Until now, we were watching the world and getting prepared for Coronavirus infection in Pakistan. And now, since the virus is here as the first two cases of Coronavirus infection have been confirmed, it may spread very rapidly in Pakistan.

A little detail of our patient with Coronavirus infection (admitted to PIMS hospital, Islamabad):

This is a brief history of the patient who has been diagnosed with the infection. He has a very significant travel history, although, his symptoms are very different from those defined by the WHO.

This patient is a 61 years of age male patient, a resident of Skardu, and a plumber by profession. He is diagnosed case of hypertension and ischemic heart disease for which he is receiving treatment.

Travel history of the patient admitted to PIMS hospital:

On the 13th of January, he travelled to Saudi Arabia. He first visited Madina and a week later to Makkah. After two weeks he visited Najaf, then Karbala, and then Iran Qom. He stayed for a week at each place. He stayed in Iran for a total of one month.

Aboard February 23, he returned to Pakistan on an unidentified aeroplane (Probably via Iran airline as the pilot was talking in the Persian language).

He arrived at Lahore first, and then he and his brother-in-law travelled to Khannapul. On February 25, he went to Benazir Bhutto Hospital for a cardiac checkup and subsequently to the Pakistan Institute Of Medical Sciences in Islamabad.

Symptoms of our patient with coronavirus infection:

He started with body pains which were mild at the start but then gradually his pains worsened. He also developed excessive sweating and a low-grade fever, headache, and myalgias.

He has no symptoms of flu, nasal discharge, cough, chest pain, shortness of breath, or diarrhoea.

He has severe skeletal pains so much so that he can not sleep.

Below are the case definitions of confirmed, PUI (a person under investigation), probable, and presumed coronavirus infected cases:

WHO Case definitions for 2019-nCoV infections:

• PUI (Person under investigation):

  • Acute respiratory illness, or pneumonia
  • An individual with a fever
  • any of the following:
    • Close contact with a confirmed or probable case of 2019-nCoV OR
    • Travel to Wuhan, China in the 14 days before the onset of illness OR
    • Close contact with a person with acute respiratory illness who has been to Wuhan, China within 14 days prior to their illness onset

• Probable Case for COVID-19 infection:

  • An individual with a fever of 38 C and

    • Indications of a serious sickness (such as ARDS) or an influenza-like illness with potentially fatal side effects such as encephalitis and myocarditis

    • New-onset dyspnea or cough

    • Any of the following:

      1. Close contact with a person who has had an acute respiratory illness and visited Wuhan, China within the previous 14 days of the commencement of their sickness

      2. Whose 2019-nCoV laboratory diagnostic is either unavailable or negative (if specimen quality of timing is suspect)

      3. Travel to Wuhan, China, within 14 days of becoming unwell

      4. Close contact with a 2019-nCoV case that has been identified or is suspected

• Confirmed Case for COVID-19:

  • A verified case is one that has had at least two distinct genomic targets identified by real-time PCR or one target identified by sequencing AND confirmed by the National Microbiological Laboratory using nucleic acid testing.

• Presumptive Positive Case for COVID-19:

  • An individual whose Public Health Ontario Laboratory screening result was positive but was not verified by the National Microbiological Laboratory

This patient could have already spread the infection to many people!

This patient did not fulfil the criteria for the above case definitions. That could be the reason he was travelling around and spreading the infection and could not be identified. Secondly, our patients might not present with symptoms like the rest of the world. Flu and respiratory tract symptoms are very commonly self-treated by our patients. They are even not reported and patients do not take necessary contact precautions to prevent respiratory tract symptoms. Self-medication is also common. Everything is available over the counter and treated with antibiotics. Lastly, we have to make our definitions to diagnose the patients at an early stage. This patient presented primarily with body pains, sweating, and low-grade fever.

The absence of respiratory symptoms does not rule out COVID-19 infection.

Probably, when the patient develops symptoms of pneumonia, that means he is developing complications of the COVID-19 infection. More than 80,000 patients have been diagnosed with the COVID-19 disorder and about 3000 deaths have occurred worldwide. Before any deaths occur, we should identify and screen patients who develop the acute onset of body aches, fever, and sweating. Contact precautions and isolation of these patients at the start of the symptoms may prevent the further spread of the infection.

WHO recommended Tests centres for Coronavirus in Pakistan:

WHO contact:

• Pakistan Institute of Medical Sciences

  • G-8, Islamabad,
  • Ph: (051) 9261170

• Islamabad

  • Dr Michael Lukwiya
  • 0300 8429534
  • lukwiyam@who.int

• Islamabad

  • Dr Salman Ahmed
  • Cell # 0333-5384248
  • Chak Shahzad, Islamabad
  • salman14m@gmail.com
  • National Institute of Health
  • Ph: 051-9255815

• Peshawar

  • Dr Saeed Khan
  • Ph: 091-9223472
  • khansae@who.int
  • Police Rd, PTCL Colony, Peshawar, Khyber Pakhtunkhwa
  • The care facility send the samples to NIH-Islamabad
  • Police & Services Hospital Peshawar
  • 0300 5903375

• Quetta

  • Dr Dawood Riaz
  • riazd@who.int
  • Fatima Jinnah Chest and General Hospital – Quetta
  • The care facility send the samples to NIH-Islamabad
  • Bahadurabad, Wahdat Colony, Quetta, Balochistan
  • Sheikh Zahid Hospital – Quetta
  • 0333-7804297
  • Mastung Rd, Quetta, Balochistan

• Karachi

  • Dr Haris Mustafa
  • hmustafa@who.int
  • 0333-1595551

  • Agha Khan Hospital

    • National Stadium Rd, Aga Khan University Hospital, Karachi, Karachi City, and
  • Jinnah Post Graduate Medical Center
  • Rafiq، Sarwar Shaheed Rd, Karachi Cantonment,
    • Ph: 021-99201300
•  

• Lahore

  • Dr Irfan Ahmad
  • ahmadi@who.int
  • 03246327085

In conclusion:

It may be very difficult for us to contain the COVID-19 Coronavirus infection in Pakistan as our social and cultural practices are very different.

Furthermore, no effective treatment is available, supportive treatment may be all that we could provide to our patients.

Intensive care and HDUs (high dependency units) support may not be sufficient as our hospitals are already packed.

Antimalarial medications (such as hydroxychloroquine and chloroquine) are thought to limit the illness to the upper respiratory tract and lower the likelihood of pneumonia linked to COVID-19. The prevention of Coronavirus infection may involve the use of antimalarial medications.