The state of health in Pakistan and its provinces and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

Background Understanding health trends and estimating the burden of disease at the national and subnational levels helps policy makers track progress and identify disparities in overall health performance. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides comprehensive estimates for Pakistan. Comparison of health indicators since 1990 provides valuable insights about Pakistan's ability to strengthen its health-care system, reduce inequalities, improve female and child health outcomes, achieve universal health coverage, and meet the UN Sustainable Development Goals. We present estimates of the burden of disease, injuries, and risk factors for Pakistan provinces and territories from 1990 to 2019 based on GBD 2019 to improve health and health outcomes in the country. Methods We used methods and data inputs from GBD 2019 to estimate socio-demographic index, total fertility rate, cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years, healthy life expectancy, and risk factors for 286 causes of death and 369 causes of non-fatal health loss in Pakistan and its four provinces and three territories from 1990 to 2019. To generate estimates for Pakistan at the national and subnational levels, we used 68 location-years of data to estimate Pakistan-specific demographic indicators, 316 location-years of data for Pakistan-specific causes of death, 579 location-years of data for Pakistan-specific non-fatal outcomes, 296 location-years of data for Pakistan-specific risk factors, and 3089 location-years of data for Pakistan-specific covariates. Findings Life expectancy for both sexes in Pakistan increased nationally from 61 center dot 1 (95% uncertainty interval [UI] 60 center dot 0-62 center dot 1) years in 1990 to 65 center dot 9 (63 center dot 8-67 center dot 8) years in 2019;however, these gains were not uniform across the provinces and federal territories. Pakistan saw a narrowing of the difference in healthy life expectancy between the sexes from 1990 to 2019, as health gains for women occurred at faster rates than for men. For women, life expectancy increased by 8 center dot 2% (95% UI 6middot3-13middot8) between 1990 and 2019, whereas the male life expectancy increased by 7 center dot 6% (3 center dot 5-11 center dot 8). Neonatal disorders, followed by ischaemic heart disease, stroke, diarrhoeal diseases, and lower respiratory infections were the leading causes of all-age premature mortality in 2019. Child and maternal malnutrition, air pollution, high systolic blood pressure, dietary risks, and tobacco consumption were the leading all-age risk factors for death and disability-adjusted life-years at the national level in 2019. Five non-communicable diseases-ischaemic heart disease, stroke, congenital defects, cirrhosis, and chronic kidney disease-were among the ten leading causes of years of life lost in Pakistan. Burden varied by socio-demographic index. Notably, Balochistan and Khyber Pakhtunkhwa had the lowest observed gains in life expectancy. Dietary iron deficiency was the leading cause of years lived with disability for both men and women in 1990 and 2019. Low birthweight and short gestation and particulate matter pollution were the leading contributors to overall disease burden in both 1990 and 2019 despite moderate improvements, with a 23 center dot 5% (95% UI 3 center dot 8-39 center dot 2) and 27 center dot 6% (14 center dot 3-38 center dot 6) reduction in age-standardised attributable DALY rates during the study period. Interpretation Our study shows that progress has been made on reducing Pakistan's disease burden since 1990, but geographical, age, and sex disparities persist. Equitable investment in the health system, as well as the prioritisation of high-impact policy interventions and programmes, are needed to save lives and improve health outcomes. Pakistan is facing several domestic and foreign challenges-the Taliban's return to power in Afghanistan, political turmoil, catastrophic flooding, the COVID-19 pandemic-that will shape the trajectory of the country's health and development. Pakistan must address the burden of infectious disease and curb rising rates of non-communicable diseases. Prioritising these three areas will enhance Pakistan's ability to achieve universal health coverage, meet its Sustainable Development Goals, and improve the overall health outcomes.

Hematologic Outcomes of COVID-19 Patients with and without G6PD Deficiency: A Comparative Study.

INTRODUCTION: Patients with multiple comorbidities who have coronavirus disease 2019 (COVID-19) have high morbidity and mortality. Glucose-6-phosphate dehydrogenase (G6PD) deficiency has been shown to have an enhanced effect on coronavirus in an earlier study. METHODS: We conducted this comparative observational study to evaluate the effects of COVID-19 disease on G6PD deficiency based on the hematologic parameters, COVID-19-related hospitalizations, and mortality in the state of Qatar between January 2020 and May 2020 at four designated COVID-19 facilities. We identified 41 patients with G6PD deficiency who had documented COVID-19 infection. We compared the results with 241 patients with COVID-19 infection who tested negative for G6PD deficiency.: Results: Comparing the COVID-19 positive G6PD deficient with COVID-19 positive G6PD normal activity showed that G6PD normal group had higher white blood cell count (WBC), absolute neutrophil count (ANC), lymphocytes, eosinophils, and monocytes counts versus the G6PD deficient group (p < 0.001). CONCLUSIONS: When compared with COVID-19 patients with normal G6PD, patients with COVID-19 infection and G6PD deficiency had lower total WBC, ANC, lymphocyte, monocyte, and eosinophil counts. However, no evidence of increased hemolysis, thrombosis, morbidity, or mortality was observed in COVID-19 patients with G6PD deficiency.

Hematologic Outcomes of COVID-19 Patients with and without G6PD Deficiency: A Comparative Study

Introduction: Patients with multiple comorbidities who have coronavirus disease 2019 (COVID-19) have high morbidity and mortality. Glucose-6-phosphate dehydrogenase (G6PD) deficiency has been shown to have an enhanced effect on coronavirus in an earlier study. Methods: We conducted this comparative observational study to evaluate the effects of COVID-19 disease on G6PD deficiency based on the hematologic parameters, COVID-19-related hospitalizations, and mortality in the state of Qatar between January 2020 and May 2020 at four designated COVID-19 facilities. We identified 41 patients with G6PD deficiency who had documented COVID-19 infection. We compared the results with 241 patients with COVID-19 infection who tested negative for G6PD deficiency.: Results: Comparing the COVID-19 positive G6PD deficient with COVID-19 positive G6PD normal activity showed that G6PD normal group had higher white blood cell count (WBC), absolute neutrophil count (ANC), lymphocytes, eosinophils, and monocytes counts versus the G6PD deficient group (p < 0.001). Conclusions: When compared with COVID-19 patients with normal G6PD, patients with COVID-19 infection and G6PD deficiency had lower total WBC, ANC, lymphocyte, monocyte, and eosinophil counts. However, no evidence of increased hemolysis, thrombosis, morbidity, or mortality was observed in COVID-19 patients with G6PD deficiency.

The Confluence Between COVID-19 and Informal Externalisation Agreements and the Precarious State of the Right to Seek Asylum

The swift closure of international borders with the outbreak of the COVID-19 pandemic has placed the right to seek asylum in a precarious position. The paper questions the impact of COVID-19 on the right to seek asylum in the face of the informal externalisation agreements (IEA) concluded by the European Union (EU) Border States and other destination states to shift border management to neighbouring transit states. The paper argues that IEA marginalised the right to seek asylum well before the outbreak of COVID-19. The pandemic's impact on the right to seek asylum, per se, is temporal, which can be defused through enhanced procedural measures. However, in the long run, COVID-19 provides an alibi to the Border States to further externalise asylum and migration controls through IEA. Thereby, COVID-19, along with IEA, is highly likely to make the right to seek asylum obsolete. © 2022 Transnational Press London Ltd. All rights reserved.

Preliminary Data on COVID-19 in Patients with Hemoglobinopathies: A Multicentre ICET-A Study.

OBJECTIVES: This study aims to investigate, retrospectively, the epidemiological and clinical characteristics, laboratory results, radiologic findings, and outcomes of COVID-19 in patients with transfusion-dependent ß thalassemia major (TM), ß-thalassemia intermedia (TI) and sickle cell disease (SCD). DESIGN: A total of 17 Centers, from 10 countries, following 9,499 patients with hemoglobinopathies, participated in the survey. MAIN OUTCOME DATA: Clinical, laboratory, and radiologic findings and outcomes of patients with COVID-19 were collected from medical records and summarized. RESULTS: A total of 13 patients, 7 with TM, 3 with TI, and 3 with SCD, with confirmed COVID-19, were identified in 6 Centers from different countries. The overall mean age of patients was 33.7±12.3 years (range:13-66); 9/13 (69.2%) patients were females. Six patients had pneumonia, and 4 needed oxygen therapy. Increased C-reactive protein (6/10), high serum lactate dehydrogenase (LDH; 6/10), and erythrocyte sedimentation rate (ESR; 6/10) were the most common laboratory findings. 6/10 patients had an exacerbation of anemia (2 with SCD). In the majority of patients, the course of COVID-19 was moderate (6/10) and severe in 3/10 patients. A 30-year-old female with TM, developed a critical SARS-CoV-2 infection, followed by death in an Intensive Care Unit. In one Center (Oman), the majority of suspected cases were observed in patients with SCD between the age of 21 and 40 years. A rapid clinical improvement of tachypnea/dyspnea and oxygen saturation was observed, after red blood cell exchange transfusion, in a young girl with SCD and worsening of anemia (Hb level from 9.2 g/dl to 6.1g/dl). CONCLUSIONS: The data presented in this survey permit an early assessment of the clinical characteristics of COVID 19 in different countries. 70% of symptomatic patients with COVID- 19 required hospitalization. The presence of associated co-morbidities can aggravate the severity of COVID- 19, leading to a poorer prognosis irrespective of age.

Aurasperone A Inhibits SARS CoV-2 In Vitro: An Integrated In Vitro and In Silico Study.

Several natural products recovered from a marine-derived Aspergillus niger were tested for their inhibitory activity against SARS CoV-2 in vitro. Aurasperone A (3) was found to inhibit SARS CoV-2 efficiently (IC50 = 12.25 µM) with comparable activity with the positive control remdesivir (IC50 = 10.11 µM). Aurasperone A exerted minimal cytotoxicity on Vero E6 cells (CC50 = 32.36 mM, SI = 2641.5) and it was found to be much safer than remdesivir (CC50 = 415.22 µM, SI = 41.07). To putatively highlight its molecular target, aurasperone A was subjected to molecular docking against several key-viral protein targets followed by a series of molecular dynamics-based in silico experiments that suggested Mpro to be its primary viral protein target. More potent anti-SARS CoV-2 Mpro inhibitors can be developed according to our findings presented in the present investigation.

Multisystem inflammatory syndrome in children (MIS-C) related to COVID-19 infection in the state of Qatar: Association with Kawasaki-like Illness.

INTRODUCTION: World Health Organization (WHO) is encouraging reporting of children with Multisystem Inflammatory Syndrome (MIS-C) associated with SARS-CoV-2 infection for better understanding and management of the disease. METHODOLOGY: This retrospective study included the first 15 pediatrics patient with a confirmed diagnosis of MIS-C associated with SARS-CoV-2 infection in the state of Qatar. We studied and analyzed their demographic data, clinical manifestations, laboratory tests, treatment, and outcome. RESULTS: A total of 15 children were studied (mean age 3.5 ± 2.7year). Recent severe acute respiratory syndrome coronavirus 2 infection was identified in all of them (100%). The majority of these patients had 4 or more systems involvement. Nine of the 15 presented with Kawasaki disease - picture and all had gastrointestinal symptoms (vomiting and diarrhea). Five required Pediatrics Intensive Care Unit (PICU) admission. Lab investigations revealed high D-Dimer, hyponatremia, and hypoalbuminemia in all. Low hemoglobin (Hb) , thrombocytopenia, and sterile pyuria occurred in 86.6%, 60% and 75% of them, respectively. Treatment with combined anti-inflammatory medications (intravenous immunoglobulin, corticosteroids) was used in along with immunomodulatory agents (Anakinra) in a selected group of refractory patients. No mortality happened. CONCLUSION: Our young children who presented with MIS-C related to SARS-CoV-2 infection had significantly higher Kawasaki-disease picture compared to other reports. One third of them required PICU admission but no mortality occurred.

Proposed Scoring System for Evaluating Clinico-radiological Severity of COVID- 19 using Plain Chest X- ray (CXR) changes (CO X-RADS): Preliminary results.

BACKGROUND: Plain chest radiograph (CXR), although less sensitive than chest CT, is usually the first-line imaging modality used for patients with symptomatic SARS-CoV-2 infection. The relation between radiological changes in CXR and clinical severity of the disease in symptomatic patients with COVID 19 has not been fully studied and there is no scoring system for the severity of the lung involvement, using the plain CXR. AIM OF THE STUDY: Current COVID-19 radiological literature is dominated by CT and a detailed description CXR appearances in relation to the disease time course is lacking. We propose an easy scoring system (CO X-RADS) to describe the severity of chest involvement in symptomatic COVID 19 patients using CXR and to correlate the radiological changes with the clinical severity of the disease. PATIENTS AND METHODS: The clinical manifestations and CXR findings were recorded in 500 symptomatic COVID-19 positive patients who were admitted to Hamad Medical Corporation (HMC) COVID-19 designated facility Center from January to June 2020. The severity and outcome of the disease included: intensive care unit admission, need for oxygen therapy, mechanical ventilation. and mortality rate. RESULTS: Most of our symptomatic patients (86.8%) had mild and moderate clinical manifestations. The remaining 13.2% had severe manifestations, including: fever, persistent dry cough, shortness of breath, dyspnea, abdominal and generalized body pains. Based on our radiological scoring system (0 to 10) patients were distributed according to their CXR findings into different categories and according to our suggested (CO X-RADS) severity system into five categories (0 to IV). Patients with mild clinical manifestations showed low scoring in CXR (score 0 up to 4) and they represented 72% of our patients. Patients with moderately severe clinical manifestations showed mainly GGO (scoring 5 and 6) and represented about 14.8% of patients. Patients presented with severe clinical manifestations had obvious lung consolidations at the time of presentation with CXR scoring system ≥ 7 and represented about 13.2% of patients. CONCLUSION: We proposed a simple CXR reporting scoring system (CO X-RADS) to categorize COVID-19 patients according to their radiological severity. This radiological score was correlated well with the clinical severity score of patients. We encourage other centers to test this scoring system in correlation with the clinical status of patients.

Living with coronavirus! can the immunoglobulin report (Immunity certificate) help?

In December 2019 from Wuhan, China, a respiratory disease emerged and soon spread to different parts of the world. It was declared a public health emergency of international concern (PHEIC) and a pandemic on 30 January 2020 by the World Health Organization (WHO). The available test usually measures the binding antibodies and not neutralizing antibodies (NAB);therefore, we could not be sure whether these antibodies will protect against re-infection or not. However, in many viral diseases, total antibody responses usually correlate with NAB and we may consider it to be the same. Considering the huge economic impact the pandemic has and a successful vaccine seems distant in the near future, the world needs to learn to live with corona, as the impact of joblessness, economic recession, and hunger will kill more than the virus itself.

Prevalence, clinical manifestations, and biochemical data of type 2 diabetes mellitus versus nondiabetic symptomatic patients with COVID-19: A comparative study.

BACKGROUND: There is a scarcity of data regarding the effect of Type 2 diabetes mellitus (T2DM) and associated comorbidities on the clinical presentation and outcome of symptomatic patients with -COVID-19 infection in comparison with non-diabetic patients. AIM OF THE STUDY: We described and compared the clinical presentation and radiological and hematological data of a cohort of symptomatic COVID19 positive T2DM diabetic patients (n = 59) versus another cohort of non-diabetic symptomatic COVID19 positive patients (n =244) diagnosed at the same time from January 2020 to May 2020. Associated comorbidities were -assessed, and the Charlson Comorbidity Index was calculated. The outcomes including duration of hospitalization, duration of Intensive Care Unit (ICU) stay, duration of mechanical ventilation, and duration of O2 -supplementation were assessed. RESULTS: Prevalence of T2DM in symptomatic COVID19 positive patients was 59/303 (=19.5%).  Diabetic patients had higher prevalence of hypertension, chronic kidney disease (CKD) and cardiac dysfunction [coronary heart disease (CHD)], and congestive heart failure (CHF). Charlson Comorbidity score was significantly higher in the T2DM patients (2.4± 1.6) versus the non-diabetic -patients (0.28 ± 0.8; p: < 0.001). Clinically and radiologically, T2DM patients had significantly higher percentage of pneumonia, severe pneumonia and ARDS versus the non-diabetic patients. Hematologically, diabetic patients had significantly higher C-reactive protein (CRP), higher absolute neutrophilic count (ANC) and lower counts of lymphocytes and eosinophils compared to non-diabetic patients. They had significantly higher systolic and diastolic blood pressures, longer duration of hospitalization, ICU stay, mechanical ventilation and oxygen therapy. CRP was correlated significantly with the duration of stay in the ICU and the duration for oxygen supplementation (r = 0.37 and 0.42 respectively; p: <0.01). CONCLUSIONS: T2DM patients showed higher inflammatory response to COVID 19 with higher absolute neutrophilic count (ANC) and CRP with lower lymphocytic and eosinophilic counts. Diabetic patients had more comorbidities and more aggressive course of the disease with higher rate of ICU admission and longer need for hospitalization and oxygen use.

Newly-onset type 1 diabetes mellitus precipitated by COVID-19 in an 8-month-old infant.

Type 1 diabetes mellitus (T1DM) is rare in infants and toddlers and is usually associated with a relatively high mortality when complicated with diabetic ketoacidosis (DKA). In infants, the classical symptoms of DKA are atypical and therefore many infants with DKA are mistreated for infections. We report a case of DKA precipitated by COVID-19 in an 8-month-old infant with newly diagnosed diabetes mellitus. This case is reported in view of its rarity and originality. The relation between T1DM and COVID19 infection is discussed.

A comprehensive update of ICET-A Network on COVID-19 in thalassemias: what we know and where we stand.

A review of the literature on COVID-19 pandemic in patients with thalassemias is presented. Globally, the prevalence of COVID-19 among  ß-thalassemia patients seems to be lower than in general population; associated co-morbidities aggravated the severity of  COVID- 19, leading to a poorer prognosis, irrespective of age. A multicenter registry will enhance the understanding of COVID-19 in these patients and will lead to more evidence-based management recommendations.