August 15, 2020

Understanding Covid-19 pandemic in Gilgit Baltistan through the lens of Public Health

The outbreak of Coronavirus Disease 2019 (COVID-19), which started in Wuhan, China, in late 2019, has now spread to about 188 countries of the world and has been declared a global pandemic by the World Health Organization (WHO) on March 11, 2020.

The first case of COVID-19 was reported in Sindh province of Pakistan on February 26, 2020. On the same day, another case was also confirmed by the Federal Ministry of Health in Islamabad. Both confirmed cases were from citizens who traveled to the Islamic Republic of Iran for pilgrimage and returned to their hometowns of Karachi and Rawalpindi with initial respiratory symptoms of the virus.

The index case of COVID-19 in Gilgit Baltistan was documented on March 2, 2020 and the patient was a 45-year -older woman who had returned home from Iran after pilgrimage. With the identification of the first COVID-19 patient, the pandemic started placing heavy burdens on the already overstretched health system in Gilgit Baltistan. Like many other countries and regions globally, the local health system of Gilgit Baltistan was also unprepared for such a large-scale outbreak. Secondary care health facilities were without ventilators and isolation beds.  Health workers had no easy access to personal protective devices (PPEs).  Because of the unavailability of internet or poor internet connectivity, most health providers in remote rural areas had no access to online training materials on Infection Prevention and Control (IPC) and case management guidelines of COVID-19. Despite COVID-19 risks, doctors, nurses, and other medical staff in the region devoted themselves to saving lives. Dr.Osama Riaz from Gilgit Baltistan was the first healthcare provider in Pakistan who lost his life to COVID-19.

As of August 14, 2020, the deadly virus has hit all four provinces and three federally administered areas (Islamabad, AJK and Gilgit Baltistan) and has infected nearly 288,047 people and claimed 6,162 lives, according to data collected by Ministry of National Health Services, Regulation and Coordination (MNHSRC).

The confirmed coronavirus cases in Gilgit Baltistan has increased to 2,452. If you look at a news website, you will see many beautiful graphics and dashboards that will provide you with the latest COVID-19 statistics revealing the number of total confirmed cases, number of tests, recoveries, and deaths. Sometimes, you will feel a relief when the overall trend on the graph is on a downward slope. Many times, these will add to your fear and stress when the numbers are on an upward trajectory. The question that can be asked is: what is the best way to measure the progress of the COVID-19 outbreak? An entirely accurate and a real-time snapshot of the progress is not possible for many reasons, but there are many key metrics that can paint a picture of the outbreak’s trajectory in Gilgit Baltistan. I have outlined here a few of those metrics to understand how successful we are in preventing the coronavirus spread based on daily COVID-19 data reported by the Ministry of National Health Services.

DAILY CONFIRMED CASES: Daily case count is a crucial indicator of community spread and indicates if the infection is under control.
Data Source: Ministry of National Health Services Pakistan

The daily count can be confusing if reports from far-flung hospitals and labs are delayed and hence lumped into single days. To prevent the data from skewing too far in the other direction, data scientists usually use the moving average of daily new COVID-19 cases to calculate the rate of change. For today’s analysis, I have used a 7-day moving average. As shown in the graph above, the 7-day moving average of daily new cases in Gilgit Baltistan was declining between June 6, and July 10 then again began to trend back upward, which at the time of writing this article appears to be holding fairly steady at just under 30 cases per day. The data shows that the number of new COVID-19 cases reported each day is on a downward trend, but the outbreak is not yet contained.
To know how bad the outbreak has been in Gilgit Baltistan and how many people are infected with the coronavirus compared to other provinces and regions in Pakistan, it is important to visualize the data per 100,000 population since the start of the outbreak.
Data Source: Ministry of National Health Services Pakistan

The data in the table above shows that Gilgit Baltistan is the third most affected province/region in Pakistan, with the highest reported number of COVID-19 cases per 100,000 population (after Islamabad and Sindh). From the beginning of the pandemic up to August 14, 129 people in 100,000 were infected with the coronavirus. If we look at the previous two-week period, then the data depicts a surprising result. Gilgit Baltistan has reported more cases per 100,000 residents in the last 14 days (@17 cases per 100,000 population). The daily case count here might not reflect the real picture on the ground as there would have been many infected people in the population who had never manifested any symptoms or might have exhibited mild ones and hence did not get tested for COVID-19.

 DEATHS: Another important indicator for measuring the burden of the COVID-19 in the community is mortality.
 Data Source: Ministry of National Health Services Pakistan

The table above provides two types of mortality statistics. The figures on the left side show the number of deaths per 100 confirmed cases (called case fatality ratio). The right side shows a total fatalities per 100,000 population (that includes the general population, with both confirmed COVID-19 cases and healthy people).  The overall case fatality ratio of Gilgit Baltistan (as of August 14) is 2.4 %, which is the third-highest in the country after Khyber Pakhtunkhwa and Azad Kashmir. Similarly, since the beginning of the outbreak, the region has reported 3.16 deaths per 100,000 population, which is a little above the national average of 2.95. The observed differences in mortality are likely due to different population demographics, characteristics of the health care system and differences in the number of people tested across different provinces. There could also be many other reasons which would be known after detailed research studies.

POSITIVE TEST RATE: This metric measures the percentage of people who test positive for the coronavirus of those overall, who have been tested.

Data Source: Ministry of National Health Services Pakistan
The test positive rate will be high if the number of positive tests is too high or if the number of total tests is too low. A higher test positive rate suggests higher transmission, and there are likely more people with coronavirus in the community who have not been tested yet.

Gilgit Baltistan recorded its lowest positivity rate between April 12 -May 5, at approximately 5 %. After May 7, the positivity rate started climbing and reached 28 % on August 1. One of the reasons other than higher community transmission was the lowest testing rate. According to official figures, 4,613 tests were performed in Gilgit Baltistan in May (with an average of 154 tests per day), 4,881 tests were conducted in June (with an average of 163 tests per day) and around 2,465 tests (with an average of 82 tests per day) were processed in July. It means the number of tests in July went down by almost 50 %, and this can also be seen in the graph above. However, in August, the number of tests has started to increase at an average of 128 tests per day (as of August 14).

On May 12, 2020, the World Health Organization (WHO) advised governments that before reopening the test positivity rate should be at or below 5 % for at least 14 days.
Gilgit Baltistan's seven-day moving average positivity rate stands at 16 % (as of August 14), which is still higher than the WHO’s recommended positivity rate of 5 %.
Data Source: Ministry of National Health Services Pakistan

If we look at the test positivity rate of all provinces and regions in Pakistan, then it becomes evident that only Punjab, Sindh, Islamabad, and Azad Kashmir have successfully brought down their test positivity rates below WHO recommended level of 5%. Khyber Pakhtunkhwa and Balochistan provinces stand at 5 % and 6 % respectively while Gilgit Baltistan stands at much higher than other provinces (at 16 %)

To further lower the positive test rate, the focus must be simultaneously on reducing the amount of coronavirus transmission and increasing the number of people who get tested. To further reduce the transmission of COVID-19, people of Gilgit Baltistan need to continue complying with strict preventive measures such as wearing face masks, ensuring physical distancing, maintaining good hand and respiratory hygiene, and avoiding large gatherings.

As Gilgit Baltistan is among the coldest regions in Pakistan so the coming winter might be a little harder than the previous ones. It could complicate the COVID-19 response if the outbreak is not controlled before the start of cold weather. The task of finding out who is sick with COVID-19 and who is suffering from a simple respiratory tract illness will be more arduous and complicated than we can imagine. The pressure for COVID-19 tests might push existing clinical labs to their limit. The demand for hospital beds may outpace the supply, and this could further strain an already strained health care system in Gilgit Baltistan. It’s time to stay more cautious and act responsibly to help the government in controlling the spread of the disease.