Why Isn’t Pakistan’s COVID-19 Death Rate Falling as Quickly as Infections?

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Why Isn’t Pakistan’s COVID-19 Death Rate Falling as Quickly as Infections?

The fatality rate trails behind infections, so Pakistan’s morbidity rates will take awhile to fall.

Why Isn’t Pakistan’s COVID-19 Death Rate Falling as Quickly as Infections?

A health care worker takes a nasal swab sample from a woman at a COVID-19 testing facility at a hospital in Karachi, Pakistan, Wednesday, Dec. 30, 2020.

Credit: AP Photo/Fareed Khan

It’s 10:30 p.m. on a Tuesday. Dr. Khalid Khan’s shift in the COVID-19 ward at Peshawar’s Khyber Teaching Hospital (KTH) has just ended. “I have never felt so devastated before,” he told The Diplomat, describing the last three months as a “harrowing experience.”

“A nine-month pregnant 22-year-old COVID-positive woman was admitted to our hospital a few weeks back,” he reminisced. “The obstetrician-gynecologist performed a cesarean with a spinal anesthesia on her to deliver a healthy baby boy.”

But it was too late for the mother. “Her left lung had turned into ash and vitals kept falling,” said Khan.

After a 36-day battle with the virus, the young woman passed away without getting a chance to hold her firstborn. “The image of her family standing by the bed, waiting for a miracle, still haunts me.”

A Steep Ascent

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After an exponential increase, Pakistan’s trajectory of COVID-19 infections appears to be plunging, as daily cases fell to 838 from 2,517 a month ago. Although hospitalizations have also dropped, the death toll remains stubbornly high, with 59 fatalities recorded on June 14 and 37 on June 20.

More than a year into the pandemic, the South Asian country has reported over 949,000 cases and 22,000 deaths. Amid new variants and vaccinations, about 42 percent of Pakistan’s total infections and 50 percent of the deaths were recorded in the last four months.

It took 308 days (or 10 months) for Pakistan’s death toll to cross the 10,000 mark, and the number doubled in just 143 days (4.5 months). The stats reflect global trends, as a John Hopkins University tally estimated that new coronavirus deaths doubled the world over in just five months.

The Institute for Health Metric and Evaluation in Washington estimated Pakistan’s daily COVID-19 fatalities to be 4.4 times larger than the reported number of deaths. “As far as we can tell, the case fatality rate (CFR) has remained around 2 percent,” insisted Dr. Faisal Sultan, the country’s de facto health minister. “There’s only a fractional difference.”

The unprecedented surge in fatalities across the world is in stark contrast to previous waves. While research confirms the higher transmissibility of new variants, there is no concrete proof to suggest augmented lethality.

Patient Behavior

“There’s nothing dramatically different in how patients are presenting symptoms,” said Dr. Faisal Mahmood, head of Infectious Disease at the Agha Khan University Hospital (AKUH) in Karachi. “We’ve seen people who deteriorate fast in all three waves.”

He recalled seeing a patient at the beginning of the pandemic. “He [the patient] was fine in the morning and was set to be discharged the next day. Come evening, he was put on a ventilator.”

“What’s unusual is that in the previous waves we saw the first week of infection would tend to be more fever and the second week is when the patient may worsen,” he continued. “But what we’re seeing now is that patients deteriorate very early on in the disease.”

In Peshawar, Khan can relate. In the first and second waves, he was periodically stationed in the COVID-19 ward at the tertiary care hospital. In the third wave, however, he was moved there indefinitely.

“We would see about 15-20 critical patients a day during peak coronavirus wave last year,” he said. “It was manageable until a few months back when the daily inflow of critical patients rose to 40-45.”

“There’s a bit of a bias here,” cautioned Mahmood. “In the first wave, patients with a positive test result and mild symptoms were running to the hospitals. Now they tend to come when the condition is a bit more severe.”

Treatment doctors also claim that patients are taking longer to recover from the viral damage and, in some cases, not responding to treatments. Talking to The Diplomat, Amesh Adalja, a senior scholar at the John Hopkins Center for Health Security, explained that delayed medical care can make recovery less likely and precludes the use of certain treatments when they will be most impactful.

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The Younger Population at Risk?

Dawn reported in April that the infection rate in the younger population, the 20-45 age group, shot up by 300 percent in Islamabad. The federal capital had recorded 2,029 cases in children aged below 10 through September 1, 2020 – the number swelled by 400 percent to 8,305 by March 31, 2021. Similarly, infections in the 10-20 age group rose from 4,533 to 17,441.

“Younger individuals, especially with a pre-existing condition, can still have a severe case. While it is true that they are less likely to have a fatal illness, it is not a zero risk,” stressed Adalja.

The uptick in infection rate in the younger population reflects the widespread community transmission across the country.

What About Vaccinations?

Initially, Pakistan had to deal with a shortage of vaccine supply and address hesitancy. But with donations and purchases from China and Russia and allocation from COVAX Facility, the government managed to secure over 18 million doses.

In late May, the authorities opened up a vaccination campaign for everyone aged 18 and above. Pakistan has administered 11,085,787 shots of Sinopharm, SinoVac, CanSino, Oxford-AstraZeneca, and Pfizer vaccines. As of June 14, the total number of fully vaccinated people stood at 3,0006,048 while 5,902,003 have received the first jab.

So far, Pakistan has only vaccinated 1.3 percent of its population.

While it is impressive that the vaccine campaign is digitized and linked with national identity cards, allowing a robust tracking system, it is a double-edged sword. Accessing vaccines is difficult for stateless and migrant workers, travelers, and citizens who haven’t gotten around to getting a national identity card issued yet.

“But they make up a small percentage of the population,” argued Sultan. “While we want to vaccinate the entire population, our priority is to vaccinate the 90 percent.”

Even so, he added, the National Command and Operations Centre (NCOC) will soon be issuing a policy in this regard.

Although it is too early to see an impact of vaccination, Mahmood disclosed that the majority of the COVID-19 patients admitted at AKUH tend to be unvaccinated or partially vaccinated. “Keep in mind that the vast majority of the population was never offered the vaccine until recently,” he reflected.

In a bid to encourage vaccination, the federal and provincial governments are introducing carrot and stick policies, with Sindh and Punjab threatening to block mobile connections of unvaccinated people and the center restricting local tourism to only those who are fully vaccinated.

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Why Isn’t the Death Toll Coming Down?

In an epidemiological context, the fatality rate trails behind infections. Generally, death occurs about two to three weeks after an individual contracts the virus. Simply put, the deaths of today are reflective of the situation of three weeks ago, when the COVID-19 infection rate was on the higher side.

“The pattern would be that the infections rate slows down, hospitalizations surge before decreasing, and the deaths will be the last to fall,” said Dr. Mahmood.

“It’s a runaway boulder in some ways: If the wave hasn’t caught momentum, then it’s easier to contain the spread. Once it takes off, it spreads like wildfire as we saw in India and the United Kingdom,” he added.

Reflecting on factors that may have helped Pakistan contain the spread despite low compliance with COVID-19 restrictions, the infectious disease expert said the South Asian country was blessed with a younger population, to begin with. “Then there’s less missing between a lot of our networks of people. And because ours isn’t a travel destination, the influx of virus is limited compared to the U.K., the United States, and Europe.”

“One thing we always forget is that no matter how the virus mutates, the way it spreads remains the same. So, preventive measures will stop the transmission,” he continued. “New variants are a concern, but the most significant worry is that our behavior helps spread it.”