Tuesday, June 9, 2020

About 5% of Confirmed COVID19 Cases Currently Hospitalized in Pakistan

Pakistan has so far had just over 100,000 confirmed cases of COVID19. About 5,000 are currently in hospitals, including 1,000 in critical condition and 278 on ventilators, according to the World Heath Organization representative in Pakistan. Over 32,000 have recovered and 2,000 have died. Data from multiple countries shows that only a few of those who go on the ventilators survive. It takes highly skilled pulmonologists to insert the ventilator, a skill that is not widely available. Meanwhile, antibodies testing in Karachi indicates millions in Pakistan may have already been infected with COVID19 without any symptoms or sickness. More testing is uncovering more of those already infected but only have mild symptoms and unlikely to get sick or die.

Pakistan Hospitalization Data. Source: WHO
Hospitalizations in Pakistan:

About 5,000 Pakistanis are currently in hospitals, including 1,000 in critical condition and 278 on ventilators, according to World Heath Organization representative in Pakistan. Over 32,000 have recovered and 2,000 have died. Data from multiple countries shows that only a few of those who go on the ventilators survive. It takes highly skilled pulmonologists to insert the ventilator, a skill that is not widely available.

Nearly 2,000 of the 100,000 confirmed coronavirus cases have died, bringing Pakistan's fatality rate to about 2%, among the lowest in the world. The number of deaths are now doubling every 18 days, a period three times longer than at the start of the pandemic.


COVID19 Testing and Cases:

Media headlines tend to highlight record single day spikes in confirmed cases. What they don't tell you is the record spike in tests almost every single day in Pakistan. It is very simple: The more you test the more cases you will confirm as long as the virus is in the community.  More testing is uncovering more of those already infected but only have mild symptoms and unlikely to get sick or die.


COVID19 Tests and Cases. Source: Pakistan Ministry of Health

Antibodies testing in Pakistan's largest city Karachi has revealed that 15% of the citizens are asymptomatic carriers of the coronavirus, a figure close to WHO's estimate of 16% for the global population.

Coronavirus Antibodies
Serological Testing:

Antibodies testing of 7,000 adults in Karachi reveals that as many as 15% of them have already been exposed to COVID19 without experiencing symptoms, according to a study by Dr. Wajiha Javed, an epidemiologist and head of public health and research at Getz Pharma in Pakistan. This data raises the possibility that millions of Pakistanis may have already been exposed to coronavirus. It takes at least 40% of the population to be exposed to build herd immunity. This may be the only way to normalcy unless there is a vaccine available sooner.

Human Immune Response:

Human body naturally produces antibodies to fight viruses of various kinds, including the coronavirus. Presence of antibodies in a person confirms that he or she has been exposed to a virus regardless of symptoms. Serology tests can detect body's immune response to even a low-level viral load. Such an immune response also occurs to a vaccine which does not make you sick but helps build immunity. More low level exposure to viruses in large numbers of people is in fact a good thing because it helps build herd immunity. However, the most vulnerable population such as the elderly must be isolated until herd immunity is achieved. It takes at least 40% of the population to be exposed to build herd immunity.


Getz Study:

Getz Pharma's Dr. Wajiha Javed told me in the latest update on her ongoing work that serology tests have so far been administered to 7,000 adults aged 18-65 over the last 6 weeks in Karachi. 15% of them have tested positive for COVID19 antibodies. People tested included those working for banks, restaurants, textile mills, factories, media and health care workers.

Antibody testing kits detect the response of the body rather than the virus or antigen itself. These tests do not have the issue of low viral load. Antibody tests can detect exposure to Covid-19 even in asymptomatic cases. Generally, antibody testing kits have a high level of accuracy, especially on sequential testing. The kit Getz Pharma has been using has a sensitivity (the ability to correctly detect positive cases) of 95.3% and specificity (the ability to correctly detect negative cases) of 98.7% for IgG, and the sensitivity is 86.48% and specificity is 95.18% for IgM, according to Dr. Wajiha Javed.

Pakistan COVID19 Death Rate Among The World's Lowest. Source: Our World in Data 

Asymptomatic Carriers: 

Over 90% of those who tested positive in Karachi did not have any symptoms or had only mild symptoms, Dr. Wajiha Javed recently wrote in Dawn newspaper.  But some were infectious and they were spreading the virus to others. Because of their non-existent or mild symptoms, they had not reached out to a PCR testing facility to get tested for Covid-19, and were only incidentally picked out for the antibody test during Getz's study. This data raises the possibility that millions of Pakistanis may have already been exposed to coronavirus.

Summary:

About 5% of the 100,000 confirmed COVID19 in Pakistan are currently hospitalized. About 2,000 of the 100,000 confirmed coronavirus cases have died, bringing Pakistan's fatality rate to about 2%, among the lowest in the world. The number of deaths are now doubling every 18 days, a much longer period than at the start of the pandemic.  As many as 15% of Karachi adults have been exposed to COVID19 with over 90% of them showing no symptoms, according to a Getz Pharma study in Pakistan. This is close to WHO's 16% of the global asymptomatic carrier population. Presence of antibodies in a person confirms that he or she has been exposed to a virus regardless of symptoms. It can even detect body's immune response to a low-level viral load. Getz Pharma's antibodies test data suggests the possibility that millions of Pakistanis may have already been exposed to coronavirus.  Such an immune response also occurs to a vaccine which does not make you sick but helps build immunity. More low level exposure to viruses in large numbers of people is in fact a good thing because it helps build herd immunity. This may be the only way to normalcy unless there is a vaccine available sooner.

Related Links:

Haq's Musings

South Asia Investor Review

Antibodies Testing Results in Karachi

Vast Majority of Pakistanis Support Imran Khan's Handling of Covid19 Crisis

Pakistani-American Woman Featured in Netflix Documentary "Pandemic"

Coronavirus Lockdown, Lives and Livelihoods

Can Pakistan Effectively Respond to Coronavirus Outbreak? 

How Grim is Pakistan's Social Sector Progress?

Pakistan Fares Marginally Better Than India On Disease Burdens

Can Imran Khan Lead Pakistan to the Next Level?

Democracy vs Dictatorship in Pakistan

Pakistan Child Health Indicators

Pakistan's Balance of Payments Crisis

Panama Leaks in Pakistan

Conspiracy Theories About Pakistan Elections"

PTI Triumphs Over Corrupt Dynastic Political Parties

Strikingly Similar Narratives of Donald Trump and Nawaz Sharif

Nawaz Sharif's Report Card

Riaz Haq's Youtube Channel

8 comments:

nayyer ali said...

The use of antibody tests has a number of limitations. First is significant false positive rates, as high as 2-3%, which inflates the estimate of the population exposed. Secondly is whether the sample is truly random cross section of the entire population, or is concentrated in groups most likely to have been exposed. This appears to be what occurred in Karachi study. I highly doubt 15% of the population has been infected. Additionally, the WHO data did not state that 16% of the global population are asymptomatic carriers. Carriers are people who continue to have infection but no symptoms. With this virus, the infection clears in 2-3 weeks, often with minimal symptoms, but there are no true long term carriers of the virus. WHO stated that about 16% of infections result in no symptoms, and that is still an area under study.
To get a reasonable estimate of total infected, the best number to use is actual deaths. As the virus has a .5-1% fatality rate, the infected number can be estimated at 100-200x the number of deaths. This needs to adjust for the fact that deaths can lag and occur weeks after infection, and that death rates can vary based on health care system and demographics of the population. The relatively low number of deaths in Pakistan is good news but remains a puzzle. Are some deaths occurring at home or without testing and missing from the stats? A good way to figure that out is to count total excess deaths over expected for the relevant time frame and assume those represent Corona virus mortality.
Finally, at least in the US, going on a ventilator usually but not always results in survival, though you may need to be on the ventilator for 10 days to 6 weeks. I've treated and saved many patients with this who needed a ventilator.

Riaz Haq said...

NA: "Are some deaths occurring at home or without testing and missing from the stats? A good way to figure that out is to count total excess deaths over expected for the relevant time frame and assume those represent Corona virus mortality"

There were about 4,000 deaths daily in Pakistan before the current coronavirus pandemic. There's no evidence of significant change in the number of daily burials in recent months.

Here's an Express Tribune story on the subject:


"As many as 3,265 bodies were brought for burial to 30 graveyards in the metropolis in the 49 days between February 20 and April 9, official statistics from the city’s top administrative body revealed on Thursday.

Interestingly, however, the data shared by Karachi Municipal Corporation (KMC) senior municipal director Masood Alam showed that the number of burials in the city had declined by 25 per cent in the first 15 days of April, while the most burials so far this year – a total of 2,849 – were carried out in January.

As many as 13,993 people had been buried in 31 different graveyards operated by KMC during the last six months. April, with 766 burials, has seen the lowest number so far. Around 2,013 burials were done in these graveyards in October 2019, 1,807 in November 2019, 2,303 in December 2019, 2,278 in February and 1,978 in March"

-------------

"According to data obtained from government hospitals in Karachi, 10,791 patients were brought to the emergency department during the first three months of 2020. Of this, 121 of those were dead on arrival while the fatality rate was 1.12 per cent."


https://tribune.com.pk/story/2200655/1-3265-bodies-brought-burial-49-days/

Riaz Haq said...

NA: "Finally, at least in the US, going on a ventilator usually but not always results in survival, though you may need to be on the ventilator for 10 days to 6 weeks. I've treated and saved many patients with this who needed a ventilator."

Elderly covid-19 patients on ventilators usually do not survive, New York hospitals report...... No critically ill patients under the age of 30 died at the two hospitals, O’Donnell said, and only a small number of them had to be put on ventilators. But more than 80 percent of people over 80 who went on a ventilator did not survive.

https://www.washingtonpost.com/health/elderly-covid-19-patients-on-ventilators-usually-do-not-survive-new-york-hospitals-report/2020/05/19/ba20e822-99f8-11ea-89fd-28fb313d1886_story.html

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31189-2/fulltext

Riaz Haq said...

Wall Street Journal on COVID19 New York City: ”You can magically make an ICU appear, but you can’t make staff appear immediately.”

https://www.wsj.com/articles/how-new-yorks-coronavirus-response-made-the-pandemic-worse-11591908426

How New York’s Coronavirus Response Made the Pandemic Worse
The hasty expansion of medical facilities by state, city and hospital leaders led to grave mistakes, a Wall Street Journal investigation found; ‘wartime conditions’
Elmhurst Hospital in Queens, N.Y., in April. NATALIE KEYSSAR FOR THE WALL STREET JOURNAL
By Shalini Ramachandran, Laura Kusisto and Katie Honan
June 11, 2020 4:47 pm ET

New York leaders faced an unanticipated crisis as the new coronavirus overwhelmed the nation’s largest city. Their response was marred by missed warning signs and policies that many health-care workers say put residents at greater risk and led to unnecessary deaths.

In the first few days of March, Gov. Andrew Cuomo and Mayor Bill de Blasio assured New Yorkers things were under control. On March 2, Mr. de Blasio tweeted that people should go see a movie.

Riaz Haq said...

Widely available low-cost dexamethasone (low-dose steroid) treatment reduces death by up to one third in hospitalized patients with severe respiratory complications of #COVID19. It could have saved up to 5,000 lives of #coronavirus patients on #ventilators https://www.recoverytrial.net/files/recovery_dexamethasone_statement_160620_v2final.pdf

---------

A cheap and widely available drug can help save the lives of patients seriously ill with coronavirus.

The low-dose steroid treatment dexamethasone is a major breakthrough in the fight against the deadly virus, UK experts say.

The drug is part of the world's biggest trial testing existing treatments to see if they also work for coronavirus.

It cut the risk of death by a third for patients on ventilators. For those on oxygen, it cut deaths by a fifth.

Had the drug had been used to treat patients in the UK from the start of the pandemic, up to 5,000 lives could have been saved, researchers say.

And it could be of huge benefit in poorer countries with high numbers of Covid-19 patients.

https://www.bbc.com/news/health-53061281

Riaz Haq said...

#Pakistan #lockdown in 20 cities as #coronavirus ‘hotspots’: #Karachi, #Lahore, #Quetta, #Peshawar, Rawalpindi, #Islamabad, #Faisalabad, Multan, Gujranawala, Swat, Hyderabad, Sukkar, Sialkot, Gujarat, Ghotki, Larakana, Khairpur, DGKhan, Malakand & Mardan. https://tribune.com.pk/story/2242926/1-live-pakistan-start-commercial-manufacturing-covid-19-diagnostic-kits-national-tally-hits-144478/


The novel coronavirus emerged in the central China city of Wuhan towards the end of last year and proliferated to almost the whole world within a couple of months. It’s not the virulence or fatality, but the infectivity of the new virus – also known as SARS-CoV-2 – that has set off a global frenzy.

The Covid-19 respiratory illness caused by this mysterious contagion has so far infected more than 7.7 million people in 202 countries and territories of the world – and over 428,000 of them have died and counting.

Pakistan, despite its close proximity with China, remained coronavirus-free until February 26 when a young man from Karachi tested positive after returning from Iran – one of the worst-hit countries. After a brief hiatus following the first case, Covid-19 cases spiked as more pilgrims returning from Iran tested positive for the virus.

Nearly one-and-a-half months after imposing the lockdown across the country, Prime Minister Imran Khan announced to ease the lockdown in phases.

The nationwide tally of Covid-19 patients stands at 146,879 with 54,138 cases in Punjab, 55,581 in Sindh, 18,472 in Khyber-Pakhtunkhwa, 8,327 in Balochistan, 1,143 in Gilgit-Baltistan, 8,569 in Islamabad and 663 in Azad Jammu and Kashmir.

The virus has claimed at least 2,784 lives while around 53,721 coronavirus patients have recovered.

The situation remains fluid and we’re updating stats as soon as new figures are officially released.

Riaz Haq said...

COVID19 drug Dexamathsone has been found to be effective. It is widely available under various brandnames in Pakistan at very low cost.


http://www.druginfosys.com/AvailableBrands.aspx?query=4%20mg/ml&form=Inj&drugCode=222&drugName=Dexamethasone&Ing==1


Single Ingredient
Inj :20 mg2 mg/ml4 mg/ml
Eye Drops:0.1 %w/v
Oint:0.1 %w/w
Tabs:0.5 mg0.5 mg/ml
Multi Ingredient
Drops:0.1 %w/v
Eye Drops:0.1 %w/v0.2 %w/v
Ear Drops :0.1 %w/v
Eye Oint:0.1 %w/w
E and E Drops:0.1 %w/v
Oint:0.1 gm
Cream:0.1 gm0.1 %w/w0.4 %w/w0.04 %w/w3500 IU/g
Dexamethasone [Inj 4 mg/ml]
Brand Name Manufacturer/Mnf. Representative Trade Price Retail Price
ADRENAAL CIRIN PHARMACEUTICALS (PVT) LTD. 0.00 250.00
ALDRON HARMANN PHARMACEUTICAL LABORATORIES (PVT) LTD. 132.60 156.00
ATNESON ENGLISH PHARMACEUTICALS INDUSTRIES 212.50 250.00
CECIDRON CEICIL LABORATORIES LTD. 221.00 260.00
D CORT BROOKES PHARMACEUTICAL LABORATORIES (PAK.) LTD. 203.23 239.09
D SONE MEDIATE PHARMACEUTICALS (PVT) LTD 250.00 250.00
D.DRON EPHARM LABORATORIES 107.95 127.00
DANADEX DANAS PHARMACEUTICALS (PVT) LTD 0.00 250.00
DANADEX DANAS PHARMACEUTICALS (PVT) LTD 0.00 10.00
DECADRON OBS 349.35 411.00
DECADRON OBS 55.25 65.00
DELTASALONE TRIGON PHARMACEUTICALS PAKISTAN (PVT) LTD. 9.50 0.00
DEXADRIN STAR LABORATORIES (PVT) LTD. 154.70 182.00
DEXADRIN STAR LABORATORIES (PVT) LTD. 24.43 28.75
DEXAMED MUNAWAR PHARMA (PVT) LTD. 82.02 96.50
DEXAMEDRON GEOFMAN PHARMACEUTICALS 48.06 56.54
DEXAMEDRON GEOFMAN PHARMACEUTICALS 212.91 250.48
DEXAMEK KARACHI PHARMACEUTICAL LABORATORY 79.56 93.60
DEXAMETHASONE VENUS PHARMA 59.65 70.18
DEXAMETHASONE AMROS PHARMACEUTICALS. 82.28 96.80
DEXAMETHASONE IBL HEALTH CARE (PVT) LTD 0.00 0.00
DEXAMETHASONE ELKO ORGANIZATION (PVT) LTD. 0.00 0.00
DEXAMETHASONE ORIENT LABORATORIES 49.50 54.00
DEXAMETHASONE AMROS PHARMACEUTICALS. 0.00 0.00
DEXAMETHASONE DOSACO LABORATORIES 0.00 0.00
DEXAMETHASONE LAWRENCE PHARMA 54.40 64.00
DEXAMETHASONE ORIENT LABORATORIES 53.08 96.50
DEXAMETHASONE ORIENT LABORATORIES 14.45 17.00
DEXAMETHASONE VENUS PHARMA 65.66 77.25
DEXAMETHASONE VENUS PHARMA 22.95 27.00
DEXAMEX BOSCH PHARMACEUTICALS (PVT) LTD. 265.62 312.50
DEXAROID MEDICAIDS PAKISTAN (PVT) LTD. 199.38 234.57
MERRYSONE HYGEIA PHARMACEUTICALS 40.80 48.00
MERRYSONE HYGEIA PHARMACEUTICALS 212.50 250.00
METHOX MACQUINS INTERNATIONAL 89.25 105.00
NEUDEX NEUTRO PHARMA (PVT) LTD. 212.50 250.00
ORADEXON OBS 252.70 297.29
ORADEXON OBS 38.96 45.84
Z-DEX Z-JANS PHARMACEUTICAL (PVT) LTD. 0.00 160.00

Riaz Haq said...

#Pakistan's top 5 #pharma, incl GSK, Abbott, and AGP Pharma, increase profits by 37% in Q1/2020 over same period last year, to Rs2.6 billion while profits of 13 #consumer giants, incl Nestle, Packages, Pakistan Tobacco, Colgate, remained flat amid #COVID19 https://profit.pakistantoday.com.pk/2020/06/14/the-lockdowns-devastated-consumer-spending-but-food-and-pharmaceutical-companies-remain-resilient/


On the flip side, manufacturers of consumer discretionary items such as automobiles did terribly. Kumar had grouped four companies under consumer discretionaries: the three car manufacturers Indus Motors, Honda Atlas, Pak Suzuki Motors, and Thal Ltd, which manufactures jute products. The total profits of all three fell by 39% to Rs2.9 billion.

Meanwhile consumer staples – which includes 13 companies such as Nestle, Packages, Pakistan Tobacco, Colgate, among others – saw profits remain more or less stagnant, with a growth of 1% YoY to Rs8.35 billion.

“Overall slowdown in economic activity and country-wide lockdown starting during the last week of Mar-2020 in the wake of COVID-19, resulted in lower consumers’ purchasing power,” noted Kumar.

The pandemic, it seems, forced consumers to pause and consider exactly what they were opening their wallets for. In the midst of pay cuts, lay-offs, and general job uncertainty, consumers decided this was the worst possible time to buy a car.

Food and cleaning products, or items that are manufactured by Nestle, Unilever or National Foods, are deemed more of a necessity, even though this sector saw an increase in overall prices. The same goes for pharmaceuticals, which are necessities that consumers will often cut back on other spending for in order to be able to continue to afford them. This holds particularly true during a climate of a global pandemic.

This is reflected in the sales numbers as well. Sales for discretionary items (at this point, we will just call it autos), declined by 32% YoY in the first quarter of 2020. But the sales of consumer staples and pharmaceuticals, saw an uptick of 8% YoY and 7% YoY, respectively.

“We believe, due to country wide lockdown amid COVID-19 outbreak, the overall sales of the consumer segment will be affected due to supply chain disruptions, wherein consumer discretionary firms are likely to take the hit most among others,” said Kumar.

So first, let us look at the problem sector: autos. The overall slowdown in economic activity and country wide lockdowns, meant that sales took a hit. Foreseeing this, many such as Indus Motors and Honda Atlas sharply hiked their prices, in order to salvage some semblance of a profit. They should not have bothered: volumes witnessed a contraction of over 50% YoY, leading to a massive overall decline.

Of the three auto companies, Indus fared a little better, with its sales only declined by 20% YoY, compared to Honda Atlas’ 35% YoY fall, and Pak Suzuki’s abysmal 48% decline. According to the report, Indus also helped buoy the overall gross margins of this sector, which increased by 0.11 percentage points to 8.8%.

Now, to consumer staples. Much of the higher revenue in staples was actually driven by an increase in the prices of goods, as the rupee’s devaluation led to costs being passed on to consumers. There was also an increase in volumes compared to last year. Much of this growth in Kumar’s sample size was led by National Foods, which saw a 28% increase in sales compared to last year, and Unilever Pakistan Foods, which saw a 17% increase.