Covid-19 cases are surging across the country again. The number of critical care patients have doubled and the positivity rate amongst the daily tested is on the rise. Yet, we hear the deaths are “just 10,000 or so” in total. Is this far too much or far too less given Pakistan’s size, demographic and socioeconomic dynamic — all of which are clear exacerbators of coronavirus transmission? Here’s a breakdown on why the numbers are, in fact, lower than reported. In a region with relatively low levels of public health spending, the question about the reliability of data remains. Many deaths are not reported within the vital registration system.
The death toll of Covid-19 is not going to be accurate until epidemiologists and statisticians on ground in Pakistan have time to crunch the numbers. But the excess stresses on our healthcare system are clearly evident in countless first-hand reports from emergency rooms and ICUs in our hardest-hit regions.
Furthermore, there is prevalent distrust in the public health system and worry about the extent of government hospital scrutiny a positive result will bring. These concerns cannot be dismissed as paranoia. Fears of invasive procedures are associated with past trauma. Communities who believe to have experienced marginalisation may also be less likely to trust governments and health systems.
Moving on, various clinics across the globe have confirmed that more than 30% of RT-PCR results can be falsely negative depending on when the patient’s sample was collected. When patients who have symptoms of Covid-19 but are not tested, test negative or have an inconclusive result die, their deaths are not included.
Leading the Covid-19 response across the Middle East, Senior Pulmonologist Dr Rana Najmi clarified, “Pakistan has a major blind spot in the form of suspected deaths because all nucleic acid-based Covid-19 tests (including CBNAAT and RT-PCR) can sometimes return false negatives. Our counterparts at Harvard confirm that the reported rate of false negative results is as high as 50%, which is why antigen tests are not favoured as a single test for active infection.
A clinical diagnosis — which a doctor makes based on a person’s symptoms, along with other signs, like a tell-tale haze on X-rays or CT scans and low blood-oxygen levels — is a more dependable way to identify Covid-19 patients. We could be improving Covid-19 reporting in Pakistan through a number of ways, which would lead to more accurate numbers for Covid-19 deaths.”
It is possible that only a fraction of Covid-19 confirmed deaths are being recorded because of the preexisting conditions the patient may have had, like diabetes, cancer or AIDS which exacerbate Covid-19 symptoms. These so-called “deaths due to co-morbidities” are then excluded from the country’s death tolls. “The locals keep saying older people are dying as they normally would. These are the normal amount of deaths that would be occurring regardless of corona. This is far from the truth; the burden is at least 15% higher.
The percentage of elderly and young people dying in the past six months are both higher than the ‘normal’, prevalent causes of death in Pakistan,” said Dr Zamir Hidayat (name changed, Jinnah Medical Hospital, Karachi). For example, lungs are already compromised in those suffering from chronic obstructive pulmonary disease (COPD), asthma or those who are chain-smokers.
Covid-19 may be superimposed on the underlying illness. Such an individual may be Covid-19 positive, but the primary cause may be something else, like asthma or COPD. Additionally, Covid-19 is not the cause of death in patients who are immunocompromised with diseases like HIV or tuberculosis. Dr Ellie Aziz, based in Lifecare Hospital in Abu Dhabi, further commented, “During a pandemic, clinical diagnosis becomes all the more important, although not feasible due to capacity and social distancing reasons.
The fact remains between clinical criteria and a lab test, the former is more reliable, unless both tally.” Lastly, there is a dire need to understand the virology and characteristics of SARS-CoV-2 whether the antibody response is truly protective, and whether re-infection is due to fading immunity or re-infection by a mutant virus.
Winter suits many respiratory viruses and may be conducive for corona. What really matters is adopting the control and preventing public health measures. Transmission is on the rise because people are interacting indoors within their confined homes to escape ‘smart lockdowns’. There are more indoor activities with poor ventilation.
Children attending school may be carriers to elders. In summary, Covid-19 statistics are underreported in Pakistan, but not intentionally. Under-reporting occurs in every disease outbreak worldwide; however, keeping track of the Covid-19 outbreak in developing countries is especially challenging.
An evaluation of democracy-related indicators proves that countries with lower rankings are posed with greater Covid-19 underreporting issues. Maintaining an accurate account of the number of national Covid-19 cases is critical for evaluating the national and global burden of the disease and managing Covid-19 prevention and control efforts.
Therefore, correlated factors need to be addressed to reduce under-reporting. There is heavy reliance on reliable reporting: epidemiologists use it to predict a disease’s trajectory, researchers use it to develop treatments and vaccines, responders utilise it to trace transmission, and the public to protect itself. The people of Pakistan had declared a premature victory where the real battle was still to come.
The symptoms of re-infection are severe in this case and other few reported cases and re-infections have implications for vaccine development and application. What has become clear is that strong, transparent, and accountable leadership and communication strategies at all levels are crucial in Covid-19 outbreak management to ensure the successful control of the disease and to prevent secondary problems.