he said.

He said that the government will soon be able to share information on the date of availability of the corona vaccine in the country. The vaccine purchase matters have also been discussed with the provinces and a specific amount has been allocated for purchase of Corona vaccine, he added.

Some countries are preparing for approval of a vaccine and launching a mass vaccination drive to overcome the raging virus, while others are waiting for their turn to get vaccine shots available for vulnerable segments of the population and pool resources to initiate large scale vaccination drives.

Several aspects of Pakistan’s plan for procurement are obscure and unclear including the issue of funding, preparation of the vaccination plan across the country, logistics and other related issues. Moreover, the issues between the Centre and provinces, could hinder harmony in the country required to fight the national health emergency.

In public domain, perception counts the most, according to a recent survey a large segment of the population was unprepared to get the vaccine shots like other parts of the world due to scores of conspiracy theories attached with COVID-19 vaccines.

As experts and the WHO repeatedly say that a vaccine is not a magic bullet, Pakistan have to be prepared for a long struggle to overcome the disease and its side effects, for which national harmony counts the most. We hope a sane strategy from the authorities to tackle this formidable crisis.