Pakistan COVID19 Antibodies Study: 90% of Virus Carriers Have No Symptoms

Guest Post by Dr. Wajiha Javed
Head of Public Health and Research
Getz Pharma, Pakistan.

Key Findings:

 • Survey revealed that 90% of the population who tested COVID-19 positive (screened via serologic test kits) were asymptomatic carriers of the disease, who would have otherwise not presented at a government-approved PCR testing facility.

 • If the results of this study are extrapolated to the rest of the population with similar demographics, the total number of active COVID-19 infections in the country would go up to 4.11 million, which is 17.7 times higher than the current official number.

 • While these findings are restricted to Pakistan’s urban, adult, working population in various metropolises, they still provide useful insights for guiding public health practices across the country.

 • This is a groundbreaking research which can improve Pakistan’s public health response to COVID-19 by increasing testing capacity and ensuring that the true prevalence of the disease is captured via cost-effective methods, thereby reducing the burden on an already exhausted healthcare system.

Coronavirus Antibodies

Full Report:

Pakistan has faced issues regarding limited testing per million population, a cost intensive, symptom-based testing methodology in hospital settings, which focuses exclusively on Polymerase Chain Reaction (PCR) swab tests. Alongside a limitation of funds, there is a dilemma that a majority of COVID-19 positive cases do not display overt symptoms, and for a large proportion of the population that does not have access to hospitals, a more efficient testing and screening approach is required to ascertain the true prevalence of COVID-19 in Pakistan.

One such approach has been provided by Getz Pharma, the largest branded generic pharmaceutical company in Pakistan, who followed a multi-pronged approach in combating the pandemic. They conducted the first, mass-level sero-prevalence study on general, low-risk population in Pakistan. The target population was 24,210 individuals from different workplaces of Karachi tested via serological kits, and the findings have been extrapolated to the rest of the urban, adult, working population of Pakistan. This is the first of its kind, large scale, groundbreaking census in urban areas of Pakistan, conducted on healthy, asymptomatic adults between 18 to 65 years of age and depicts the true extent of the spread of the disease at 4.11 million individuals, which is 17.7 times higher than the current, official figures of COVID-19 positive cases reported.

Summary:

Population-level serologic testing is a game-changer in monitoring the prevalence and case-fatality of COVID-19 within a population, and it provides valuable insights for developing an effective pandemic response plan. This approach has important implications in guiding public health policies by increasing testing capacity via cost-effective methods. In Pakistan, Getz Pharma conducted a 100% census sero-prevalence study on a sample of individuals with follow-up and sequential testing after every 15-20 days. The sample included an adult, working population between the ages of 18-65 years in urban workplaces of Karachi. This was the first ever large-scale, cross-sectional sero-prevalence study conducted on a low-risk population to assess the prevalence of COVID-19 in Pakistan. The results revealed the prevalence of COVID-19 amongst asymptomatic people using serologic test kits, which allow mass screening hence indicating the total numbers of the infected population which may be many folds higher than indicated by PCR tests which show that only 231,818 people are currently COVID-19 positive in Pakistan.[1]

Amongst the figures from ongoing testing by the government, the proportion tested positive from the total number of people tested is termed as the positivity rate^[2] of COVID-19 infections, which is very different from the total prevalence of COVID-19 within a population. The positivity rate only considers the total number of positive cases amongst symptomatic individuals or contacts of COVID-19 positive cases tested divided by the total number of PCR tests conducted.^[3] This is in itself a volunteer bias as those who present for PCR tests are the ones having symptoms. Hence, the positivity rate cannot be used to determine the true extent of the disease as it fails to capture the proportion of positive cases within the general, low-risk population including asymptomatic carriers, who can only incidentally be identified via a mass-screening model such as the one implemented by Getz Pharma.

According to Getz Pharma’s study, out of 24,210 individuals screened, 17.5% tested positive, with 7% IgM positive, 6.0% IgG positive and 4.5% combined IgM and IgG positive. These findings have then been extrapolated to the rest of the urban, adult, working population of Pakistan, and as of 6th July, 2020, 4.11 million people in Pakistan have been infected with COVID-19 as opposed to only 231,818 as per government PCR figures.[4]

Table 1: Seroprevalence study results and extrapolations

Getz Pharma has conducted a sero-prevalence 100% testing (census) of various workplaces in Karachi including factories, corporates, restaurants, media houses, schools, banks, healthcare providers in hospitals and families of positives using USFDA EUA and CE approved serologic test kits that have been used in 38 countries globally. Serologic tests are based on the qualitative detection of IgM and IgG generated by the body in response to a SARS-CoV-2 infection.^[5] IgM is usually the first antibody type generated by the body in response to a COVID-19 infection, followed by IgG which then replaces IgM as the predominant antibody in the blood. IgM and IgG combat infections by targeting specific antigens on the surface of the virus.^[6] The kits used by Getz Pharma have a sensitivity of 95.3% and specificity of 98.7% for IgG, and the sensitivity of 86.48% and specificity of 95.18% for IgM.[7]

Getz Pharma in its efforts to contribute back into the system is also testing 25,000 frontline healthcare providers and their families free of cost. In addition to this, we are also conducting a sequential serological testing every 15 days for all of our 1500 employees to keep our workplace COVID-19 free. More details of the initiative can be found at https://www.dawn.com/news/1559103/what-does-our-seroprevalence-study-tell-us

The results presented are from a sample of 24,210 individuals taken from different workplaces of Karachi. The numbers continue to grow on a daily basis as we continue to test and enroll more people in the study.

As this is a study sample from urban workplaces and not a multistage, cluster random household survey, the extrapolation of the data obtained through this census needs to keep the following statistical considerations in mind:

1. The study population included adults between 18-65 years of age. While extrapolating it to the general population of 220 million, 53% of the population in Pakistan which is under 18 years of age and 4.5% above 65 years[8] needs to be stratified and excluded, thus restricting the universe to 93 million.

2. The population setting of this census was a dense, urban population and excluded 64 percent of the rural population of Pakistan thus reducing the universe to 33 million people from the adult, urban population. It must be noted that the infectivity quotient (R0) is very different between densely urban and less crowded rural populations ranging from 1.4 to 3.9.[9] ,[10]

3. This is a cross-sectional sero-prevalence survey which also includes people who have had COVID-19, have recovered, and are now immune. 90% of those tested positivefrom various workplaces had asymptomatic individuals who would otherwise have never presented for a PCR testing at a government approved facility and would have continued to spread the infection had they not been incidentally tested by their workplaces.

4. Serological kits like the ones Getz Pharma used are FDA EUA approved, with a false positive rate ranging from 2% to a maximum of 7% (Stanford & Massachusetts study)[11] due to nonspecific immunity & nonspecific protection to COVID-19. There may be minimum cross-reactivity with other previous SARS virus. The antibodies can be general and nonspecific to COVID-19 but may be able to provide protection from COVID-19. Studies are still underway to prove this hypothesis (mainly through passive immunization from convalescent COVID-19 plasma which has both specific COVID-19 antibodies as well as nonspecific IVIG). According to a paper published in a peer-reviewed journal in JAMA, even the "gold standard" PCR kits can have an accuracy ranging from 32% (pharyngeal swab) to 63% (nasal swab) depending on the technique of sample collection, the site and the phase of the disease.[12]

5. The initial findings from the workplace census conducted by Getz Pharma show a high prevalence of humoral, adaptive immunity (specific to COVID-19 or cross reactivity to previous SARS) in the Pakistani population, which is different from innate immunity.[13] This is the first of its kind, large scale, groundbreaking census on healthy, urban adults between 18 to 65 years of age.

6. Caution must be applied before assuming that Pakistan is entering herd immunity as there are no studies available to date on our population which show what prevalence is needed in a population before herd immunity kicks in, for how long IgG remains in the blood, and whether or not the serological response is protective or not. The prevalence needed to achieve Herd Immunity Threshold (HIT) has been cited to be 29–74% in literature.[14] Additionally, for herd immunity to be successful, the recovered individuals must carry IgG in the blood for up to many months otherwise the immunity offered is temporary and not able to contribute to herd immunity or even protection from reinfection. Hence, Getz Pharma is conducting a sequential study on recovered individuals to assess the duration of IgG level in the blood.

7. Sero-prevalence studies can allow us to assess the prevalence of the disease rather than just the incidence as indicated through PCR testing of symptomatic individuals. Sero-prevalence studies provide us information about the extent of infections which may be many folds higher than what PCR reported cases indicate[15] [16]. The Santa Clara study[17] and the Iran study[18] showed similar results what Getz Pharma found in Pakistan - the sero-positivity prevalence of COVID-19 indicated that the asymptomatic infection is much higher than the number of confirmed cases of COVID-19. According to media reports sent to Punjab Chief Minister Usman Buzdar in June 2020, up to 670,000 persons could be infected in Lahore alone,[19] yet, a month later, Pakistan is still officially reporting only a total 231,818 PCR confirmed cases (as of 6^th July, 2020)[20]. Hence the findings from the sero-prevalence study become even more significant given the context of Pakistan’s rising and under reported cases, as the official data severely under-estimates the true prevalence of infections.

8. Antibody surveys conducted in Germany, the Netherlands, and United States revealed that anywhere between 2% to 30% of certain populations have been infected with COVID-19[21], and the number of confirmed cases provided by government statistics are a much smaller fraction of the true number of people infected. According to Mark Perkins, a diagnostics expert at the World Health Organization, the current number of confirmed cases should have at least indicated 45-60% positive cases,[22] as it would have accurately demonstrated the true extent of silent transmission and possible immunity in the population. However, in reality, even the high numbers being reported are relatively small compared to the true prevalence of the virus. This means that widespread serologic testing is required to ensure that most of the population is screened for COVID-19, so the findings can then be used to better detect infection fatality rate and decide for public policy guidelines.

Like any other epidemiological survey, before it is conclusive, further studies are needed.

Study Results and Extrapolations:

1.     So far, over 24,000 people across various industries’ head offices, banks, restaurants, hospitals, schools and media houses have been screened by Getz Pharma, including all of its own workers.

2.     Out of the total sample size, the total positive cases were 17.5% in the workplace population. Most of these were ongoing infections at 11.5%, while 6% had recovered.

3.     From a sample of 24,210 individuals recruited in the study, a total of 8,937 registered employees were screened from factories and corporate offices. Out of these, 15.2% tested positive. Specifically, 7.2% tested IgM positive, while 4.8% tested IgG positive and 3.2% were combined IgM and IgG positive. This prevalence can be extrapolated to the one million registered working population of Karachi, meaning at least 152,000 infected cases in Karachi alone, with 104,000 being currently infected, unaware and spreading infection to those around them.

4.     These findings can be applied to the remaining urban workforce of Pakistan with similar demographics, between the ages of 18-65 years. By taking a base population of 61.7 million registered workers[23] between this age range in Pakistan, assuming that 36% live in urban areas with similar workplace dynamics (22.21 million), it can be extrapolated that 4,110,381 (4.11 million) from the working population are currently infected/exposed to COVID-19 as of 6^th July, 2020.

5.     From a total of 896 individuals screened from media houses and print media, 8.6% tested positive, with 4.7% IgM positive, 2.9% IgG positive and 1% with both. Taking a base population of 50,000 media individuals in Pakistan including mainstream media and print media, we can extrapolate that 4,297 individuals from the media industry of Pakistan are currently exposed to COVID-19.

6.     Amongst 3,120 healthcare workers including doctors and paramedics from different metropoles in Pakistan (Karachi, Lahore, Multan, Peshawar, Quetta) 17% tested positive, with 4.1% currently infected and 4.6% IgG positive which meant that they had been infected in the past and now recovered. Taking a base population of 313,457 healthcare workers [24] across Pakistan as per WHO EMRO, we can extrapolate that  53,248  healthcare workers are currently exposed to COVID-19.

7.     Out of a total of 7,857 individuals screened who were household contacts of a positive case, it was found that 15.9% individuals tested positive, with 4.2% IgM positive, 4.8% IgG positive and 6.8% had both. With 231,818 PCR cases being reported as of 6^th July, 2020[25], taking an average Pakistani household size of 6.7[26], the base population on family members of positive cases is 1,553,181. Given a 15.9% secondary Household attack rate, we can extrapolate that 246,508 household members of positive cases are currently exposed to COVID-19.

8.     Out of a total of 3,400 symptomatic individuals in the study, who requested for symptom-based testing at their households, 30% tested positive, with 16% IgM positive and 14% IgG positive. As of 6^th July, 2020, there have been 1,420,623 [27] symptom-based COVID-19 tests across Pakistan. If the study was to be extrapolated to all tests done who presented with symptoms, given the false negativity of PCR especially when viral load is less, and given a 30% prevalence of test positivity in individuals who have symptoms, at least    426,187 people currently have COVID-19 in Pakistan.

9.     Overall, from a sample of 24,210 individuals screened, 17.5% tested positive, with 7% IgM positive, 6.0% IgG positive and 4.5% combined IgM and IgG positive. Given the above extrapolations while keeping the study limitations in mind, we can extrapolate that as of 6^th July, 2020, currently 4.11 million individuals in Pakistan have been infected with COVID-19 as opposed to 231,818 that the official figures of Pakistan are quoting.[28]

10.  Interestingly, over 90% of those who tested COVID-19 positive did not have any symptoms. But they were infective and were continuing to spread the virus to those around them. 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 by the antibody test during the mass screening and testing campaign.

11.  While the Getz Pharma study showed sero-prevalence of 17.5% at workplaces, the newly emergent cases at 6 weeks had an incidence rate of 7%. This means that on baseline, at least 17.5% of the Pakistani adult, working class population has COVID-19 at any given point in time, and every 6 weeks 7% more cases are added to the baseline pool.

12.  We did not study people at high risk other than frontline healthcare providers. We targeted adults in the general population from all walks of life in the urban setting. Hence the findings cannot be extrapolated to rural populations.

13.  We need a household, multistage, cluster random survey to find the true extent of the disease. This is what it looks like in a highly urban, dense, adult working class population.

Glossary:

Term	Definition
Antibody	A blood protein produced in response to and counteracting a specific antigen. Antibodies combine chemically with substances which the body recognizes as alien, such as bacteria, viruses, and foreign substances in the blood.
Asymptomatic	A condition producing or showing no symptoms.
Case fatality	A case fatality rate (CFR) is the proportion of deaths within a designated population due to a given medical condition (cases), of such cases over the course of the disease. A CFR is conventionally expressed as a percentage and represents a measure of risk.
Immunity	The ability of an organism to resist a particular infection or toxin by the action of specific antibodies or sensitized white blood cells.
Immunoglobulin G	Immunoglobulin G is a type of antibody generated by the body in response to an antigen.
Immunoglobulin M	Immunoglobulin M is one of several isotypes of antibody that are produced by vertebrates. IgM is the largest antibody, and it is the first antibody to appear in the response to initial exposure to an antigen.
Infectivity quotient	In epidemiology, infectivity is the ability of a pathogen to establish an infection. More specifically, infectivity is a pathogen's capacity for horizontal transmission that is, how frequently it spreads among hosts that are not in a parent-child relationship.
SARS-CoV-2	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19), the respiratory illness responsible for the COVID-19 pandemic.
Secondary household attack rate	Secondary attack rate refers to the spread of disease in a family, household, dwelling unit, dormitory, or similar circumscribed group.
Sensitivity	The probability that a medical test will detect the condition being tested for in people who actually have the condition. A sensitive test is one that produces true positive results.
Specificity	The specificity of a test rules out someone who has not been exposed to the virus and has not developed antibodies, i.e. a true negative rate.
Serologic test	Serologic tests are blood tests that look for antibodies in your blood. They can involve a number of laboratory techniques. Different types of serologic tests are used to diagnose various disease conditions. Serologic tests have one thing in common. They all focus on proteins made by your immune system.
Seroprevalence	The level of a pathogen in a population, as measured in blood serum.
PCR	Polymerase chain reaction, or PCR, is a laboratory technique used to make multiple copies of a segment of DNA. PCR is very precise and can be used to amplify, or copy, a specific DNA target from a mixture of DNA molecules. It is used to detect the viral load of COVID-19 in the infected population.

References:

Adaptive immunity | Immune response (article) | Khan Academy [Internet]. Khan Academy. 2020. Available from: https://www.khanacademy.org/test-prep/mcat/organ-systems/the-immune-system/a/adaptive-immunity

Ahmed T, Ali SM. Characteristics of Households and Respondents. Pakistan Demographic and Health Survey. 1992 Jul;1:990-1.

Bendavid E, Mulaney B, Sood N, Shah S, Ling E, Bromley-Dulfano R, Lai C, Weissberg Z, Saavedra R, Tedrow J, Tversky D. COVID-19 Antibody Seroprevalence in Santa Clara County, California. MedRxiv. 2020 Jan 1.

COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination [Internet]. Covid.gov.pk. 2020. Available from: http://covid.gov.pk/stats/pakistan

Davis C. How Do the COVID-19 Coronavirus Tests Work? [Internet]. MedicineNet. 2020. Available from: https://www.medicinenet.com/how_do_the_covid-19_coronavirus_tests_work/article.htm

Herd immunity [Internet]. En.wikipedia.org. 2020. Available from: https://en.wikipedia.org/wiki/Herd_immunity#cite_ref-53

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. (January 2020). "Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia". The New England Journal of Medicine. 382 (13): 1199–1207. doi:10.1056/NEJMoa2001316. PMC 7121484. PMID 31995857.

Pakistan Demographics Profile 2019 [Internet]. Indexmundi.com. 2019. Available from: https://www.indexmundi.com/pakistan/demographics_profile.html

Pakistan Employed Persons | 1986-2018 Data | 2019-2020 Forecast | Historical | Chart [Internet]. Tradingeconomics.com. 2018. Available from: https://tradingeconomics.com/pakistan/employed-persons

Pakistan Medical & Dental Council > Statistics [Internet]. Pmdc.org.pk. 2019. Available from: http://www.pmdc.org.pk/statistics/tabid/103/default.aspx

Riou J, Althaus CL (January 2020). "Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020". Euro Surveillance. 25 (4). doi:10.2807/1560-7917.ES.2020.25.4.2000058. PMC 7001239. PMID 32019669.

Shaikh H. How can we protect contract and informal workers in Pakistan? [Internet].    DAWN.COM. 2019. Available from: https://www.dawn.com/news/1484090#

Shakiba M, Nazari SS, Mehrabian F, Rezvani SM, Ghasempour Z, Heidarzadeh A. Seroprevalence of COVID-19 virus infection in Guilan province, Iran. medRxiv. 2020 Jan 1.

Vogel G. Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable [Internet]. Science | AAAS. 2020. Available from: https://www.sciencemag.org/news/2020/04/antibody-surveys-suggesting-vast-undercount-coronavirus-infections-may-be-unreliable

Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, Tan W. Detection of SARS-CoV-2 in different types of clinical specimens. Jama. 2020 May 12;323(18):1843-4.

WHO EMRO | Health service delivery [Internet]. Emro.who.int. 2020. Available from: http://www.emro.who.int/pdf/pak/programmes/service-delivery.pdf?ua=1

Xu Wanzhou, Li Wei, He Xiaoyun, Zhang Caiqing, Mei Siqing, Li Congrong. Serum 2019 New coronavirus IgM and IgG antibodies jointly detect the diagnostic value of the new coronavirus infection .J/OL. Chinese Journal of Test Medicine. 2020;43. DOI: 10.3760/cma.j.cn114452-20200223-00109 

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[1] COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination. Covid.gov.pk. 2020

[2] Geo.tv. 2020. Pakistan’s Positivity Rate Of COVID-19 'High', Finds WHO. [online] Available at: https://www.geo.tv/latest/293192-pakistans-positivity-rate-of-covid-19-high-finds-who

[3] Livengood, P., 2020. Austin's Positivity Rate Is The Highest In The Country. So What Does That Mean?. [online] www.kvue.com. Available at: https://www.kvue.com/article/news/health/coronavirus/coronavirus-austin-positivity-rate-covid19-texas-explainer/269-99f46ba3-e44f-4d3b-acbf-63216330a3b4

[4] COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination.

[5] Davis, 2020. How Do the COVID-19 Coronavirus Tests Work? Available from: https://www.medicinenet.com/how_do_the_covid-19_coronavirus_tests_work/article.htm

[6] Davis, 2020

[7] Xu Wanzhou, Li Wei, He Xiaoyun, Zhang Caiqing, Mei Siqing, Li Congrong. Serum 2019 New coronavirus IgM and IgG antibodies jointly detect the diagnostic value of the new coronavirus infection .J/OL. Chinese Journal of Test Medicine. 2020;43.

[8] Pakistan Demographics Profile 2019. Indexmundi.com. 2019

[9] Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. (January 2020). "Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia". The New England Journal of Medicine. 382 (13): 1199–1207. doi:10.1056/NEJMoa2001316. PMC 7121484. PMID 31995857.

[10]  Riou J, Althaus CL (January 2020). "Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020". Euro Surveillance. 25 (4). doi:10.2807/1560-7917.ES.2020.25.4.2000058. PMC 7001239. PMID 32019669.

[11] Bendavid et al., COVID-19 Antibody Seroprevalence in Santa Clara County, California. MedRxiv. 2020 Jan 1.

[12] Wang et al., Detection of SARS-CoV-2 in different types of clinical specimens. Jama. 2020

[13] Adaptive immunity | Immune response (article) | Khan Academy [Internet]. Khan Academy. 2020. Available from: https://www.khanacademy.org/test-prep/mcat/organ-systems/the-immune-system/a/adaptive-immunity

[14] Herd immunity [Internet]. En.wikipedia.org. 2020. Available from: https://en.wikipedia.org/wiki/Herd_immunity#cite_ref-53

[15] Bendavid et al., COVID-19 Antibody Seroprevalence in Santa Clara County, California. MedRxiv. 2020 Jan 1.

[16] Shakiba et al., Seroprevalence of COVID-19 virus infection in Guilan province, Iran. medRxiv. 2020 Jan 1.

[17] Bendavid et al., 2020

[18] Shakiba et al., 2020

[19] Junaidi I. Govt decides to hold Covid-19 prevalence survey [Internet]. DAWN.COM. 2020. Available from: https://www.dawn.com/news/1560956

[20] COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination.

[21] Vogel G. Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable [Internet]. Science | AAAS. 2020. Available from: https://www.sciencemag.org/news/2020/04/antibody-surveys-suggesting-vast-undercount-coronavirus-infections-may-be-unreliable

[22] Vogel, 2020.

[23] Shaikh H. How can we protect contract and informal workers in Pakistan? [Internet].    DAWN.COM. 2019. Available from: https://www.dawn.com/news/1484090#

[24] WHO EMRO | Health service delivery [Internet]. Emro.who.int. 2020. Available from: http://www.emro.who.int/pdf/pak/programmes/service-delivery.pdf?ua=1

[25] COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination. Covid.gov.pk. 2020

[26] Ahmed T, Ali SM. Characteristics of Households and Respondents. Pakistan Demographic and Health Survey. 1992 Jul;1:990-1.

[27] COVID-19 Health Advisory Platform

[28] COVID-19 Health Advisory Platform

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